Editor,
The work of West and Gregor again points out the importance of sclerotomy complications following pars plana vitrectomy. They demonstrate that, even in the hands of a skillful and experienced surgeon, vitreous hemorrhage after vitrectomy for diabetic retinopathy is common and requires vitreous cavity washout (VCWO) in 12% of cases. In their series,
over half of the eyes had detectable fibrovascular...
Editor,
The work of West and Gregor again points out the importance of sclerotomy complications following pars plana vitrectomy. They demonstrate that, even in the hands of a skillful and experienced surgeon, vitreous hemorrhage after vitrectomy for diabetic retinopathy is common and requires vitreous cavity washout (VCWO) in 12% of cases. In their series,
over half of the eyes had detectable fibrovascular ingrowth (FVI) as the cause of the hemorrhage. Interestingly, in this case series of 159 eyes, no occurrences of anterior hyaloidal fibrovascular proliferation (AHPV)
were noted.
Definition of the relationship between these two entities has been controversial, to say the least.
Part of the controversy is due to a misunderstanding of the nature and pathogenesis of FVI. As McLeod points out in his editorial, FVI is a term that has been used inadvisedly, suggesting the episcleral tissue grows into the eye through the sclerotomy incision [1]. While episcleral tissue,
scleral fibroblasts, and ciliary epithelium all contribute, the majority of the fibroproliferative healing of a sclerotomy originates from the uvea of the ciliary body [2].
In normal wound healing, early fibrovascular proliferation in the incision is followed by its involution and contraction, with the result being the small scar seen at the internal aspect of a healed sclerotomy [2].
Inevitably, because of the proximity of the vitreous base and anterior hyaloid, vitreous strands are adherent to the wound and fibrous tissue extends a short way into the vitreous body. This tissue may contain blood
vessels, even with normal healing. From this perspective, all sclerotomy wounds heal with fibrovascular ingrowth. That is, ingrowth of tissue from the eye wall extends into the vitreous cavity. Fortunately, only in unusual circumstances does this process become exaggerated and result in what clinicians have termed FVI with its concomitant intraocular mischief [3].
McLeod pointed out that ischemia is an important factor in inducing FVI and that it is seen mainly following vitrectomy for ischemic retinopathies. I agree that this is the case if one includes anterior proliferative vitreoretinopathy (APVR) in this group. Patients with APVR
who have had previous vitrectomy frequently have an excessive amount of fibrovascular scarring from their sclerotomies that significantly affects the pathologic anatomy of the basal vitreous and its environs. These
patients, however, often have had extensive scleral buckling and cryopexy, processes which undoubtedly induce some anterior ischemia in themselves [2].
In the series of West and Gregor, no patient was found to have a retinal detachment utlrasonographically or at the time of VCWO. In the original description of AHFP, most of the patients had retinal detachments that had required scleral buckling [4]. Since retinal detachment and scleral buckling exacerbate anterior ischemia, it is likely that AHFP, which is fibrovascular proliferation into the vitreous base from the retina and ciliary body, is induced by an ischemic drive similar to that casing FVI. The two entities exist on a continuum. When there is a surgical injury
such as a sclerotomy, with disruption of tissue and inoculation of blood into the surrounding vitreous, excessive proliferation may occur with less
induction than that which causes AHFP. Personally, although I have observed cases of AHFP without having previous vitrectomy, I have never seen a case of post-vitrectomy AHFP without some concurrent FVI.
Finally, I'd like to make two other points. The first is that West and Gregor used clinical criteria to determine whether or not FVI existed and caused the recurrent vitreous hemorrhage. I have observed vitreous hemorrhage in an autopsy eye from what grossly appeared to be a normally
healed sclerotomy wound [5]. Microscopically, that white scar contained numerous capillaries that were the source of the hemorrhage. Therefore, it may be that some of their non-FVI patients might actually have had vitreous hemorrhage from a sub-clinical FVI. Furthermore, FVI can involute with time, becoming less vascular in its appearance. So, the
frequency of FVI may be even higher than reported.
Lastly, I agree that episcleral sentinel vessels, externally entering the wound site, sometimes, but now always, indicate a possible FVI. These vessels are the result of a high degree of metabolic activity during the healing of sclerotomy wounds and may persist even though wound fibroplasia becomes involutional and clinically unimportant. Similar vessels are seen microscopically in the ciliary body [2]. When present, sentinel[2] vessels
should raise our suspicions of FVI; but they do not rule it in, nor does their absence rule it out.
References
1. McLeod D. Entry site neovascularisation after diabetic vitrectomy. Br J Ophthalmol 2000;84:810-811.
2. Kreiger A. The pars plana incision: experimental studies, pathologic observations, and clinical experience. Trans Amer Ophthalmol Soc 1991;89:549-621.
3. Kreiger A, Straatsma B, Foos R. Incisional complications in pars plana vitrectomy. Mod Prob Ophthalmol 1977;18:210-233.
4. Lewis H, Abrams G, Williams G. Anterior hyaloidal fibrovascular proliferation after diabetic vitrectomy. Am J Ophthalmol 1987;104:607-613.
5. Foos R, Kreiger A, Nofsinger K. Pathologic study following vitrectomy for proliferative diabetic retinopathy. Retina 1985;5:101-106.
In his second eLetter (1), Dua continues his criticism of our
proposed modification of the classification of ocular surface burns(2)
but
once again fails to understand our motivation, which is to simplify the
grading of such injuries in the light of recent advances in the
management
of ocular surface disease (3-6). The result is a modification of a well
established classification, which is easily reme...
In his second eLetter (1), Dua continues his criticism of our
proposed modification of the classification of ocular surface burns(2)
but
once again fails to understand our motivation, which is to simplify the
grading of such injuries in the light of recent advances in the
management
of ocular surface disease (3-6). The result is a modification of a well
established classification, which is easily remembered and can be used
by
all ophthalmologists and not just by corneal specialists. The Dua, King
and Joseph classification (7) allows quantification of the injury, which
is useful in a research environment but is trapped in its detail for
routine clinical use.
We would reiterate that our modifications are based on
recent advances in the management of ocular surface injuries, which have
meant that even severe injuries can have good outcomes (3-6). This is
the
rationale for having Grade III as the most severe injury grade and for
uniformly assigning to it a guarded prognosis. Within that grade,
different injury patterns will have different management protocols and
different rates of recovery. The work by Roper Hall (8) elegantly showed
that a good and doubtful prognosis correlated respectively to less or
more
than one third of conjunctival ischaemia at the limbus. Hence we
retained
this element of his classification to separate Grade II and Grade III in
our modification. It serves to identify a serious ocular surface injury
to
the non-corneal specialist who can then arrange an appropriate referral.
Dua's confusion about the role of 'OR' in our table in order to define
the
Grade of injury is actually dealt with in the text of the original
article
(2): the Grade of the injury is assigned simply on the basis of the most
severe sign, rather than on the complex analysis of a combination of
signs.
Dua is supportive of our inclusion of conjunctival injury in our
proposed modification (1) but disagrees with the inclusion of tarsal
conjunctival assessment, on the basis that it does not influence
prognosis. This is clearly wrong. Contiguous tarsal and bulbar injury
can
lead to symblepharon formation and shortening of the conjunctival
fornices, which is detrimental to the ocular surface and therefore
deserves inclusion in any assessment of ocular surface injury. The
bulbar
and tarsal conjunctiva extends into the fornices and forniceal
conjunctival involvement is therefore included in the measured area of
involvement - important for possible stem cell sites (9).
We would leave it to readers of the Journal and those involved in
this field to judge the value of the different grading systems.
References
1. Dua HS. Classification of ocular surface burns. Br J Ophthalmol
eLetter ( 11 August 2004)
2. Harun S, Srinivasan S, Hollingworth K, Batterbury M, Kaye SB.
Modification of the classification of ocular chemical injuries. Br J
Ophthalmol 2003;88:1353-1354
3. Kobayashi A, Shirao Y, Yoshita T, et al.Temporory amniotic
membrane patching for acute chemical burns. Eye 2003; 17: 149-158
4. Stoiber J, Muss WH, Pohla-Gubo G, Ruckhofer J, Grabner G.
Histopathology of human corneas after amniotic membrane and limbal stem
cell transplantation for severe chemical burn. Cornea
2002;21(5):482-489.
5.Nishiwaki-Dantas MC, Dantas PE, Reggi JR. Ipsilateral limbal
translocation for treatment of partial limbal deficiency secondary to
ocular alkali burn. Br J Ophthalmol 2001;85(9):1031-1033
6.Ozdemir O, Tekeli O, Ornek K, Arslanpence A, Yalcindag NF. Limbal
autograft and allograft transplantations in patients with corneal burns.
Eye 2004;18(3):241-248
7.Dua HS, King AJ, Joseph A. A new classification of ocular surface
burns. Br J Ophthalmol 2001;85:1379-1383
8.Roper-Hall MJ. Themal and chemical burns.Trans Ophthalmol Soc UK
1965;85:631-53
9.Wei Z-G, Cotsarelis G, Sun T-T, Lavker RM. Label-retaining cells
are preferentially located in the forniceal epithelium:implications on
conjunctival epithelial haemostasis. Invest Ophthal Vis Sci
1995;36:236-46
I read the article by Pun et al.[1] with interest. My experience with
ketamine is (thankfully) limited to operating in Bosnia after the war.
Out of the six patients one vomited on the field. Difficulty is
encountered in re-ops due to lack of muscle paralysis. Ketamine also
has well known after
effects. In my opinion it is neither safe nor effective. Learning and
using safe anesthesia techniques...
I read the article by Pun et al.[1] with interest. My experience with
ketamine is (thankfully) limited to operating in Bosnia after the war.
Out of the six patients one vomited on the field. Difficulty is
encountered in re-ops due to lack of muscle paralysis. Ketamine also
has well known after
effects. In my opinion it is neither safe nor effective. Learning and
using safe anesthesia techniques would be the best in any country.
Reference
(1) M S Pun, J Thakur, G Poudyal, R Gurung, S Rana, G Tabin, W V Good, and S Ruit. Ketamine anaesthesia for paediatric ophthalmology surgery. Br J Ophthalmol 2003;87:535-537.
Editor,
The commentary by Waldock and Cook on the survival rates of
corneal grafts highlights a number of issues. In particular, they focus on the lack of long-term follow-up data in the UK. The value of such data is clearly evident from the Australian Corneal Graft Register.[1] Moreover,
in the present climate of clinical audit and evidence-based medicine, the collection of such data has surely become a...
Editor,
The commentary by Waldock and Cook on the survival rates of
corneal grafts highlights a number of issues. In particular, they focus on the lack of long-term follow-up data in the UK. The value of such data is clearly evident from the Australian Corneal Graft Register.[1] Moreover,
in the present climate of clinical audit and evidence-based medicine, the collection of such data has surely become a necessity.[2] Many of the questions raised, whether simply comparing graft survival rates of individual units with national data or investigating more fundamental
issues such as HLA matching, visual outcome or surgeon experience, require large amounts of data, properly designed studies and appropriate statistical analysis-capabilities beyond most individual centres, but readily achievable within the NHS. The way forward as shown by the organ
transplant community, and to a certain extent by corneal graft surgeons, is through well-organized, centralized data collection and analysis. e.g.[1] [3] [4]
The good news is that just such a system is now in place for all corneal graft surgeons in the UK. The Royal College of Ophthalmologists and the UK Transplant (UKT) have initiated an Ocular Tissue Transplant Audit, which will provide the data for answering the sorts of questions posed by Waldock and Cook. Indeed, the Audit is already being used for data capture for the Corneal Transplant Follow-up Study II, which aims to resolve the uncertainty surrounding HLA-DR matching and corneal graft rejection. Instead of just one-year follow-up as in the original CTFS,[4]
follow-up for these patients will continue in the long-term through the Audit.
As important, however, is the opportunity for all ocular tissue transplants to be recorded and the outcome audited. Indeed one can foresee the day when this will be obligatory, as is the case with solid organs. To record such data with UKT will not only provide surgeons with details of their own activity, but an independent confidential analysis of
clinical outcomes, which they will increasingly be expected to have available.
References
1. Williams KA, Muehlberg SM, Lewis RF, et al. The Australian corneal graft registry 1996 report. Adelaide: Mercury Press, 1997.
2. Coster DJ. Evaluation of corneal transplantation [editorial]. Br J Ophthalmol 1997;81:618-619.
3. United Kingdom Transplant Support Service Authority Renal Transplant Audit 1984-1993. Bristol: UKTSSA, 1995.
4. Vail A, Gore SM, Bradley BA, et al. Conclusions of the corneal transplant follow-up study. Br J Ophthalmol
1997;81:631-6.
We read with interest the report by Henderson et al.[1] The title of the paper includes the word "early" and the
median time to leak is 3.5 days, but the range of time taken for bleb
leakage to develop extends to 408 days postoperatively. We do not think
this is early nor a postoperative complication.
Wound leakage complicates the management of trabeculectomy: some eyes
develop anter...
We read with interest the report by Henderson et al.[1] The title of the paper includes the word "early" and the
median time to leak is 3.5 days, but the range of time taken for bleb
leakage to develop extends to 408 days postoperatively. We do not think
this is early nor a postoperative complication.
Wound leakage complicates the management of trabeculectomy: some eyes
develop anterior chamber shallowing, choroidal detachment and even
hypotony, causing the clinician to intervene by a variety of methods.
Whilst leakage is occurring subconjunctival fibrosis may proceed
unchecked, but standard interventions, such as needling with injection of
5-fluorouracil, may be contraindicated in the presence of a wound leak.
It would be helpful for the reader to know whether any interventions were
needed or were delayed, since not only may these affect the long term
outcome but also will help to guide the surgeon managing a wound leak.
1. H W A Henderson, E Ezra, and I E Murdoch
Early postoperative trabeculectomy leakage: incidence, time course, severity, and impact on surgical outcome
Br J Ophthalmol 2004; 88: 626-629.
First of all let me congratulate the authors for their work on
exudative ARMD. But there are still some issues which need to be
brought into account:
1. Some published studies show that even 4.0 mg of intravitreal
triamcinolone has significant side effects in terms of increased IOP and
more so for eyes which needed the second dose of the triamcinolone, with
a few of them even needing a filtratio...
First of all let me congratulate the authors for their work on
exudative ARMD. But there are still some issues which need to be
brought into account:
1. Some published studies show that even 4.0 mg of intravitreal
triamcinolone has significant side effects in terms of increased IOP and
more so for eyes which needed the second dose of the triamcinolone, with
a few of them even needing a filtration surgery. In this particular
study however 25mg of Triamcinolone has been used which may cause even
more increased elevation of IOP. This issue is an important one as many
of our ARMD patients have co-existing chronic open angle glaucoma with a
compromised blood supply of the optic nerve head. With the intravitreal
steroids induced rise in IOP, we may tilt the balance on the wrong side
thereby taking their peripheral vision along-with the central loss due
to the ARMD. [1,2,5]
2. The effect of intravitreal steroids in the progression of
cataract is
not very much emphasized in various studies. If earlier cataract surgery
in treated ARMD patients is required, this has theoretical implications
in terms of ultraviolet light exposure, one of the environmental factors
implicated in ARMD. If there is no long term benefit for preventing the
progression of ARMD with the steroids then why should we increase the
chances of cataract in these patients thereby rendering their retinas
more vulnerable to damage caused by the UV radiation?[2]
3. Various in-vitro studies suggest that down-regulation of
inflammatory
markers and changes in the endothelial cell permeability are probably
the
modes of action of triamcinolone in exudative ARMD, but all these
actions
are probably only for the duration when the steroids are in high
concentration in the vicinity. To maintain high concentrations
triamcinolone should be injected repeatedly and probably that is the
reason the improvement fades with time in many patients. Moreover none
of the studies published so far have been long enough to actually give a
fair idea about the long term outcome. The longest duration for which
the follow up has been done is 18 months. [3,4]
We need data from multicenter, placebo-controlled trials on a much larger population with long-term follow-up to establish the efficacy of the drug and assess possible side effects and complications. Until then we should probably reserve this therapy for those cases where
there is recurrence after laser treatment.[5]
References
(1) Danis RP, Ciulla TA, Pratt LM, Anliker W. Intravitreal triamcinolone acetonide in exudative age-related macular degeneration. Retina 2000; 20(3):244-50.
(2) Challa JK, Gillies MC, Penfold PL, Gyory JF, Hunyor AB, Billson FA. Exudative macular degeneration and intravitreal triamcinolone: 18 month follow up. Aust N Z J Ophthalmol. 1998 Nov;26(4):277-81.
(3) Penfold PL, Gyory JF, Hunyor AB, Billson FA. Exudative macular
degeneration and intravitreal triamcinolone. A pilot study. Aust N Z J
Ophthalmol 1995 Nov;23(4):293-8.
(4) Jonas JB, Kreissig I, Degenring R. Intraocular pressure after
intravitreal injection of triamcinolone acetonide. Br J Ophthalmol 2003 Jan;87(1):24-7.
(5) Ranson NT, Danis RP, Ciulla TA, Pratt L. Intravitreal
triamcinolone in subfoveal recurrence of choroidal neovascularisation
after laser treatment in macular degeneration.
Br J Ophthalmol 2002 May; 86(5):527-9.
Editor,
We read with interest the paper by Minasian et al. They quote that pain experienced during an injection is related to the temperature of the injection and the speed of delivery of the solution.[1] [2]
In their article, they have used all anaesthetics at room temperature. We have been pre-warming our anaesthetic solutions routinely for cataract surgery. We use a heat pad (Dreamland appliance...
Editor,
We read with interest the paper by Minasian et al. They quote that pain experienced during an injection is related to the temperature of the injection and the speed of delivery of the solution.[1] [2]
In their article, they have used all anaesthetics at room temperature. We have been pre-warming our anaesthetic solutions routinely for cataract surgery. We use a heat pad (Dreamland appliance services model HP3, 240V,52-60W) to warm solutions to 40ºC prior to subtenon's injection. We have noted that patients found this less painful than non pre-warmed solutions.
There are reports to support that pre-warming anaesthetic solution is less painful than using solutions at room temperature.[3] [4] Increasing
temperature or pH (alkalinising the anaesthetic solution) works in the
same fashion, that is, by increasing the concentration of non-ionised form
which is more lipid soluble and results in almost immediate sensory
blockade.[2] [5] [6] Though altering the pH and pre-warming the anaesthetic
solution have been tried separately, we have not encountered any study
that combines both these variables. We believe that such a study would be
worthwhile and needs to be looked at. Even if the pH of the solution
changes after warming, we do not believe that pH is a factor in reducing
pain, as confirmed by their study.
References
1. Gillart T, Bazin JE, Montetagaud M, et al. The effects of volume and
speed of injection in peribulbar anaesthesia. Anaesthesia 1998;53:486-91.
2. Christoph R, Buchanan L, Schwatz S. Pain reduction in local
anaesthetic administration through pH buffering. Ann Emerg Med
1998;17:117-20.
3. Ursell PG, Spalton DJ. The effect of solution temperature on the pain
of peribulbar anaesthesia. Ophthalmology 1996;103:839-41.
4. Hamilton RC. Does warming of anaesthetic solutions improve analgesia
and akinesia in retrobulbar anaesthesia? Ophthalmology 1997;104:429-32.
5. Ritchie JM, Ritchie B, Greenford B. The active structure of local
anaesthetics. J Pharmacol Exp Ther 1965;150:152-9.
6. Kamaya H, Hayes JJ, Ueda I. Dissociation constants of local
anaesthetics and their temperature dependence. Anaesth Analg 1983;62:1025-30.
We read with interest the article by Gouws et al.[1] on the apparent
increased incidence of cystoid macular oedema (CMO) in
phacoemulsification
patients when trypan blue was used to stain the anterior capsule.
Trypan blue was commonly used in both anterior and posterior
segment
surgeries.[2-4] If trypan blue does cause macular toxicity, its risks
should
theoretically be higher when used...
We read with interest the article by Gouws et al.[1] on the apparent
increased incidence of cystoid macular oedema (CMO) in
phacoemulsification
patients when trypan blue was used to stain the anterior capsule.
Trypan blue was commonly used in both anterior and posterior
segment
surgeries.[2-4] If trypan blue does cause macular toxicity, its risks
should
theoretically be higher when used in posterior segment surgeries.
However,
studies on the use of trypan blue, both in the anterior[2,3] and
posterior[4,5] segments, did not show apparent toxicity.
Thus, it would be appreciated if the authors could clarify whether
other potential confounders were assessed in their study, including:
1. Other causes of CMO such as diabetes, uveitis and prostaglandin
use;
2. Operating time since photo-toxicity from the operative
microscope[6] per
se is a risk factor for CMO development. It appears that only operations
for patients in group B were performed by one surgeon, if operations for
patients in group A (with trypan blue use) were done by trainees, the
operative time is expected to be longer;
3. Whether all patients received a fundus examination with dilated
pupil
after the operation. If these were only performed in patients with sub-
optimal visual acuities, the incidence of CMO may be underestimated.
Finally, we concur with the authors' view that we should try all
means in terms of minimising any theoretical toxicities of trypan blue.
It
is our routine to actively remove trypan blue with the bimanual
irrigation
aspiration system as soon as the anterior capsule has been stained. It
is
very effective and the potential toxicities might be reduced.
References
1. Gouws P, Merriman M, Goethals S, Simcock PR, Greenwood RJ,
Wright
G. Cystoid macular oedema with trypan blue use. Br J Ophthalmol. 2004
Oct;88(10):1348-9.
2. Melles GR, de Waard PW, Pameyer JH, Houdijn Beekhuis W. Trypan
blue capsule staining to visualize the capsulorhexis in cataract
surgery.
J Cataract Refract Surg. 1999 Jan;25(1):7-9.
3. Dada VK, Sharma N, Sudan R, Sethi H, Dada T, Pangtey MS.Anterior
capsule staining for capsulorhexis in cases of white cataract:
comparative
clinical study. J Cataract Refract Surg. 2004 Feb;30(2):326-33.
4. Feron EJ, Veckeneer M, Parys-Van Ginderdeuren R, Van Lommel A,
Melles GR, Stalmans P. Trypan blue staining of epiretinal membranes in
proliferative vitreoretinopathy. Arch Ophthalmol. 2002 Feb;120(2):141-4.
5. Li K, Wong D, Hiscott P, Stanga P, Groenewald C, McGalliard J.
Trypan blue staining of internal limiting membrane and epiretinal
membrane
during vitrectomy: visual results and histopathological findings. Br J
Ophthalmol. 2003 Feb;87(2):216-9.
6. Donzis PB, DeBartolo DF, Lewen RM, May DR. Light-induced
maculopathy and cystoid macular edema. J Cataract Refract Surg. 1988
Jan;14(1):84-5.
We were interested to read of the positive feedback that Zaldi et al.
received from patients attending Saturday morning Ophthalmic clinics at
Hillingdon Hospital.[1] The authors raise some interesting questions that we
are delighted to be able to address. We feel it is important to highlight
the differences between this and our two-centre study.[2] Whilst both groups
aimed to address the same...
We were interested to read of the positive feedback that Zaldi et al.
received from patients attending Saturday morning Ophthalmic clinics at
Hillingdon Hospital.[1] The authors raise some interesting questions that we
are delighted to be able to address. We feel it is important to highlight
the differences between this and our two-centre study.[2] Whilst both groups
aimed to address the same issue, the cohort of individuals questioned, the
delivery of the questionnaire and the nature of the questions that were
asked differed in the two studies.
Zaldi et al. questioned a group of patients attending a Saturday
morning clinic in London. This was a select group and excluded all those
individuals who either failed to attend or attended during Mon-Fri. In
contrast, we invited all patients attending out-patients over a 2 week
period to participate in an effort to minimise bias from selecting just
one day of the week. Secondly, we conducted our survey at two centres, one
in the North (Leeds) and one in the South West (Bristol) in an attempt to
more accurately reflect public opinion across the UK. Zaldi et al. point
out that in London there is a unique weekday congestion charge that might
bias the results from their study in favour of attendance at a Saturday
morning clinic.
In the London study the questionnaire was verbally administered by
the examining ophthalmologist which might have introduced a ‘desire to
please’ from the patients and therefore bias the results. We felt that by
allowing individuals to remain anonymous we might obtain more accurate
responses to our questionnaire.
Finally, and perhaps of most importance, is the fact that the
questions differed in the two studies. The London group directly asked
their patients to state whether they had a preference for either a
Saturday morning or a 9am-5pm weekday clinic. This produced the figure
that 50% did not mind when they attended and 41% preferred a Saturday
morning. By contrast in our study we asked individuals to state whether
their appointment time was ‘convenient’ or ‘inconvenient’. We found that
89% individuals found their weekday appointment time convenient. A further
7% preferred a different time within the existing 8am-5pm weekday
framework. Only 4% stated that a weekday appointment between 8am-5pm was
inconvenient. We then asked patients to comment on whether they would find
alternative clinic times convenient or inconvenient. We did not ask
patients to rank these alternatives in order of preference. From this
question we found that 52% would find a Saturday morning appointment
convenient. Although the questions are slightly different in the 2
studies, our figure of 52% is in broad agreement with the London study
which showed 50% individuals did not mind whether they attended on a
weekday or a Saturday morning.
We conclude by stressing that only 4% individuals found their 8am-5pm
weekday appointment time inconvenient and 48% would find a Saturday
morning appointment inconvenient. Given that the Government supports
‘patient choice’, we feel that these figures justify an expansion of the
existing framework rather than the introduction of regular ‘out of hours’
clinics.
References
(1) Zaidi FH, Lee N. Public opinion favours out-of-hours clinics: interviews challenge multi-centre questionnaire [electronic response to Churchill et al. Public opinion on weekend and evening outpatient clinics] bjophthalmol.com 2003 http://bjo.bmjjournals.com/cgi/eletters/87/3/257#133
(2) A J Churchill, C Gibbon, S Anand, and M McKibbin. Public opinion on weekend and evening outpatient clinics. Br J Ophthalmol 2003;87:257-258.
Dear Sir,
In India, we very commonly see mature cataracts. Doing capsulorhexis with
injection of dye is done very routinely by many of us. Forunately no
untoward reaction has been reported so far. This helps us to carry out the
phaco procedure with ease.
Editor,
The work of West and Gregor again points out the importance of sclerotomy complications following pars plana vitrectomy. They demonstrate that, even in the hands of a skillful and experienced surgeon, vitreous hemorrhage after vitrectomy for diabetic retinopathy is common and requires vitreous cavity washout (VCWO) in 12% of cases. In their series, over half of the eyes had detectable fibrovascular...
Dear Editor
In his second eLetter (1), Dua continues his criticism of our proposed modification of the classification of ocular surface burns(2) but once again fails to understand our motivation, which is to simplify the grading of such injuries in the light of recent advances in the management of ocular surface disease (3-6). The result is a modification of a well established classification, which is easily reme...
Dear Editor
I read the article by Pun et al.[1] with interest. My experience with ketamine is (thankfully) limited to operating in Bosnia after the war. Out of the six patients one vomited on the field. Difficulty is encountered in re-ops due to lack of muscle paralysis. Ketamine also has well known after effects. In my opinion it is neither safe nor effective. Learning and using safe anesthesia techniques...
Editor,
The commentary by Waldock and Cook on the survival rates of corneal grafts highlights a number of issues. In particular, they focus on the lack of long-term follow-up data in the UK. The value of such data is clearly evident from the Australian Corneal Graft Register.[1] Moreover, in the present climate of clinical audit and evidence-based medicine, the collection of such data has surely become a...
Dear Editor
We read with interest the report by Henderson et al.[1] The title of the paper includes the word "early" and the median time to leak is 3.5 days, but the range of time taken for bleb leakage to develop extends to 408 days postoperatively. We do not think this is early nor a postoperative complication.
Wound leakage complicates the management of trabeculectomy: some eyes develop anter...
Dear Editor
First of all let me congratulate the authors for their work on exudative ARMD. But there are still some issues which need to be brought into account:
1. Some published studies show that even 4.0 mg of intravitreal triamcinolone has significant side effects in terms of increased IOP and more so for eyes which needed the second dose of the triamcinolone, with a few of them even needing a filtratio...
Editor,
We read with interest the paper by Minasian et al. They quote that pain experienced during an injection is related to the temperature of the injection and the speed of delivery of the solution.[1] [2]
In their article, they have used all anaesthetics at room temperature. We have been pre-warming our anaesthetic solutions routinely for cataract surgery. We use a heat pad (Dreamland appliance...
Dear Editor
We read with interest the article by Gouws et al.[1] on the apparent increased incidence of cystoid macular oedema (CMO) in phacoemulsification patients when trypan blue was used to stain the anterior capsule.
Trypan blue was commonly used in both anterior and posterior segment surgeries.[2-4] If trypan blue does cause macular toxicity, its risks should theoretically be higher when used...
Dear Editor
We were interested to read of the positive feedback that Zaldi et al. received from patients attending Saturday morning Ophthalmic clinics at Hillingdon Hospital.[1] The authors raise some interesting questions that we are delighted to be able to address. We feel it is important to highlight the differences between this and our two-centre study.[2] Whilst both groups aimed to address the same...
Dear Sir,
In India, we very commonly see mature cataracts. Doing capsulorhexis with injection of dye is done very routinely by many of us. Forunately no untoward reaction has been reported so far. This helps us to carry out the phaco procedure with ease.
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