626 e-Letters

  • Comments on article "Impact of surgical timing on postoperative ocular motility in orbital blowout fractures

    We have read the article”Impact of surgical timing of postoperative ocular motility in orbital blowout fractures” by Yukito Yamanaka, Akihide Watanabe, Chie Sotozono, Shigeru Kinoshita published in BJO on July 25 2017.The article discusses a new technique of Hess Area Ratio (HAR) and CT-scan findings for determining the appropriate time for surgery and predict the outcomes following orbital fracture repair.
    We want to congratulate the authors for this successful review article. We would like to comment on some points in the methodology and results of this article and make some contributions.The incisions described in the article have some shortcomings and are not currently the favoured approach. The Lynch incision described in the article has been the traditional approach for medial wall fractures but can result in severe scarring or webbing of the medial canthal skin ; therefore the transcaruncular approach is favoured.1 The subciliary incision too can cause ectropion and a transconjunctival approach is preferred.2 The number of patients mentioned in the results section who had poor improvement of HAR% differs being recorded as 22 earlier and then later in the article as 24.The diagnosis of tissue incarceration causing ocular motility disturbances after surgery is more related to various ocular motility tests rather than CT-SCAN findings alone.3 The authors have diagnosed muscle and tissue incarceration based solely on CT-SCAN findings and have not commented on t...

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  • Comment on “The role of specific visual subfields in collisions with oncoming cars during simulated driving in patients with advanced glaucoma”

    Kenzo J. Koike, MD1; Lauren S. Blieden, MD1,2; Yvonne I. Chu, MD1; Silvia Orengo-Nania, MD1,2; Kristin S. Biggerstaff, MD2; Bac T. Nguyen, MD1; Peter T. Chang, MD1,2; Benjamin J. Frankfort, MD, PhD1

    Assessing the visual standards to safely operate a motor vehicle is a challenging topic and discussion that we regularly encounter in our glaucoma population. Multi-centered and population-based studies previously have shown that patients with glaucoma are at particularly increased driving risk, due to their visual deficits.1,2 As such, we greatly appreciate the contributions from Kunimatsu-Sanuki and colleagues, who evaluated patients with advanced glaucoma, and how they performed with a driving simulator. As part of their analysis, the authors focused on specific visual sub-fields, and how those may correlate with the incidence of motor vehicle collisions (MVCs). Their conclusions noted that inferior visual field deficits, age, and visual acuity, were significant factors that contributed to the rate of MVCs. However, we noticed that visual acuity of the better eye (recorded as logMAR) was a significantly higher risk factor (odds ratio of 28.59 and 75.71 for analyses 1 and 2, respectively, as shown in Table 3) for collisions during simulated driving. With such a dramatically higher risk of simulated collision based on visual acuity, it is likely that this parameter alone is the most significant factor to influence the risk of MVCs. As there is some discrepancy in the li...

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  • Optic nerve head swelling on ultrasound and optical coherence tomography in children

    Dear Editor,
    we read with great interest the article by Dahlmann-Noor et al. concerning the possibility to detect optic nerve (ON) head swelling on ultrasound and OCT. 1
    They reported 61 children , investigated for ‘suspicious discs’ that underwent both US and OCT. Among these only 3 children had intracranial hypertension (IHT) but all of them were diagnosed as having drusen on US; even the three children with IHT had ‘small linear’ drusen.
    We would like to comment on small linear drusen that seem to have been undetected by OCT. This is very unlikely. Much care must be taken to diagnose linear drusen with ultrasound because this image could be an artifact due to the strong echoes coming from a surface where the sound beam is perpendicular .
    Measuring optic nerve sheath diameter (ONSD) with B-scan has recently become popular, but there is not a global agreement on how to perform such a measurement as some authors suggest performing axial measurements, some others coronal axis measurements.3-5 Furthermore to establish a cutoff between normal and increased ONSD can be very challenging due to the so-called blooming effect. This B-scan related effect, that should not be confused with the Doppler related one, is due to the lack of sensitivity standard setting: the ON image obtained with a low sensitivity setting will result in larger ON dimensions compared to the ones provided by the same image, increasing the sensitivity setting.
    The authors...

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  • Comment: “The patient is speaking”: discovering the patient voice in ophthalmology

    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...

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  • Classification Of Diabetic Macular Odema Using Ultra- Wide field angiography and implications for response to anti-VEGF therapy

    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...

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  • Response to Thevi T comments

    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...

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  • Bilateral Descemet membrane detachment and Terrien’s marginal degeneration

    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...

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  • Amniotic membrane graft to conjunctival flap in treatment of non-viral resistant infectious keratitis: a randomised clinical study

    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...

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  • Higher posterior capsular rupture rates in male patients

    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...

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  • LETTER TO EDITOR-Treatment patterns and medication adherence of patients with glaucoma in South Korea

    Dear 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.