The recent study by Vega-Estrada et al highlights some of the challenges in diagnosing keratoconus in Down syndrome (DS).[1] Previous studies have shown that the cornea of individuals with DS without evidence of keratoconus appear to be steeper and thinner than the general population, both being features characteristic of keratoconus.[2] Vega-Estrada et al further identified that posterior keratometry was similar in DS to mild keratoconus, however, a lesser degree of posterior elevation was observed in the DS group.[1] This may be related to the younger mean age of the cohort with DS, small sample size or diagnostic criteria. The authors concluded that the corneal features analysed in the DS cohort were in the range of normal to mild keratoconus.[1]
We would like to further highlight some of the challenges associated with image acquisition when performing corneal topo/tomography in patients with DS. Some of the ophthalmic manifestations such as slanted and small palpebral apertures, nystagmus and strabismus can affect fixation. We have also observed additional common behavioural responses that affect fixation and alignment; patients squeezing the eyes shut in response to the examiner touching the eyelids or involuntarily opening the mouth when asked to keep the eyes wide open.
Misaligned fixation while acquiring corneal tomography images is known to result in false keratoconus features.[3] In addition to the reported overlap in corneal features in DS and ke...
The recent study by Vega-Estrada et al highlights some of the challenges in diagnosing keratoconus in Down syndrome (DS).[1] Previous studies have shown that the cornea of individuals with DS without evidence of keratoconus appear to be steeper and thinner than the general population, both being features characteristic of keratoconus.[2] Vega-Estrada et al further identified that posterior keratometry was similar in DS to mild keratoconus, however, a lesser degree of posterior elevation was observed in the DS group.[1] This may be related to the younger mean age of the cohort with DS, small sample size or diagnostic criteria. The authors concluded that the corneal features analysed in the DS cohort were in the range of normal to mild keratoconus.[1]
We would like to further highlight some of the challenges associated with image acquisition when performing corneal topo/tomography in patients with DS. Some of the ophthalmic manifestations such as slanted and small palpebral apertures, nystagmus and strabismus can affect fixation. We have also observed additional common behavioural responses that affect fixation and alignment; patients squeezing the eyes shut in response to the examiner touching the eyelids or involuntarily opening the mouth when asked to keep the eyes wide open.
Misaligned fixation while acquiring corneal tomography images is known to result in false keratoconus features.[3] In addition to the reported overlap in corneal features in DS and keratoconus, fixation misalignment combined with sub-optimal quality scans may affect the reliability and repeatability of corneal topo/tomography in this population and poses challenges in diagnosing and assessing progression of keratoconus. The latter is particularly pertinent when considering the indication for corneal collagen cross-linking in patients with DS. Vega-Estrada et al have very usefully highlighted the limitations in diagnosis of keratoconus in DS and contributed to the resolution of this important issue.[1]
References
1. Vega-Estrada A, Fariselli C, Alio JL. Posterior corneal features in patients with down syndrome and their relation with keratoconus. Br J Ophthalmol Published Online First: 2 Mar 2020. doi:10.1136/bjophthalmol-2019-314939.
2. Alio JL, Vega-Estrada A, Sanz P, et al. Corneal morphologic characteristics in patients with down syndrome. JAMA Ophthalmol 2018;136:971-8.
3. Belin MW, Khachikian SS. An introduction to understanding elevation‐based topography: how elevation data are displayed–a review. Clin Exp Ophthalmol 2009;37:14-29.
We appreciate the authors' interest in our study. In their letter to the editor regarding our meta-analysis[1], the authors raise an issue regarding the inclusion of the diseases in the two groups i.e. limbal stem cell deficiency (LSCD) and ocular surface disease (OSD). We adhered to the categorization of the diseases as indicated or mentioned in the publications which were included in the meta-analysis. Our literature search based on combinations of various “key-words” or “key-terms” returned results as depicted in the categorization of the diseases in the study.[2,3] LSCD being a sub-set of OSD, has signs and symptoms in common with many other conditions, hence it was important that the term “limbal stem cell deficiency” appeared in the publications for the study participants to be categorized into the LSCD group.[2,3,4]
The lack of consideration of the severity of LSCD and OSD was unavoidable due to the limited data within the source publications. It is apparent that the severity of the disease may affect the corneal epithelial basal cell density (BCD) and nerve fibre parameters.[5,6] The lack of data is likely explained by the difficulty in imaging in the more severe disease when corneal transparency is reduced; the corneal basal cells and nerves are difficult to image using confocal microscopy when the cornea is not clear. This is an important factor which is highlighted in our study.[1] Furthermore, our analysis did not attempt to c...
We appreciate the authors' interest in our study. In their letter to the editor regarding our meta-analysis[1], the authors raise an issue regarding the inclusion of the diseases in the two groups i.e. limbal stem cell deficiency (LSCD) and ocular surface disease (OSD). We adhered to the categorization of the diseases as indicated or mentioned in the publications which were included in the meta-analysis. Our literature search based on combinations of various “key-words” or “key-terms” returned results as depicted in the categorization of the diseases in the study.[2,3] LSCD being a sub-set of OSD, has signs and symptoms in common with many other conditions, hence it was important that the term “limbal stem cell deficiency” appeared in the publications for the study participants to be categorized into the LSCD group.[2,3,4]
The lack of consideration of the severity of LSCD and OSD was unavoidable due to the limited data within the source publications. It is apparent that the severity of the disease may affect the corneal epithelial basal cell density (BCD) and nerve fibre parameters.[5,6] The lack of data is likely explained by the difficulty in imaging in the more severe disease when corneal transparency is reduced; the corneal basal cells and nerves are difficult to image using confocal microscopy when the cornea is not clear. This is an important factor which is highlighted in our study.[1] Furthermore, our analysis did not attempt to correlate the BCD and corneal nerve parameters in LSCD (or OSD) based on disease severity, the analysis reported the difference in these parameters in LSCD and OSD to those participants with the normal ocular surface.
The authors report the analysis of corneal nerve fibre length (CNFL) after removing 7 studies from the OSD group and suggest that CNFL was reduced in LSCD compared to OSD. However, removing these studies caused a significant increase in the overall heterogeneity as the I-square value increased to 88.7% as compared to 49.6% in the published report. Furthermore, due to the lack of data in the LSCD group (only 2 studies), it is difficult to draw meaningful conclusions. We addressed this issue of power and what conclusions could be confidently made in the limitation section of our paper. For BCD, after redoing the analysis as suggested by the authors, we did not find a significant difference in the weighted mean difference (WMD) between LSCD and OSD (P=0.11). In addition, the modified analysis showed increased heterogeneity where the I-square value increased to 61.9% compared to 56.1% in the published report. Hence, when statistically considered, we cannot conclude there exists a significant difference in BCD between OSD and LSCD, based on current evidence.
Various studies have shown reduced corneal nerve parameters and BCD even in systemic diseases like diabetes.[7] Hence, central corneal BCD and nerve fibre parameters need to be used in conjunction with both the clinical presentation and any laboratory results. After considering the Clemence et al.’s suggestions, we are confident that our analysis and method for characterizing the participants remains correct.
Meta-analysis depends on research groups spending much time and resources collecting primary data. We remain indebted to the authors of the papers we included in our analysis and again thank those that sent us missing data and responded to our queries that enabled the inclusion of their work. When more studies are completed, updated analysis and conclusions can be made on differences in BCD and corneal nerve morphology in OSD and LSCD.
Authors: Pradipta Bhattacharya, M Phil., Katie Edwards, Ph.D., Damien Harkin, Ph.D., Katrina L Schmid, PhD.
Financial Disclosures/ Conflict of Interest: None reported.
REFERENCES
1. Bhattacharya P, Edwards K, Harkin D, Schmid KL. Central corneal basal cell density and nerve parameters in ocular surface disease and limbal stem cell deficiency: a review and meta-analysis. Br J Ophthalmol 2020.
2. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med 2009;18;151(4):W-65.
3. Shortt AJ, Tuft SJ, Daniels JT. Corneal stem cells in the eye clinic. Br Med Bull 2011;100:209–25.
4. Deng SX, Borderie V, Chan CC, Dana R, Figueiredo FC, Gomes JA, Pellegrini G, Shimmura S, Kruse FE, International Limbal Stem Cell Deficiency Working Group. Global consensus on definition, classification, diagnosis, and staging of limbal stem cell deficiency. Cornea 2019;38(3):364-75.
5. Chan EH, Chen L, Rao JY, Yu F, Deng SX. Limbal basal cell density decreases in limbal stem cell deficiency. Am J Ophthalmol 2015;160(4):678-84.
6. Deng SX, Sejpal KD, Tang Q, Aldave AJ, Lee OL, Yu F. Characterization of limbal stem cell deficiency by in vivo laser scanning confocal microscopy: a microstructural approach. Arch Ophthalmol 2012;130(4):440-5.
7. Dehghani C, Pritchard N, Edwards K, Russell AW, Malik RA, Efron N. Abnormal anterior corneal morphology in diabetes observed using in vivo laser-scanning confocal microscopy. Ocul Surface 2016;14(4):507-14.
We have read the review article entitled “Ocular complications of cat scratch disease” Johnson A. Br J Ophthalmol 2020;0:1-7. We want to congratulate the author for this important review article, and make some contributions.
In the review article, it has been indicated that optical coherence tomography (OCT) imaging is of value to monitoring cat scratch disease (CSD), particularly for neuroretinitis and multifocal retinitis.
We would like to highlight a feature of focal retinitis with spectral domain optical coherence tomography (SD-OCT). Small areas of retinitis, less than 500 microns in diameter, can be seen on OCT imaging. These appear as areas of focal hyper-reflectivity of the inner retinal layers and decreased reflectivity causing a shadow on the outer retinal layers and choroid. This was seen in two patients presenting to our service recently with Bartonella henselae CSD diagnosed clinically and confirmed by positive serology.
The first case was a 49-year-old Caucasian male who presented with bilateral inflammatory papillitis and multifocal retinitis without a macular star, confirmed with serology as Bartonella henselae (IgG >2048). He had good presenting Snellen visual acuities of 6/5 right, 6/6 left. OCT imaging at acute presentation showed multifocal retinitis seen as small areas retinal hyper-reflectivity of the inner retina with outer retinal disruption. The disease resolved without treatment in 8 months, with...
We have read the review article entitled “Ocular complications of cat scratch disease” Johnson A. Br J Ophthalmol 2020;0:1-7. We want to congratulate the author for this important review article, and make some contributions.
In the review article, it has been indicated that optical coherence tomography (OCT) imaging is of value to monitoring cat scratch disease (CSD), particularly for neuroretinitis and multifocal retinitis.
We would like to highlight a feature of focal retinitis with spectral domain optical coherence tomography (SD-OCT). Small areas of retinitis, less than 500 microns in diameter, can be seen on OCT imaging. These appear as areas of focal hyper-reflectivity of the inner retinal layers and decreased reflectivity causing a shadow on the outer retinal layers and choroid. This was seen in two patients presenting to our service recently with Bartonella henselae CSD diagnosed clinically and confirmed by positive serology.
The first case was a 49-year-old Caucasian male who presented with bilateral inflammatory papillitis and multifocal retinitis without a macular star, confirmed with serology as Bartonella henselae (IgG >2048). He had good presenting Snellen visual acuities of 6/5 right, 6/6 left. OCT imaging at acute presentation showed multifocal retinitis seen as small areas retinal hyper-reflectivity of the inner retina with outer retinal disruption. The disease resolved without treatment in 8 months, with final Snellen visual acuities of 6/5 right and 6/6 left.
An area of retinitis was also demonstrated in a 9-year-old Caucasian girl with CSD. CSD was confirmed with positive serologic testing for Bartonella henselae (IgG >2048, IgM <20). She presented with a four-day history of reduced vision in her left eye and a gastrointestinal illness, and had recently been scratched by a stray kitten. She developed bilateral neuroretinitis with presenting Snellen visual acuities of 6/6 right and count fingers left. A small area of juxtafoveal retinitis was demonstrated on OCT in her right eye as inner retinal hyper-reflectivity, casting a shadow on the outer retina and underlying choroid. She was treated with oral doxycycline, oral rifampicin and oral prednisone. After two weeks treatment the focal retinitis was smaller but with persistent loss of inner retinal architecture and shadowing the outer retinal and choroid, and this area had reduced further after 36 days with visualization of the outer retina and choroid in the affected area.
There are few studies documenting OCT findings in CSD. Most common findings include flattening of the foveal contour, thickening of the neurosensory retina and the presence of subretinal fluid associated with neuroretinitis.[1] Exudate associated with neuroretinitis appears as multiple hyper-reflective foci in the outer plexiform layer[2] and can lead to disruption and loss of the external limiting membrane, ellipsoid zone and interdigitation zone.[3]
To our knowledge only two other paper have described the OCT finding of focal retinitis.[4,5] This OCT sign can persist for months but with gradual decreased reflectivity of the lesion and improved visualization of outer retina as the disease resolves.[4]
References
1. Ksiaa I, Abroug N, Mahmoud A, Zina S, Hedayatfar A, Attia S, Khochtali S, Khairallah M. Update on Bartonella neuroretinitis. Journal of Current Ophthalmology. 2019;31:254-61.
2. Habot-Wilner Z, Zur D, Goldstein M, Goldenberg D, Shulman S, Kesler A, Giladi M, Neudorfer M. Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis. Eye. 2011;25:1064-8.
3. Mello LGM, Lima LH, Cabral T, Rodrigues MZ, Pecanha PM, Belfort R. Bartonella Quintana-associated neuroretinitis: longitudinal spectral-domain optical coherence tomographic findings. Retinal Cases & Brief Reports. 2016;0:1-6.
4. Empeslidis T, Tsauousis KT, Konidaris V, Pradeep A, Deane J. Multifocal chorioretinitis caused by Bartonella henselae: imaging findings of spectral domain optical coherence tomography during treatment with trimethoprim-sulfamethoxazole. Eye. 2014;28:907-9.
5. Pichi F, Srivastava S, Levinson A, Baynes KM, Traut C, Lowder CY. A focal chorioretinal Bartonella lesion analyzed by optical coherence tomography angiography. Ophthalmic Surg Lasers Imaging Retina. 2016;47:585-8.
Dear Editor,
We read with great interest the excellent paper by Sagiv and collegues Ocular preservation with neoadjuvant Vismodegib in patients with locally advanced periocular basal cell carcinoma.(1)
The article is a great contribution for a topic with a growing, but still limited worldwide experience. Our interest is to discuss the surgical approach after neoadjuvant Vismodegib.
The authors present a patient with a 5x4cm locally advanced periocular basal cell carcinoma (LAP-BCC) with small nerve perineural invasion (>0.1mm) involving lower eyelid, inner canthus and cheek. The patient showed a significant response after 10 months of Vismodegib. Anyhow, it was clearly a partial response with 3 suspicious areas of BCC after treatment. The authors decided to treat separately each area with surgery, and histology (en face sections) confirmed the presence of tumor in two. The reconstructive outcome was excellent, and at the time of publication the patient was free of disease, 11 months after surgery.
We agree with the authors, when they consider as a limitation the fact that “surgery did not always include the entire area of the original tumor”.
Most studies involving smoothened inhibitors thus far have measured clinical tumor shrinkage but not true histologic margin control. Even after a complete clinical response (CCR), there is no way to assure that it will result in a complete histological clearance (CHR).
Dear Editor,
We read with great interest the excellent paper by Sagiv and collegues Ocular preservation with neoadjuvant Vismodegib in patients with locally advanced periocular basal cell carcinoma.(1)
The article is a great contribution for a topic with a growing, but still limited worldwide experience. Our interest is to discuss the surgical approach after neoadjuvant Vismodegib.
The authors present a patient with a 5x4cm locally advanced periocular basal cell carcinoma (LAP-BCC) with small nerve perineural invasion (>0.1mm) involving lower eyelid, inner canthus and cheek. The patient showed a significant response after 10 months of Vismodegib. Anyhow, it was clearly a partial response with 3 suspicious areas of BCC after treatment. The authors decided to treat separately each area with surgery, and histology (en face sections) confirmed the presence of tumor in two. The reconstructive outcome was excellent, and at the time of publication the patient was free of disease, 11 months after surgery.
We agree with the authors, when they consider as a limitation the fact that “surgery did not always include the entire area of the original tumor”.
Most studies involving smoothened inhibitors thus far have measured clinical tumor shrinkage but not true histologic margin control. Even after a complete clinical response (CCR), there is no way to assure that it will result in a complete histological clearance (CHR).
Several authors discussed this issue. Tang and Alcalay reported a small number of LA-BCC treated with neoadjuvant Vismodegib plus Mohs surgery (MS).2-3 Although they observed a significant tumor shrinkage, they found islands of BCC within all their debulking specimens.(2-3) Ching in a series with 6 LA-BCCs,(4) with bone involvement, reported that multiple superficial biopsies done after neoadjuvant Vismodegib, showed no evidence of BCC . However, all the surgically resected specimens revealed residual tumor. After this data, Ching states that the effect of Hh inhibitor is suppressive rather than curative and should be followed by definitive surgery.
Koekelkoren, after treating 4 cases with “giant” LA-BCC, indicates that resistance to Vismodegib seems to occur more often in deep tumor planes near bone or cartilage and suggests this may be related with suboptimal blood perfusion, resulting in lower Vismodegib tissue levels.(5)
So far, we have treated 13 patients with LAP-BCC with neoadjuvant Vismodegib + MS. The first eight cases were included in a paper published last year.(6) We observed 9 CCR, 3 partial responses and 1 patient progressed. Out of the 9 CCR one patient refused surgery and is without evidence of disease after 34 months. We confirmed 6/8 CHR and found persistent tumor with MS in 2 patients. With a mean follow up of 24.6 months, one patient with a CHR recurred 17 months after MS. Therefore, 3/9 cases with a CCR either had persistent tumor at the time of MS or recurred lately, probably due to skip tumor areas.
We believe this evidence supports our position. Neoadjuvant Vismodegib may lead to missing discontiguous tumor on surgery. This may eventually progress to more aggressive histology, including thin strands of BCC, immersed in dense inflammatory/scar tissue. The evaluation of surgical margins in this scenario may be challenging.
We also differ with the authors about the need of a free flap for reconstruction in this case. Due to the difference in color and texture with facial skin, we try to avoid free flaps for cheek reconstruction and prefer a Mustardé flap (or a cervicofacial flap) combined with an oculoplastic repair for the eyelids.
Bibliography
1. Sagiv O, Nagarajan P, Ferrarotto R, Kandl TJ, Thakar SD, Glisson BS, Altan M, Esmaeli B. Br J Ophthalmol. 2019 Jun;103(6):775-780. Ocular preservation with neoadjuvant vismodegib in patients with locally advanced periocular basal cell carcinoma Br J Ophthalmol. 2019 Jun;103(6):775-780
2. Tang N, Ratner D. Implementation of systemic hedgehog inhibitors in daily practice as neoadjuvant therapy. J Natl Compr Canc Netw 2017; 15:537–43
3. Alcalay J, Tauber G, Fenig E, Hodak E. Vismodegib as a neoadjuvant treatment to mohs surgery for aggressive basal cell carcinoma. J Drugs Dermatol 2015;14:219–23.
4. Ching JA, Curtis HL, Braue JA, Kudchadkar RR, Mendoza TI, Messina JL, Cruse CW, MD, Smith DJ, Harrington MA. The Impact of Neoadjuvant Hedgehog Inhibitor Therapy on the Surgical Treatment of Extensive Basal Cell Carcinoma. Ann Plast Surg 2015;74: S193–S197
5. Koekelkoren FHJ, Roodbergen SL, Baerveldt EM, Maat APWM, Monserez DA, Grunhagen DJ, Mureau MAM, de Haas ERM, PhD, Nijsten EC, Wakkee M. Vismodegib for giant, locally advanced, basal cell carcinoma and its complex position in clinical practice. JAAD Case Reports 2019; 5:267-70.
6. González AR, Etchichury D, Gil ME, Del Aguila R. Neoadjuvant Vismodegib and Mohs Micrographic Surgery for Locally Advanced Periocular Basal Cell Carcinoma. Ophthalmic Plast Reconstr Surg. 2019; 35(1):56-61.
We read with great interest this comparison between selective laser trabeculoplasty (SLT) and medication for Open-Angle Glaucoma (OAG). (1)
The recent LiGHT trial (2), an important landmark in the management of glaucoma, suggests that SLT represents an ideal first-line treatment option of ocular hypertension (OHT) and open angle glaucoma (OAG) in terms of decreased costs, with similar efficacy and quality of life when comparing to medication. The strength of the trial resides in its methodology, limiting most of the bias seen in the previous retrospective studies on the subject. Despite the fact that their conclusions seemed to be echoing various other authors (3,4) there is still debate as to whether SLT should become a first-line treatment.
The current powerful meta-analysis by Chi et al on 1229 patients (14 articles, 8 randomized clinical trials), may become the final argument on the debate demonstrating that not only is SLT not inferior to medical therapy in terms of IOP-lowering effect or safety, but it allows for significantly lesser use of medication. (1)
The longer duration of effect, minimized cost, and safety of SLT are especially important in settings with difficult access to care, such as in developing countries, or in patients with decreased mobility. A recent study on incarcerated patients showed that even when measures are taken to administer and control patients’ adherence to treatment, substantial nonadherence persists. (5)
It is ri...
We read with great interest this comparison between selective laser trabeculoplasty (SLT) and medication for Open-Angle Glaucoma (OAG). (1)
The recent LiGHT trial (2), an important landmark in the management of glaucoma, suggests that SLT represents an ideal first-line treatment option of ocular hypertension (OHT) and open angle glaucoma (OAG) in terms of decreased costs, with similar efficacy and quality of life when comparing to medication. The strength of the trial resides in its methodology, limiting most of the bias seen in the previous retrospective studies on the subject. Despite the fact that their conclusions seemed to be echoing various other authors (3,4) there is still debate as to whether SLT should become a first-line treatment.
The current powerful meta-analysis by Chi et al on 1229 patients (14 articles, 8 randomized clinical trials), may become the final argument on the debate demonstrating that not only is SLT not inferior to medical therapy in terms of IOP-lowering effect or safety, but it allows for significantly lesser use of medication. (1)
The longer duration of effect, minimized cost, and safety of SLT are especially important in settings with difficult access to care, such as in developing countries, or in patients with decreased mobility. A recent study on incarcerated patients showed that even when measures are taken to administer and control patients’ adherence to treatment, substantial nonadherence persists. (5)
It is risky to compare such a study with likely inmate-specific risk factors to the current COVID-19 pandemic context. However, with social distancing measures in effect, and government-mandated restrictions or lockdowns, there is a reduced mobility of patients, likely leading to reduced medication adherence. In this time especially, ophthalmologists should strongly consider SLT as a first-line treatment in an attempt to limit patient visits and increase the likelihood to achieve durable IOP-reduction. Evidently, since the procedure is performed within close proximity to the patient, protective measures should be taken to limit contact and the risk of disease spreading.
Sincerely yours,
1. Chi SC, Kang Y-N, Hwang D-K, Liu CJ-L. Selective laser trabeculoplasty versus medication for open-angle glaucoma: systematic review and meta-analysis of randomised clinical trials. Br J Ophthalmol. 2020 Feb 12;
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet Lond Engl. 2019 Apr 13;393(10180):1505–16.
3. Elahi S, Rao HL, Dumitru A, Mansouri K. Predictors of Success in Selective Laser Trabeculoplasty: Data from the Lausanne Laser Trabeculoplasty Registry. J Glaucoma. 2020 May 8;
4. Realini T, Shillingford-Ricketts H, Burt D, Balasubramani GK. West Indies Glaucoma Laser Study (WIGLS)-2: Predictors of Selective Laser Trabeculoplasty Efficacy in Afro-Caribbeans With Glaucoma. J Glaucoma. 2018;27(10):845–8.
5. Kanu LN, Jang I, Oh DJ, Tiwana MS, Mehta AA, Dikopf MS, et al. Glaucoma Care of Prison Inmates at an Academic Hospital. JAMA Ophthalmol. 2020 Feb 20;
We thank Dr. Shukla for his interest in our article and his comments 1, 2.
In our study all consecutive cases of rhegmatogenous retinal detachment (RD) that underwent pars plana vitrectomy (PPV) were included in the study regardless of complexity, type of tear, lens or refractive status, or use of supplemental buckle in order to reduce selection bias and to allow study of various subgroups of patients. For the same reason the 13 cases with silicone oil present at the time of last follow-up were not excluded. The paper referenced by Dr. Shukla reports a retinal re-detachment rate of 13.2% after removal of silicone oil (ROSO), with many of the cases performed prior to the era of small gauge vitrectomy and wide-angle viewing systems (WAVS) 3. Encircling endolaser photocoagulation further reduces the re-detachment rate to 8.6% 4. More recent surgical techniques are likely associated with a lower retinal re-detachment rate. Nevertheless, a presumed retinal re-detachment of 13.2% following ROSO corresponds to an estimated 1.7 eyes with recurrent RD out of the 13 eyes with residual silicone oil in our series 3. This in turn corresponds to a 0.5% difference in the overall single surgery success rate (SSSR) in 312 eyes. It could therefore be safely assumed that inclusion of the small group with silicone oil at the last follow-up visit did not affect the overall success rate significantly, but reduced chances of introducing a selection bias.
We thank Dr. Shukla for his interest in our article and his comments 1, 2.
In our study all consecutive cases of rhegmatogenous retinal detachment (RD) that underwent pars plana vitrectomy (PPV) were included in the study regardless of complexity, type of tear, lens or refractive status, or use of supplemental buckle in order to reduce selection bias and to allow study of various subgroups of patients. For the same reason the 13 cases with silicone oil present at the time of last follow-up were not excluded. The paper referenced by Dr. Shukla reports a retinal re-detachment rate of 13.2% after removal of silicone oil (ROSO), with many of the cases performed prior to the era of small gauge vitrectomy and wide-angle viewing systems (WAVS) 3. Encircling endolaser photocoagulation further reduces the re-detachment rate to 8.6% 4. More recent surgical techniques are likely associated with a lower retinal re-detachment rate. Nevertheless, a presumed retinal re-detachment of 13.2% following ROSO corresponds to an estimated 1.7 eyes with recurrent RD out of the 13 eyes with residual silicone oil in our series 3. This in turn corresponds to a 0.5% difference in the overall single surgery success rate (SSSR) in 312 eyes. It could therefore be safely assumed that inclusion of the small group with silicone oil at the last follow-up visit did not affect the overall success rate significantly, but reduced chances of introducing a selection bias.
In our series a supplemental encircling scleral buckle (SB) (42 silicone band) was used in 34% of the eyes. Throughout the study there was a decreasing trend in the use of supplemental SB while the outcomes remained stable. This has been discussed in detail in a sequel publication5. Dr. Shukla comments, “the optional use of scleral buckle in this study is confusing”. It is clear from the data that good anatomic outcomes may be achieved with PPV without vitreous base (VB) shaving in both PPV and PPV+SB groups. The author further states “the vitreous base-shaving is critical to anatomical success when no encirclage is used”. This is an assumption that is not supported by the findings of our study: 195 (94.7%) of 206 eyes without SB had reattachment of the retina with a single surgery. The reference that is provided is a retrospective series of RDs that underwent PPV and silicone oil between 2000 and 2012, many of which were presumably performed without the use of small gauge vitrectomy or WAVS3. The study retrospectively identified vitreous remnants during retinal re-detachment surgery and equated this finding to inadequate VB shaving rather than inadequate vitreous removal. Using WAVS, it is possible to visualize the retina periphery to the vicinity of the VB and remove the peripheral vitreous effectively without a need for scleral depressed shaving of the VB6. Removal of clinically significant peripheral vitreous without VB shaving avoids leaving significant amounts of vitreous remnant and is compatible with good anatomic success rate. Dr. Shukla states “the authors reported no additional benefit from buckling”. We reported, “the single-surgery success rate was similar in eyes with and without SB (95.2% and 94.7%)” and cautioned against comparative interpretation of these findings as eyes with SB likely had more complex retinal detachments. Dr. Shukla further comments “We therefore do not have clarity about the one moot issue this study could settle: whether vitrectomy sans base-shaving is good enough for simple RD at least”. The answer to this comment-question is clear: Using WAVS and small gauge vitrectomy systems, vitrectomy without routine prophylactic scleral depressed shaving of VB may be associated with good anatomic outcomes (95% SSSR) for retinal detachments with a range of complexities including simple RDs2.
A recent report by Sohn and colleagues detailed the characteristics and outcomes of retinal detachment surgery for eyes with posteriorly inserted vitreous base (PIVB)7. The authors suggested encircling endolaser photocoagulation or supplemental scleral buckle in these cases. In our series, PIVB was noted in a minority of cases. In these cases encircling endolaser photocoagulation was performed posterior to the insertion of the vitreous base with additional septate pattern in each quadrant. Supplemental SB was considered if retinal detachment with multiple tears was present inferiorly. While a thorough removal of peripheral vitreous makes clinical sense, there is no evidence in the literature that shaving of the vitreous base improves anatomic outcomes in cases with PIVB.
In our series, GRTs measured from 3 to 11 clock hours, with the majority measuring between 4-6 clock hours. Proliferative vitreoretinopathy ranged from none to funnel retinal detachment. Seven (50%) of 14 eyes with GRT had supplemental SB, 11 (79%) eyes had silicone oil tamponade, and 2 of the 8 phakic eyes had removal of cataractous lens in order to improve visualization. At the last follow-up, silicone oil was present in 3 eyes. Dr. Shukla comments that vitreous base shaving is considered non-negotiable in a GRT and references a review article on GRT by Shunmugam and colleagues 8. The article cites 2 studies published in 1981 and 1992 in support of shaving of the vitreous base in the management of RD associated with GRT9, 10. Interestingly, within the same section, it is stated “opposite the GRT, however, because of the adherence of the vitreous base, limited vitrectomy is advisable to avoid circumferential extension of the GRT or the formation of further retinal breaks”. It appears that shaving of the vitreous base has uncertain merit for these cases. In the area corresponding to GRT, the VB is partly removed during removal of the anterior flap of the GRT and the remainder covers the surface of pars plana. In the area outside of the GRT, retinal laser photocoagulation applied posterior to the VB margin reduces risk of retinal detachment originating from this area.
In summary, introduction of 3-port pars plana vitrectomy in the 1970s transformed management of retinal detachment. Some of the early reports suggested that shaving of the VB may be associated with improved outcomes. Since the early days of PPV, many advances have been made including the introduction of endolaser photocoagulation, perfluorocarbon heavy liquid, WAVS, sclerotomy cannula systems, fast cutting small gauge vitrectomy systems, high precision microinstrumentation, chromophore-assisted visualization of the vitreous and preretinal membranes, and effective ocular anti-inflammatory pharmacotherapy. With continued advances in vitrectomy surgery, there is a need for reevaluation and modification of our surgical techniques.
We read with great interest the article entitled ‘Prevalence of guttae in the graft following corneal transplantation’ by Nahum et al, published in the May 2015 issue of the British Journal of Ophthalmology [1] . The authors reported the prevalence of cornea guttata postkeratoplasty in a large population of 1116 patients to be 4%. They also found that guttae postkeratoplasty do not negatively affect the visual acuity, endothelial cell density, or graft survival during the initial two postoperative years. The content of this article is important and well put, since this is the first study to reveal the prevalence and sequelae of postkeratoplasty guttae on the corneal graft.
Based on our clinical experience and on multiple published studies, the prevalence of cornea guttata in the normal population is estimated to be higher than 4% [2]. However, the low prevalence reached by Nahum et al, is explained mainly by the preoperative screening of the donor corneas for guttae, as stated in the article. Therefore, it would be very interesting if the authors can provide an estimation of the percentage of donor corneas that are usually discarded by the guttae screening in their eye bank.
Up to our knowledge, guttae are very often not detectable using inverted light microscopy, thus guttae screening as a part of the routine examination of the donor corneas is a challenging task. There is only one study performed by Borderie et al in 2001 [3], that aimed to detect the pres...
We read with great interest the article entitled ‘Prevalence of guttae in the graft following corneal transplantation’ by Nahum et al, published in the May 2015 issue of the British Journal of Ophthalmology [1] . The authors reported the prevalence of cornea guttata postkeratoplasty in a large population of 1116 patients to be 4%. They also found that guttae postkeratoplasty do not negatively affect the visual acuity, endothelial cell density, or graft survival during the initial two postoperative years. The content of this article is important and well put, since this is the first study to reveal the prevalence and sequelae of postkeratoplasty guttae on the corneal graft.
Based on our clinical experience and on multiple published studies, the prevalence of cornea guttata in the normal population is estimated to be higher than 4% [2]. However, the low prevalence reached by Nahum et al, is explained mainly by the preoperative screening of the donor corneas for guttae, as stated in the article. Therefore, it would be very interesting if the authors can provide an estimation of the percentage of donor corneas that are usually discarded by the guttae screening in their eye bank.
Up to our knowledge, guttae are very often not detectable using inverted light microscopy, thus guttae screening as a part of the routine examination of the donor corneas is a challenging task. There is only one study performed by Borderie et al in 2001 [3], that aimed to detect the presence of guttae during organ culture. Unfortunately, this study did not clearly describe the features of guttae detected using light microscopy, and the pictures provided did not show specific and distinct findings. Moreover, a clear association proving that the guttae suspected preoperatively in the eye bank correspond to the postoperative guttae detected by specular microscopy was missing.
Therefore, it would be of great importance to the eye banks on an international level to be informed in detail about the preoperative guttae screening process that was performed by Nahum et al, explaining the exact methods followed by their eye bank and clarifying the guttae features as visualized by inverted light microscopy.
References:
1. Nahum Y, Canton V, Ponzin D, Busin M. Prevalence of guttae in the graft following corneal transplantation. Br J Ophthalmol. 2015;99(12):1660-1663.
2. Zoega GM, Arnarsson A, Sasaki H, Söderberg PG, Jonasson F. The 7-year cumulative incidence of cornea guttata and morphological changes in the corneal endothelium in the Reykjavik Eye Study. Acta Ophthalmol. 2013;91(3):212-218.
3. Borderie VM, Sabolic V, Touzeau O, Scheer S, Carvajal-Gonzalez S, Laroche L. Screening human donor corneas during organ culture for the presence of guttae. Br J Ophthalmol. 2001;85(3):272-276.
Bonafede et al1 analyzed the change over time in hypermetropia in children from the USA with partially and fully accommodative esotropia. This study complements a previous long-term follow-up multi-center publication on 164 hypermetropic children from USA, Germany, and Israel2. The follow-up was comparable: ages 3.5-10.5 years in the previous article compared to 3-12 years in the current paper. The range of spherical equivalent refractive error in the previous paper was categorized as +1-3Diopters (D) (mild hypermetropes) and +5-8D (high hypermetropes). In contrast, the current study included also moderate hypermetropes, because it involved a group with less than +4D hypermetropes and a group of children with hypermetropia of +4D or more. Esotropia in the previous study was not present in any of the mild hypermetropes but was present in half (48%) of the high hypermetropes. Due to a decrease in hypermetropia over time beyond the age of 6 years old, mild hypermetropes in the previous study were weaned from glasses (-0.095 D/year), while the high hypermetropes remained in glasses (-0.037 D/year). Similarly, because of a mean decrease of -0.17 D/year that occurred only from age 7 to 15 years, subjects in the current study with a “smaller baseline” (i.e., mild) hypermetropia stopped wearing glasses. However, most moderate and high hypermetropes beyond the age of 12 years remained in glasses (-0.18 D/year).
Bonafede et al1 analyzed the change over time in hypermetropia in children from the USA with partially and fully accommodative esotropia. This study complements a previous long-term follow-up multi-center publication on 164 hypermetropic children from USA, Germany, and Israel2. The follow-up was comparable: ages 3.5-10.5 years in the previous article compared to 3-12 years in the current paper. The range of spherical equivalent refractive error in the previous paper was categorized as +1-3Diopters (D) (mild hypermetropes) and +5-8D (high hypermetropes). In contrast, the current study included also moderate hypermetropes, because it involved a group with less than +4D hypermetropes and a group of children with hypermetropia of +4D or more. Esotropia in the previous study was not present in any of the mild hypermetropes but was present in half (48%) of the high hypermetropes. Due to a decrease in hypermetropia over time beyond the age of 6 years old, mild hypermetropes in the previous study were weaned from glasses (-0.095 D/year), while the high hypermetropes remained in glasses (-0.037 D/year). Similarly, because of a mean decrease of -0.17 D/year that occurred only from age 7 to 15 years, subjects in the current study with a “smaller baseline” (i.e., mild) hypermetropia stopped wearing glasses. However, most moderate and high hypermetropes beyond the age of 12 years remained in glasses (-0.18 D/year).
In conclusion, data derived from both studies, pertaining to children with or without esotropia, reveals that only mild hypermetropes will be weaned from glasses in their teens. In contrast, moderate and high hypermetropes will remain in glasses. We congratulate the authors of the current study for their contribution that makes it possible based on data collated from around the world to inform parents whether their child will need glasses beyond childhood.
References:
1. Bonafede L, Bender L, Shaffer J, et al. Refractive change in children with accommodative esotropia. British Journal of Ophthalmology 2020;104:1283-1287.
2. Mezer E, Meyer E, Wygnanski-Jaffe T, Haase W, Shauly Y, Biglan AW. The long-term outcome of the refractive error in children with hypermetropia. Graefes Arch Clin Exp Ophthalmol. 2015;253(7):1013-1019.
We thank Svasti-Salee, Snead and Alexander [1] for their interest in our study and their comment regarding the reliability of spectral domain optical coherence tomography (SD-OCT) in differentiating a completely attached hyaloid versus complete posterior vitreous detachment (PVD).
To address the author’s question, in our post-hoc analysis, only SD-OCT was used to diagnose PVD status. A slit-lamp examination specifically assessing for PVD was not performed per protocol in the TREND study, [2] therefore data other than SD-OCT were not available for post-hoc analysis.
The accepted clinical methods to determine PVD include slit-lamp examination, dynamic ultrasonography and SD-OCT, while previous generations of OCT (time-domain OCT) potentially offered insufficient resolution and field of view. Of those methods, SD-OCT has the main advantage of being operator independent and allowing systematic, standardized evaluation in a reading center setting. The approach chosen for the analysis of the TREND dataset has been repeatedly performed in several prior studies, with similar outcome data. [3-5]
A recent study cited by the authors [6] reports that PVD status on SD-OCT did not correlate well to intraoperative findings when patients underwent vitrectomy. However, vitrectomy surgery is performed in patients with vitreomacular interface disease, where often a multi-layered posterior vitreous cortex cleaving into separate planes is found, making...
We thank Svasti-Salee, Snead and Alexander [1] for their interest in our study and their comment regarding the reliability of spectral domain optical coherence tomography (SD-OCT) in differentiating a completely attached hyaloid versus complete posterior vitreous detachment (PVD).
To address the author’s question, in our post-hoc analysis, only SD-OCT was used to diagnose PVD status. A slit-lamp examination specifically assessing for PVD was not performed per protocol in the TREND study, [2] therefore data other than SD-OCT were not available for post-hoc analysis.
The accepted clinical methods to determine PVD include slit-lamp examination, dynamic ultrasonography and SD-OCT, while previous generations of OCT (time-domain OCT) potentially offered insufficient resolution and field of view. Of those methods, SD-OCT has the main advantage of being operator independent and allowing systematic, standardized evaluation in a reading center setting. The approach chosen for the analysis of the TREND dataset has been repeatedly performed in several prior studies, with similar outcome data. [3-5]
A recent study cited by the authors [6] reports that PVD status on SD-OCT did not correlate well to intraoperative findings when patients underwent vitrectomy. However, vitrectomy surgery is performed in patients with vitreomacular interface disease, where often a multi-layered posterior vitreous cortex cleaving into separate planes is found, making an accurate diagnosis challenging. Obviously, vitrectomy cannot be used for “diagnostic” purposes.
In contrast, patients with neovascular age-related macular degeneration (AMD) are considered to follow the usual age-dependent evolution of vitreomacular detachment [7], where a complete separation of the posterior vitreous cortex is the most common configuration in people over 70.
In summary, we argue that the authors’ concern may apply less to an AMD patient population, but rather to eyes with vitreomacular interface disease. In patients with AMD, we consider SD-OCT the gold standard for diagnosing the clinical stages of PVD, including differentiation between complete PVD and posterior vitreous attachment.
1 Svasti-Salee CR, Snead MP, Alexander P. Response to 'Effect of posterior vitreous detachment on treat-and-extend versus monthly ranibizumab for neovascular age-related macular degeneration'. Br J Ophthalmol e-letter
2 Silva R, Berta A, Larsen M, et al. Treat-and-Extend versus Monthly Regimen in Neovascular Age-Related Macular Degeneration: Results with Ranibizumab for the TREND Study. Ophthalmology 2018;125(1):57-65.
3 Mayr-Sponer U, Waldstein SM, Kundi M, et al. Influence of the vitreomacular interface on outcomes of ranibizumab therapy in neovascular age-related macular degeneration. Ophthalmology 2013;120(12):2620-29.
4 Ciulla TA, Ying GS, Maguire MG, et al. Influence of the vitreomacular interface on treatment outcomes in the comparison of age-related macular degeneration treatments trials. Ophthalmology 2015;122(6):1203-11.
5 Waldstein SM, Montuoro A, Podkowinski D, et al. Evaluating the impact of vitreomacular adhesion on anti-VEGF therapy for retinal vein occlusion using machine learning. Sci Rep 2017;7(1):2928.
6 Hwang ES, Kraker JA, Griffin KJ, et al. Accuracy of spectral-domain OCT of the macula for detection of complete posterior vitreous detachment. Ophthalmol Retina 2020;4(2):148-153.
7 Itakura H, Kishi S. Evolution of vitreomacular detachment in healthy subjects. JAMA Ophthalmol. 2013;131(10):1348-52.
This is an informative article highlighting the difficulties in diagnosing optic nerve hypoplasia (ONH) in infants. Comparisons were made of the reliability of MRI orbit to that of fundal photography, with the authors concluding that the latter was superior to neuroimaging for diagnostic purposes. Whilst valid, this may imply that MRI brain scans are not indicated when a diagnosis of ONH is under consideration.
ONH has an incidence of between 2-10.9 per 100,000 births, systemic associations include developmental delay and neurologic deficits in over 50% and endocrine dysfunction in just over one-quarter of patients.(1) Children may display midline structural defects (abnormalities of the septum pellucidum, corpus callosum and pituitary axis), in addition to other cortical abnormalities, thus requiring neuroimaging.(1,2) A diagnosis of septo-optic dysplasia becomes appropriate when two out of three features are present: ONH, midline abnormalities and pituitary insufficiency. As babies and infants with ONH present primarily with abnormal visual behaviour, nystagmus, strabismus or amblyopia, from as early as 3 months of age, the Ophthalmologist may be the first specialist to evaluate the patient, and so the importance of investigating the wider clinical and radiological features cannot be overstated. This was not mentioned in this paper by Kruglyakova et al.
Whilst one can argue that a normal MRI brain scan in a child with ONH is not predictive of future end...
This is an informative article highlighting the difficulties in diagnosing optic nerve hypoplasia (ONH) in infants. Comparisons were made of the reliability of MRI orbit to that of fundal photography, with the authors concluding that the latter was superior to neuroimaging for diagnostic purposes. Whilst valid, this may imply that MRI brain scans are not indicated when a diagnosis of ONH is under consideration.
ONH has an incidence of between 2-10.9 per 100,000 births, systemic associations include developmental delay and neurologic deficits in over 50% and endocrine dysfunction in just over one-quarter of patients.(1) Children may display midline structural defects (abnormalities of the septum pellucidum, corpus callosum and pituitary axis), in addition to other cortical abnormalities, thus requiring neuroimaging.(1,2) A diagnosis of septo-optic dysplasia becomes appropriate when two out of three features are present: ONH, midline abnormalities and pituitary insufficiency. As babies and infants with ONH present primarily with abnormal visual behaviour, nystagmus, strabismus or amblyopia, from as early as 3 months of age, the Ophthalmologist may be the first specialist to evaluate the patient, and so the importance of investigating the wider clinical and radiological features cannot be overstated. This was not mentioned in this paper by Kruglyakova et al.
Whilst one can argue that a normal MRI brain scan in a child with ONH is not predictive of future endocrinopathy (3), the importance of evaluation by the Paediatric team should not be lost to the readers. One fears that the message the reader may fail to grasp is that at the time of diagnosis, an opportunity presents itself for the Ophthalmologist to include the wider paediatric multidisciplinary team to investigate and manage potential endocrine and neurodevelopmental complications, which are common in children with this congenital ocular defect.(4)
References
1. Mohney BG, Young RC, Diehl N. Incidence and associated endocrine and neurologic abnormalities of optic nerve hypoplasia. JAMA Ophthalmol. 2013 Jul;131(7):898-902.
2. Webb EA, Dattani MT. Septo-optic Dysplasia. Eur J Hum Genet. 2010 Apr;18(4):393-7.
3. Qian X, Fouzdar Jain S, Morgan LA, Kruse T, Cabrera M, Suh DW. Neuroimaging and endocrine disorders in paediatric optic nerve hypoplasia. Br J Ophthalmol. 2018 Jul;102(7):906-910.
4. Parr JR, Dale NJ, Shaffer LM, Salt AT. Social communication difficulties and autism spectrum disorder in young children with optic nerve hypoplasia and/or septo-optic dysplasia. Dev Med Child Neurol. 2010 Oct;52(10):917-21.
The recent study by Vega-Estrada et al highlights some of the challenges in diagnosing keratoconus in Down syndrome (DS).[1] Previous studies have shown that the cornea of individuals with DS without evidence of keratoconus appear to be steeper and thinner than the general population, both being features characteristic of keratoconus.[2] Vega-Estrada et al further identified that posterior keratometry was similar in DS to mild keratoconus, however, a lesser degree of posterior elevation was observed in the DS group.[1] This may be related to the younger mean age of the cohort with DS, small sample size or diagnostic criteria. The authors concluded that the corneal features analysed in the DS cohort were in the range of normal to mild keratoconus.[1]
We would like to further highlight some of the challenges associated with image acquisition when performing corneal topo/tomography in patients with DS. Some of the ophthalmic manifestations such as slanted and small palpebral apertures, nystagmus and strabismus can affect fixation. We have also observed additional common behavioural responses that affect fixation and alignment; patients squeezing the eyes shut in response to the examiner touching the eyelids or involuntarily opening the mouth when asked to keep the eyes wide open.
Misaligned fixation while acquiring corneal tomography images is known to result in false keratoconus features.[3] In addition to the reported overlap in corneal features in DS and ke...
Show MoreTo the Editor,
We appreciate the authors' interest in our study. In their letter to the editor regarding our meta-analysis[1], the authors raise an issue regarding the inclusion of the diseases in the two groups i.e. limbal stem cell deficiency (LSCD) and ocular surface disease (OSD). We adhered to the categorization of the diseases as indicated or mentioned in the publications which were included in the meta-analysis. Our literature search based on combinations of various “key-words” or “key-terms” returned results as depicted in the categorization of the diseases in the study.[2,3] LSCD being a sub-set of OSD, has signs and symptoms in common with many other conditions, hence it was important that the term “limbal stem cell deficiency” appeared in the publications for the study participants to be categorized into the LSCD group.[2,3,4]
The lack of consideration of the severity of LSCD and OSD was unavoidable due to the limited data within the source publications. It is apparent that the severity of the disease may affect the corneal epithelial basal cell density (BCD) and nerve fibre parameters.[5,6] The lack of data is likely explained by the difficulty in imaging in the more severe disease when corneal transparency is reduced; the corneal basal cells and nerves are difficult to image using confocal microscopy when the cornea is not clear. This is an important factor which is highlighted in our study.[1] Furthermore, our analysis did not attempt to c...
Show MoreDear Editor,
We have read the review article entitled “Ocular complications of cat scratch disease” Johnson A. Br J Ophthalmol 2020;0:1-7. We want to congratulate the author for this important review article, and make some contributions.
In the review article, it has been indicated that optical coherence tomography (OCT) imaging is of value to monitoring cat scratch disease (CSD), particularly for neuroretinitis and multifocal retinitis.
We would like to highlight a feature of focal retinitis with spectral domain optical coherence tomography (SD-OCT). Small areas of retinitis, less than 500 microns in diameter, can be seen on OCT imaging. These appear as areas of focal hyper-reflectivity of the inner retinal layers and decreased reflectivity causing a shadow on the outer retinal layers and choroid. This was seen in two patients presenting to our service recently with Bartonella henselae CSD diagnosed clinically and confirmed by positive serology.
The first case was a 49-year-old Caucasian male who presented with bilateral inflammatory papillitis and multifocal retinitis without a macular star, confirmed with serology as Bartonella henselae (IgG >2048). He had good presenting Snellen visual acuities of 6/5 right, 6/6 left. OCT imaging at acute presentation showed multifocal retinitis seen as small areas retinal hyper-reflectivity of the inner retina with outer retinal disruption. The disease resolved without treatment in 8 months, with...
Show MoreDear Editor,
We read with great interest the excellent paper by Sagiv and collegues Ocular preservation with neoadjuvant Vismodegib in patients with locally advanced periocular basal cell carcinoma.(1)
The article is a great contribution for a topic with a growing, but still limited worldwide experience. Our interest is to discuss the surgical approach after neoadjuvant Vismodegib.
The authors present a patient with a 5x4cm locally advanced periocular basal cell carcinoma (LAP-BCC) with small nerve perineural invasion (>0.1mm) involving lower eyelid, inner canthus and cheek. The patient showed a significant response after 10 months of Vismodegib. Anyhow, it was clearly a partial response with 3 suspicious areas of BCC after treatment. The authors decided to treat separately each area with surgery, and histology (en face sections) confirmed the presence of tumor in two. The reconstructive outcome was excellent, and at the time of publication the patient was free of disease, 11 months after surgery.
We agree with the authors, when they consider as a limitation the fact that “surgery did not always include the entire area of the original tumor”.
Most studies involving smoothened inhibitors thus far have measured clinical tumor shrinkage but not true histologic margin control. Even after a complete clinical response (CCR), there is no way to assure that it will result in a complete histological clearance (CHR).
Several authors discuss...
Show MoreWe read with great interest this comparison between selective laser trabeculoplasty (SLT) and medication for Open-Angle Glaucoma (OAG). (1)
Show MoreThe recent LiGHT trial (2), an important landmark in the management of glaucoma, suggests that SLT represents an ideal first-line treatment option of ocular hypertension (OHT) and open angle glaucoma (OAG) in terms of decreased costs, with similar efficacy and quality of life when comparing to medication. The strength of the trial resides in its methodology, limiting most of the bias seen in the previous retrospective studies on the subject. Despite the fact that their conclusions seemed to be echoing various other authors (3,4) there is still debate as to whether SLT should become a first-line treatment.
The current powerful meta-analysis by Chi et al on 1229 patients (14 articles, 8 randomized clinical trials), may become the final argument on the debate demonstrating that not only is SLT not inferior to medical therapy in terms of IOP-lowering effect or safety, but it allows for significantly lesser use of medication. (1)
The longer duration of effect, minimized cost, and safety of SLT are especially important in settings with difficult access to care, such as in developing countries, or in patients with decreased mobility. A recent study on incarcerated patients showed that even when measures are taken to administer and control patients’ adherence to treatment, substantial nonadherence persists. (5)
It is ri...
We thank Dr. Shukla for his interest in our article and his comments 1, 2.
In our study all consecutive cases of rhegmatogenous retinal detachment (RD) that underwent pars plana vitrectomy (PPV) were included in the study regardless of complexity, type of tear, lens or refractive status, or use of supplemental buckle in order to reduce selection bias and to allow study of various subgroups of patients. For the same reason the 13 cases with silicone oil present at the time of last follow-up were not excluded. The paper referenced by Dr. Shukla reports a retinal re-detachment rate of 13.2% after removal of silicone oil (ROSO), with many of the cases performed prior to the era of small gauge vitrectomy and wide-angle viewing systems (WAVS) 3. Encircling endolaser photocoagulation further reduces the re-detachment rate to 8.6% 4. More recent surgical techniques are likely associated with a lower retinal re-detachment rate. Nevertheless, a presumed retinal re-detachment of 13.2% following ROSO corresponds to an estimated 1.7 eyes with recurrent RD out of the 13 eyes with residual silicone oil in our series 3. This in turn corresponds to a 0.5% difference in the overall single surgery success rate (SSSR) in 312 eyes. It could therefore be safely assumed that inclusion of the small group with silicone oil at the last follow-up visit did not affect the overall success rate significantly, but reduced chances of introducing a selection bias.
In our series a supplemental...
Show MoreWe read with great interest the article entitled ‘Prevalence of guttae in the graft following corneal transplantation’ by Nahum et al, published in the May 2015 issue of the British Journal of Ophthalmology [1] . The authors reported the prevalence of cornea guttata postkeratoplasty in a large population of 1116 patients to be 4%. They also found that guttae postkeratoplasty do not negatively affect the visual acuity, endothelial cell density, or graft survival during the initial two postoperative years. The content of this article is important and well put, since this is the first study to reveal the prevalence and sequelae of postkeratoplasty guttae on the corneal graft.
Based on our clinical experience and on multiple published studies, the prevalence of cornea guttata in the normal population is estimated to be higher than 4% [2]. However, the low prevalence reached by Nahum et al, is explained mainly by the preoperative screening of the donor corneas for guttae, as stated in the article. Therefore, it would be very interesting if the authors can provide an estimation of the percentage of donor corneas that are usually discarded by the guttae screening in their eye bank.
Up to our knowledge, guttae are very often not detectable using inverted light microscopy, thus guttae screening as a part of the routine examination of the donor corneas is a challenging task. There is only one study performed by Borderie et al in 2001 [3], that aimed to detect the pres...
Show MoreDear Editor,
Bonafede et al1 analyzed the change over time in hypermetropia in children from the USA with partially and fully accommodative esotropia. This study complements a previous long-term follow-up multi-center publication on 164 hypermetropic children from USA, Germany, and Israel2. The follow-up was comparable: ages 3.5-10.5 years in the previous article compared to 3-12 years in the current paper. The range of spherical equivalent refractive error in the previous paper was categorized as +1-3Diopters (D) (mild hypermetropes) and +5-8D (high hypermetropes). In contrast, the current study included also moderate hypermetropes, because it involved a group with less than +4D hypermetropes and a group of children with hypermetropia of +4D or more. Esotropia in the previous study was not present in any of the mild hypermetropes but was present in half (48%) of the high hypermetropes. Due to a decrease in hypermetropia over time beyond the age of 6 years old, mild hypermetropes in the previous study were weaned from glasses (-0.095 D/year), while the high hypermetropes remained in glasses (-0.037 D/year). Similarly, because of a mean decrease of -0.17 D/year that occurred only from age 7 to 15 years, subjects in the current study with a “smaller baseline” (i.e., mild) hypermetropia stopped wearing glasses. However, most moderate and high hypermetropes beyond the age of 12 years remained in glasses (-0.18 D/year).
In conclusion, data derived from both...
Show MoreDear Editor,
We thank Svasti-Salee, Snead and Alexander [1] for their interest in our study and their comment regarding the reliability of spectral domain optical coherence tomography (SD-OCT) in differentiating a completely attached hyaloid versus complete posterior vitreous detachment (PVD).
To address the author’s question, in our post-hoc analysis, only SD-OCT was used to diagnose PVD status. A slit-lamp examination specifically assessing for PVD was not performed per protocol in the TREND study, [2] therefore data other than SD-OCT were not available for post-hoc analysis.
The accepted clinical methods to determine PVD include slit-lamp examination, dynamic ultrasonography and SD-OCT, while previous generations of OCT (time-domain OCT) potentially offered insufficient resolution and field of view. Of those methods, SD-OCT has the main advantage of being operator independent and allowing systematic, standardized evaluation in a reading center setting. The approach chosen for the analysis of the TREND dataset has been repeatedly performed in several prior studies, with similar outcome data. [3-5]
A recent study cited by the authors [6] reports that PVD status on SD-OCT did not correlate well to intraoperative findings when patients underwent vitrectomy. However, vitrectomy surgery is performed in patients with vitreomacular interface disease, where often a multi-layered posterior vitreous cortex cleaving into separate planes is found, making...
Show MoreThis is an informative article highlighting the difficulties in diagnosing optic nerve hypoplasia (ONH) in infants. Comparisons were made of the reliability of MRI orbit to that of fundal photography, with the authors concluding that the latter was superior to neuroimaging for diagnostic purposes. Whilst valid, this may imply that MRI brain scans are not indicated when a diagnosis of ONH is under consideration.
ONH has an incidence of between 2-10.9 per 100,000 births, systemic associations include developmental delay and neurologic deficits in over 50% and endocrine dysfunction in just over one-quarter of patients.(1) Children may display midline structural defects (abnormalities of the septum pellucidum, corpus callosum and pituitary axis), in addition to other cortical abnormalities, thus requiring neuroimaging.(1,2) A diagnosis of septo-optic dysplasia becomes appropriate when two out of three features are present: ONH, midline abnormalities and pituitary insufficiency. As babies and infants with ONH present primarily with abnormal visual behaviour, nystagmus, strabismus or amblyopia, from as early as 3 months of age, the Ophthalmologist may be the first specialist to evaluate the patient, and so the importance of investigating the wider clinical and radiological features cannot be overstated. This was not mentioned in this paper by Kruglyakova et al.
Whilst one can argue that a normal MRI brain scan in a child with ONH is not predictive of future end...
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