The authors would like to thank Dr. MAYURI BORGOHAIN et al. for their interest on our study ‘Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial’, and appreciate their insightful comments.
First, in this study, for “Combined Subconjunctival Injection of Dexamethasone”, we means combination subconjunctival injection of Dexamethasone with anti-glaucoma drug (such as topical pilocarpine, beta-blocker, brinzolamide, and alpha-2 agonists).
Second, for better investigating the effectiveness of injection of dexamethasone, the control group was designed to not subjected to any topical anti-inflammatory drug. Moreover, Patients that were excluded with a usage of topical anti-inflammatory drugs (including NASIDs and steroids), which was mentioned in the method part.
Third, the range of intraocular pressure (IOP) in those 42 eyes was 27-60 mmHg.
Fourth, to study the window period from onset of acute attack for maximum efficacy of subconjunctival dexamethasone injection, we performed correlation analysis between the duration before recruitment with the decrease of IOP (IOPbaseline – IOP24h)，and found that the decrease of IOP was corelated with the duration before recruitment (r = -0.481, p = 0.002). Moreover, about one half of patients that the duration less than 5 days had more efficacy of subconjunctival dexamethasone injection.
Given the lack of level 1 evidence there is no unified consensus among peripheral nerve experts on the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives for peripheral nerve reconstruction at various gap lengths [1-3]. Moreover, as the authors correctly point out in their correspondence, no trials exist comparing the use of ANAs to nerve autografts in corneal neurotization, nullifying their claim of nerve autograft superiority for this procedure. Of note, Avance® allografts have become “on label” for corneal neurotization since my last correspondence.
In comparing the study by Catapano et al to the study by Leyngold et al it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al were under 18 years of age. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. Catapano et al reported mean CCS at 30.0±26.8mm at 6 months postoperatively, with a significant number (44%) of patients in their study having CCS at or below 10...
Given the lack of level 1 evidence there is no unified consensus among peripheral nerve experts on the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives for peripheral nerve reconstruction at various gap lengths [1-3]. Moreover, as the authors correctly point out in their correspondence, no trials exist comparing the use of ANAs to nerve autografts in corneal neurotization, nullifying their claim of nerve autograft superiority for this procedure. Of note, Avance® allografts have become “on label” for corneal neurotization since my last correspondence.
In comparing the study by Catapano et al to the study by Leyngold et al it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al were under 18 years of age. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. Catapano et al reported mean CCS at 30.0±26.8mm at 6 months postoperatively, with a significant number (44%) of patients in their study having CCS at or below 10mm and peripheral corneal sensation (PCS) at or below 30mm at that time. Among the three patients (43%) reported by Leyngold et al who had corneal sensation measurements under 35mm one had a follow up of only 3 months, second patient achieved an improvement of 34mm at 10 months after surgery despite multiple medical comorbidities, and the last patient was shown to have corneal nerve regeneration on in vivo confocal microscopy, improved ocular surface and visual acuity. Also, four patients in the study by Catapano et al were found to have persistent epithelial defects (PEDs) 24 months after the surgery (21%) compared to only 1 patient (14%) reported by Leyngold et al at 1 month postoperatively.
Finally, the authors state that they “have yet to encounter a suboptimal neurotization outcome with use of nerve autografts to route sensory axons of the great auricular nerve to the cornea” based on only two of their published cases [7]. This quantity of cases is not sufficient to draw any conclusions regarding clinical outcomes of this technique.
References:
1. Brooks DN, Weber RV, Chao JD, et al. Processed nerve allografts for peripheral nerve reconstruction: A multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions. Microsurgery. 2012 Jan; 32(1)
2. Zuniga JR, Williams F, Petrisor D. A case-and-control, multi-site, positive controlled, prospective study of the safety and effectiveness of immediate inferior alveolar nerve processed nerve allograft reconstruction with ablation of the mandible for benign pathology. J Oral Maxillofac Surg. 2017 Dec; 75(12): 2669-2681.
3. Rinker BD, Zoldos J, Weber RV, et al. Use of processed nerve allografts to repair nerve injuries greater than 25 mm in the hand. Ann Plast Surg. 2017 Jun; 78(6S Suppl 5): S292-S295. 10.1097/SAP.0000000000001037
4. Catapano J, Fung SSM, Halliday W, et al. Treatment of neurotrophic keratopathy with minimally invasive corneal neurotisation: long-term clinical outcomes and evidence of corneal reinnervation. British J Ophthalmol. 2019:bjophthalmol-2018-313042.
5. Leyngold IM, Yen MT, Tian J, et al. Minimally invasive corneal neurotization with acellular nerve allograft: surgical technique and clinical outcomes. Ophthalmic Plast Reconstr Surg 2019;35:133–40.
6. Park J, Charlson E, Leyngold IM, et al. Corneal neurotization: A review of pathophysiology and outcomes. Ophthalmic Plast Reconstr Surg. 2020; Jan 8. doi: 10.1097/IOP.0000000000001583. [Epub ahead of print]
7. Jowett N, Pineda II R. Corneal neurotisation by great auricular nerve transfer and scleral-corneal tunnel incisions for neurotrophic keratopathy. Br J of Ophthalmol. 2018 Nov 23. pii: bjophthalmol-2018-312563
To,
The editor
We would like to congratulate Huang et al. for their study ‘Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial’.1 However, we have few queries and seek your kind attention.
First, as mentioned in this article, a previous study in dogs showed combination of topical anti-inflammatory eye drops was beneficial during treatment.2They had conducted this present study as there was no data on humans regarding a randomised controlled trial that demonstrates the effectiveness of anti-inflammatory drugs for the treatment of human eyes suffering from acute primary angle closure (APAC). However, as the title suggested combination of subconjunctival dexamethasone injection, it implied combination of it with other anti-inflammatory drugs. However, the injection group was not subjected to any other anti-inflammatory drugs.
Second, the authors’ previous study showed that the inflammatory response in the aqueous humor from APAC patient was evident and that multiple inflammatory factors were elevated significantly.3 Topical steroids help to reduce intraocular inflammation make the patient more comfortable.4 However; the control group was not subjected to any topical anti-inflammatory drug.
Third, we are interested to know about the range of intraocular pressure (IOP) in those 42 eyes; the highest and lowest IOP recorded.
Fourth, we are also interested to know r...
To,
The editor
We would like to congratulate Huang et al. for their study ‘Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial’.1 However, we have few queries and seek your kind attention.
First, as mentioned in this article, a previous study in dogs showed combination of topical anti-inflammatory eye drops was beneficial during treatment.2They had conducted this present study as there was no data on humans regarding a randomised controlled trial that demonstrates the effectiveness of anti-inflammatory drugs for the treatment of human eyes suffering from acute primary angle closure (APAC). However, as the title suggested combination of subconjunctival dexamethasone injection, it implied combination of it with other anti-inflammatory drugs. However, the injection group was not subjected to any other anti-inflammatory drugs.
Second, the authors’ previous study showed that the inflammatory response in the aqueous humor from APAC patient was evident and that multiple inflammatory factors were elevated significantly.3 Topical steroids help to reduce intraocular inflammation make the patient more comfortable.4 However; the control group was not subjected to any topical anti-inflammatory drug.
Third, we are interested to know about the range of intraocular pressure (IOP) in those 42 eyes; the highest and lowest IOP recorded.
Fourth, we are also interested to know regarding any window period from onset of acute attack for maximum efficacy of subconjunctival dexamethasone injection?
References
1. Huang W, Li X, Gao K, et al. Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial. Br J Ophthalmol 2019;0:1–5. doi:10.1136/bjophthalmol-2018-313473
2. Miller PE, Schmidt GM, Vainisi SJ, et al. The efficacy of topical prophylactic antiglaucoma therapy in primary closed angle glaucoma in dogs: a multicenter clinical trial. J Am Anim Hosp Assoc 2000;36:431–8.
3. Huang W, Gao X, Chen S, et al. Vascular endothelial growth factor is increased in aqueous humor of acute primary angle-closure eyes. J Glaucoma 2016;25:e647–51.
4. See JL, Aquino MD, Aduan J, Chew PT. Management of angle closure glaucoma. Indian J Ophthalmol 2011;59, Suppl S1:82-7.
To the Editor:
We herein respond to the letter written by Camus et al raising the issue of “ultra-low” dose radiation therapy (4 Gy) vs. the “standard low-dose” radiation therapy (24-30 Gy) for lymphomas of the orbit, eyelid, and conjunctiva, also referred to as “ocular adnexal lymphoma” (OAL). First off, it is important to point out that the goals of the retrospective multicenter general review of marginal zone lymphoma coordinated by Professor Steffen Heegaard in Denmark which also included some of our patients from M. D. Anderson was not to compare the efficacy of various treatment strategies.(1) Indeed it is challenging to draw practice altering conclusions from a retrospective multi-center study given the usual limitations, most notably the variation in staging and treatment approaches across various continents as noted by Camus et al.
However, we agree with Camus et al that our encouraging preliminary observations in 22 patients with OAL treated with ultra-low dose radiation therapy (4Gy) suggested a very good response rate (100% ORR:86% CR, 14%% PR) for B-cell orbital and ocular adnexal lymphomas;(2) as such we started a prospective trial of ultra-low dose radiation for ocular adnexal lymphoma patients at MD Anderson Cancer Center soon thereafter (Clinicaltrials.gov identifier NCT02494700)The study aims to evaluate the efficacy of response adapted radiation therapy for this patient population, whereby all patients are treated to an initial 4 Gy in...
To the Editor:
We herein respond to the letter written by Camus et al raising the issue of “ultra-low” dose radiation therapy (4 Gy) vs. the “standard low-dose” radiation therapy (24-30 Gy) for lymphomas of the orbit, eyelid, and conjunctiva, also referred to as “ocular adnexal lymphoma” (OAL). First off, it is important to point out that the goals of the retrospective multicenter general review of marginal zone lymphoma coordinated by Professor Steffen Heegaard in Denmark which also included some of our patients from M. D. Anderson was not to compare the efficacy of various treatment strategies.(1) Indeed it is challenging to draw practice altering conclusions from a retrospective multi-center study given the usual limitations, most notably the variation in staging and treatment approaches across various continents as noted by Camus et al.
However, we agree with Camus et al that our encouraging preliminary observations in 22 patients with OAL treated with ultra-low dose radiation therapy (4Gy) suggested a very good response rate (100% ORR:86% CR, 14%% PR) for B-cell orbital and ocular adnexal lymphomas;(2) as such we started a prospective trial of ultra-low dose radiation for ocular adnexal lymphoma patients at MD Anderson Cancer Center soon thereafter (Clinicaltrials.gov identifier NCT02494700)The study aims to evaluate the efficacy of response adapted radiation therapy for this patient population, whereby all patients are treated to an initial 4 Gy in 2 fractions and the additional 20 Gy (to complete the current standard of care radiation therapy dose of 24 Gy, is reserved for non-responders). The total accrual goal for this prospective trial is 50 patients; to date we have enrolled 41 patients in this prospective trial and have also treated at least 30 additional patients off protocol with the ultra-low dose regimen (inclusive of the patients reported in our initial retrospective analysis). We fully expect to publish the results of this prospective trial in a major oncology journal once the total accrual goal is reached. Based on our interim analysis and our collective observations in over 70 orbits treated with ultra-low dose radiation therapy (4Gy) at MD Anderson to date, we are optimistic that this significant lowering of dose of radiation therapy will be a major paradigm shift for management of low grade ocular adnexal lymphomas in routine practice in the future.
As Camus et al pointed out this much lower dose of radiation therapy is associated with significantly less ocular toxicity, it is less expensive, more convenient for patients (only two sessions of radiation), and importantly can also be repeated in cases of relapse or progression over time in the orbit. With regards to the issue of follow up time, we have been carefully following our original 22 patients treated with ultra-low dose radiation (4 Gy) and published in 2016.(2) We plan to publish a follow-up study on those original 22 patients once the median follow up time gets closer to 5 years. This may coincide with the publication of our prospective trial data and hopefully the two follow up publications will decrease the understandable sense of “dilemma” expressed by Camus et al regarding the ideal radiation dose for low grade , stage IE, ocular adnexal lymphomas.
Corresponding Author:
Bita Esmaeli, MD, FACS
Orbital Oncology & Ophthalmic Plastic Surgery
Department of Plastic Surgery
The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd, Unit 1488, Houston, Texas 77030
Tel: 713-792-4457. Fax: 713-794-4662
1. Hindsø TG, Esmaeli B, Holm F, et al. International multicentre retrospective cohort study of ocular
adnexal marginal zone B-cell lymphoma. Br. J. Ophthalmol. 2019;bjophthalmol-2019-314008.
2. Pinnix CC, Dabaja BS, Milgrom SA, et al. Ultra-low-dose radiotherapy for definitive management of
ocular adnexal B-cell lymphoma. Head Neck. 2017;39(6):1095–1100.
We read the study by Vinciguerra et al. on cornea biomechanical properties of open angle glaucoma, ocular hypertension, normal tension and normal eyes assessed with dynamic air-puff applanation [1]. The study reported significant correlations between the properties and types of glaucoma. Most of the study patients were also under anti-glaucoma medication. Interestingly, the study did not assess the potential confounding effects of the anterior chamber on assessment of corneal biomechanical properties [1]. However, we wish to bring to the notice of the authors our earlier study on the same subject [2]. In our study, open and closed angle patients under the anti-glaucoma medication were assessed with air-puff applanation to determine if medication altered corneal biomechanical properties. The highlight of the study was that anterior chamber depth (ACD) was also included as a covariate in addition to other tomographic features [2]. Our study clearly showed that the ACD had a significant effect of the level of bIOP among the different types of glaucoma patient [2]. The ACD is a direct indicator of the volume of vault space between the cornea and the lens. This vault space resisted the inward motion of the cornea during the first half of the applanation. If ACD was lower, then bIOP was greater and vice versa. In patients with angle closure glaucoma, we expect the ACD to be less than NTG and normal eyes [1,2]. Hence, the results from the Vinciguerra et al. study could be skewed...
We read the study by Vinciguerra et al. on cornea biomechanical properties of open angle glaucoma, ocular hypertension, normal tension and normal eyes assessed with dynamic air-puff applanation [1]. The study reported significant correlations between the properties and types of glaucoma. Most of the study patients were also under anti-glaucoma medication. Interestingly, the study did not assess the potential confounding effects of the anterior chamber on assessment of corneal biomechanical properties [1]. However, we wish to bring to the notice of the authors our earlier study on the same subject [2]. In our study, open and closed angle patients under the anti-glaucoma medication were assessed with air-puff applanation to determine if medication altered corneal biomechanical properties. The highlight of the study was that anterior chamber depth (ACD) was also included as a covariate in addition to other tomographic features [2]. Our study clearly showed that the ACD had a significant effect of the level of bIOP among the different types of glaucoma patient [2]. The ACD is a direct indicator of the volume of vault space between the cornea and the lens. This vault space resisted the inward motion of the cornea during the first half of the applanation. If ACD was lower, then bIOP was greater and vice versa. In patients with angle closure glaucoma, we expect the ACD to be less than NTG and normal eyes [1,2]. Hence, the results from the Vinciguerra et al. study could be skewed because of variation in ACD of the study patients. We highly encourage the authors to reanalyze their data after including ACD as a co-variate in the generalized linear models [1].
References
1. Vinciguerra R, Rehman S, Vallabh NA, et al. Corneal biomechanics and biomechanically corrected intraocular pressure in primary open-angle glaucoma, ocular hypertension and controls. Br J Ophthalmol. 2019; In press.
2. Tejwani S, Francis M, Dinakaran S, et al. Influence of Anterior Biometry on Corneal Biomechanical Stiffness of Glaucomatous Eyes Treated with Chronic Medication or Filtration Surgery. J Glaucoma. 2019;28:626-632.
To,
The editor
We would like to congratulate and highly appreciate Ha et al. for this simple and innovative study on ‘Changes in intraocular pressure during reading or writing on smartphones in patients with normal tension glaucoma’. However, we have few queries and seek your kind attention.
First, out of 38 trabeculectomised eyes, 12 were not using any anti-glaucoma medications whereas remaining was on some antiglaucoma medications. An overall analysis was done including all trabeculectomised eyes. However, we think, it would have been better analyzed if the authors had compared eyes with or without antiglaucoma medications separately. We are interested to know the pattern of intraocular pressure (IOP) fluctuation in eyes with trabeculectomy not using any antiglaucoma medications.
Second, in this present study, no control group was included.
Third, it was established that there is circadian pattern of IOP change in normal tension glaucoma patients. Therefore, we are interested to know whether IOP was measured in all patients at the same time of day or was it measured at different times of the day.
References
1. Ha A, Kim Y K, Kim J et al. Changes in intraocular pressure during reading or writing on smartphones in patients with normal-tension glaucoma. Br J Ophthalmol. 2019; Sep314467doi.org/10.1136/bjophthalmol-2019-314467
2. Lee Y R, Kook M S, Joe S G et al. Circadian (24- hour) pattern of intraocular pressure and visual...
To,
The editor
We would like to congratulate and highly appreciate Ha et al. for this simple and innovative study on ‘Changes in intraocular pressure during reading or writing on smartphones in patients with normal tension glaucoma’. However, we have few queries and seek your kind attention.
First, out of 38 trabeculectomised eyes, 12 were not using any anti-glaucoma medications whereas remaining was on some antiglaucoma medications. An overall analysis was done including all trabeculectomised eyes. However, we think, it would have been better analyzed if the authors had compared eyes with or without antiglaucoma medications separately. We are interested to know the pattern of intraocular pressure (IOP) fluctuation in eyes with trabeculectomy not using any antiglaucoma medications.
Second, in this present study, no control group was included.
Third, it was established that there is circadian pattern of IOP change in normal tension glaucoma patients. Therefore, we are interested to know whether IOP was measured in all patients at the same time of day or was it measured at different times of the day.
References
1. Ha A, Kim Y K, Kim J et al. Changes in intraocular pressure during reading or writing on smartphones in patients with normal-tension glaucoma. Br J Ophthalmol. 2019; Sep314467doi.org/10.1136/bjophthalmol-2019-314467
2. Lee Y R, Kook M S, Joe S G et al. Circadian (24- hour) pattern of intraocular pressure and visual field damage in eyes with normal tension glaucoma. Investigative Ophthalmology and visual science February 2012, vol. 53, 881-887.doi:10.1167/iovs.11-7846
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Although the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of the...
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Although the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of these services will make for more efficient productivity at referral centers, and the patients will avoid having to spend the time and expense to travel to secondary and tertiary centers for basic eye care.3 Practical training of primary care providers is needed to ensure the transfer of skills, but for this training to have long-term impact on service delivery, primary health centers need to be properly equipped and training programs need to be well integrated into the health systems and, in particular, the referral networks, to ensure that patients with more serious conditions are accessing specialists.3-5
Health systems, therefore, need to have adequate financing available, but the costs of universal eye health are a barrier to remote and resource-limited communities in nearly all countries. For example, the burden of out-of-pocket costs of cataract surgery hits the middle-class populations of higher income countries the hardest.6 Innovative, cost-effective solutions must be employed to better tailor the universal access of eye care to a local population. In developing countries, the provision of phacoemulsification and the maintenance of the required equipment are too expensive for most of the patients and facilities. In these settings, manual small-incision cataract surgery (MSICS) is the more appropriate surgical technique, having the same advantages of phaco in terms of outcomes and faster surgical time and recovery, but MSICS also has a shorter learning curve and drastically lower costs.7-9
At the primary care level, cost-effective technology, such as the use of artificial intelligence and smart phones in telemedicine for the purposes of examination and diagnosis, appears to be an appropriate solution to overcoming financial barriers, again saving patients both the time and the expense of traveling to secondary and tertiary care centers.10-13 The diagnostic accuracy of telemedicine models has been validated; however, for the models to work, attention is again placed on the referral network, which has to be strengthened to be able to manage the increase in caseload.12
References
1. Resnikoff S, Lansingh VC, Washburn L, et al. Estimated number of ophthalmologists worldwide (International Council of Ophthalmology Update): will we meet the needs? Br J Ophthalmol 02 July 2009. doi:10.1136/bjophthamol-2019-314336 [Epub ahead of print]
2. World Health Organization. Universal eye health: a global action plan 2014–2019. [A66/11 – 28 March 2013]. 2013. Available: http://www.who.int/blindness/EyeHealthActionPlanWHA66.pdf. [Accessed September 5, 2019].
3. Mafwiri MM, Jolley E, Hunter J, Gilbert CE, Schmidt E. Mixed methods evaluation of a primary eye care training programme for primary health workers in Morogoro Tanzania. BMC Nurs 2016;15:41.
4. Jolley E, Mafwiri M, Hunter J, Schmidt E. Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts. BMC Health Serv Res 2017;17(1):823.
5. Yip JLY, Bright T, Ford S, Mathenge W, Faal H; Rwanda Primary Eye Care Process evaluation group. Process evaluation of a National Primary Eye Care Programme in Rwanda. BMC Health Serv Res 2018;18:950.
6. Lansingh VC, Carter MJ, Eckert KA, Winthrop KL, Furtado JM, Resnikoff S. Affordability of cataract surgery using the Big Mac prices. Rev Mex Oftalmol 2015;89:21–30.
7. Singh K, Misbah A, Saluja P, Singh AK. Review of manual small-incision cataract surgery. Indian J Ophthalmol 2017;65:1281–88.
8. Gogate P, Optom JJ, Deshpande S, Naidoo K. Meta-analysis to compare the safety and efficacy of manual small incision cataract surgery and phacoemulsification. Middle East Afr J Ophthalmol 2015;22:362–9.
9. Ruit S, Gurung R, Vyas S. The role of small incision suture-less cataract surgery in the developed world. Curr Opin Ophthalmol 2018;29:105–9.
10. Delgoshaei B, Mobinizadeh M, Mojdekar R, Afzal E, Arabloo J, Mohamadi E. Telemedicine: a systematic review of economic evaluations. Med J Islam Repub Iran 2017;31:113.
11. Shi L, Wu H, Dong J, Jiang K, Lu X, Shi J. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol 2015;99:823–31.
12. Wong TY, Sabanayagam C. Strategies to tackle the global burden of diabetic retinopathy: from epidemiology to artificial intelligence. Ophthalmologica. 2019 Aug 13:1-12. doi: 10.1159/000502387. [Epub ahead of print]
13. Mohammadpour M, Heidari Z, Mirghorbani M, Hashemi H. Smartphones, tele-ophthalmology, and VISION 2020. Int J Ophthalmol 2017;10:1909–18.
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
The article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge i...
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
The article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge in ophthalmology. Over the years, the number of doctors unsure in dealing with the most basic eye problems increases. Therefore, we should focus on basic ophthalmology education so that doctors working in the primary care of the population can routinely refer patients to ophthalmologists.
The use of artificial intelligence may be another alternative that can identify ophthalmic diseases with as good accuracy as experts. Artificial intelligence algorithms can be used in telemedicine programs to serve populations of countries that have an irregular distribution of ophthalmologists on their territory, facilitating access to eye examinations with consequent early identification of disease.3
REFERENCE
1. Resnikoff S, Lansingh VC, Washburn L, Felch W, Gauthier TM, Taylor HR, Eckert K, Parke D, Wiedemann PEstimated number of ophthalmologists worldwide (International Council of Ophthalmologyupdate): will we meet the needs? Br J Ophthalmol. 2019 Jul 2. pii: bjophthalmol-2019-314336.
2. Quillen DA, Harper RA, Haik BG. Medical student education in ophthalmology: Crisis and opportunity. Ophthalmology. 2005;112(11):1867–8.
3. Surendran TS, Raman R. Teleophthalmology in diabetic retinopathy. J
Diabetes Sci Technol. 2014; 8: 262-6.
I read with interest the article by Kern et al: Implementation of a cloud-based referral platform in ophthalmology making telemedicine services a reality in eye care. I agree entirely that this is a way forward in ophthalmology, and increasing cooperation between optometrists and ophthalmologists is vital and in the best interests of the patient as well as the NHS.
However, there is an important sentence in the introduction which is incorrect:
'The Opticians Act 1989 obligates UK optometrists to refer any incidental eye abnormality detected during an NHS eye test to a Hospital Eye Services (HES) unless they provide a sufficient disease description including medical advice to the patient.7 '
The obligation on an optometrist to refer a person who appears to be suffering from an injury or disease of the eye applied to any consultation, whether NHS or private. However, this was removed on 1 January 2000 when the General Optical Council’s Rules relating to Injury or Disease of the Eye (1999) came into force. Optometrists now have discretion as to whether or not to refer patients, and indeed many such patients are successfully managed in primary care as a result.
We thank Dr. Montserrat for the letter regarding our article “Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism.”1
Their first concern is that the predictability of the FS-LASIK group was 65% of eyes within ±0.5 diopter (D), which is also different from our experience. Of note, 95% of eyes were within ±1.25 D in the FS-LASIK group. This may be due to the long-term follow-up of 3 years leading to variability in the manifest refraction over time. In fact, our predictability results were similar to that of other long-term studies, as shown in Table 1.1-5 Moreover, it is likely a reflection of selection bias in our retrospective analysis i.e. patients with visual complaints were more willing to participate in the follow-up at 3 years – and we had acknowledged this as a limitation in our discussion. However, the probability of this bias may be the same for both surgical procedures and therefore did not significantly affect the final conclusion in our analysis.
Table1 Summary of Long-term Predictability Results for LASIK
Study Eyes （patients） Preoperative MRSE (D) Follow-up ± 0.50 of Emmetropia (%)
Han T 41(41) −7.15±1.92 3 years 65
Kobashi H 30(30) −3.81±1.40 2 years 73
Alio JL 97(70) −7.15±1.92 10 years 49
Zalentein WN 38(21) spere of -6.55±1.74 2 years 63
O'Doherty M 94(49) −4.85±2.35 5 years 60 ...
We thank Dr. Montserrat for the letter regarding our article “Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism.”1
Their first concern is that the predictability of the FS-LASIK group was 65% of eyes within ±0.5 diopter (D), which is also different from our experience. Of note, 95% of eyes were within ±1.25 D in the FS-LASIK group. This may be due to the long-term follow-up of 3 years leading to variability in the manifest refraction over time. In fact, our predictability results were similar to that of other long-term studies, as shown in Table 1.1-5 Moreover, it is likely a reflection of selection bias in our retrospective analysis i.e. patients with visual complaints were more willing to participate in the follow-up at 3 years – and we had acknowledged this as a limitation in our discussion. However, the probability of this bias may be the same for both surgical procedures and therefore did not significantly affect the final conclusion in our analysis.
Table1 Summary of Long-term Predictability Results for LASIK
Study Eyes （patients） Preoperative MRSE (D) Follow-up ± 0.50 of Emmetropia (%)
Han T 41(41) −7.15±1.92 3 years 65
Kobashi H 30(30) −3.81±1.40 2 years 73
Alio JL 97(70) −7.15±1.92 10 years 49
Zalentein WN 38(21) spere of -6.55±1.74 2 years 63
O'Doherty M 94(49) −4.85±2.35 5 years 60
MSRE = manifest spherical refractive equivalent; D = diopters;
The conclusion of this study is that both SMILE and FS-LASIK were safe and equally effective for myopic and astigmatic correction. Short -term studies have reached similar conclusions, and no long-term studies show that FS-LASIK has better refractive outcomes than SMILE.2, 6
In this study, the Visumax system was used to make corneal flaps. While different machines may have different refractive outcomes, studies have reported that the Vismax and Intralase system have similar refractive results.7, 8 Moreover, a large number of basic and clinical studies comparing SMILE and FS-LASIK also used the same platforms (as in our study). 9-13 We also look forward to the comparison of SMILE and FS-LASIK with other platforms, but this does not affect the significance of our research.
We appreciate this opportunity to clarify these questions.
References
1. Han T., Xu Y., Han X., Zeng L., Shang J., Chen X. and Zhou X. Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism. Br J Ophthalmol. 2019;103:565-568.
2. Kobashi H., Kamiya K., Igarashi A., Takahashi M. and Shimizu K. Two-years results of small-incision lenticule extraction and wavefront-guided laser in situ keratomileusis for Myopia. Acta Ophthalmol. 2018;96:e119-e126.
3. Alio J. L., Muftuoglu O., Ortiz D., Perez-Santonja J. J., Artola A., Ayala M. J., Garcia M. J. and de Luna G. C. Ten-year follow-up of laser in situ keratomileusis for myopia of up to -10 diopters. Am J Ophthalmol. 2008;145:46-54.
4. Zalentein W. N., Tervo T. M. and Holopainen J. M. Seven-year follow-up of LASIK for myopia. J Refract Surg. 2009;25:312-318.
5. O'Doherty M., O'Keeffe M. and Kelleher C. Five year follow up of laser in situ keratomileusis for all levels of myopia. Br J Ophthalmol. 2006;90:20-23.
6. Xia L. K., Ma J., Liu H. N., Shi C. and Huang Q. Three-year results of small incision lenticule extraction and wavefront-guided femtosecond laser-assisted laser in situ keratomileusis for correction of high myopia and myopic astigmatism. Int J Ophthalmol. 2018;11:470-477.
7. Rosman M., Hall R. C., Chan C., Ang A., Koh J., Htoon H. M., Tan D. T. and Mehta J. S. Comparison of efficacy and safety of laser in situ keratomileusis using 2 femtosecond laser platforms in contralateral eyes. J Cataract Refract Surg. 2013;39:1066-1073.
8. Ang M., Mehta J. S., Rosman M., Li L., Koh J. C., Htoon H. M., Tan D. and Chan C. Visual outcomes comparison of 2 femtosecond laser platforms for laser in situ keratomileusis. J Cataract Refract Surg. 2013;39:1647-1652.
9. Dong Z., Zhou X., Wu J., Zhang Z., Li T., Zhou Z., Zhang S. and Li G. Small incision lenticule extraction (SMILE) and femtosecond laser LASIK: comparison of corneal wound healing and inflammation. Br J Ophthalmol. 2014;98:263-269.
10. Riau A. K., Angunawela R. I., Chaurasia S. S., Lee W. S., Tan D. T. and Mehta J. S. Early corneal wound healing and inflammatory responses after refractive lenticule extraction (ReLEx). Invest Ophthalmol Vis Sci. 2011;52:6213-6221.
11. Ang M., Ho H., Fenwick E., Lamoureux E., Htoon H. M., Koh J., Tan D. and Mehta J. S. Vision-related quality of life and visual outcomes after small-incision lenticule extraction and laser in situ keratomileusis. J Cataract Refract Surg. 2015;41:2136-2144.
12. Liu M., Chen Y., Wang D., Zhou Y., Zhang X., He J., Zhang T., Sun Y. and Liu Q. Clinical Outcomes After SMILE and Femtosecond Laser-Assisted LASIK for Myopia and Myopic Astigmatism: A Prospective Randomized Comparative Study. Cornea. 2016;35:210-216.
13. Hou J., Wang Y., Lei Y. and Zheng X. Comparison of effective optical zone after small-incision lenticule extraction and femtosecond laser-assisted laser in situ keratomileusis for myopia. J Cataract Refract Surg. 2018;44:1179-1185.
The authors would like to thank Dr. MAYURI BORGOHAIN et al. for their interest on our study ‘Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial’, and appreciate their insightful comments.
First, in this study, for “Combined Subconjunctival Injection of Dexamethasone”, we means combination subconjunctival injection of Dexamethasone with anti-glaucoma drug (such as topical pilocarpine, beta-blocker, brinzolamide, and alpha-2 agonists).
Second, for better investigating the effectiveness of injection of dexamethasone, the control group was designed to not subjected to any topical anti-inflammatory drug. Moreover, Patients that were excluded with a usage of topical anti-inflammatory drugs (including NASIDs and steroids), which was mentioned in the method part.
Third, the range of intraocular pressure (IOP) in those 42 eyes was 27-60 mmHg.
Fourth, to study the window period from onset of acute attack for maximum efficacy of subconjunctival dexamethasone injection, we performed correlation analysis between the duration before recruitment with the decrease of IOP (IOPbaseline – IOP24h)，and found that the decrease of IOP was corelated with the duration before recruitment (r = -0.481, p = 0.002). Moreover, about one half of patients that the duration less than 5 days had more efficacy of subconjunctival dexamethasone injection.
Given the lack of level 1 evidence there is no unified consensus among peripheral nerve experts on the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives for peripheral nerve reconstruction at various gap lengths [1-3]. Moreover, as the authors correctly point out in their correspondence, no trials exist comparing the use of ANAs to nerve autografts in corneal neurotization, nullifying their claim of nerve autograft superiority for this procedure. Of note, Avance® allografts have become “on label” for corneal neurotization since my last correspondence.
In comparing the study by Catapano et al to the study by Leyngold et al it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al were under 18 years of age. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. Catapano et al reported mean CCS at 30.0±26.8mm at 6 months postoperatively, with a significant number (44%) of patients in their study having CCS at or below 10...
Show MoreTo,
Show MoreThe editor
We would like to congratulate Huang et al. for their study ‘Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial’.1 However, we have few queries and seek your kind attention.
First, as mentioned in this article, a previous study in dogs showed combination of topical anti-inflammatory eye drops was beneficial during treatment.2They had conducted this present study as there was no data on humans regarding a randomised controlled trial that demonstrates the effectiveness of anti-inflammatory drugs for the treatment of human eyes suffering from acute primary angle closure (APAC). However, as the title suggested combination of subconjunctival dexamethasone injection, it implied combination of it with other anti-inflammatory drugs. However, the injection group was not subjected to any other anti-inflammatory drugs.
Second, the authors’ previous study showed that the inflammatory response in the aqueous humor from APAC patient was evident and that multiple inflammatory factors were elevated significantly.3 Topical steroids help to reduce intraocular inflammation make the patient more comfortable.4 However; the control group was not subjected to any topical anti-inflammatory drug.
Third, we are interested to know about the range of intraocular pressure (IOP) in those 42 eyes; the highest and lowest IOP recorded.
Fourth, we are also interested to know r...
To the Editor:
We herein respond to the letter written by Camus et al raising the issue of “ultra-low” dose radiation therapy (4 Gy) vs. the “standard low-dose” radiation therapy (24-30 Gy) for lymphomas of the orbit, eyelid, and conjunctiva, also referred to as “ocular adnexal lymphoma” (OAL). First off, it is important to point out that the goals of the retrospective multicenter general review of marginal zone lymphoma coordinated by Professor Steffen Heegaard in Denmark which also included some of our patients from M. D. Anderson was not to compare the efficacy of various treatment strategies.(1) Indeed it is challenging to draw practice altering conclusions from a retrospective multi-center study given the usual limitations, most notably the variation in staging and treatment approaches across various continents as noted by Camus et al.
However, we agree with Camus et al that our encouraging preliminary observations in 22 patients with OAL treated with ultra-low dose radiation therapy (4Gy) suggested a very good response rate (100% ORR:86% CR, 14%% PR) for B-cell orbital and ocular adnexal lymphomas;(2) as such we started a prospective trial of ultra-low dose radiation for ocular adnexal lymphoma patients at MD Anderson Cancer Center soon thereafter (Clinicaltrials.gov identifier NCT02494700)The study aims to evaluate the efficacy of response adapted radiation therapy for this patient population, whereby all patients are treated to an initial 4 Gy in...
Show MoreWe read the study by Vinciguerra et al. on cornea biomechanical properties of open angle glaucoma, ocular hypertension, normal tension and normal eyes assessed with dynamic air-puff applanation [1]. The study reported significant correlations between the properties and types of glaucoma. Most of the study patients were also under anti-glaucoma medication. Interestingly, the study did not assess the potential confounding effects of the anterior chamber on assessment of corneal biomechanical properties [1]. However, we wish to bring to the notice of the authors our earlier study on the same subject [2]. In our study, open and closed angle patients under the anti-glaucoma medication were assessed with air-puff applanation to determine if medication altered corneal biomechanical properties. The highlight of the study was that anterior chamber depth (ACD) was also included as a covariate in addition to other tomographic features [2]. Our study clearly showed that the ACD had a significant effect of the level of bIOP among the different types of glaucoma patient [2]. The ACD is a direct indicator of the volume of vault space between the cornea and the lens. This vault space resisted the inward motion of the cornea during the first half of the applanation. If ACD was lower, then bIOP was greater and vice versa. In patients with angle closure glaucoma, we expect the ACD to be less than NTG and normal eyes [1,2]. Hence, the results from the Vinciguerra et al. study could be skewed...
Show MoreTo,
The editor
We would like to congratulate and highly appreciate Ha et al. for this simple and innovative study on ‘Changes in intraocular pressure during reading or writing on smartphones in patients with normal tension glaucoma’. However, we have few queries and seek your kind attention.
First, out of 38 trabeculectomised eyes, 12 were not using any anti-glaucoma medications whereas remaining was on some antiglaucoma medications. An overall analysis was done including all trabeculectomised eyes. However, we think, it would have been better analyzed if the authors had compared eyes with or without antiglaucoma medications separately. We are interested to know the pattern of intraocular pressure (IOP) fluctuation in eyes with trabeculectomy not using any antiglaucoma medications.
Second, in this present study, no control group was included.
Third, it was established that there is circadian pattern of IOP change in normal tension glaucoma patients. Therefore, we are interested to know whether IOP was measured in all patients at the same time of day or was it measured at different times of the day.
References
Show More1. Ha A, Kim Y K, Kim J et al. Changes in intraocular pressure during reading or writing on smartphones in patients with normal-tension glaucoma. Br J Ophthalmol. 2019; Sep314467doi.org/10.1136/bjophthalmol-2019-314467
2. Lee Y R, Kook M S, Joe S G et al. Circadian (24- hour) pattern of intraocular pressure and visual...
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Show MoreAlthough the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of the...
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
Show MoreThe article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge i...
I read with interest the article by Kern et al: Implementation of a cloud-based referral platform in ophthalmology making telemedicine services a reality in eye care. I agree entirely that this is a way forward in ophthalmology, and increasing cooperation between optometrists and ophthalmologists is vital and in the best interests of the patient as well as the NHS.
However, there is an important sentence in the introduction which is incorrect:
'The Opticians Act 1989 obligates UK optometrists to refer any incidental eye abnormality detected during an NHS eye test to a Hospital Eye Services (HES) unless they provide a sufficient disease description including medical advice to the patient.7 '
The obligation on an optometrist to refer a person who appears to be suffering from an injury or disease of the eye applied to any consultation, whether NHS or private. However, this was removed on 1 January 2000 when the General Optical Council’s Rules relating to Injury or Disease of the Eye (1999) came into force. Optometrists now have discretion as to whether or not to refer patients, and indeed many such patients are successfully managed in primary care as a result.
We thank Dr. Montserrat for the letter regarding our article “Three-year outcomes of small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for myopia and myopic astigmatism.”1
Their first concern is that the predictability of the FS-LASIK group was 65% of eyes within ±0.5 diopter (D), which is also different from our experience. Of note, 95% of eyes were within ±1.25 D in the FS-LASIK group. This may be due to the long-term follow-up of 3 years leading to variability in the manifest refraction over time. In fact, our predictability results were similar to that of other long-term studies, as shown in Table 1.1-5 Moreover, it is likely a reflection of selection bias in our retrospective analysis i.e. patients with visual complaints were more willing to participate in the follow-up at 3 years – and we had acknowledged this as a limitation in our discussion. However, the probability of this bias may be the same for both surgical procedures and therefore did not significantly affect the final conclusion in our analysis.
Table1 Summary of Long-term Predictability Results for LASIK
Show MoreStudy Eyes （patients） Preoperative MRSE (D) Follow-up ± 0.50 of Emmetropia (%)
Han T 41(41) −7.15±1.92 3 years 65
Kobashi H 30(30) −3.81±1.40 2 years 73
Alio JL 97(70) −7.15±1.92 10 years 49
Zalentein WN 38(21) spere of -6.55±1.74 2 years 63
O'Doherty M 94(49) −4.85±2.35 5 years 60
...
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