We read with great interest the article entitled ‘Prevalence of guttae in the graft following corneal transplantation’ by Nahum et al, published in the May 2015 issue of the British Journal of Ophthalmology [1] . The authors reported the prevalence of cornea guttata postkeratoplasty in a large population of 1116 patients to be 4%. They also found that guttae postkeratoplasty do not negatively affect the visual acuity, endothelial cell density, or graft survival during the initial two postoperative years. The content of this article is important and well put, since this is the first study to reveal the prevalence and sequelae of postkeratoplasty guttae on the corneal graft.
Based on our clinical experience and on multiple published studies, the prevalence of cornea guttata in the normal population is estimated to be higher than 4% [2]. However, the low prevalence reached by Nahum et al, is explained mainly by the preoperative screening of the donor corneas for guttae, as stated in the article. Therefore, it would be very interesting if the authors can provide an estimation of the percentage of donor corneas that are usually discarded by the guttae screening in their eye bank.
Up to our knowledge, guttae are very often not detectable using inverted light microscopy, thus guttae screening as a part of the routine examination of the donor corneas is a challenging task. There is only one study performed by Borderie et al in 2001 [3], that aimed to detect the pres...
We read with great interest the article entitled ‘Prevalence of guttae in the graft following corneal transplantation’ by Nahum et al, published in the May 2015 issue of the British Journal of Ophthalmology [1] . The authors reported the prevalence of cornea guttata postkeratoplasty in a large population of 1116 patients to be 4%. They also found that guttae postkeratoplasty do not negatively affect the visual acuity, endothelial cell density, or graft survival during the initial two postoperative years. The content of this article is important and well put, since this is the first study to reveal the prevalence and sequelae of postkeratoplasty guttae on the corneal graft.
Based on our clinical experience and on multiple published studies, the prevalence of cornea guttata in the normal population is estimated to be higher than 4% [2]. However, the low prevalence reached by Nahum et al, is explained mainly by the preoperative screening of the donor corneas for guttae, as stated in the article. Therefore, it would be very interesting if the authors can provide an estimation of the percentage of donor corneas that are usually discarded by the guttae screening in their eye bank.
Up to our knowledge, guttae are very often not detectable using inverted light microscopy, thus guttae screening as a part of the routine examination of the donor corneas is a challenging task. There is only one study performed by Borderie et al in 2001 [3], that aimed to detect the presence of guttae during organ culture. Unfortunately, this study did not clearly describe the features of guttae detected using light microscopy, and the pictures provided did not show specific and distinct findings. Moreover, a clear association proving that the guttae suspected preoperatively in the eye bank correspond to the postoperative guttae detected by specular microscopy was missing.
Therefore, it would be of great importance to the eye banks on an international level to be informed in detail about the preoperative guttae screening process that was performed by Nahum et al, explaining the exact methods followed by their eye bank and clarifying the guttae features as visualized by inverted light microscopy.
References:
1. Nahum Y, Canton V, Ponzin D, Busin M. Prevalence of guttae in the graft following corneal transplantation. Br J Ophthalmol. 2015;99(12):1660-1663.
2. Zoega GM, Arnarsson A, Sasaki H, Söderberg PG, Jonasson F. The 7-year cumulative incidence of cornea guttata and morphological changes in the corneal endothelium in the Reykjavik Eye Study. Acta Ophthalmol. 2013;91(3):212-218.
3. Borderie VM, Sabolic V, Touzeau O, Scheer S, Carvajal-Gonzalez S, Laroche L. Screening human donor corneas during organ culture for the presence of guttae. Br J Ophthalmol. 2001;85(3):272-276.
We read with interest the study by Özsaygili et al. in which the authors report that the presence or absence of posterior vitreous detachment (PVD) purportedly had no influence on the efficacy of aflibercept intravitreal injections in patients with diabetic macular oedema (DMO). We question the validity of this conclusion since it is known that eyes with attached vitreous require more injections to manage exudative age-related macular degeneration than eyes with PVD.1 This is presumed to be due to interference with macular access by anti-vascular endothelial growth factor (anti-VEGF) by the posterior vitreous cortex. The same mechanism of action could be expected in eyes with DMO. Thus, there may be alternative explanations for the observed lack of an effect of PVD status on the response to aflibercept. We hypothesize that the findings are due to both the unreliable diagnosis of PVD by spectral domain optical coherence tomography (SD-OCT) alone, and the possible presence of vitreoschisis.
Previous studies have shown that SD-OCT is not a robust way to diagnose PVD, since the positive predictive value is only approximately 50%.2, 3 Rather, ultrasound is the recommended way to detect complete PVD (Figure 1).2 Did Özsaygili et al. perform ultrasound in their patients? If not, they would be unable to determine true PVD status, and the validity of their conclusion needs to be called into question.
Additionally, it is unclear from the study by Özsaygili et al. wheth...
We read with interest the study by Özsaygili et al. in which the authors report that the presence or absence of posterior vitreous detachment (PVD) purportedly had no influence on the efficacy of aflibercept intravitreal injections in patients with diabetic macular oedema (DMO). We question the validity of this conclusion since it is known that eyes with attached vitreous require more injections to manage exudative age-related macular degeneration than eyes with PVD.1 This is presumed to be due to interference with macular access by anti-vascular endothelial growth factor (anti-VEGF) by the posterior vitreous cortex. The same mechanism of action could be expected in eyes with DMO. Thus, there may be alternative explanations for the observed lack of an effect of PVD status on the response to aflibercept. We hypothesize that the findings are due to both the unreliable diagnosis of PVD by spectral domain optical coherence tomography (SD-OCT) alone, and the possible presence of vitreoschisis.
Previous studies have shown that SD-OCT is not a robust way to diagnose PVD, since the positive predictive value is only approximately 50%.2, 3 Rather, ultrasound is the recommended way to detect complete PVD (Figure 1).2 Did Özsaygili et al. perform ultrasound in their patients? If not, they would be unable to determine true PVD status, and the validity of their conclusion needs to be called into question.
Additionally, it is unclear from the study by Özsaygili et al. whether vitreoschisis, defined as a split within the posterior vitreous cortex (Figure 2), was observed or documented. Although SD-OCT has the ability to detect vitreoschisis4–6, “what we see depends mainly on what we look for”, as Sir John William Lubbock once wrote. If there were cases in the series assembled by Özsaygili et al. with anomalous PVD and vitreoschisis, this could be incorrectly diagnosed as PVD, and the access of aflibercept into the macula may have been hindered by the outer wall of the vitreoschisis cavity (Figure 2), giving another reason for the false impression that PVD plays no role on aflibercept response in patients with diabetic macular oedema.
In conclusion, we agree with Sir Lubbock that we see what we seek and thus invite the authors to re-examine their data with the foregoing in mind.
References:
1. Sebag J. Vitreous in age-related macular degeneration therapy - The medium is the message. Retina. 2015;35(9):1715-1718. doi:10.1097/IAE.0000000000000718.
2. Hwang ES, Kraker JA, Griffin KJ, Sebag J, Weinberg D V, Kim JE. Accuracy of Spectral-Domain OCT of the Macula for Detection of Complete Posterior Vitreous Detachment. Ophthalmol Retin. 2020;4(2):148-153. doi:10.1016/j.oret.2019.10.013.
3. Abraham JR, Ehlers JP. Posterior Vitreous Detachment: Methods for Detection. Ophthalmol Retin. 2020;4(2):119-121. doi:10.1016/j.oret.2019.12.014.
4. Sebag J. Vitreoschisis. Graefe’s Arch Clin Exp Ophthalmol. 2008;246(3):329-332. doi:10.1007/s00417-007-0743-x.
5. Gupta P, Yee KMP, Garcia P, et al. Vitreoschisis in macular diseases. Br J Ophthalmol. 2011;95(3):376-380. doi:10.1136/bjo.2009.175109.
6. Sebag J. Vitreoschisis in diabetic macular edema. Invest Ophthalmol Vis Sci. 2011;52(11):8455-8456. doi:10.1167/iovs.11-8333.
We read with interest the post-hoc study by Waldstein and colleagues concerning the impact of posterior vitreous detachment (PVD) on the efficacy of anti-VEGF treatment in neovascular age-related macular degeneration (AMD). However, the reliability of spectral-domain optical coherence tomography (SD-OCT) in confirming PVD status, upon which the findings of this study are dependent, is questionable.[1, 2] In particular, OCT is poor at distinguishing between fully attached vitreous and complete PVD.
Hwang et al recently reported limited sensitivity of SD-OCT in detecting complete PVD when compared to clinical findings at the time of vitrectomy.[1] It was found that among patients awaiting vitrectomy, OCT diagnosis of complete PVD (based on the absence of visible posterior vitreous cortex or a premacular bursa on SD-OCT) had a positive predictive value of just 53% when compared to intra-operative findings.
PVD remains a clinical diagnosis that is based on the identification of the posterior hyaloid membrane (PHM), a diaphanous, wrinkled film observable during biomicroscopic examination. The Weiss ring which it incorporates is a more variable and less reliable confirmatory sign of PHM detachment from the optic nerve head. The visible PHM is a consistent clinical finding in patients with PVD and correlates histopathologically with a type IV collagen basement membrane which begins life attached to the retina as the internal limiting membrane.[3...
We read with interest the post-hoc study by Waldstein and colleagues concerning the impact of posterior vitreous detachment (PVD) on the efficacy of anti-VEGF treatment in neovascular age-related macular degeneration (AMD). However, the reliability of spectral-domain optical coherence tomography (SD-OCT) in confirming PVD status, upon which the findings of this study are dependent, is questionable.[1, 2] In particular, OCT is poor at distinguishing between fully attached vitreous and complete PVD.
Hwang et al recently reported limited sensitivity of SD-OCT in detecting complete PVD when compared to clinical findings at the time of vitrectomy.[1] It was found that among patients awaiting vitrectomy, OCT diagnosis of complete PVD (based on the absence of visible posterior vitreous cortex or a premacular bursa on SD-OCT) had a positive predictive value of just 53% when compared to intra-operative findings.
PVD remains a clinical diagnosis that is based on the identification of the posterior hyaloid membrane (PHM), a diaphanous, wrinkled film observable during biomicroscopic examination. The Weiss ring which it incorporates is a more variable and less reliable confirmatory sign of PHM detachment from the optic nerve head. The visible PHM is a consistent clinical finding in patients with PVD and correlates histopathologically with a type IV collagen basement membrane which begins life attached to the retina as the internal limiting membrane.[3-5]
We would be interested to learn whether the baseline evaluation of the patients in the reported study included a clinical assessment of PVD status and whether clinical separation of the posterior hyaloid membrane correlated with response to anti-VEGF therapy. We agree with the authors that there is evidence that PVD status may significantly impact the response of neovascular AMD to anti-VEGF therapy but SD-OCT must be combined with meticulous clinical slit-lamp examination to reliably determine the true status of the posterior hyaloid membrane.
1 Hwang ES, Kraker JA, Griffin KJ, et al. Accuracy of spectral-domain OCT of the macula for detection of complete posterior vitreous detachment. Ophthalmol Retina 2020;4(2):148-153.
2 Kičová N, Bertelmann T, Irle S, et al. Evaluation of a posterior vitreous detachment: a comparison of biomicroscopy, B-scan ultrasonography and optical coherence tomography to surgical findings with chromodissection. Acta Ophthalmol 2012;90(4):e264-268.
3 Snead MP, Snead DR, James S, et al. Clinicopathological changes at the vitreoretinal junction: posterior vitreous detachment. Eye (Lond) 2008;22(10):1257–1262.
4 Snead MP, Snead DRJ, Richards AJ, et al. Clinical, histological and ultrastructural studies of the posterior hyaloid membrane. Eye (Lond) 2002;16(4),447-453.
5 Fincham GS, James S, Spickett C, et al. Posterior vitreous detachment and the posterior hyaloid membrane. Ophthalmology 2018;125(2):227-236.
Dr. Portabella reviewed the stability of 345 consecutive cases of scleral-sutured posterior chamber IOLs retrospectively.1 In discussing sutured scleral-fixated IOLs several main points must be considered: 1) type of suture utilized; 2) length of follow-up; 3) multiple surgeons or single surgeon; 4) type of knot utilized; and 5) reoperation rate.
This paper by Portabella et al.1 involved use of Prolene (polypropylene) or Mersilene sutures, follow-up with a maximum of 10 years, multiple surgeons, a knot with a single loop through the sclera and around the haptic, and a reoperation rate of 7.2%. The Vote et al study2 reviewed 61 eyes with Prolene sutures, follow-up with a maximum of 10.6 years, multiple surgeons, variable knots, and an extremely high rate of redislocation of 26.2%, which they postulated was due to suture breakage. This high rate of redislocation has not been confirmed in any other study.3,4
A recent study by Kokame et al3 involved 118 eyes utilizing 10-0 Prolene sutures, a single surgeon, follow-up of up to 24.75 years, a knot with two sutures - one secured to the haptic by a cow-hitch and the other to the sclera with both sutures tied together in a single knot under a scleral flap, and a broken suture rate of 0.5% (1/214 fixation sutures). The maximum follow-up of 24.75 years with stable fixation strongly supports the stability of 10-0 Prolene. Higher rates of redislocations of sutured scleral-fixated IOLs can be due to multiple surgeo...
Dr. Portabella reviewed the stability of 345 consecutive cases of scleral-sutured posterior chamber IOLs retrospectively.1 In discussing sutured scleral-fixated IOLs several main points must be considered: 1) type of suture utilized; 2) length of follow-up; 3) multiple surgeons or single surgeon; 4) type of knot utilized; and 5) reoperation rate.
This paper by Portabella et al.1 involved use of Prolene (polypropylene) or Mersilene sutures, follow-up with a maximum of 10 years, multiple surgeons, a knot with a single loop through the sclera and around the haptic, and a reoperation rate of 7.2%. The Vote et al study2 reviewed 61 eyes with Prolene sutures, follow-up with a maximum of 10.6 years, multiple surgeons, variable knots, and an extremely high rate of redislocation of 26.2%, which they postulated was due to suture breakage. This high rate of redislocation has not been confirmed in any other study.3,4
A recent study by Kokame et al3 involved 118 eyes utilizing 10-0 Prolene sutures, a single surgeon, follow-up of up to 24.75 years, a knot with two sutures - one secured to the haptic by a cow-hitch and the other to the sclera with both sutures tied together in a single knot under a scleral flap, and a broken suture rate of 0.5% (1/214 fixation sutures). The maximum follow-up of 24.75 years with stable fixation strongly supports the stability of 10-0 Prolene. Higher rates of redislocations of sutured scleral-fixated IOLs can be due to multiple surgeons inexperienced with secure knot tying with the slippery Prolene suture, and knot integrity of a single loop around the haptic through the sclera with one suture knot creating the scleral fixation. Histopathologic studies of 10-0 Prolene sutures do not show evidence of cracking, wrinkling, flaking, or degradation of 10-0 Prolene sutures 10.5 years after placement.5
Gregg T Kokame MD MMM
Chief of Ophthalmology
University of Hawaii School of Medicine
Honolulu, Hawaii, USA
References:
1. Portabella M, Nadal J, Alarex de Toledo J et al. Long-term outcome of scleral-sutured posterior chamber intraocular lens: a case series. Br J Ophthalmol 2020;104:712-717. Doi: 10.1136/brjophthalmol-2019-314054.
2. Vote BJ, Tranos P, Bunce C, Charteris DG, Da Cruz L. Long term outcome of combined pars plana vitrectomy and scleral fixated posterior chamber intraocular lens implantation. Am J Ophthalmol 2006; 141(2):308-312. doi:10.1016/j.ajo.2005.09.012
3. Kokame GT, Yanagihara RT, Shantha JG, Kaneko KN, Long Term Outcome of Pars Plana Vitrectomy and Sutured Scleral-Fixated Posterior Chamber Intraocular Lens Implantation or Repositioning, American Journal of Ophthalmology 2018 May;189:10-16. doi: 10.1016/j.ajo.2018.01.034
4. Bading G, Hillenkamp J, Sachs HG, Gabel VP, Framme C. Long-term safety and functional outcome of combined pars plana vitrectomy and scleral-fixated sutured posterior chamber lens implantation. Am J Ophthalmol 2007;144(3):371–377. doi: 10.1016/j.ajo.2007.05.014.
5. Parekh P, Green WR, Stark WJ, Akpek EK. Subluxation of suture-fixated posterior chamber intraocular lenses a clinicopathologic study. Ophthalmology 2007;114(2):232-237.
Tabandeh and colleagues[1] presented a contrarian viewpoint on the redundancy of scleral-depressed vitreous base shaving: a procedure we have come to take for granted during vitrectomy for retinal detachment (RD). Their excellent outcomes are great news for trainee surgeons, as lens touch is likely during meticulous base dissection in phakic eyes. Sutureless micro-incision vitreous surgery is indeed more secure with residual peripheral vitreous, which plugs the sclerotomy leaks. The authors’ attribution of their high success rate to circumferential laser photocoagulation is validated by a randomized clinical trial.[2] The cases with residual silicone oil (13/89; 15%) should however not be included in the anatomical success; a significant percentage of them re-detach after oil removal.[3]
The optional use of scleral buckle in this study is confusing. The authors have not specified the choice of buckle (most probably an encircling belt-buckle). Vitreous base-shaving is critical to anatomical success when no encirclage is used.[3] The authors reported no additional benefit from buckling, though it was preferentially performed for complex detachments. We therefore do not have clarity about the one moot issue this study could settle: whether vitrectomy sans base-shaving is good enough for simple RD at least. A recent study suggested that anterior dissection is essential in the presence of posteriorly inserted vitreous base.[4] Did the authors observe this vitreous config...
Tabandeh and colleagues[1] presented a contrarian viewpoint on the redundancy of scleral-depressed vitreous base shaving: a procedure we have come to take for granted during vitrectomy for retinal detachment (RD). Their excellent outcomes are great news for trainee surgeons, as lens touch is likely during meticulous base dissection in phakic eyes. Sutureless micro-incision vitreous surgery is indeed more secure with residual peripheral vitreous, which plugs the sclerotomy leaks. The authors’ attribution of their high success rate to circumferential laser photocoagulation is validated by a randomized clinical trial.[2] The cases with residual silicone oil (13/89; 15%) should however not be included in the anatomical success; a significant percentage of them re-detach after oil removal.[3]
The optional use of scleral buckle in this study is confusing. The authors have not specified the choice of buckle (most probably an encircling belt-buckle). Vitreous base-shaving is critical to anatomical success when no encirclage is used.[3] The authors reported no additional benefit from buckling, though it was preferentially performed for complex detachments. We therefore do not have clarity about the one moot issue this study could settle: whether vitrectomy sans base-shaving is good enough for simple RD at least. A recent study suggested that anterior dissection is essential in the presence of posteriorly inserted vitreous base.[4] Did the authors observe this vitreous configuration and its effect in any of their cases?
The study included 14 giant retinal tears (GRT), and reported 93% single-surgery success rate. It is important to know the size of GRTs, presence/severity of PVR, need for encirclage, concomitant lens removal, and the nature of postoperative tamponade. These details are necessary to replicate the excellent outcomes without vitreous base-shaving, considered non-negotiable in a GRT.[5]
REFERENCES
1. Tabandeh H, London NJS, Boyer DS, et al. Outcomes of small-gauge vitreoretinal surgery without scleral-depressed shaving of the vitreous base in the era of wide-angle viewing systems. Br J Ophthalmol 2019;103:1765-8.
2. Avitabile T, Longo A, Lentini G, et al. Retinal detachment after silicone oil removal is prevented by 360° laser treatment. Br J Ophthalmol 2008;92:1479-82.
3. Teke MY, Balikoglu-Yilmaz M, Yuksekkaya P, et al. Surgical outcomes and incidence of retinal redetachment in cases with complicated retinal detachment after silicone oil removal: univariate and multiple risk factors analysis. Retina 2014;34:1926-38.
4. Sohn EH, Strohbehn A, Stryjewski T, et al. Posteriorly inserted vitreous base: preoperative characteristics, intraoperative findings, and outcomes after vitrectomy. Retina 2020;40:943-50.
5. Shunmugam M, Ang GS, Lois N. Giant retinal tears. Surv Ophthalmol 2014;59:192-216.
The review article by Thng ZX, De Smet MD, Lee CS, et al 1highlights the most intriguing aspects on use of immunosuppressants during and post COVID-19 pandemic. The authors have presented evidences based on various reports in a very well-structured manner and we would like to first thank and congratulate the authors for their work. The review covers the wide range of faculties of medicine where immune suppression is likely to be the main stay of treatment. At the same time, they have also very neatly presented with the “clear cut “ guidelines on the dosing of these various medications at different scenarios and patient status.
While the article additionally covers the following aspects very well ;
1) Does the use of immunosuppressive present as an independent risk factor for contracting COVID -19 in patients under them?
2) Does it affect the severity of COVID -19 ?
We have few inquiries to make to the authors regarding the use of immunosuppressive in ophthalmology during this difficult time.
The authors have used the term “high dose steroids” in their article. Firstly, we are curious to understand what would be the considered the criteria to define a “high dosage” of steroid in ophthalmology. From our understanding, it depends upon the class of steroid used and the body weight2 but should we also need to consider the duration of use and cumulative dosage over a stretch of time to define it?
The review article by Thng ZX, De Smet MD, Lee CS, et al 1highlights the most intriguing aspects on use of immunosuppressants during and post COVID-19 pandemic. The authors have presented evidences based on various reports in a very well-structured manner and we would like to first thank and congratulate the authors for their work. The review covers the wide range of faculties of medicine where immune suppression is likely to be the main stay of treatment. At the same time, they have also very neatly presented with the “clear cut “ guidelines on the dosing of these various medications at different scenarios and patient status.
While the article additionally covers the following aspects very well ;
1) Does the use of immunosuppressive present as an independent risk factor for contracting COVID -19 in patients under them?
2) Does it affect the severity of COVID -19 ?
We have few inquiries to make to the authors regarding the use of immunosuppressive in ophthalmology during this difficult time.
The authors have used the term “high dose steroids” in their article. Firstly, we are curious to understand what would be the considered the criteria to define a “high dosage” of steroid in ophthalmology. From our understanding, it depends upon the class of steroid used and the body weight2 but should we also need to consider the duration of use and cumulative dosage over a stretch of time to define it?
Also, referring to various publications , the definition also seems to vary even if the class of steroids are same but administered via a different route2,3 . Most likely it is related to the bioavailability but the term “high dose” in general, really seems to be creating a confusion to ophthalmologists. 4
Since the authors of this review are also the renowned key members of the various uveitis societies and have been involved in preparing protocols and guidelines , we like to draw their attention to revisit the issue and reach a consensus to use the term “high dose “ more judiciously by providing it with a more categorical definition.
On a final note, while the authors have advised to keep steroids/immunomodulators as low as possible, we would like to inquire on what are the recommendations for pathologies – such as retinal vasculitis, VKH ,SO , Optic neuritis ,traumatic optic neuropathy ,etc. which require “high dosage” or “mega- dosage” in a pulsed or a non-pulsed manner. 2,3,5 It would be of great value for clinicians around the world if the authors could provide their recommendations on such entities.
Reference:
1. Thng ZX, De Smet MD, Lee CS, et al COVID-19 and immunosuppression: a review of current clinical experiences and implications for ophthalmology patients taking immunosuppressive drugs British Journal of Ophthalmology Published Online First: 12 June 2020. doi: 10.1136/bjophthalmol-2020-316586.
2. Sherif Z, Pleyer U: Corticosteroids in Ophthalmology: Past – Present – Future. Ophthalmologica 2002;216:305-315. doi: 10.1159/000066189.
3. Charkoudian LD, Ying GS, Pujari SS, et al. High-dose intravenous corticosteroids for ocular inflammatory diseases. Ocul Immunol Inflamm. 2012;20(2):91‐99. doi:10.3109/09273948.2011.646382.
4. Yu-Wai-Man P, Griffiths PG. Steroids for traumatic optic neuropathy. Cochrane Database Syst Rev. 2011;(1):CD006032. Published 2011 Jan 19. doi:10.1002/14651858.CD006032.pub3.
5. O’Keefe GA, Rao AN. Vogt–Koyanagi–Harada disease. Surv Ophthalmol. 2017;62(1):1–25.
We read with great interest this comparison between selective laser trabeculoplasty (SLT) and medication for Open-Angle Glaucoma (OAG). (1)
The recent LiGHT trial (2), an important landmark in the management of glaucoma, suggests that SLT represents an ideal first-line treatment option of ocular hypertension (OHT) and open angle glaucoma (OAG) in terms of decreased costs, with similar efficacy and quality of life when comparing to medication. The strength of the trial resides in its methodology, limiting most of the bias seen in the previous retrospective studies on the subject. Despite the fact that their conclusions seemed to be echoing various other authors (3,4) there is still debate as to whether SLT should become a first-line treatment.
The current powerful meta-analysis by Chi et al on 1229 patients (14 articles, 8 randomized clinical trials), may become the final argument on the debate demonstrating that not only is SLT not inferior to medical therapy in terms of IOP-lowering effect or safety, but it allows for significantly lesser use of medication. (1)
The longer duration of effect, minimized cost, and safety of SLT are especially important in settings with difficult access to care, such as in developing countries, or in patients with decreased mobility. A recent study on incarcerated patients showed that even when measures are taken to administer and control patients’ adherence to treatment, substantial nonadherence persists. (5)
It is ri...
We read with great interest this comparison between selective laser trabeculoplasty (SLT) and medication for Open-Angle Glaucoma (OAG). (1)
The recent LiGHT trial (2), an important landmark in the management of glaucoma, suggests that SLT represents an ideal first-line treatment option of ocular hypertension (OHT) and open angle glaucoma (OAG) in terms of decreased costs, with similar efficacy and quality of life when comparing to medication. The strength of the trial resides in its methodology, limiting most of the bias seen in the previous retrospective studies on the subject. Despite the fact that their conclusions seemed to be echoing various other authors (3,4) there is still debate as to whether SLT should become a first-line treatment.
The current powerful meta-analysis by Chi et al on 1229 patients (14 articles, 8 randomized clinical trials), may become the final argument on the debate demonstrating that not only is SLT not inferior to medical therapy in terms of IOP-lowering effect or safety, but it allows for significantly lesser use of medication. (1)
The longer duration of effect, minimized cost, and safety of SLT are especially important in settings with difficult access to care, such as in developing countries, or in patients with decreased mobility. A recent study on incarcerated patients showed that even when measures are taken to administer and control patients’ adherence to treatment, substantial nonadherence persists. (5)
It is risky to compare such a study with likely inmate-specific risk factors to the current COVID-19 pandemic context. However, with social distancing measures in effect, and government-mandated restrictions or lockdowns, there is a reduced mobility of patients, likely leading to reduced medication adherence. In this time especially, ophthalmologists should strongly consider SLT as a first-line treatment in an attempt to limit patient visits and increase the likelihood to achieve durable IOP-reduction. Evidently, since the procedure is performed within close proximity to the patient, protective measures should be taken to limit contact and the risk of disease spreading.
Sincerely yours,
1. Chi SC, Kang Y-N, Hwang D-K, Liu CJ-L. Selective laser trabeculoplasty versus medication for open-angle glaucoma: systematic review and meta-analysis of randomised clinical trials. Br J Ophthalmol. 2020 Feb 12;
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet Lond Engl. 2019 Apr 13;393(10180):1505–16.
3. Elahi S, Rao HL, Dumitru A, Mansouri K. Predictors of Success in Selective Laser Trabeculoplasty: Data from the Lausanne Laser Trabeculoplasty Registry. J Glaucoma. 2020 May 8;
4. Realini T, Shillingford-Ricketts H, Burt D, Balasubramani GK. West Indies Glaucoma Laser Study (WIGLS)-2: Predictors of Selective Laser Trabeculoplasty Efficacy in Afro-Caribbeans With Glaucoma. J Glaucoma. 2018;27(10):845–8.
5. Kanu LN, Jang I, Oh DJ, Tiwana MS, Mehta AA, Dikopf MS, et al. Glaucoma Care of Prison Inmates at an Academic Hospital. JAMA Ophthalmol. 2020 Feb 20;
Dear Editor,
We have read the clinical case report entitled “Ocular manifestations of a patient hospitalized with a new coronavirus disease confirmed in 2019” by Chen L, et al.1 We congratulate the authors for this important work and wish to share our comment concerning the retinal findings. The authors indicated that Spectral-domain optical coherence tomography (SD-OCT) imaging was normal in both eyes. However, we would like to highlight the presence of hyper-reflective focal points at the level of the internal plexiform layer (IPL) and the ganglion cell layer (GCL). The report later published by Marinho PM, et al. in Lancet on May 12, 2020 "Retinal findings in patients with COVID-19" described the presence of focal hyperreflective dots at the IPL and GCL levels in all patients (24 eyes of 12 patients), which was the first report of SD-OCT retinal abnormalities in patients with COVID 19.2 We compared the two SD-OCT images published by Chen L, et al. to those published by Marinho PM, et al. All images were reviewed by two different retina specialists (NM, RTJH), and our analysis was strongly consistent. We have implemented the algorithm using the Python script3 to adjust the size and resolution of the images, and flipped the C by Marinho PM, et al. using fovea as the reference to obtain comparable images. We overlaid the images published by Chen L, et al. with those published by Marinho PM, et al. We were able to demonstrate that the hyperreflective lesions...
Dear Editor,
We have read the clinical case report entitled “Ocular manifestations of a patient hospitalized with a new coronavirus disease confirmed in 2019” by Chen L, et al.1 We congratulate the authors for this important work and wish to share our comment concerning the retinal findings. The authors indicated that Spectral-domain optical coherence tomography (SD-OCT) imaging was normal in both eyes. However, we would like to highlight the presence of hyper-reflective focal points at the level of the internal plexiform layer (IPL) and the ganglion cell layer (GCL). The report later published by Marinho PM, et al. in Lancet on May 12, 2020 "Retinal findings in patients with COVID-19" described the presence of focal hyperreflective dots at the IPL and GCL levels in all patients (24 eyes of 12 patients), which was the first report of SD-OCT retinal abnormalities in patients with COVID 19.2 We compared the two SD-OCT images published by Chen L, et al. to those published by Marinho PM, et al. All images were reviewed by two different retina specialists (NM, RTJH), and our analysis was strongly consistent. We have implemented the algorithm using the Python script3 to adjust the size and resolution of the images, and flipped the C by Marinho PM, et al. using fovea as the reference to obtain comparable images. We overlaid the images published by Chen L, et al. with those published by Marinho PM, et al. We were able to demonstrate that the hyperreflective lesions in both images co-localized in the IPL and GCL layers. This indicates that the hyperreflective foci that we observed in the OCT images by Chen L, et al. are correlating with the retinal findings described by Marinho PM, et al.
References
1. Chen L, Liu M, Zhang Z, et al. Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease. Br J Ophthalmol. 2020;104:748‐51.
2. Marinho PM, Marcos AAA, Romano AC, Nascimento H, Belfort R Jr. Retinal findings in patients with COVID-19. Lancet. 2020;395(10237):1610. doi:10.1016/S0140-6736(20)31014-X
3. Späth H. Fitting affine and orthogonal transformations between two
sets of points. Mathematical Communications. 2004;9: 27-34
We have read the review article entitled “Ocular complications of cat scratch disease” Johnson A. Br J Ophthalmol 2020;0:1-7. We want to congratulate the author for this important review article, and make some contributions.
In the review article, it has been indicated that optical coherence tomography (OCT) imaging is of value to monitoring cat scratch disease (CSD), particularly for neuroretinitis and multifocal retinitis.
We would like to highlight a feature of focal retinitis with spectral domain optical coherence tomography (SD-OCT). Small areas of retinitis, less than 500 microns in diameter, can be seen on OCT imaging. These appear as areas of focal hyper-reflectivity of the inner retinal layers and decreased reflectivity causing a shadow on the outer retinal layers and choroid. This was seen in two patients presenting to our service recently with Bartonella henselae CSD diagnosed clinically and confirmed by positive serology.
The first case was a 49-year-old Caucasian male who presented with bilateral inflammatory papillitis and multifocal retinitis without a macular star, confirmed with serology as Bartonella henselae (IgG >2048). He had good presenting Snellen visual acuities of 6/5 right, 6/6 left. OCT imaging at acute presentation showed multifocal retinitis seen as small areas retinal hyper-reflectivity of the inner retina with outer retinal disruption. The disease resolved without treatment in 8 months, with...
We have read the review article entitled “Ocular complications of cat scratch disease” Johnson A. Br J Ophthalmol 2020;0:1-7. We want to congratulate the author for this important review article, and make some contributions.
In the review article, it has been indicated that optical coherence tomography (OCT) imaging is of value to monitoring cat scratch disease (CSD), particularly for neuroretinitis and multifocal retinitis.
We would like to highlight a feature of focal retinitis with spectral domain optical coherence tomography (SD-OCT). Small areas of retinitis, less than 500 microns in diameter, can be seen on OCT imaging. These appear as areas of focal hyper-reflectivity of the inner retinal layers and decreased reflectivity causing a shadow on the outer retinal layers and choroid. This was seen in two patients presenting to our service recently with Bartonella henselae CSD diagnosed clinically and confirmed by positive serology.
The first case was a 49-year-old Caucasian male who presented with bilateral inflammatory papillitis and multifocal retinitis without a macular star, confirmed with serology as Bartonella henselae (IgG >2048). He had good presenting Snellen visual acuities of 6/5 right, 6/6 left. OCT imaging at acute presentation showed multifocal retinitis seen as small areas retinal hyper-reflectivity of the inner retina with outer retinal disruption. The disease resolved without treatment in 8 months, with final Snellen visual acuities of 6/5 right and 6/6 left.
An area of retinitis was also demonstrated in a 9-year-old Caucasian girl with CSD. CSD was confirmed with positive serologic testing for Bartonella henselae (IgG >2048, IgM <20). She presented with a four-day history of reduced vision in her left eye and a gastrointestinal illness, and had recently been scratched by a stray kitten. She developed bilateral neuroretinitis with presenting Snellen visual acuities of 6/6 right and count fingers left. A small area of juxtafoveal retinitis was demonstrated on OCT in her right eye as inner retinal hyper-reflectivity, casting a shadow on the outer retina and underlying choroid. She was treated with oral doxycycline, oral rifampicin and oral prednisone. After two weeks treatment the focal retinitis was smaller but with persistent loss of inner retinal architecture and shadowing the outer retinal and choroid, and this area had reduced further after 36 days with visualization of the outer retina and choroid in the affected area.
There are few studies documenting OCT findings in CSD. Most common findings include flattening of the foveal contour, thickening of the neurosensory retina and the presence of subretinal fluid associated with neuroretinitis.[1] Exudate associated with neuroretinitis appears as multiple hyper-reflective foci in the outer plexiform layer[2] and can lead to disruption and loss of the external limiting membrane, ellipsoid zone and interdigitation zone.[3]
To our knowledge only two other paper have described the OCT finding of focal retinitis.[4,5] This OCT sign can persist for months but with gradual decreased reflectivity of the lesion and improved visualization of outer retina as the disease resolves.[4]
References
1. Ksiaa I, Abroug N, Mahmoud A, Zina S, Hedayatfar A, Attia S, Khochtali S, Khairallah M. Update on Bartonella neuroretinitis. Journal of Current Ophthalmology. 2019;31:254-61.
2. Habot-Wilner Z, Zur D, Goldstein M, Goldenberg D, Shulman S, Kesler A, Giladi M, Neudorfer M. Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis. Eye. 2011;25:1064-8.
3. Mello LGM, Lima LH, Cabral T, Rodrigues MZ, Pecanha PM, Belfort R. Bartonella Quintana-associated neuroretinitis: longitudinal spectral-domain optical coherence tomographic findings. Retinal Cases & Brief Reports. 2016;0:1-6.
4. Empeslidis T, Tsauousis KT, Konidaris V, Pradeep A, Deane J. Multifocal chorioretinitis caused by Bartonella henselae: imaging findings of spectral domain optical coherence tomography during treatment with trimethoprim-sulfamethoxazole. Eye. 2014;28:907-9.
5. Pichi F, Srivastava S, Levinson A, Baynes KM, Traut C, Lowder CY. A focal chorioretinal Bartonella lesion analyzed by optical coherence tomography angiography. Ophthalmic Surg Lasers Imaging Retina. 2016;47:585-8.
Dear Editor,
We read with great interest the excellent paper by Sagiv and collegues Ocular preservation with neoadjuvant Vismodegib in patients with locally advanced periocular basal cell carcinoma.(1)
The article is a great contribution for a topic with a growing, but still limited worldwide experience. Our interest is to discuss the surgical approach after neoadjuvant Vismodegib.
The authors present a patient with a 5x4cm locally advanced periocular basal cell carcinoma (LAP-BCC) with small nerve perineural invasion (>0.1mm) involving lower eyelid, inner canthus and cheek. The patient showed a significant response after 10 months of Vismodegib. Anyhow, it was clearly a partial response with 3 suspicious areas of BCC after treatment. The authors decided to treat separately each area with surgery, and histology (en face sections) confirmed the presence of tumor in two. The reconstructive outcome was excellent, and at the time of publication the patient was free of disease, 11 months after surgery.
We agree with the authors, when they consider as a limitation the fact that “surgery did not always include the entire area of the original tumor”.
Most studies involving smoothened inhibitors thus far have measured clinical tumor shrinkage but not true histologic margin control. Even after a complete clinical response (CCR), there is no way to assure that it will result in a complete histological clearance (CHR).
Dear Editor,
We read with great interest the excellent paper by Sagiv and collegues Ocular preservation with neoadjuvant Vismodegib in patients with locally advanced periocular basal cell carcinoma.(1)
The article is a great contribution for a topic with a growing, but still limited worldwide experience. Our interest is to discuss the surgical approach after neoadjuvant Vismodegib.
The authors present a patient with a 5x4cm locally advanced periocular basal cell carcinoma (LAP-BCC) with small nerve perineural invasion (>0.1mm) involving lower eyelid, inner canthus and cheek. The patient showed a significant response after 10 months of Vismodegib. Anyhow, it was clearly a partial response with 3 suspicious areas of BCC after treatment. The authors decided to treat separately each area with surgery, and histology (en face sections) confirmed the presence of tumor in two. The reconstructive outcome was excellent, and at the time of publication the patient was free of disease, 11 months after surgery.
We agree with the authors, when they consider as a limitation the fact that “surgery did not always include the entire area of the original tumor”.
Most studies involving smoothened inhibitors thus far have measured clinical tumor shrinkage but not true histologic margin control. Even after a complete clinical response (CCR), there is no way to assure that it will result in a complete histological clearance (CHR).
Several authors discussed this issue. Tang and Alcalay reported a small number of LA-BCC treated with neoadjuvant Vismodegib plus Mohs surgery (MS).2-3 Although they observed a significant tumor shrinkage, they found islands of BCC within all their debulking specimens.(2-3) Ching in a series with 6 LA-BCCs,(4) with bone involvement, reported that multiple superficial biopsies done after neoadjuvant Vismodegib, showed no evidence of BCC . However, all the surgically resected specimens revealed residual tumor. After this data, Ching states that the effect of Hh inhibitor is suppressive rather than curative and should be followed by definitive surgery.
Koekelkoren, after treating 4 cases with “giant” LA-BCC, indicates that resistance to Vismodegib seems to occur more often in deep tumor planes near bone or cartilage and suggests this may be related with suboptimal blood perfusion, resulting in lower Vismodegib tissue levels.(5)
So far, we have treated 13 patients with LAP-BCC with neoadjuvant Vismodegib + MS. The first eight cases were included in a paper published last year.(6) We observed 9 CCR, 3 partial responses and 1 patient progressed. Out of the 9 CCR one patient refused surgery and is without evidence of disease after 34 months. We confirmed 6/8 CHR and found persistent tumor with MS in 2 patients. With a mean follow up of 24.6 months, one patient with a CHR recurred 17 months after MS. Therefore, 3/9 cases with a CCR either had persistent tumor at the time of MS or recurred lately, probably due to skip tumor areas.
We believe this evidence supports our position. Neoadjuvant Vismodegib may lead to missing discontiguous tumor on surgery. This may eventually progress to more aggressive histology, including thin strands of BCC, immersed in dense inflammatory/scar tissue. The evaluation of surgical margins in this scenario may be challenging.
We also differ with the authors about the need of a free flap for reconstruction in this case. Due to the difference in color and texture with facial skin, we try to avoid free flaps for cheek reconstruction and prefer a Mustardé flap (or a cervicofacial flap) combined with an oculoplastic repair for the eyelids.
Bibliography
1. Sagiv O, Nagarajan P, Ferrarotto R, Kandl TJ, Thakar SD, Glisson BS, Altan M, Esmaeli B. Br J Ophthalmol. 2019 Jun;103(6):775-780. Ocular preservation with neoadjuvant vismodegib in patients with locally advanced periocular basal cell carcinoma Br J Ophthalmol. 2019 Jun;103(6):775-780
2. Tang N, Ratner D. Implementation of systemic hedgehog inhibitors in daily practice as neoadjuvant therapy. J Natl Compr Canc Netw 2017; 15:537–43
3. Alcalay J, Tauber G, Fenig E, Hodak E. Vismodegib as a neoadjuvant treatment to mohs surgery for aggressive basal cell carcinoma. J Drugs Dermatol 2015;14:219–23.
4. Ching JA, Curtis HL, Braue JA, Kudchadkar RR, Mendoza TI, Messina JL, Cruse CW, MD, Smith DJ, Harrington MA. The Impact of Neoadjuvant Hedgehog Inhibitor Therapy on the Surgical Treatment of Extensive Basal Cell Carcinoma. Ann Plast Surg 2015;74: S193–S197
5. Koekelkoren FHJ, Roodbergen SL, Baerveldt EM, Maat APWM, Monserez DA, Grunhagen DJ, Mureau MAM, de Haas ERM, PhD, Nijsten EC, Wakkee M. Vismodegib for giant, locally advanced, basal cell carcinoma and its complex position in clinical practice. JAAD Case Reports 2019; 5:267-70.
6. González AR, Etchichury D, Gil ME, Del Aguila R. Neoadjuvant Vismodegib and Mohs Micrographic Surgery for Locally Advanced Periocular Basal Cell Carcinoma. Ophthalmic Plast Reconstr Surg. 2019; 35(1):56-61.
We read with great interest the article entitled ‘Prevalence of guttae in the graft following corneal transplantation’ by Nahum et al, published in the May 2015 issue of the British Journal of Ophthalmology [1] . The authors reported the prevalence of cornea guttata postkeratoplasty in a large population of 1116 patients to be 4%. They also found that guttae postkeratoplasty do not negatively affect the visual acuity, endothelial cell density, or graft survival during the initial two postoperative years. The content of this article is important and well put, since this is the first study to reveal the prevalence and sequelae of postkeratoplasty guttae on the corneal graft.
Based on our clinical experience and on multiple published studies, the prevalence of cornea guttata in the normal population is estimated to be higher than 4% [2]. However, the low prevalence reached by Nahum et al, is explained mainly by the preoperative screening of the donor corneas for guttae, as stated in the article. Therefore, it would be very interesting if the authors can provide an estimation of the percentage of donor corneas that are usually discarded by the guttae screening in their eye bank.
Up to our knowledge, guttae are very often not detectable using inverted light microscopy, thus guttae screening as a part of the routine examination of the donor corneas is a challenging task. There is only one study performed by Borderie et al in 2001 [3], that aimed to detect the pres...
Show MoreWe read with interest the study by Özsaygili et al. in which the authors report that the presence or absence of posterior vitreous detachment (PVD) purportedly had no influence on the efficacy of aflibercept intravitreal injections in patients with diabetic macular oedema (DMO). We question the validity of this conclusion since it is known that eyes with attached vitreous require more injections to manage exudative age-related macular degeneration than eyes with PVD.1 This is presumed to be due to interference with macular access by anti-vascular endothelial growth factor (anti-VEGF) by the posterior vitreous cortex. The same mechanism of action could be expected in eyes with DMO. Thus, there may be alternative explanations for the observed lack of an effect of PVD status on the response to aflibercept. We hypothesize that the findings are due to both the unreliable diagnosis of PVD by spectral domain optical coherence tomography (SD-OCT) alone, and the possible presence of vitreoschisis.
Previous studies have shown that SD-OCT is not a robust way to diagnose PVD, since the positive predictive value is only approximately 50%.2, 3 Rather, ultrasound is the recommended way to detect complete PVD (Figure 1).2 Did Özsaygili et al. perform ultrasound in their patients? If not, they would be unable to determine true PVD status, and the validity of their conclusion needs to be called into question.
Additionally, it is unclear from the study by Özsaygili et al. wheth...
Show MoreDear Editor,
We read with interest the post-hoc study by Waldstein and colleagues concerning the impact of posterior vitreous detachment (PVD) on the efficacy of anti-VEGF treatment in neovascular age-related macular degeneration (AMD). However, the reliability of spectral-domain optical coherence tomography (SD-OCT) in confirming PVD status, upon which the findings of this study are dependent, is questionable.[1, 2] In particular, OCT is poor at distinguishing between fully attached vitreous and complete PVD.
Hwang et al recently reported limited sensitivity of SD-OCT in detecting complete PVD when compared to clinical findings at the time of vitrectomy.[1] It was found that among patients awaiting vitrectomy, OCT diagnosis of complete PVD (based on the absence of visible posterior vitreous cortex or a premacular bursa on SD-OCT) had a positive predictive value of just 53% when compared to intra-operative findings.
PVD remains a clinical diagnosis that is based on the identification of the posterior hyaloid membrane (PHM), a diaphanous, wrinkled film observable during biomicroscopic examination. The Weiss ring which it incorporates is a more variable and less reliable confirmatory sign of PHM detachment from the optic nerve head. The visible PHM is a consistent clinical finding in patients with PVD and correlates histopathologically with a type IV collagen basement membrane which begins life attached to the retina as the internal limiting membrane.[3...
Show MoreDr. Portabella reviewed the stability of 345 consecutive cases of scleral-sutured posterior chamber IOLs retrospectively.1 In discussing sutured scleral-fixated IOLs several main points must be considered: 1) type of suture utilized; 2) length of follow-up; 3) multiple surgeons or single surgeon; 4) type of knot utilized; and 5) reoperation rate.
This paper by Portabella et al.1 involved use of Prolene (polypropylene) or Mersilene sutures, follow-up with a maximum of 10 years, multiple surgeons, a knot with a single loop through the sclera and around the haptic, and a reoperation rate of 7.2%. The Vote et al study2 reviewed 61 eyes with Prolene sutures, follow-up with a maximum of 10.6 years, multiple surgeons, variable knots, and an extremely high rate of redislocation of 26.2%, which they postulated was due to suture breakage. This high rate of redislocation has not been confirmed in any other study.3,4
A recent study by Kokame et al3 involved 118 eyes utilizing 10-0 Prolene sutures, a single surgeon, follow-up of up to 24.75 years, a knot with two sutures - one secured to the haptic by a cow-hitch and the other to the sclera with both sutures tied together in a single knot under a scleral flap, and a broken suture rate of 0.5% (1/214 fixation sutures). The maximum follow-up of 24.75 years with stable fixation strongly supports the stability of 10-0 Prolene. Higher rates of redislocations of sutured scleral-fixated IOLs can be due to multiple surgeo...
Show MoreTabandeh and colleagues[1] presented a contrarian viewpoint on the redundancy of scleral-depressed vitreous base shaving: a procedure we have come to take for granted during vitrectomy for retinal detachment (RD). Their excellent outcomes are great news for trainee surgeons, as lens touch is likely during meticulous base dissection in phakic eyes. Sutureless micro-incision vitreous surgery is indeed more secure with residual peripheral vitreous, which plugs the sclerotomy leaks. The authors’ attribution of their high success rate to circumferential laser photocoagulation is validated by a randomized clinical trial.[2] The cases with residual silicone oil (13/89; 15%) should however not be included in the anatomical success; a significant percentage of them re-detach after oil removal.[3]
Show MoreThe optional use of scleral buckle in this study is confusing. The authors have not specified the choice of buckle (most probably an encircling belt-buckle). Vitreous base-shaving is critical to anatomical success when no encirclage is used.[3] The authors reported no additional benefit from buckling, though it was preferentially performed for complex detachments. We therefore do not have clarity about the one moot issue this study could settle: whether vitrectomy sans base-shaving is good enough for simple RD at least. A recent study suggested that anterior dissection is essential in the presence of posteriorly inserted vitreous base.[4] Did the authors observe this vitreous config...
The review article by Thng ZX, De Smet MD, Lee CS, et al 1highlights the most intriguing aspects on use of immunosuppressants during and post COVID-19 pandemic. The authors have presented evidences based on various reports in a very well-structured manner and we would like to first thank and congratulate the authors for their work. The review covers the wide range of faculties of medicine where immune suppression is likely to be the main stay of treatment. At the same time, they have also very neatly presented with the “clear cut “ guidelines on the dosing of these various medications at different scenarios and patient status.
While the article additionally covers the following aspects very well ;
1) Does the use of immunosuppressive present as an independent risk factor for contracting COVID -19 in patients under them?
2) Does it affect the severity of COVID -19 ?
We have few inquiries to make to the authors regarding the use of immunosuppressive in ophthalmology during this difficult time.
The authors have used the term “high dose steroids” in their article. Firstly, we are curious to understand what would be the considered the criteria to define a “high dosage” of steroid in ophthalmology. From our understanding, it depends upon the class of steroid used and the body weight2 but should we also need to consider the duration of use and cumulative dosage over a stretch of time to define it?
Also, referring to various public...
Show MoreWe read with great interest this comparison between selective laser trabeculoplasty (SLT) and medication for Open-Angle Glaucoma (OAG). (1)
Show MoreThe recent LiGHT trial (2), an important landmark in the management of glaucoma, suggests that SLT represents an ideal first-line treatment option of ocular hypertension (OHT) and open angle glaucoma (OAG) in terms of decreased costs, with similar efficacy and quality of life when comparing to medication. The strength of the trial resides in its methodology, limiting most of the bias seen in the previous retrospective studies on the subject. Despite the fact that their conclusions seemed to be echoing various other authors (3,4) there is still debate as to whether SLT should become a first-line treatment.
The current powerful meta-analysis by Chi et al on 1229 patients (14 articles, 8 randomized clinical trials), may become the final argument on the debate demonstrating that not only is SLT not inferior to medical therapy in terms of IOP-lowering effect or safety, but it allows for significantly lesser use of medication. (1)
The longer duration of effect, minimized cost, and safety of SLT are especially important in settings with difficult access to care, such as in developing countries, or in patients with decreased mobility. A recent study on incarcerated patients showed that even when measures are taken to administer and control patients’ adherence to treatment, substantial nonadherence persists. (5)
It is ri...
Dear Editor,
Show MoreWe have read the clinical case report entitled “Ocular manifestations of a patient hospitalized with a new coronavirus disease confirmed in 2019” by Chen L, et al.1 We congratulate the authors for this important work and wish to share our comment concerning the retinal findings. The authors indicated that Spectral-domain optical coherence tomography (SD-OCT) imaging was normal in both eyes. However, we would like to highlight the presence of hyper-reflective focal points at the level of the internal plexiform layer (IPL) and the ganglion cell layer (GCL). The report later published by Marinho PM, et al. in Lancet on May 12, 2020 "Retinal findings in patients with COVID-19" described the presence of focal hyperreflective dots at the IPL and GCL levels in all patients (24 eyes of 12 patients), which was the first report of SD-OCT retinal abnormalities in patients with COVID 19.2 We compared the two SD-OCT images published by Chen L, et al. to those published by Marinho PM, et al. All images were reviewed by two different retina specialists (NM, RTJH), and our analysis was strongly consistent. We have implemented the algorithm using the Python script3 to adjust the size and resolution of the images, and flipped the C by Marinho PM, et al. using fovea as the reference to obtain comparable images. We overlaid the images published by Chen L, et al. with those published by Marinho PM, et al. We were able to demonstrate that the hyperreflective lesions...
Dear Editor,
We have read the review article entitled “Ocular complications of cat scratch disease” Johnson A. Br J Ophthalmol 2020;0:1-7. We want to congratulate the author for this important review article, and make some contributions.
In the review article, it has been indicated that optical coherence tomography (OCT) imaging is of value to monitoring cat scratch disease (CSD), particularly for neuroretinitis and multifocal retinitis.
We would like to highlight a feature of focal retinitis with spectral domain optical coherence tomography (SD-OCT). Small areas of retinitis, less than 500 microns in diameter, can be seen on OCT imaging. These appear as areas of focal hyper-reflectivity of the inner retinal layers and decreased reflectivity causing a shadow on the outer retinal layers and choroid. This was seen in two patients presenting to our service recently with Bartonella henselae CSD diagnosed clinically and confirmed by positive serology.
The first case was a 49-year-old Caucasian male who presented with bilateral inflammatory papillitis and multifocal retinitis without a macular star, confirmed with serology as Bartonella henselae (IgG >2048). He had good presenting Snellen visual acuities of 6/5 right, 6/6 left. OCT imaging at acute presentation showed multifocal retinitis seen as small areas retinal hyper-reflectivity of the inner retina with outer retinal disruption. The disease resolved without treatment in 8 months, with...
Show MoreDear Editor,
We read with great interest the excellent paper by Sagiv and collegues Ocular preservation with neoadjuvant Vismodegib in patients with locally advanced periocular basal cell carcinoma.(1)
The article is a great contribution for a topic with a growing, but still limited worldwide experience. Our interest is to discuss the surgical approach after neoadjuvant Vismodegib.
The authors present a patient with a 5x4cm locally advanced periocular basal cell carcinoma (LAP-BCC) with small nerve perineural invasion (>0.1mm) involving lower eyelid, inner canthus and cheek. The patient showed a significant response after 10 months of Vismodegib. Anyhow, it was clearly a partial response with 3 suspicious areas of BCC after treatment. The authors decided to treat separately each area with surgery, and histology (en face sections) confirmed the presence of tumor in two. The reconstructive outcome was excellent, and at the time of publication the patient was free of disease, 11 months after surgery.
We agree with the authors, when they consider as a limitation the fact that “surgery did not always include the entire area of the original tumor”.
Most studies involving smoothened inhibitors thus far have measured clinical tumor shrinkage but not true histologic margin control. Even after a complete clinical response (CCR), there is no way to assure that it will result in a complete histological clearance (CHR).
Several authors discuss...
Show MorePages