We have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These...
We have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These barriers exist from both a patient’s and clinician’s perspective. The most obvious hurdle is the disparity in subject knowledge between both parties and the potential for patients to feel isolated during discussion. Therefore, it is crucial that patient involvement is designed in a way that recognizes this, and provides adequate support either through training schemes or debriefing with expert members prior to meetings(3). There may be resistance from clinicians concerned that the need to accommodate patient understanding may restrict the scope of discussion. Other patient concerns include time commitment and logistical concerns such as travel reimbursements(3), both of which should be adequately addressed. Additionally, care must be taken when defining the patient recruitment criteria in order to ensure the volunteers are truly representative of the patient population concerned.
Ultimately, we applaud the efforts of this article in highlighting what is currently an inadequately tapped resource in the realm of ophthalmology, and we hope to see the ‘patient voice’ become an intrinsic part of future research.
References
1. Dean, S., Mathers, J., Calvert, M., Kyte, D., Conroy, D., Folkard, A., Southworth, S., Murray, P. and Denniston, A. (2017). "The patient is speaking": discovering the patient voice in ophthalmology. The British Journal of Ophthalmology, [online] 101(6), pp.700-708. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28455280 [Accessed 20 Sep. 2017].
2. Burns, K., Rizvi, L., Charteris, A., Laskey, S., Batty, S., Chokar, K. and Choong, K. (2017). Characterizing Citizens’ Preferences for Engagement in Patient Care and Research in Adult and Pediatric Intensive Care Units. Journal of Intensive Care, [online] Available at: http://journals.sagepub.com/doi/full/10.1177/0885066617729127[Accessed 20 Sep. 2017].
Chalmers, J., Timothy, A., Polverino, E., Almagro, M., Ruddy, T., Powell, P. and Boyd, J. (2017). Patient participation in ERS guidelines and research projects: the EMBARC experience. European Respiratory Journal, [online] 13(3), pp.194-207. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584721/ - C1[Accessed 20 Sep. 2017].
Dear Sir,
We read the article "Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy" by Xue K, et al1 with great interest. The authors aimed to classify Diabetic macular odema [DMO] using ultra-widefield flourescein angiography [UWFA] and evaluate response to anti-vascular endothelial growth factor [anti-VEGF]. They concluded that UWFA facilitates detection of peripheral ishemia. DMO group with significant peripheral ishemia responded well to anti-VEGF therapy than other groups. We congratulate the author for their lightening study about subject and would like to make some contributions about study.
The study did not mention the severity of diabetes of the patients enrolled in the study nor systemic comorbid conditions like glycemic control, systolic hypertension, protinuria1, which would alter the incidence of macular odema.2, 3
The study selected patients with DMO who have been given subthreshold micropulse diode laser. As it was not mentioned in the study, we wonder if the study desires to see the response of anti-VEGF in non-resolving macular odema patients alone. Also, it was to our surprise why patients with Panretinal photocoagulation were not excluded from the study while classifying the patients into 3 groups .
The classification of DMO into three groups was not clearly satisfying because there would be always a component of ishemia overlapping between t...
Dear Sir,
We read the article "Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy" by Xue K, et al1 with great interest. The authors aimed to classify Diabetic macular odema [DMO] using ultra-widefield flourescein angiography [UWFA] and evaluate response to anti-vascular endothelial growth factor [anti-VEGF]. They concluded that UWFA facilitates detection of peripheral ishemia. DMO group with significant peripheral ishemia responded well to anti-VEGF therapy than other groups. We congratulate the author for their lightening study about subject and would like to make some contributions about study.
The study did not mention the severity of diabetes of the patients enrolled in the study nor systemic comorbid conditions like glycemic control, systolic hypertension, protinuria1, which would alter the incidence of macular odema.2, 3
The study selected patients with DMO who have been given subthreshold micropulse diode laser. As it was not mentioned in the study, we wonder if the study desires to see the response of anti-VEGF in non-resolving macular odema patients alone. Also, it was to our surprise why patients with Panretinal photocoagulation were not excluded from the study while classifying the patients into 3 groups .
The classification of DMO into three groups was not clearly satisfying because there would be always a component of ishemia overlapping between the different groups. Third group was basically with neovascularisation according to the author, but ishemia is the basic driving cause for neovascularisation. Also, it was not mentioned about type of neovascularisation that was considered in the third group, Neovascularisation of disc [NVD] OR Neovasculasiation elsewhere [NVE]. Since neovascularisation at disc would suggest that there is global ishemia. So we feel second and third group were not clearly defined by authors in the study.
According to the study, group 2 i.e. with peripheral ishemic group responded better to anti-VEGF than other groups. We wonder how would this grouping alter the management of DMO in any way, as it is already known that DMO treated with anti-VEGF would improve vision and reduce the macular odema.4, 5
Financial Support and Sponsorship
Nil
Conflicts of Interest
There are no conflicts of interest
References:
1. Xue K etal. Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy. Br J Ophthalmol 2017; 101:559-563.
2. Early treatment for diabetic retinopathy study [ETDRS] research group .ETDRS design and baseline patient characteristics. ETDRS report number 7 .Ophthalmology 1991; 98: 741 - 756.
3. Ronald KLIEN, MD, MPH, Michaiel D. Knudston, MS, etal. WISCONSON EPIDEMIOLOGICAL STUDY OF DIABETIC RETINOPATHY, the twenty five year incidence of macular odema in persons with type 1 diabetes .Ophthalmology 2009; 116 [3]: 497-503.
4. Paul Mitchell MD, PhD, Francesco Bandello, MD, FEBO; etal. RESTORE STUDY. Ranibizumab monotherapy or combined with laser versus monotherapy for diabetic macular odema. Ophthalmology 2011; 118 [4]: 615-25.
5. Pascale Massin, MD, PhD, Francesco Bandello ,MD ,FEBO etal Safety and efficacy of Ranibizumab in Diabetic Macular Edema [RESOLVE STUDY]. Diabetes care 2010; 33: 2399-2405.
Dear Sir
Thanks for this notification
1. Preoperative and postoperative characteristics for the CF group are shown in Table 2 (line 13)
Answer: This was a typing error hoping if it will be corrected to: preoperative and postoperative characteristics for the AMG group are shown in Table 2
2. The study does not mention about the location postoperatively. How will the site of the ulcer change from central to paracentral and vice versa?
Answer: Eighteen from twenty patients in each group showed healing of the ulcer, and two cases in each group were sent for keratoplasty (from 4 to 8 days after intervention). So, there is no need to mention size of the ulcer. Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
So the description of the ulcer will be changed from peripheral to central.
There was no need to mention this as the ulcers healed.
3. There is no mention about the complications studied. Descemetocele and perforations occurred preoperatively.
Answer: Three cases with perforation and one case with descemetocele were referred to immediate keratoplasty, and other ulcers healed, so there were no complications to be mentioned. Regarding other complications in secondary outcome measures, there were no complications and this was mentio...
Dear Sir
Thanks for this notification
1. Preoperative and postoperative characteristics for the CF group are shown in Table 2 (line 13)
Answer: This was a typing error hoping if it will be corrected to: preoperative and postoperative characteristics for the AMG group are shown in Table 2
2. The study does not mention about the location postoperatively. How will the site of the ulcer change from central to paracentral and vice versa?
Answer: Eighteen from twenty patients in each group showed healing of the ulcer, and two cases in each group were sent for keratoplasty (from 4 to 8 days after intervention). So, there is no need to mention size of the ulcer. Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
So the description of the ulcer will be changed from peripheral to central.
There was no need to mention this as the ulcers healed.
3. There is no mention about the complications studied. Descemetocele and perforations occurred preoperatively.
Answer: Three cases with perforation and one case with descemetocele were referred to immediate keratoplasty, and other ulcers healed, so there were no complications to be mentioned. Regarding other complications in secondary outcome measures, there were no complications and this was mentioned in the discussion section in the second paragraph of the last page.
We read with interest the study by Odayappan et al regarding outcomes of air descemetopexy for Descemet membrane detachment (DMD). [1] It is interesting to note the lack of corneal pathology associated with DMD in their case series, and the discussion regarding the contribution of incision sites. We would like to raise the issue of peripheral corneal pathology as a contributing factor in DMD. Recently we had a complex case involving a 91-year-old with extensive Terrien’s marginal degeneration and corneal scarring, who underwent right cataract surgery. This was complicated by DMD and he had successful air descemetopexy within the first month. He then proceeded to have left cataract surgery, with a residual air bubble left in the anterior chamber, yet he still developed DMD. We scheduled surgery but he was unable to attend due to illness and hospital admission. When he was reviewed at 3 months post operatively, the DMD had reattached, with normalised pachymetry and visual acuity of 6/12 bilaterally.
While we agree that air descemetopexy is an efficient treatment modality for DMD, our case highlights that other co-morbidities can influence management. As the anatomical and visual outcomes were similar in both eyes, our case raises the issue of lack of clear guidance in the literature regarding when to intervene in DMD and when to observe.
Terrien’s marginal degeneration is a slowly progressive thinning of the peripheral cornea, with formation of a scarred gutte...
We read with interest the study by Odayappan et al regarding outcomes of air descemetopexy for Descemet membrane detachment (DMD). [1] It is interesting to note the lack of corneal pathology associated with DMD in their case series, and the discussion regarding the contribution of incision sites. We would like to raise the issue of peripheral corneal pathology as a contributing factor in DMD. Recently we had a complex case involving a 91-year-old with extensive Terrien’s marginal degeneration and corneal scarring, who underwent right cataract surgery. This was complicated by DMD and he had successful air descemetopexy within the first month. He then proceeded to have left cataract surgery, with a residual air bubble left in the anterior chamber, yet he still developed DMD. We scheduled surgery but he was unable to attend due to illness and hospital admission. When he was reviewed at 3 months post operatively, the DMD had reattached, with normalised pachymetry and visual acuity of 6/12 bilaterally.
While we agree that air descemetopexy is an efficient treatment modality for DMD, our case highlights that other co-morbidities can influence management. As the anatomical and visual outcomes were similar in both eyes, our case raises the issue of lack of clear guidance in the literature regarding when to intervene in DMD and when to observe.
Terrien’s marginal degeneration is a slowly progressive thinning of the peripheral cornea, with formation of a scarred gutter due to stromal degeneration. We wonder if wound architecture during cataract surgery is compromised in this setting, predisposing to DMD. Previous reports have encouraged the use of ultrasound and topography in the diagnosis of Terrien’s. [2,3] We recommend the use of anterior segment OCT as an invaluable adjunct in diagnosing peripheral corneal pathology, for confirming the diagnosis of DMD, and monitoring progress.
References:
1. Odayappan A, Shivananda N, Ramakrishnan S, Krishnan T, Nachiappan S, Krishnamurthy S. A retrospective study on the incidence of post-cataract surgery Descemet's membrane detachment and outcome of air descemetopexy. Br J Ophthalmol. 2017 Jun 13. pii: bjophthalmol-2016-309766. doi:
10.1136/bjophthalmol-2016-309766. [Epub ahead of print]
2. Skribek A, Sohár N, Gyetvai T, Nógrádi A, Kolozsvári L. Role of ultrasound biomicroscopy in diagnosis and treatment of Terrien disease. Cornea. 2008 May;27(4):427-33.
3. Fernandes M. Scanning slit topography: diagnostic boon in presumed unilateral Terrien's marginal degeneration. Cont Lens Anterior Eye. 2011 Dec;34(6):282-6.
Dear Editor,
I read with interest the above randomised clinical study published by
Abdulhalim et al in BrJ Ophthal 2015;99:59-63.
The main outcome measures were location, size and depth of the lesion,
epithelialisation time and persistence of infection. Secondary outcome
measures include visual acuity and other complications.
Table 1 states Demographic data and preoperative characteristics for
conjunctival flap group.
Table 2 states Demographic data and preoperative characteristics for
amniotic transplant group.
However in the narration in Results-it states preoperative and
postoperative characteristics for the CF group are shown in Table 1 (line
5) preoperative and postoperative characteristics for the CF group are
shown in Table 1. preoperative and postoperative characteristics for the CF
group are shown in Table 2 (line 13). This is very confusing.
Table 3 shows a comparison of CF group and AMG. Here the preoperative and
postoperative characteristics are all in one table.
The main outcome measures were location. The study does not mention about
the location postoperatively. How will the site of the ulcer change from
central to paracentral and vice versa? There is no mention about the size
and depth of the ulcer- which is also a parameter that was studied.There is
no mention about the complications studied. Descematocoele and perforations...
Dear Editor,
I read with interest the above randomised clinical study published by
Abdulhalim et al in BrJ Ophthal 2015;99:59-63.
The main outcome measures were location, size and depth of the lesion,
epithelialisation time and persistence of infection. Secondary outcome
measures include visual acuity and other complications.
Table 1 states Demographic data and preoperative characteristics for
conjunctival flap group.
Table 2 states Demographic data and preoperative characteristics for
amniotic transplant group.
However in the narration in Results-it states preoperative and
postoperative characteristics for the CF group are shown in Table 1 (line
5) preoperative and postoperative characteristics for the CF group are
shown in Table 1. preoperative and postoperative characteristics for the CF
group are shown in Table 2 (line 13). This is very confusing.
Table 3 shows a comparison of CF group and AMG. Here the preoperative and
postoperative characteristics are all in one table.
The main outcome measures were location. The study does not mention about
the location postoperatively. How will the site of the ulcer change from
central to paracentral and vice versa? There is no mention about the size
and depth of the ulcer- which is also a parameter that was studied.There is
no mention about the complications studied. Descematocoele and perforations
occured pre-operatively.
Was the visual acuity best corrected or uncorrected visual acuity.
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be aff...
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be affected by trauma, and traumatic cataract carries an increased risk of PCR. We would welcome further discussion of this less recognised risk factor for PCR.
References:
1. Salowi MA, Chew FLM, Adnan TH, Ismail M, Goh PP: The Malaysian Cataract Surgery Registry: risk Indicators for posterior capsular rupture. The British journal of ophthalmology 2017.
2. Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Asaria RH, Galloway P, Sparrow JM: The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss. Eye (London, England) 2009, 23(1):31-37.
3. Shalchi Z, Okada M, Whiting C, Hamilton R: Risk of Posterior Capsule Rupture During Cataract Surgery in Eyes With Previous Intravitreal Injections. American journal of ophthalmology 2017, 177:77-80.
4. Chatziralli IP, Peponis V, Parikakis E, Maniatea A, Patsea E, Mitropoulos P: Risk factors for intraoperative floppy iris syndrome: a prospective study. Eye (London, England) 2016, 30(8):1039-1044.
I whole heartedly appreciate the work conducted by Chan Yun Kim et al in studying the treatment patterns and medication adherence of patients with glaucoma in South Korea.This study concluded that medication non adherence was seen more commonly in males , increased daily number of administration and increase in the number of eyedrops. We have also conducted a similar study at our centre in North India and would like to share our results .Our results are in agreement to the work conducted by Chan Yun Kim stating that increased number of instillation and increased number of eyedrops contribute significantly to medication non adherence. However, in our study we also found that medication adherence varies in different severity grades of glaucoma with severe stages being significantly more adherent than mild to moderate stages of glaucoma.Additionally, there was no difference found in medication adherence among males or females.
We again express our gratitude to the researcher in enlightening our minds regarding medication adherence in South Korean population.
We thank Sarmad et al. for their interest in our publication. Our study is a retrospective review of several variables regarding non-traumatic corneal perforations (1). In handling clinical records for a retrospective analysis, missing variables represent a common problem. In relation to the location of corneal perforation, information was not available in 25 eyes thus the number does not match. Hence, in consideration of this inevitable flaw we decided not to include the anatomical location of perforation into the model presented in the manuscript, therefore all the variables included in this statistical model had no missing values.
Clinical treatment of corneal perforation is often complex and a single intervention may not address the patient full pathology, therefore more than one treatment is frequently used. (2) This explains the increased number of initial treatments in the first clinical intervention, one example of this scenario are the patients needing simultaneous tectonic penetrating keratoplasty to restore ocular integrity and concurrent amniotic membrane transplantation to aid in the control of ocular surface. (2)(3)
These two situations might not be precise in our manuscript, but we take the opportunity of this letter to clarify them. However, that is unquestionably far from compromising the validity of the conclusions. Definitely, as any retrospective study, and as we mention in the discussion of our article, there are li...
We thank Sarmad et al. for their interest in our publication. Our study is a retrospective review of several variables regarding non-traumatic corneal perforations (1). In handling clinical records for a retrospective analysis, missing variables represent a common problem. In relation to the location of corneal perforation, information was not available in 25 eyes thus the number does not match. Hence, in consideration of this inevitable flaw we decided not to include the anatomical location of perforation into the model presented in the manuscript, therefore all the variables included in this statistical model had no missing values.
Clinical treatment of corneal perforation is often complex and a single intervention may not address the patient full pathology, therefore more than one treatment is frequently used. (2) This explains the increased number of initial treatments in the first clinical intervention, one example of this scenario are the patients needing simultaneous tectonic penetrating keratoplasty to restore ocular integrity and concurrent amniotic membrane transplantation to aid in the control of ocular surface. (2)(3)
These two situations might not be precise in our manuscript, but we take the opportunity of this letter to clarify them. However, that is unquestionably far from compromising the validity of the conclusions. Definitely, as any retrospective study, and as we mention in the discussion of our article, there are limitations including the lack of a standard algorithm of treatment and the impossibility to include other variables that might alter the final outcomes of the patients. Therefore, and as we also discussed, this imply that the conclusions presented must be taken with caution. Thus, when interpreting the results of a retrospective study it is important to understand and be aware of the possible bias and limitations, allowing the reader to take advantage of the many strengths of this design into incorporation of knowledge into their daily clinical practice. (4)
References.
1) Loya-Garcia D, Serna-Ojeda JC, Pedro-Aguilar L, et al. Non-traumatic corneal perforations: aetiology, treatment and outcomes. Br J Ophthalmol. 2017;101(5):634-639.
2) Jhanji V, Young AL, Mehta JS, et al. Management of corneal perforation. Surv Ophthalmol. 2011;56(6):522-38.
3) Dua HS, Gomes JA, King AJ, et al. The Amniotic Membrane in Ophthalmology. Surv Opthalmol 2004; 49:51-77.
4) Euser AM, Zoccali C, Jager KJ, et al. Cohort studies: prospective versus retrospective. Nephron Clin Pract. 2009;113(3):c214-7.
We warmly thank Calugaru D and associates for their correspondence regarding our article entitled " Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema".1
We agree with them about some of the challenges concerning our study. As we have acknowledged in the limitation section of our article, our study is limited by several biases, as its design was retrospective. In particular, patients selection and follow-up represented some of the major flaws in our study. We collected data about patients switched to dexamethasone for different reasons; some patients were treatment-naïve, other had already undergone treatments for diabetic macular edema (DME). No one disclosed any feature of chronic long-standing DME; all of them received prompt therapy after DME diagnosis.
Some of them showed a good response to ranibizumab loading-dose, with satisfying reduction of macular thickness after the injections. Nevertheless, no patient disclosed a completely dry macula after the anti-vascular endothelial growth factor (VEGF) loading-dose.
As far as it regards the final functional and anatomical gain at the end of the follow-up, the Authors state that the outcomes of this series were unsatisfactory. However, in the non-responders group, despite initial poor results, the best-corrected visual acuity (BCVA) had improved significantly (p<0.05) and clinically (> 5 letters), as highlighted in the...
We warmly thank Calugaru D and associates for their correspondence regarding our article entitled " Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema".1
We agree with them about some of the challenges concerning our study. As we have acknowledged in the limitation section of our article, our study is limited by several biases, as its design was retrospective. In particular, patients selection and follow-up represented some of the major flaws in our study. We collected data about patients switched to dexamethasone for different reasons; some patients were treatment-naïve, other had already undergone treatments for diabetic macular edema (DME). No one disclosed any feature of chronic long-standing DME; all of them received prompt therapy after DME diagnosis.
Some of them showed a good response to ranibizumab loading-dose, with satisfying reduction of macular thickness after the injections. Nevertheless, no patient disclosed a completely dry macula after the anti-vascular endothelial growth factor (VEGF) loading-dose.
As far as it regards the final functional and anatomical gain at the end of the follow-up, the Authors state that the outcomes of this series were unsatisfactory. However, in the non-responders group, despite initial poor results, the best-corrected visual acuity (BCVA) had improved significantly (p<0.05) and clinically (> 5 letters), as highlighted in the text.
The analysis of central macular thickness (CMT) at 12 months on optical coherence tomography disclosed that the poor and good responders reached CMT of 363 microns and of 359 microns, respectively. Despite being more than the cutoff for the upper level of normal CMT, as suggested by the Authors, for DME eyes a CMT of ~350um should be considered as a good outcome, as values inferior to this cut-off would indicate impending atrophy of the neurovascular tissue. As a validation of our approach, we referred to the latest Diabetic Retinopathy Clinical Research Network (DRCR.net) guidelines about persistent macular thickening after ranibizumab treatment, according to which CMT appeared to be a less important prognostic factor in DME outcomes. In fact, persistent macular edema was associated with similar long-term improvement in visual acuity showed by patients in which DME did not persist.2 Finally, we would like to specify that we analyzed data of included patients until 12-months follow-up; these patients did not conclude treatment for DME, and most of them continued to receive injections for their condition.
We perfectly agree that, along with CMT, other OCT biomarkers (as disorganization of the retinal inner layers, integrity of the ellipsoid zone and of the cone outer segment tips, presence of taut internal limiting membrane or epiretinal membrane, and vitreomacular traction) should be analyzed in order to predict the prognostic outcome of diabetic patients.3-4 A specific analysis of these parameters was beyond our purposes, but we will include them in a future more complete stepwise linear regression analysis of the data presented in the present study.
We listed the complications of treatment experienced by patients who underwent dexamethasone (DEX) implant, with particular attention to intraocular pressure increase as well as cataract worsening. These two are well-known side-effects of dexamethasone implant and their rate did not exceed the expectations in our study.5 Despite these complications, intravitreal steroids have shown a good safety profile in long-term prospective studies, especially in those cases when anti-VEGF are contraindicated, or fewer intravitreal injections regimen is required.
In conclusion, we kindly disagree with the conclusion of the Authors and we further demonstrated the usefulness of switching the therapeutic drug in diabetic patients non-responders to anti-VEGF the by replying to this letter.
References:
1. Cicinelli MV, Cavalleri M, Querques L, et al. Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema. Br J Ophthalmol 2017; http:/ dx. doi. org/ 10.1136/bjophthalmol-2017-310242.
2. Bressler SB, Ayala AR, Bressler NM, Melia M, Qin H, Ferris FL 3rd, Flaxel CJ, Friedman SM, Glassman AR, Jampol LM, Rauser ME; Diabetic Retinopathy Clinical Research Network. Persistent Macular Thickening After Ranibizumab Treatment for Diabetic Macular Edema With Vision Impairment. JAMA Ophthalmol. 2016 Mar;134(3):278-85. doi: 10.1001/jamaophthalmol.2015.5346.
3. Sun JK, Lin MM, Lammer J, Prager S, Sarangi R, Silva PS, Aiello LP. Disorganization of the retinal inner layers as a predictor of visual acuity in eyes with center-involved diabetic macular edema. JAMA Ophthalmol. 2014 Nov;132(11):1309-16.
4. Iacono P, Parodi MB, Scaramuzzi M, Bandello F. Morphological and functional changes in recalcitrant diabetic macular oedema after intravitreal dexamethasone implant. Br J Ophthalmol. 2016 Sep 13. pii: bjophthalmol-2016-308726. doi: 10.1136/bjophthalmol-2016-308726.
5. Boyer DS, Yoon YH, Belfort R Jr, et al; Ozurdex MEAD Study Group. Three-year, randomized, sham-controlled trial of dexamethasone intravitreal implant in patients with diabetic macular edema. 2014;121:1904-1914.
Dear Editor,
We read your article titled- Non-traumatic corneal perforations: aetiology, treatment and outcomes: with great interest. Corneal perforation is an acute ophthalmic emergency. This review describes the aetiology, plausible location and the multiple ways to approach the management of this condition in a very a systematic manner.
We do appreciate the organised mode of stratification and care of non- traumatic corneal perforation presented in the article. However, although the results are interesting, we feel that caution should be exercised when drawing conclusions from this data.
Initially, in results there are 127 eyes of 116 patients under the review. However, while describing the anatomical location of the perforation, only 102 eyes have been accounted for, with no records for the remaining 25 eyes. This would change the calculated p value significantly.
Similarly, where the initial treatments for perforations were being reviewed 133 eyes were mentioned as treated, thus including six extra unaccounted for eyes to the total. This would seriously jeopardise the authenticity of the calculated results.
Hence, there appears to be serious doubts regarding the validity of the conclusions of this review. A clearer and more detailed explanation or a recalculation of the results is warranted in this regard.
We have read with interest the article by Dean et al(1). We completely agree with the premise that the ‘patient voice’ is not being fully utilised in all facets of ophthalmic care, ranging from research to clinical practice. Evidence suggests that rather than being a tokenistic addition, listening to the ‘patient voice’ can provide tangible improvements in cost efficiency and healthcare outcomes(2).
A successful project spearheaded by the European Respiratory Society (ERS) called EMBARC(3) (European Multicentre Bronchiectasis Audit and Research Collaboration) sought to be a patient focused project, despite scarce existing infrastructure for patient involvement(3). In the research sphere of the project, patients were involved in clinical trials and studies. They played key roles in study design, wrote letters to secure financial backing for bronchiectasis-related projects, and were active members of advisory boards and ethical committees. Patients were a valuable asset on guideline panels, providing an alternative insight on the merits and negatives of various interventions, as well as their general acceptability. This initiative is a model example of how patients can influence the path research takes, and provides a tested framework for future ophthalmic research to be highly patient-relevant.
Undoubtedly, there will be barriers to effective patient involvement in medical research and these will require flexible and innovative approaches to be overcome. These...
Show MoreDear Sir,
Show MoreWe read the article "Classification of diabetic macular odema using ultra-widefield angiography and implications for response to anti-VEGF therapy" by Xue K, et al1 with great interest. The authors aimed to classify Diabetic macular odema [DMO] using ultra-widefield flourescein angiography [UWFA] and evaluate response to anti-vascular endothelial growth factor [anti-VEGF]. They concluded that UWFA facilitates detection of peripheral ishemia. DMO group with significant peripheral ishemia responded well to anti-VEGF therapy than other groups. We congratulate the author for their lightening study about subject and would like to make some contributions about study.
The study did not mention the severity of diabetes of the patients enrolled in the study nor systemic comorbid conditions like glycemic control, systolic hypertension, protinuria1, which would alter the incidence of macular odema.2, 3
The study selected patients with DMO who have been given subthreshold micropulse diode laser. As it was not mentioned in the study, we wonder if the study desires to see the response of anti-VEGF in non-resolving macular odema patients alone. Also, it was to our surprise why patients with Panretinal photocoagulation were not excluded from the study while classifying the patients into 3 groups .
The classification of DMO into three groups was not clearly satisfying because there would be always a component of ishemia overlapping between t...
Dear Sir
Show MoreThanks for this notification
1. Preoperative and postoperative characteristics for the CF group are shown in Table 2 (line 13)
Answer: This was a typing error hoping if it will be corrected to: preoperative and postoperative characteristics for the AMG group are shown in Table 2
2. The study does not mention about the location postoperatively. How will the site of the ulcer change from central to paracentral and vice versa?
Answer: Eighteen from twenty patients in each group showed healing of the ulcer, and two cases in each group were sent for keratoplasty (from 4 to 8 days after intervention). So, there is no need to mention size of the ulcer. Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
Regarding site of the ulcer; some paracentral ulcer are creeping and/or enlarging in size to involve the central part.
So the description of the ulcer will be changed from peripheral to central.
There was no need to mention this as the ulcers healed.
3. There is no mention about the complications studied. Descemetocele and perforations occurred preoperatively.
Answer: Three cases with perforation and one case with descemetocele were referred to immediate keratoplasty, and other ulcers healed, so there were no complications to be mentioned. Regarding other complications in secondary outcome measures, there were no complications and this was mentio...
We read with interest the study by Odayappan et al regarding outcomes of air descemetopexy for Descemet membrane detachment (DMD). [1] It is interesting to note the lack of corneal pathology associated with DMD in their case series, and the discussion regarding the contribution of incision sites. We would like to raise the issue of peripheral corneal pathology as a contributing factor in DMD. Recently we had a complex case involving a 91-year-old with extensive Terrien’s marginal degeneration and corneal scarring, who underwent right cataract surgery. This was complicated by DMD and he had successful air descemetopexy within the first month. He then proceeded to have left cataract surgery, with a residual air bubble left in the anterior chamber, yet he still developed DMD. We scheduled surgery but he was unable to attend due to illness and hospital admission. When he was reviewed at 3 months post operatively, the DMD had reattached, with normalised pachymetry and visual acuity of 6/12 bilaterally.
While we agree that air descemetopexy is an efficient treatment modality for DMD, our case highlights that other co-morbidities can influence management. As the anatomical and visual outcomes were similar in both eyes, our case raises the issue of lack of clear guidance in the literature regarding when to intervene in DMD and when to observe.
Terrien’s marginal degeneration is a slowly progressive thinning of the peripheral cornea, with formation of a scarred gutte...
Show MoreDear Editor,
I read with interest the above randomised clinical study published by
Abdulhalim et al in BrJ Ophthal 2015;99:59-63.
The main outcome measures were location, size and depth of the lesion,
epithelialisation time and persistence of infection. Secondary outcome
measures include visual acuity and other complications.
Table 1 states Demographic data and preoperative characteristics for
conjunctival flap group.
Table 2 states Demographic data and preoperative characteristics for
amniotic transplant group.
However in the narration in Results-it states preoperative and
postoperative characteristics for the CF group are shown in Table 1 (line
5) preoperative and postoperative characteristics for the CF group are
shown in Table 1. preoperative and postoperative characteristics for the CF
group are shown in Table 2 (line 13). This is very confusing.
Table 3 shows a comparison of CF group and AMG. Here the preoperative and
postoperative characteristics are all in one table.
The main outcome measures were location. The study does not mention about
Show Morethe location postoperatively. How will the site of the ulcer change from
central to paracentral and vice versa? There is no mention about the size
and depth of the ulcer- which is also a parameter that was studied.There is
no mention about the complications studied. Descematocoele and perforations...
We read with great interest the study by Salowi and colleagues,[1] analysing risk factors for posterior capsular rupture (PCR) in over 150,000 cataract operations across Malaysia. Many of the significant risk factors were expected and well-recognised, such as junior surgeon or pseudoexfoliation. An interesting finding was increased PCR in males, with odd ratio 1.11 (95% confidence interval 1.04 to 1.17).
Male gender has been found to be a risk factor for PCR in other large retrospective studies. The Cataract National Dataset of 55,567 cataract operations across 12 National Health Service Trusts in the UK found male gender to have an adjusted odds ratio of 1.28 (95% CI 1.13-1.45).[2] We recently reviewed 62,994 cataract operations performed at Moorfields, showing male gender as a significant risk for PCR, with OR 1.490 (95% CI 1.274–1.741).[3] This risk was similar to junior surgeon (OR 1.483) or prior intravitreal injection (OR 1.664), an increasingly acknowledged predictor of complicated surgery.
The reasons for increased PCR in male patients is unclear. Males are significantly more likely to take tamsulosin, an alpha receptor blocker used in the treatment of benign prostatic hypertrophy. This can lead to poor pupillary dilation and intraoperative floppy iris syndrome (IFIS).[4] Although this can be effectively managed with intracameral phenylephrine, iris hooks or Malyugin ring, it remains a risk factor for PCR. Furthermore, males are more likely to be aff...
Show MoreDear sir/maam
I whole heartedly appreciate the work conducted by Chan Yun Kim et al in studying the treatment patterns and medication adherence of patients with glaucoma in South Korea.This study concluded that medication non adherence was seen more commonly in males , increased daily number of administration and increase in the number of eyedrops. We have also conducted a similar study at our centre in North India and would like to share our results .Our results are in agreement to the work conducted by Chan Yun Kim stating that increased number of instillation and increased number of eyedrops contribute significantly to medication non adherence. However, in our study we also found that medication adherence varies in different severity grades of glaucoma with severe stages being significantly more adherent than mild to moderate stages of glaucoma.Additionally, there was no difference found in medication adherence among males or females.
We again express our gratitude to the researcher in enlightening our minds regarding medication adherence in South Korean population.
Dear editor.
We thank Sarmad et al. for their interest in our publication. Our study is a retrospective review of several variables regarding non-traumatic corneal perforations (1). In handling clinical records for a retrospective analysis, missing variables represent a common problem. In relation to the location of corneal perforation, information was not available in 25 eyes thus the number does not match. Hence, in consideration of this inevitable flaw we decided not to include the anatomical location of perforation into the model presented in the manuscript, therefore all the variables included in this statistical model had no missing values.
Clinical treatment of corneal perforation is often complex and a single intervention may not address the patient full pathology, therefore more than one treatment is frequently used. (2) This explains the increased number of initial treatments in the first clinical intervention, one example of this scenario are the patients needing simultaneous tectonic penetrating keratoplasty to restore ocular integrity and concurrent amniotic membrane transplantation to aid in the control of ocular surface. (2)(3)
These two situations might not be precise in our manuscript, but we take the opportunity of this letter to clarify them. However, that is unquestionably far from compromising the validity of the conclusions. Definitely, as any retrospective study, and as we mention in the discussion of our article, there are li...
Show MoreWe warmly thank Calugaru D and associates for their correspondence regarding our article entitled " Early response to ranibizumab predictive of functional outcome after dexamethasone for unresponsive diabetic macular oedema".1
Show MoreWe agree with them about some of the challenges concerning our study. As we have acknowledged in the limitation section of our article, our study is limited by several biases, as its design was retrospective. In particular, patients selection and follow-up represented some of the major flaws in our study. We collected data about patients switched to dexamethasone for different reasons; some patients were treatment-naïve, other had already undergone treatments for diabetic macular edema (DME). No one disclosed any feature of chronic long-standing DME; all of them received prompt therapy after DME diagnosis.
Some of them showed a good response to ranibizumab loading-dose, with satisfying reduction of macular thickness after the injections. Nevertheless, no patient disclosed a completely dry macula after the anti-vascular endothelial growth factor (VEGF) loading-dose.
As far as it regards the final functional and anatomical gain at the end of the follow-up, the Authors state that the outcomes of this series were unsatisfactory. However, in the non-responders group, despite initial poor results, the best-corrected visual acuity (BCVA) had improved significantly (p<0.05) and clinically (> 5 letters), as highlighted in the...
Dear Editor,
We read your article titled- Non-traumatic corneal perforations: aetiology, treatment and outcomes: with great interest. Corneal perforation is an acute ophthalmic emergency. This review describes the aetiology, plausible location and the multiple ways to approach the management of this condition in a very a systematic manner.
We do appreciate the organised mode of stratification and care of non- traumatic corneal perforation presented in the article. However, although the results are interesting, we feel that caution should be exercised when drawing conclusions from this data.
Initially, in results there are 127 eyes of 116 patients under the review. However, while describing the anatomical location of the perforation, only 102 eyes have been accounted for, with no records for the remaining 25 eyes. This would change the calculated p value significantly.
Similarly, where the initial treatments for perforations were being reviewed 133 eyes were mentioned as treated, thus including six extra unaccounted for eyes to the total. This would seriously jeopardise the authenticity of the calculated results.
Hence, there appears to be serious doubts regarding the validity of the conclusions of this review. A clearer and more detailed explanation or a recalculation of the results is warranted in this regard.
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