With great interest,We have read the article by Chidambara1 and
partners on characteristics and quantification of vascular changes in
macular telangiectasia type 2( MacTel 2) on optical coherence tomography
angiography(OCTA).The authors concluded that OCTA helps understand the
pathology and disease progression better in MacTel 2.We commend their
interesting and important work on this subject.However, w...
With great interest,We have read the article by Chidambara1 and
partners on characteristics and quantification of vascular changes in
macular telangiectasia type 2( MacTel 2) on optical coherence tomography
angiography(OCTA).The authors concluded that OCTA helps understand the
pathology and disease progression better in MacTel 2.We commend their
interesting and important work on this subject.However, we have a question
for the authors concerning intra- and inter-observer variation and the
reproducibility of the OCTA examination.
As far as I know, reproducibility and repeatability are indicators of
the applicability of any instrument as a diagnostic tool in clinical
practice2.OCTA is extremely sensitive to motion, some images had
significant artifacts even with the motion correction algorithm. Operator
learning curve, media opacity, and patient cooperation were factors in
poor-quality images3.If the subjects had repeated instances of unstable
fixation,the image would appear with white ambiguous lines.The analysis
software would mistake these white ambiguous lines for blood vessels and
would overestimate the retinal vessel density.Therefore,intra- and inter-
observer variation would be relatively large. I think the authors should
perform a reproducibility analysis to prove the stability of the OCTA
system examination.If such an analysis had been performed and intra- and
inter- observer variation exceeded a certain percent,the results of this
study might have been shown to be unreliable.
REFERENCES
1. Chidambara L, Gadde SGK, Yadav NK, et al. Characteristics and
quantification of vascular changes in macular telangiectasia type 2 on
optical coherence tomography angiography. Br J Ophthalmol 2016:2015-
307941.
2. Carpineto P, Mastropasqua R, Marchini G, et al. Reproducibility and
repeatability of foveal avascular zone measurements in healthy subjects by
optical coherence tomography angiography. Br J Ophthalmol 2015.
3. Hwang TS, Gao SS, Liu L, et al. Automated Quantification of Capillary
Nonperfusion Using Optical Coherence Tomography Angiography in Diabetic
Retinopathy. JAMA OPHTHALMOL 2016:1-7.
I read with great interest the article by Romero- Aroca et al. titled "Changes observed in diabetic retinopathy: eight-year follow-up of a Spanish population" [1]. Insulin usage has found to be a risk factor for progression of DRP. Authors conclude this result as relaxation of patients in metabolic control. Beside this conclusion, insulin analogues may directly cause progression of DRP. Insulin and its analogues stimulate ins...
I read with great interest the article by Romero- Aroca et al. titled "Changes observed in diabetic retinopathy: eight-year follow-up of a Spanish population" [1]. Insulin usage has found to be a risk factor for progression of DRP. Authors conclude this result as relaxation of patients in metabolic control. Beside this conclusion, insulin analogues may directly cause progression of DRP. Insulin and its analogues stimulate insulin like growth hormone-1 (IGF-1) receptors, like growth hormone. There is a strong relationship between growth hormone and progression of DRP. Diabetic retinopathy regresses after surgical ablation or spontaneous infarction of pituitary gland [2]. Growth hormone deficiency is a protective factor for development of diabetic retinopathy in dwarfs [3]. Development of diabetic retinopathy is significantly higher in pubertal subjects than pre -pubertal subjects, despite the same glycemic control [4]. Thus, insulin analogues may cause progression of DRP through growth hormone-like effect. But I hypothesize that insulin analogues may cause progression of DRP only after deterioration of inner blood retinal barrier [5]. Hyperglycemia is a major risk factor for development of DRP. High blood glucose levels cause inner blood-retinal barrier deterioration by polyol pathway, non-enzymatic protein glycation and oxidative stress. Insulin analogues decrease blood glucose level and protect pericytes and inner blood-retinal barrier. When inner blood-retinal barrier is intact, insulin analogues may pass into the retinal tissue in very small amounts. After impairment of inner blood retinal barrier, insulin analogues may pass into the retinal tissue in much more amounts. Thus, insulin analogues may pass retinal tissue after impairment of inner blood retinal barrier and cause progression of DRP by growth hormone like effect. But before impairment, analogues can not pass through inner blood retinal barrier to cause progression of DRP, even delay onset of DRP by decreasing high blood glucose that impair pericytes.
References
1. Romero-Aroca P, de la Riva-Fernandez S, Valls-Mateu A, Sagarra-Alamo R, Moreno-Ribas A, Soler N. Changes observed in diabetic retinopathy: eight- year follow-up of a Spanish population. Br J Ophthalmol. 2016 Jan 14.
2. Adams, D.A., Rand, R.W., Roth, N.H., Dashe, A.M., Gipstein, R.M., Heuser, G. Hypophysectomy in diabetic retinopathy. The relationship between the degree of pituitary ablation and ocular response. Diabetes. 1974;23:698???707.
3. Merimee, T.J. A follow-up study of vascular disease in growth-hormone-deficient dwarfs with diabetes. N Engl J Med. 1978;298:1217???1222.
4. Murphy, R.P., Nanda, M., Plotnick, L., Enger, C., Vitale, S., Patz, A. The relationship of puberty to diabetic retinopathy. Arch Ophthalmol. 1990;108:215???218.
5. Kaya A, Kar T, Aksoy Y, Ozalper V, Basbug B. Insulin analogues may accelerate progression of diabetic retinopathy after impairment of inner blood-retinal barrier. Med Hypotheses. 2013 Dec;81(6):1012-4. 4.
Response to E-letter.
Thank very much for reading our article. It is true that oral insulin
analogues can lead to increased growth hormone, increasing its effect over
diabetic retinopathy, but previously it should exist a blood-retina
barrier (BRB), despite in patients with preexisting diabetic retinopathy
the BRB rupture exist in some amount. It is possible that oral insulin
analogues can affect the diabetic retinopathy...
Response to E-letter.
Thank very much for reading our article. It is true that oral insulin
analogues can lead to increased growth hormone, increasing its effect over
diabetic retinopathy, but previously it should exist a blood-retina
barrier (BRB), despite in patients with preexisting diabetic retinopathy
the BRB rupture exist in some amount. It is possible that oral insulin
analogues can affect the diabetic retinopathy level, but in patients
without diabetic retinopathy the BRB should be intact. In the present
study we demonstrate two findings, the first is the number of patients
with any-DR who increased selectively in two age groups: in patients with
age between 41-50 and patients with age between 51-60; and the second
finding is that patients with advanced-DR, showed an increase in the 31-
40, 41-50, 51-60 and 61-70 age groups. In all groups the HbA1c increased
progressively since 2008 to 2014. Can the insulin analogues do any
effects? It is difficult to give an answer. Attending our knowledge is a
possibility, but I say you a question. What is the more important effect
over the diabetic retinopathy the bad glycemic levels or the treatment by
insulin or analogues, due this bad control? In fact, is very difficult to
answer this question, in our initial studies long time ago ( ), the
insulin is an independent factor in diabetic retinopathy development, but
when we apply multivariate analysis using logistic regression the insulin
is a confounding risk factor overlapped to glycemic levels. Respect our
conclusion about a poor control of glycemic levels in the previously cited
age groups is a reality in our Country, it seems it exists a relaxation in
diabetes control exercised by patients, and all staff involved in the
treatment of diabetes should strive to re-educate patients with diabetes,
reminding how important is the glycemic control to prevent serious
complications such as diabetic retinopathy. Finally thank you very much
for your contribution to our problem.
References.
1. Romero-Aroca P, Salvat-Serra M, Mendez-Marin I, Martinez-Salcedo I.
[Is microalbuminuria a risk factor for diabetic retinopathy?]. J Fr
Ophtalmol. 2003;26(7):680-4.
2. Romero-Aroca P, Calvino-Dominguez O, del Castillo-Dejardin D.
[Epidemiologic study of diabetic retinopathy in a primary care unit]. Arch
Soc Esp Oftalmol. 2000;75(3):147-52.
3. Romero-Aroca P, Espeso-Sentis O, Sarda-Aure P, del Castillo-Dejardin D.
[Relationship between microalbuminuria and diabetic retinopathy in type 1
diabetes mellitus]. Rev Clin Esp. 2000;200(7):351-4.
Changing from pro re nata treatment regimen to a treat and extend
regimen with ranibizumab in neovascular age-related macular degeneration
Dan Calugaru, Mihai Calugaru
Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Changing from pro re nata treatment regimen to a treat and extend
regimen with ranibizumab in neovascular age-related macular degeneration.
Hatz and Prunte. Br J Ophthalmol 2016...
Changing from pro re nata treatment regimen to a treat and extend
regimen with ranibizumab in neovascular age-related macular degeneration
Dan Calugaru, Mihai Calugaru
Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Changing from pro re nata treatment regimen to a treat and extend
regimen with ranibizumab in neovascular age-related macular degeneration.
Hatz and Prunte. Br J Ophthalmol 2016; http:/dx.
doi.org/10.1136/bjophthalmol-2015-307299.
Dear Editor
We would like to address several limitations arisen from the interesting
study by Hatz and Prunte (1) and which can be specifically summarized as
follows:
1. The article was retrospectively conducted with the existence of a
selection bias due to the inclusion in the final analysis only those
patients who completed treat and extend (TE) follow-up of 12 months. Of
note, only patients with active disease during the last 3 months of the
pro re nata (PRN) phase were transitioned to TE treatment.
2. With the exception of data concerning the baseline choroidal
neovascularization (CNV), there were no details on the anatomical types of
neovascular maculopathy (CNV/serous and/or hemorrhagic detachment of the
neurosensory retina or retinal pigment epithlium [RPE]/retinal hard
exudates/subretinal and sub-RPE fibrovascular proliferation/disciform scar
[subretinal fibrosis]), at baseline visit, as well as before and after
switching from a PRN to a TE treatment regimen.
3. There were no data referring to the proportion of eyes considered
"dry" on optical coherence tomography as per criterion of central retinal
thickness (CRT) < 320 microns (2), before and after switching to a TE
algorithm.
4. The comparative analysis of the visual and morphologic outcomes of
the two treatment regimens was fairly inconclusive. Thus, there was a mean
visual acuity (VA) gain of approximately 5 Early Treatment Diabetic
Retinopathy Study (ETDRS) letters in comparison with the baseline VA at
the end of the PRN phase; this value increased subsequently by an average
of approximately 5 letters until the month 12 of the TE phase. The CRT
decreased by a mean of 86 microns in relation to the baseline value, up to
the end of the PRN phase; this CRT reduction increased thereafter by a
mean of 35 microns until the month 12 of the TE phase. Importantly, during
the TE period of this study, patients received approximately two more
injections over a 12-month period than during 12 months of PRN treatment.
5. Implementation of the 2-sequence, 2-period, 2-treatment algorithm
design in which each patient was assigned to a sequence of treatment, did
not provide the answer to the question which of the 2 treatment approaches
was more efficiently. On the contrary, the disadvantages of such a study
could not be avoided. Thus, the washout period, which is essential between
periods of such a study in terms of aliased effects, was not precisely
delimited and the impact of the significant carryover effects may be
confounded with direct treatment effects, in the sense that these effects
could not be estimated separately being able to bias the interpretation of
data analysis.
Altogether, regardless of the treatment approaches chosen (TE/PRN
algorithm), the efficacy of therapy depends primarily on the promptness of
the therapy after neovascular age-related degeneration diagnosis (3,4).
References
1. Hatz K, Prunte C. Changing from pro re nata treatment regimen to a
treat and extend regimen with ranibizumab in neovascular age-related
degeneration. Br J Ophthalmol 2016; http:/dx. doi.org/10.1136/bjophthalmol
-2015-307299.
2. Grover S, Murthy RK, Brar VS, and Chalam KV. Normative data for macular
thickness by high-definition spectral-domain optical coherence tomography
(spectralis). Arch Ophthalmol 2009;148-271.
3. Calugaru D, Calugaru M. Treat-and-extend intravitreal bevacizumab for
branch retinal vein occlusion. Ophthalmic Surg Lasers Imaging Retina
2015;46:994.
4. Calugaru D, Calugaru M. Comment on:"Central retinal vein
occlusion:modyfing current treatment protocols." Eye 2016;
http:/dx.doi.org/10.1038/eye.2016.83.
With interest we have read the article of Ruiters et al.1 in which
they present a 3 dimensional method for ocular prosthesis manufacturing.
In our practice we also manufacture individual customized ocular
prosthesis using 3D techniques. We confirm that this computer aided method
improves prosthetic fitting and may aid the production process when
translated into 3D prints. Our method does however differ on several
points....
With interest we have read the article of Ruiters et al.1 in which
they present a 3 dimensional method for ocular prosthesis manufacturing.
In our practice we also manufacture individual customized ocular
prosthesis using 3D techniques. We confirm that this computer aided method
improves prosthetic fitting and may aid the production process when
translated into 3D prints. Our method does however differ on several
points. First, in contrast to the authors, we make use of a mould, second
we use MRI instead of cone beam CT.
We agree with Ruiters et al.1 that the method of impression-moulding
without other assistance frequently results in poor fitting prostheses.
However, when assisted with 3D imaging a concise delineation of the socket
can be made. The impression reflects the lines and curves of the posterior
part of the socket in its most natural shape since it is introduced in a
liquid state. The thickness of the mould depends on the amount of used
silicone, hence it is not an adequate measure to use one-on-one for the
thickness of the prosthesis. We believe this mistake is frequently made
and may be the cause of bad fitting prostheses. We reject the argument of
Ruiters et al.1 that introduction of moulding materials cause distortion
of the socket, in fact we have experienced that a conformer, as used by
the authors, does result in a distortion of the socket : when delineating
the socket visualized on 3D images with a solid conformer in situ the
delineation follows exactly the contours of the conformer.
We use a special MRI program for orbital scanning taking only 5 - 6
minutes. In patients younger than 7 years scanning can be performed with
general anesthesia, older patients can be instructed to lay still, head
fixation eliminates motion artefacts as is also mentioned by Ruiters et
al.1 MRI imaging avoids exposure to radiation, and MR- images will
better depict the orbital soft tissues.
In an upcoming paper we will expound our method.
1. Computer-aided design and three-dimensional printing in the
manufacturing of an ocular prosthesis. S?bastien Ruiters, Yi Sun, St?phan
de Jong, Constantinus Politis, Ilse Mombaerts. Br J Ophthalmol 2016;100:7
879-881
We read with great interest the study titled as "Comparison of
trabeculectomy versus Ex-PRESS: 3-year follow-up" by Gonzalez-Rodriguez et
al [1].We congratulate their efforts for conducting the study with a
follow up of 3 years, making the results more significant.They concluded
that success rates, mean IOP, number of anti-glaucoma medications and
final visual acuities were similar between the two groups after 3 years.
T...
We read with great interest the study titled as "Comparison of
trabeculectomy versus Ex-PRESS: 3-year follow-up" by Gonzalez-Rodriguez et
al [1].We congratulate their efforts for conducting the study with a
follow up of 3 years, making the results more significant.They concluded
that success rates, mean IOP, number of anti-glaucoma medications and
final visual acuities were similar between the two groups after 3 years.
The positive points in favour of Ex-PRESS implant, are its standardized
pore size leading to more predictable filtration and consequently
avoidance of hypotony & other complications and a shorter learning
curve.
Interestingly many studies have also claimed that Ex-PRESS has a
faster visual recovery. In fact, the authors showed from their first year
data that by one month the Ex-PRESS group reached the baseline acuity
whereas in the trabeculectomy group, acuity remained significantly lower
from baseline at each study visit from day 1 to 6 months. However, when
excluding patients who needed a repeat glaucoma procedure, the acuity was
found to be better in Ex-PRESS group compared to Trabeculectomy group at
all time points. In our opinion, this data would have been more promising
had the authors mentioned the test-retest variability as well as the
confidence intervals of the visual acuity measurements in either group.
The e?ects of the Ex-PRESS device on cornea were previously evaluated by
the authors in their 1 year results [2]. We are keen to know their
findings with regards to corneal health at last follow-up.
The results of this study are consistent with other published
reports, proving that, there is actually no difference in success rates
between Ex-PRESS and trabeculectomy [3,4]. Though Ex-PRESS implant is
considered to be another good option in our surgical armamentarium, the
significant cost difference needs to be considered in conjunction with
e?cacy and safety, if Ex-PRESS is to supersede trabeculectomy [5].
REFERENCES -
1. Gonzalez-Rodriguez JM, et al. Br J Ophthalmol 2015
2. Wagschal et al. Prospective Randomized Study Comparing Ex-PRESS to
Trabeculectomy: 1-Year Results. J Glaucoma 2015;24:624-629.
3. Netland PAet al. Randomized, prospective, comparative trial of EX-
PRESS glaucoma filtration device versus trabeculectomy (XVT study). Am J
Ophthalmol 2014;157:433-40.e3.
4. Dahan E, Ben Simon GJ, Lafuma A. Comparison of trabeculectomy and
Ex-PRESS implantation in fellow eyes of the same patient: a prospective,
randomised study. Eye (Lond) 2012;26:703-10.
5. Buys YM. Trabeculectomy with ExPRESS: weighing the benefits and
cost. CurrOpin Ophthalmol 2013;24:111-18.
Anatomical effects of dexamethasone intravitreal implant in diabetic
macular oedema; a pooled analysis of 3-year phase lll trials
Dan Calugaru, Mihai Calugaru
Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Anatomical effects of dexamethasone intravitreal implant in diabetic
macular oedema: a pooled analysis of 3-year phase lll trials. Danis et al
Br J Ophthalmol 2016;100:796-801.
Anatomical effects of dexamethasone intravitreal implant in diabetic
macular oedema; a pooled analysis of 3-year phase lll trials
Dan Calugaru, Mihai Calugaru
Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Anatomical effects of dexamethasone intravitreal implant in diabetic
macular oedema: a pooled analysis of 3-year phase lll trials. Danis et al
Br J Ophthalmol 2016;100:796-801.
Dear Editor
We would like to address several challenges arisen from the study by Danis
et al (1) and which can be specifically summarized as follows:
1. There was a selection bias owing to the inclusion in the study of
both the treatment-na?ve patients and those with previous treatments
(focal/grid laser, intravitreal steroid, and specific anti-vascular
endothelial growth factor [VEGF] agents).
2. Although the final central subfield retinal thickness (CSRT)
values of the two dexamethasone implant (DEX implant; Ozurdex Allergan,
Irvine, California, USA) groups (eg, 345.7 and 339 microns in the DEX
implant 0.7 mg and DEX implant 0.35 mg groups, respectively) were
significantly reduced in comparison with the sham group (398.8 microns)
yet the structural outcomes of this study were poor. Of note, all these
CSRT values are much more than the cutoff (252 microns) for the upper
level of the normal CSRT (212 +/-20 microns) plus 2 standard deviations
(2). The persistence of high values of the CSRT as well as the high
proportions of study eyes with CSRT > 250 microns at the final visit
(eg, 60.2 %, 58.7%, and 71.6% in the DEX implant 0.7 mg, DEX implant 0.35
mg, and sham groups, respectively) highlight unresolved macular edema due
to insufficient macular deturgescence and indicate that the disease
process is still active and progressive requiring further treatment with
anti-angiogenic agents.
3. The final unsatisfactory anatomic results of this study could be
explained by the low frequency of injections (a median of four to five
injections over a 3-year period) and the long-standing duration of
diabetic macular oedema (DME) (between 23.6 and 25.9 months in the three
groups of patients). These facts promoted the delayed occurrence of a
permanent retinal capillaropathy owing to permanent breakdown of the inner
and outer endothelial blood-retinal barriers. However, this condition is
incurable due to the ischemic irreversible lesions to the macular retinal
ganglion cell complex, close to the foveola, with macular oedema being a
minor factor. The saw-tooth pattern of the profile of mean change in CSRT
versus time highlights the fact that the authors have not taken into
account the currently valid recommendations that the duration of ? 3-line
improvement after DEX implant is typically 2-3 months (3), and that
reinjections generally will be performed after 4-5 months (4). If these
assertions had been considered, the design and outcomes of the present
study would have been completely different.
Altogether, regardless of the intravitreal pharmacotherapy chosen,
namely, specific or nonspecific (DEX implant) anti-VEGF agents, the
efficacy of treatment depends primarily on the promptness of the therapy
after DME onset. Both groups of anti-VEGF substances provide similar rates
of vision improvement but with superior anatomic outcomes and fewer
injections in the DEX implant-treated eyes. However, more patients
receiving the DEX implant lose vision mainly due to cataract.
References
1. Danis RP, Sadda S, Li XY, et al. Anatomical effects of dexamethasone
intravitreal implant in diabetic macular oedema: a pooled analysis of 3-
year phase lll trials. Br J Ophthalmol 2016; 100:796-801.
2. Chan A, Duker JS, Ko TH, et al. Normal macular thickness measurements
in healthy eyes using Stratus optical coherence tomography. Arch
Ophthalmol 2006;124;193-198.
3. Kuppermann BD, Haller JA, Bandello F. Onset and duration of visual
acuity improvement after dexamethasone intravitreal implant in eyes with
macular edema due to retinal vein occlusion. Retina 2014;34:1743-1749.
4. Coscas G, Augustin A, Bandello F, et al. Retreatment with Ozurdex for
macular edema secondary to retinal vein occlusion. Eur J Ophthalmol
2014;24:1-9.
Dear Editor,
We thank Drs Gupta and Ram for their interest in our recent paper on the
anatomical effects of dexamethasone intravitreal implant (DEX implant) in
eyes with diabetic macular oedema [1] and appreciate the opportunity to
respond to their comments. Their letter highlights various patient- and
treatment-related factors that potentially might have influenced the
retinal findings described in our analysis. We pro...
Dear Editor,
We thank Drs Gupta and Ram for their interest in our recent paper on the
anatomical effects of dexamethasone intravitreal implant (DEX implant) in
eyes with diabetic macular oedema [1] and appreciate the opportunity to
respond to their comments. Their letter highlights various patient- and
treatment-related factors that potentially might have influenced the
retinal findings described in our analysis. We provide here some further
clarification on the specific points raised in their letter.
Firstly, the MEAD study data do not allow us to determine with certainty
the treatment-free interval preceding DEX implant injection. However, we
can confirm that all enrolled patients were required to discontinue
intravitreal anti-VEGF and triamcinolone treatment at least 3 and 6
months, respectively, prior to study entry. Also, ranibizumab was not
available at the start of the study (2004) and only 7% of patients had
received prior anti-VEGF therapy. Moreover, randomization is likely to
have minimized any imbalance between the treatment groups. Secondly,
patients presenting with epiretinal membrane or vitreomacular traction
syndrome at the initial screening visit were excluded from study entry.
Thirdly, regarding the issue of insulin and oral hypoglycaemic use and
changes in antidiabetic treatment during the study, randomization
presumably minimized any influence these factors might have had on study
outcomes. Fourthly, the study was not designed to assess the comparative
efficacy of the 0.35 mg and 0.7 mg implants. However, since HbA1c assays
over the course of the study showed no significant difference in glycaemic
control between the three treatment arms, the MEAD findings indicate that
the two implants are of comparable efficacy in reducing macular oedema.
Finally, for information on the effects of DEX implant on lens status the
reader is referred to the primary paper of the MEAD Study Group [2].
Ronald P. Danis, M.D.
Srinivas Sadda, M.D.
Xiao-Yan Li, M.D.
Harry Cui, MS.
Yehia Hashad, M.D.
Scott M. Whitcup, M.D.
Fundus Photograph Reading Center, Department of Ophthalmology and
Visual Sciences, University of Wisconsin-Madison, 2870 University Avenue,
Madison, Wisconsin 53711.
E-mail: rpdanis@wisc.edu
References 1. Danis RP, Sadda S, Li XY, et al. Anatomical effects of
dexamethasone intravitreal implant in diabetic macular oedema: a pooled
analysis of 3- year phase III trials. Br J Ophthalmol 2016;100:796-801. 2.
Boyer DS, Yoon YH, Belfort R, et al. Three-year, randomized, sham-
controlled trial of dexamethasone intravitreal implant in patients with
diabetic macular edema. Ophthalmology 2014;121:1904-14.
Conflict of Interest:
RPD and SS have received grant support and consulting fees from Allergan, Inc. X-YL and YH are employees of Allergan, Inc.
eLetter
Comment on: The impact of donor age and endothelial cell density on graft
survival following penetrating keratoplasty
Parul Chawla Gupta, MS; Jagat Ram, MS, FAMS
Department of Ophthalmology
Post Graduate Institute of Medical Education and Research, Chandigarh,
India, 160012
Corresponding author
Dr. Jagat Ram, MS, FAMS
Professor and Head
Department of Ophthalmology
Post Graduate Institute of Medical Education and Re...
eLetter
Comment on: The impact of donor age and endothelial cell density on graft
survival following penetrating keratoplasty
Parul Chawla Gupta, MS; Jagat Ram, MS, FAMS
Department of Ophthalmology
Post Graduate Institute of Medical Education and Research, Chandigarh,
India, 160012
Corresponding author
Dr. Jagat Ram, MS, FAMS
Professor and Head
Department of Ophthalmology
Post Graduate Institute of Medical Education and Research, Chandigarh,
India, 160012
Email id: drjagatram@gmail.com
Conflict of interest and source of funding- None declared
Dear Editor,
We read with interest the recent paper by Wakefield and associates [1]
analysing if donor age and preoperative endothelial cell density (ECD)
affects corneal endothelial failure following penetrating keratoplasty
(PK). While the study is indeed interesting, we herein address important
issues, some of which warrant further discussion. First, the authors have
determined the overall 5-year graft survival rate due to endothelial
failure in all recipients. No mention has been made of the endothelial
cell density/loss at 5 years after surgery in all age groups. Was there
any significant difference in the endothelial cell density in all groups?
Second, diabetic status has been few of the factors affecting corneal
endothelial cell counts. In patients with diabetes (after adjusting age),
the cell count is lesser by 66 cells (95% CI, 6.3-125.9) compared with
controls [2]. Did the authors take into consideration the presence or
absence of diabetes mellitus in all groups since higher prevalence of
diabetes in the younger age group donors could have decreased the graft
survival ultimately making it comparable with the graft survival of
corneas from elderly donors. Third, cigarette smoking reduces endothelial
cell counts [3]. Smoking history should also have been considered while
comparing the graft survival rates in all the groups. Moreover, advanced
nuclear cataract and chronic pulmonary disease are significant risk
factors for reduced endothelial density. Although the mechanisms are
unknown, patients with these risk factors may have a poor endothelial
reserve [4]. The authors should therefore rule out all the aforementioned
factors before analyzing the results.
References
1. Wakefield MJ, Armitage WJ, Jones MNA, et al. Br J Ophthalmol
2016;100:986-989.
2. Sudhir RR, Raman R, Sharma T. Changes in the Corneal Endothelial Cell
Density and Morphology in Patients With Type 2 Diabetes Mellitus: a
Population Based Study, Sankara Nethralaya Diabetic Retinopathy And
Molecular Genetics Study (SN-DREAMS, Report 23). Cornea 2012; 0:1-4.
3. Ilhan N, Ilhan O, Coskun M, et al. Effects of Smoking on Central
Corneal Thickness and the Corneal Endothelial Cell Layer in Otherwise
Healthy Subjects. Eye Contact Lens. 2015; 10.1097/ICL.0000000000000212
4. Ishikawa A. Risk factors for reduced corneal endothelial cell density
before cataract surgery. J Cataract Refract Surg. 2002;28(11):1982-92.
eLetter
Comment on: Risk factors for low vision related functioning in the Mycotic
Ulcer Treatment Trial: a randomised trial comparing natamycin with
voriconazole
Parul Chawla Gupta, MS; Jagat Ram, MS, FAMS
Department of Ophthalmology
Post Graduate Institute of Medical Education and Research, Chandigarh,
India, 160012
Corresponding author
Dr. Jagat Ram, MS, FAMS
Professor and Head
Department of Ophthalmology
Post Graduate...
eLetter
Comment on: Risk factors for low vision related functioning in the Mycotic
Ulcer Treatment Trial: a randomised trial comparing natamycin with
voriconazole
Parul Chawla Gupta, MS; Jagat Ram, MS, FAMS
Department of Ophthalmology
Post Graduate Institute of Medical Education and Research, Chandigarh,
India, 160012
Corresponding author
Dr. Jagat Ram, MS, FAMS
Professor and Head
Department of Ophthalmology
Post Graduate Institute of Medical Education and Research, Chandigarh,
India, 160012
Email id: drjagatram@gmail.com
Conflict of interest and source of funding- None declared
Dear Editor,
We read with interest the recent paper by Rose- Nussbaumer and associates
[1] determining the risk factors for low vision-related quality of life
in patients with fungal keratitis. While the study is indeed interesting,
we herein address important issues, some of which warrant further
discussion. First, the authors stated in the abstract "Those who required
therapeutic penetrating keratoplasty had an average of 25.2 points
decrease on VFQ after correcting for treatment arm (95% CI ?31.8 to ?18.5,
p<0.001).". However, in the manuscript it is mentioned that "study
participants who required therapeutic penetrating keratoplasty (TPK) had
significantly worse VFQ scores than those who did not, with those having
undergone TPK scoring on average 25.5 points lower on VFQ (95% CI ?32.0 to
?18.9, p<0.001)." Second, since marital status is one of the robust
predictor of health outcomes, it should have been taken into account as it
may affect the quality of life in the study patients. It has been seen
that divorced and widowed men report higher rates of depressive symptoms
than married men [2]. Third, presence of other comorbidities like
diabetes, cancer, organic disorders/cognitive impairment or current use of
any medication due to a psychiatric disorder eg. antidepressants should be
ruled out. Moreover, use of topical nonselective beta-blockers or intake
of oral lipophilic beta blockers for hypertensives should also be
considered since they may lead to depression [3, 4] and subsequently
affect quality of life.
References
1. Rose- Nussbaumer J, Prajna NV, Krishnan T, et al. Br J Ophthalmol
2016;100:929-932.
2. Jang SN, Kawachi I, Chang J et al. Marital status, gender, and
depression: Analysis of the baseline survey of the Korean Longitudinal
Study of Ageing (KLoSA). Soc Sci Med 2009; 11(12): 1608-15.
3. Verbeek DE, van Riezen J, de Boer RA, van Melle JP, de Jonge P. A
review on the putative association between beta-blockers and depression.
Heart Fail Clin. 2011;7(1):89-99.
4. Augustin A, Sahel JA, Bandello F et al. Anxiety and depression
prevalence rates in age-related macular degeneration. Invest Ophthalmol
Vis Sci. 2007;48(4):1498-503.
EDITOR:
With great interest,We have read the article by Chidambara1 and partners on characteristics and quantification of vascular changes in macular telangiectasia type 2( MacTel 2) on optical coherence tomography angiography(OCTA).The authors concluded that OCTA helps understand the pathology and disease progression better in MacTel 2.We commend their interesting and important work on this subject.However, w...
I read with great interest the article by Romero- Aroca et al. titled "Changes observed in diabetic retinopathy: eight-year follow-up of a Spanish population" [1]. Insulin usage has found to be a risk factor for progression of DRP. Authors conclude this result as relaxation of patients in metabolic control. Beside this conclusion, insulin analogues may directly cause progression of DRP. Insulin and its analogues stimulate ins...
Response to E-letter. Thank very much for reading our article. It is true that oral insulin analogues can lead to increased growth hormone, increasing its effect over diabetic retinopathy, but previously it should exist a blood-retina barrier (BRB), despite in patients with preexisting diabetic retinopathy the BRB rupture exist in some amount. It is possible that oral insulin analogues can affect the diabetic retinopathy...
Changing from pro re nata treatment regimen to a treat and extend regimen with ranibizumab in neovascular age-related macular degeneration Dan Calugaru, Mihai Calugaru Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania
Re: Changing from pro re nata treatment regimen to a treat and extend regimen with ranibizumab in neovascular age-related macular degeneration. Hatz and Prunte. Br J Ophthalmol 2016...
With interest we have read the article of Ruiters et al.1 in which they present a 3 dimensional method for ocular prosthesis manufacturing. In our practice we also manufacture individual customized ocular prosthesis using 3D techniques. We confirm that this computer aided method improves prosthetic fitting and may aid the production process when translated into 3D prints. Our method does however differ on several points....
We read with great interest the study titled as "Comparison of trabeculectomy versus Ex-PRESS: 3-year follow-up" by Gonzalez-Rodriguez et al [1].We congratulate their efforts for conducting the study with a follow up of 3 years, making the results more significant.They concluded that success rates, mean IOP, number of anti-glaucoma medications and final visual acuities were similar between the two groups after 3 years. T...
Anatomical effects of dexamethasone intravitreal implant in diabetic macular oedema; a pooled analysis of 3-year phase lll trials Dan Calugaru, Mihai Calugaru Department of Ophthalmology, Univ of Medicine Cluj-Napoca/Romania Re: Anatomical effects of dexamethasone intravitreal implant in diabetic macular oedema: a pooled analysis of 3-year phase lll trials. Danis et al Br J Ophthalmol 2016;100:796-801.
De...
Dear Editor, We thank Drs Gupta and Ram for their interest in our recent paper on the anatomical effects of dexamethasone intravitreal implant (DEX implant) in eyes with diabetic macular oedema [1] and appreciate the opportunity to respond to their comments. Their letter highlights various patient- and treatment-related factors that potentially might have influenced the retinal findings described in our analysis. We pro...
eLetter Comment on: The impact of donor age and endothelial cell density on graft survival following penetrating keratoplasty Parul Chawla Gupta, MS; Jagat Ram, MS, FAMS Department of Ophthalmology Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012 Corresponding author Dr. Jagat Ram, MS, FAMS Professor and Head Department of Ophthalmology Post Graduate Institute of Medical Education and Re...
eLetter Comment on: Risk factors for low vision related functioning in the Mycotic Ulcer Treatment Trial: a randomised trial comparing natamycin with voriconazole Parul Chawla Gupta, MS; Jagat Ram, MS, FAMS Department of Ophthalmology Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012 Corresponding author Dr. Jagat Ram, MS, FAMS Professor and Head Department of Ophthalmology Post Graduate...
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