We read with interest the BMJ Editorial Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear1. This highlights the need for risk mitigation in the context of commonplace eye examinations using the slit-lamp biomicroscope and direct ophthalmoscope, both requiring very close proximity manoeuvres within a few centimetres of the patients’ eye, nose and mouth. Droplet spread during eye examination likely increases during these prolonged direct examination techniques. Those at most risk are trainees working in accident and emergency, opticians or acute care settings who are required to see patients presenting with “red eye” for which conjunctivitis is a common cause.
Patients with conjunctivitis can be safely manged by the non-specialist using simple observation and history enquiry2 supplemented by a phone captured image. Remote-site consultation allows further discussion allowing an eye image and clinical details to be scrutinised without the requirement for on-site attendance. Currently, clinicians use mobile phone consultations to supplement and enhance care provision and it would seem prudent to adopt this more widely to minimise risk of Covid-19 transmission which might be acquired through public transport travel, waiting room exposure or face to face consultation. Notwithstanding confidentiality issues of commonly used freeware with private image messaging capabilities e.g Whatsap...
We read with interest the BMJ Editorial Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear1. This highlights the need for risk mitigation in the context of commonplace eye examinations using the slit-lamp biomicroscope and direct ophthalmoscope, both requiring very close proximity manoeuvres within a few centimetres of the patients’ eye, nose and mouth. Droplet spread during eye examination likely increases during these prolonged direct examination techniques. Those at most risk are trainees working in accident and emergency, opticians or acute care settings who are required to see patients presenting with “red eye” for which conjunctivitis is a common cause.
Patients with conjunctivitis can be safely manged by the non-specialist using simple observation and history enquiry2 supplemented by a phone captured image. Remote-site consultation allows further discussion allowing an eye image and clinical details to be scrutinised without the requirement for on-site attendance. Currently, clinicians use mobile phone consultations to supplement and enhance care provision and it would seem prudent to adopt this more widely to minimise risk of Covid-19 transmission which might be acquired through public transport travel, waiting room exposure or face to face consultation. Notwithstanding confidentiality issues of commonly used freeware with private image messaging capabilities e.g Whatsapp, secure ophthalmology data transmission, for example “Attend Anywhere” have been evaluated in Scotland (Livingstone I personal communication) and might be usefully adopted more widely3.
Ophthalmology is one of the highest patient volume specialties with an elderly patient demographic attending for chronic age-related eye diseases often with systemic co-morbidities rendering them a high-risk vulnerable group. To our knowledge there is no consistent UK-wide policy for protecting patients or professionals from Covid-19 transmission in the eye care setting. In the current climate of escalating Covid-19 numbers we suggest remote-site diagnosis using external eye image capture and/or video-consultation to be rapidly adopted by ophthalmologists as a risk mitigating, cost-effective approach to efficient triage and remote site management for all patients with the symptoms and signs of conjunctivitis who should not be referred to on-site hospital eye services.
References
1. Li J, Lam D, Chen Y, et al. Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear. Br J Ophthalmol 2020;104(3):297-298
2. Timlin H, Butler L, Wright M. The accuracy of the Edinburgh Red Eye Diagnostic Algorithm. Eye (Lond) 2015; 29(5): 619–624
3. Poyser O, Livingstone I, Ferguson A, et al. Real-Time Tele-Ophthalmology in the Emergency Department.) Invest. Ophthalmol. Vis. Sci. 2019;60(9):6124
We read with interest Babu’s report on ‘Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high volume vitreoretinal surgery centres: a pilot study’.1 As the first unit in the United Kingdom to purchase and use the NGENUITY 3D Visualization System (Alcon Laboratories, Fort Worth USA), we would like to share our experience. We assessed DAVS against analogue microscope (AM), from the Consultant surgeons’, trainees and the scrub nurses’ perspective. In our group there was a rapid adaption to the altered colours, head position and stereo vision offered by the DAVS for macular disease, with slower uptake for complex retinal detachments and trauma. In particular, we found the view and quality of image colour in macular cases to be sharp, even at high magnification, making for easier and safer membrane peels. DAVS provided a tangibly improved image quality and ease of description and teaching never previously experience by everyone present in theatre. Surgical trainees particularly benefited from better anatomical and a 3D view of the vitreoretinal pathology. Anecdotally, we tend to agree with Babu et al’s findings that the limitations lie in complex anterior segment cases, particularly with a poor red reflex, where we found the view of the posterior capsule to be compromised compared to the AM. Also, the presence of a sizeable disparity in contrast between immediately adjacent structures in the posterior segment (e.g. colobomas, asteroid hyal...
We read with interest Babu’s report on ‘Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high volume vitreoretinal surgery centres: a pilot study’.1 As the first unit in the United Kingdom to purchase and use the NGENUITY 3D Visualization System (Alcon Laboratories, Fort Worth USA), we would like to share our experience. We assessed DAVS against analogue microscope (AM), from the Consultant surgeons’, trainees and the scrub nurses’ perspective. In our group there was a rapid adaption to the altered colours, head position and stereo vision offered by the DAVS for macular disease, with slower uptake for complex retinal detachments and trauma. In particular, we found the view and quality of image colour in macular cases to be sharp, even at high magnification, making for easier and safer membrane peels. DAVS provided a tangibly improved image quality and ease of description and teaching never previously experience by everyone present in theatre. Surgical trainees particularly benefited from better anatomical and a 3D view of the vitreoretinal pathology. Anecdotally, we tend to agree with Babu et al’s findings that the limitations lie in complex anterior segment cases, particularly with a poor red reflex, where we found the view of the posterior capsule to be compromised compared to the AM. Also, the presence of a sizeable disparity in contrast between immediately adjacent structures in the posterior segment (e.g. colobomas, asteroid hyalosis) impacted on DAVS image quality. What we were not expecting was the difficulty our scrub nurses would have with the DAVS. They found that the polarised glasses rendered normal stereo vision more difficult, and the tinted lenses were a challenge when working in a dimmed ambient lighting. While the surgeons quickly adapted to the novel viewing system, our nursing colleagues found it less easy to use and took longer to adapt.
Reference:
1. Babu N, Kohli P, Jena S, et al. Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high-volume vitreoretinal surgery centre: a pilot study. British Journal of Ophthalmology 2020;104:432-436.
There is no unified consensus in the peripheral nerve literature regarding the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple well-designed peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives to nerve autografts at various gap lengths [1-3]. While there are no trials directly comparing the use of ANAs to nerve autografts in corneal neurotization, Avance® allografts have now become “on label” for corneal neurotization given the successful clinical outcomes reported by several tertiary care centers [4].
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 vs. 14% in the paper by Leyngold et al. 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. The reported CCS at 6 months postoperatively was only 30.0±26.8mm 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...
There is no unified consensus in the peripheral nerve literature regarding the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple well-designed peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives to nerve autografts at various gap lengths [1-3]. While there are no trials directly comparing the use of ANAs to nerve autografts in corneal neurotization, Avance® allografts have now become “on label” for corneal neurotization given the successful clinical outcomes reported by several tertiary care centers [4].
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 vs. 14% in the paper by Leyngold et al. 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. The reported CCS at 6 months postoperatively was only 30.0±26.8mm 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 extensive conjunctival scarring, and the last patient was shown to have corneal nerve regeneration on in vivo confocal microscopy, improved ocular surface and visual acuity despite a small improvement in average corneal sensation. 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]. Such a small number of cases is not sufficient to draw significant conclusions regarding clinical outcomes of their reported 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. 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.
5. 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.
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
It has been seventeen years since the emergence of Severe Acute Respiratory Syndrome (SARS -CoV)1 and in 2004, we reported the presence of SARS-CoV in human tears and highlighted the possibility of human transmission through tears2.
A new strain of coronavirus (2019-nCoV) has emerged recently in China.3 A recent report highlighted the possibility of transmission through tears.4 This thus serves as a timely reminder for ophthalmologists and healthcare professionals to take necessary precautions in the clinic. Furthermore, asymptomatic patients are potentially infective.3
As ophthalmologists, we sit eye-to-eye with our patients and this close proximity puts us at high risk of being exposed to such infections. When measuring intraocular pressure under topical anaesthesia, our fingers are in contact with the periocular skin or fluorescein-stained tears and it is conceivable that poor hand hygiene increases risk of disease transmission. The tips of reusable bottles of anaesthesia may also come into contact with tear fluid or eyelashes of patients at risk. Also, the use of Schirmer’s test for dry eyes or research purposes, might be sources of infection if the tear samples are not stored properly. It is thus important to ensure good hand hygiene, to wear surgical masks, and if handling infected patients, to don personal protective equipment (PPE) and goggles. It is also important to ensure proper disinfection of reusable equipment (such as tonometer tips). Alternat...
It has been seventeen years since the emergence of Severe Acute Respiratory Syndrome (SARS -CoV)1 and in 2004, we reported the presence of SARS-CoV in human tears and highlighted the possibility of human transmission through tears2.
A new strain of coronavirus (2019-nCoV) has emerged recently in China.3 A recent report highlighted the possibility of transmission through tears.4 This thus serves as a timely reminder for ophthalmologists and healthcare professionals to take necessary precautions in the clinic. Furthermore, asymptomatic patients are potentially infective.3
As ophthalmologists, we sit eye-to-eye with our patients and this close proximity puts us at high risk of being exposed to such infections. When measuring intraocular pressure under topical anaesthesia, our fingers are in contact with the periocular skin or fluorescein-stained tears and it is conceivable that poor hand hygiene increases risk of disease transmission. The tips of reusable bottles of anaesthesia may also come into contact with tear fluid or eyelashes of patients at risk. Also, the use of Schirmer’s test for dry eyes or research purposes, might be sources of infection if the tear samples are not stored properly. It is thus important to ensure good hand hygiene, to wear surgical masks, and if handling infected patients, to don personal protective equipment (PPE) and goggles. It is also important to ensure proper disinfection of reusable equipment (such as tonometer tips). Alternatively, the use of disposable equipment such as tonometer probes/cover, single-use equipment, disposable contact lenses for procedures, might eliminate the risk of viral transmission.
The emergence of this current strain coincides with the lunar new year, and we are likely to see massive people movement within China and around the world. This facilitates disease transmission and it is thus imperative to remind all healthcare professionals to practice caution when handling patients in the clinic.
References
1. World Health Organization. Severe acute respiratory syndrome (SARS): summary table of SARS cases by country on Aug 15, 2003. Available at: http://www.who.int/csr/sars/country/en/country2003_08_15.pdf. Accessed on January 24th, 2020.
2. Loon SC, Teoh SCB, Oon LLE, Se-Thoe SY, Leo YS. The severe acute respiratory syndrome coronavirus in tears. Br J Ophthalmol 2004;88:861-863.
Dr. Leyngold states we ‘fail to support [our] viewpoint with peer reviewed studies.’ Our position against the use of acellular nerve allografts (ANAs) in corneal neurotisation was grounded on robust evidence from basic science literature demonstrating their inferior performance relative to autografts for large gap nerve repair. No clinical trial comparing the two techniques exists, and in our opinion there lacks the necessary equipoise to perform such a study.
The regeneration-restrictive properties of long-segment ANAs renders them unsuitable for use in directing sensory axons to the cornea. The largest single-centre study on Avance® ANA use for peripheral nerve repair demonstrated meaningful recovery in only 54% of cases where allografts longer than 50 mm were employed [1]. Remarkably, exploitation of the suboptimal capacity of ANAs to support nerve regeneration has been proposed as a means to inhibit axon growth in the surgical management of painful neuromas [2].
In his defence of off-label use of Avance® allografts in corneal neurotisation, Dr. Leyngold cites his case-series wherein sensory improvement of 35 mm or more was documented in two of seven eyes (29%). In contrast, Catapano et al. noted sensory improvement of 35 mm or more in 16 of 18 cases (89%) where nerve autografts were employed to route healthy trigeminal sensory axons to anaesthetic corneas [3]. In our own experience, we have yet to encounter a suboptimal neurotization outcome with use of n...
Dr. Leyngold states we ‘fail to support [our] viewpoint with peer reviewed studies.’ Our position against the use of acellular nerve allografts (ANAs) in corneal neurotisation was grounded on robust evidence from basic science literature demonstrating their inferior performance relative to autografts for large gap nerve repair. No clinical trial comparing the two techniques exists, and in our opinion there lacks the necessary equipoise to perform such a study.
The regeneration-restrictive properties of long-segment ANAs renders them unsuitable for use in directing sensory axons to the cornea. The largest single-centre study on Avance® ANA use for peripheral nerve repair demonstrated meaningful recovery in only 54% of cases where allografts longer than 50 mm were employed [1]. Remarkably, exploitation of the suboptimal capacity of ANAs to support nerve regeneration has been proposed as a means to inhibit axon growth in the surgical management of painful neuromas [2].
In his defence of off-label use of Avance® allografts in corneal neurotisation, Dr. Leyngold cites his case-series wherein sensory improvement of 35 mm or more was documented in two of seven eyes (29%). In contrast, Catapano et al. noted sensory improvement of 35 mm or more in 16 of 18 cases (89%) where nerve autografts were employed to route healthy trigeminal sensory axons to anaesthetic corneas [3]. In our own experience, we 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 [4].
When counselling patients on corneal neurotisation, surgeons need be aware of the considerable evidence pointing to a higher risk of procedural failure where ANAs are substituted for nerve autografts. Articles supporting ANA use should be scrutinized for declared or undeclared conflicts of interest that may influence perception of the surgical outcome.
References:
1. Leckenby JI, Furrer C, Haug L, Juon Personeni B, Vogelin E. A retrospective case series reporting the outcomes of Avance nerve allografts in the treatment of peripheral nerve injuries. Plast Reconstr Surg 2019 doi: 10.1097/prs.0000000000006485[published Online First: Epub Date]|.
2. Hong T, Wood I, Hunter DA, et al. Neuroma Management: Capping Nerve Injuries With an Acellular Nerve Allograft Can Limit Axon Regeneration. Hand 2019:1558944719849115 doi: 10.1177/1558944719849115[published Online First: Epub Date]|.
3. 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 Journal of Ophthalmology 2019:bjophthalmol-2018-313042 doi: 10.1136/bjophthalmol-2018-313042[published Online First: Epub Date]|.
4. Jowett N, Pineda Ii R. Corneal neurotisation by great auricular nerve transfer and scleral-corneal tunnel incisions for neurotrophic keratopathy. Br J Ophthalmol 2019;103(9):1235-38 doi: 10.1136/bjophthalmol-2018-312563[published Online First: Epub Date]|.
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.
We read with interest the BMJ Editorial Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear1. This highlights the need for risk mitigation in the context of commonplace eye examinations using the slit-lamp biomicroscope and direct ophthalmoscope, both requiring very close proximity manoeuvres within a few centimetres of the patients’ eye, nose and mouth. Droplet spread during eye examination likely increases during these prolonged direct examination techniques. Those at most risk are trainees working in accident and emergency, opticians or acute care settings who are required to see patients presenting with “red eye” for which conjunctivitis is a common cause.
Patients with conjunctivitis can be safely manged by the non-specialist using simple observation and history enquiry2 supplemented by a phone captured image. Remote-site consultation allows further discussion allowing an eye image and clinical details to be scrutinised without the requirement for on-site attendance. Currently, clinicians use mobile phone consultations to supplement and enhance care provision and it would seem prudent to adopt this more widely to minimise risk of Covid-19 transmission which might be acquired through public transport travel, waiting room exposure or face to face consultation. Notwithstanding confidentiality issues of commonly used freeware with private image messaging capabilities e.g Whatsap...
Show MoreDear Sir
We read with interest Babu’s report on ‘Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high volume vitreoretinal surgery centres: a pilot study’.1 As the first unit in the United Kingdom to purchase and use the NGENUITY 3D Visualization System (Alcon Laboratories, Fort Worth USA), we would like to share our experience. We assessed DAVS against analogue microscope (AM), from the Consultant surgeons’, trainees and the scrub nurses’ perspective. In our group there was a rapid adaption to the altered colours, head position and stereo vision offered by the DAVS for macular disease, with slower uptake for complex retinal detachments and trauma. In particular, we found the view and quality of image colour in macular cases to be sharp, even at high magnification, making for easier and safer membrane peels. DAVS provided a tangibly improved image quality and ease of description and teaching never previously experience by everyone present in theatre. Surgical trainees particularly benefited from better anatomical and a 3D view of the vitreoretinal pathology. Anecdotally, we tend to agree with Babu et al’s findings that the limitations lie in complex anterior segment cases, particularly with a poor red reflex, where we found the view of the posterior capsule to be compromised compared to the AM. Also, the presence of a sizeable disparity in contrast between immediately adjacent structures in the posterior segment (e.g. colobomas, asteroid hyal...
Show MoreThere is no unified consensus in the peripheral nerve literature regarding the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple well-designed peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives to nerve autografts at various gap lengths [1-3]. While there are no trials directly comparing the use of ANAs to nerve autografts in corneal neurotization, Avance® allografts have now become “on label” for corneal neurotization given the successful clinical outcomes reported by several tertiary care centers [4].
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 vs. 14% in the paper by Leyngold et al. 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. The reported CCS at 6 months postoperatively was only 30.0±26.8mm 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...
Show MoreIt has been seventeen years since the emergence of Severe Acute Respiratory Syndrome (SARS -CoV)1 and in 2004, we reported the presence of SARS-CoV in human tears and highlighted the possibility of human transmission through tears2.
A new strain of coronavirus (2019-nCoV) has emerged recently in China.3 A recent report highlighted the possibility of transmission through tears.4 This thus serves as a timely reminder for ophthalmologists and healthcare professionals to take necessary precautions in the clinic. Furthermore, asymptomatic patients are potentially infective.3
As ophthalmologists, we sit eye-to-eye with our patients and this close proximity puts us at high risk of being exposed to such infections. When measuring intraocular pressure under topical anaesthesia, our fingers are in contact with the periocular skin or fluorescein-stained tears and it is conceivable that poor hand hygiene increases risk of disease transmission. The tips of reusable bottles of anaesthesia may also come into contact with tear fluid or eyelashes of patients at risk. Also, the use of Schirmer’s test for dry eyes or research purposes, might be sources of infection if the tear samples are not stored properly. It is thus important to ensure good hand hygiene, to wear surgical masks, and if handling infected patients, to don personal protective equipment (PPE) and goggles. It is also important to ensure proper disinfection of reusable equipment (such as tonometer tips). Alternat...
Show MoreDr. Leyngold states we ‘fail to support [our] viewpoint with peer reviewed studies.’ Our position against the use of acellular nerve allografts (ANAs) in corneal neurotisation was grounded on robust evidence from basic science literature demonstrating their inferior performance relative to autografts for large gap nerve repair. No clinical trial comparing the two techniques exists, and in our opinion there lacks the necessary equipoise to perform such a study.
The regeneration-restrictive properties of long-segment ANAs renders them unsuitable for use in directing sensory axons to the cornea. The largest single-centre study on Avance® ANA use for peripheral nerve repair demonstrated meaningful recovery in only 54% of cases where allografts longer than 50 mm were employed [1]. Remarkably, exploitation of the suboptimal capacity of ANAs to support nerve regeneration has been proposed as a means to inhibit axon growth in the surgical management of painful neuromas [2].
In his defence of off-label use of Avance® allografts in corneal neurotisation, Dr. Leyngold cites his case-series wherein sensory improvement of 35 mm or more was documented in two of seven eyes (29%). In contrast, Catapano et al. noted sensory improvement of 35 mm or more in 16 of 18 cases (89%) where nerve autografts were employed to route healthy trigeminal sensory axons to anaesthetic corneas [3]. In our own experience, we have yet to encounter a suboptimal neurotization outcome with use of n...
Show MoreThe 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...
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