We read with interest the paper by Hamada et al 1, which draws a
number of conclusions from a five year follow up study of 69 periocular
BCCs treated by conventional surgery, and in particular suggests that
there is no place for Mohs micrographic surgery (MMS) in patients with
periocular BCCs. MMS is the serial saucerisation excision with mapped
horizontal tissue sections examining 100% of the surg...
We read with interest the paper by Hamada et al 1, which draws a
number of conclusions from a five year follow up study of 69 periocular
BCCs treated by conventional surgery, and in particular suggests that
there is no place for Mohs micrographic surgery (MMS) in patients with
periocular BCCs. MMS is the serial saucerisation excision with mapped
horizontal tissue sections examining 100% of the surgical margins to
produce histological evidence of tumour negative margins. Unfortunately,
the data included in the paper are incomplete and if such conclusions are
to be considered, then further clarification is required.
Risk of BCC recurrence relates directly to the nature of the tumours
treated2. The principle risk factors for recurrence include previous
treatment, large tumour size, and an infiltrative or micronodular
histological growth pattern. No information is given on the first 2
factors and the histological subtype was non-specified in approx 45% of
cases. We calculate from the data provided that the authors experienced a
19% 5 year recurrence rate in patients with a histologically infiltrative
BCC.
If most of the “non-specified” tumours in Hamada’s series were small
nodular tumours, as the paper implies, then Hamada’s series also differs
significantly from other larger series in that it represents a group of
patients with an inherently better prognosis. Other comments hint at this,
in that 76% of BCCs were on the lower eyelid and 72% were amenable to
direct closure. If the majority of the tumours in this series were not in
a high- risk group then only one recurrence would be anticipated. In
contrast, the Australian Mohs’ database series3 reported on a much higher
incidence of high-risk tumours (50% were infiltrative, morphoeic,
basosquamous or superficial), of which only 54% were on the lower eyelid
while 41% affected the medial canthus, a site with a proven higher risk of
recurrence. Despite this, they reported a 0% recurrence rate for primary
BCCs of all histological subtypes treated by MMS surgery.
Hamada also concludes that 4mm margins are justified for well-defined
nodular tumours, on the basis of the 5-year recurrence rates and the fact
that most eyelids can still be directly repaired after such excisions. It
is of interest however that 16% of the patients reported had incomplete
tumour excision at the first attempt, although we do not know what margins
were used for this group. As conventional pathological sectioning examines
less than 1% of the margins4, it is likely that the actual incomplete
excision rate was higher.
Hamada argues that MMS is not necessary for periocular tumours on the
basis that it is difficult to obtain true MMS sections. Unless either
periosteum or anterior orbital septum are breached by the tumour, then
there is no evidence for the former statement. What about cost benefit?
MMS histology costs are greater than routine sections. However, when the
other advantages of MMS are taken into account MMS is cost-effective in
comparison to traditional surgical excision5.
The current best evidence shows that recurrence rates are lower with
MMS than with any other technique, with MMS for recurrent or high-risk
tumours showing the greatest advantage over conventional surgery.
Furthermore, Hamada acknowledges that the tissue sparing quality of MMS is
an important issue in that 36% of patients will develop a second BCC
within 5 years.
Although we believe that MMS is the treatment of choice for optimal
cure rates in periocular BCC, we would agree with Hamada that is currently
impractical for all tumours because of the patchy availability of the
service in the UK. However we believe the current evidence shows that MMS
remains the optimal treatment for all high risk tumours based on treatment
status, site, size and histological subgroup and do not feel that the data
presented warrant a different conclusion.
2. Lawrence CM. Mohs surgery - A critical review. Br J Plast Surg
1993, 46, 599-606
3. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs
Database, part II: Periocular basal cell carcinoma outcome at 5 year
follow up. Ophthalmol 2004, 111, 631-636.
4.Abide JM, Nahai F, Bennet RG. The meaning of surgical margins.
Plast Reconstr Surg 1984;73:492-6
5. Cook J, Zitelli JA. Mohs micrographic surgery: a cost analysis. J
Am Acad Dermatol. 1998; 39:698-703.
EA Barnes1, AJ Dickinson1, J AA Langtry2 and CM Lawrence2
1Department of Ophthalmology
Royal Victoria Infirmary
Newcastle-upon-Tyne, NE1 4LP
2Department of Dermatology
Royal Victoria Infirmary
Newcastle-upon-Tyne, NE1 4LP
We read with interest Jackson and Morris's response to our letter.
The author's indicated that it was not possible to conduct a repeated
measures ANOVA using SPSS. However, SPSS provides several ways to analyze
repeated measures ANOVA through the general linear model command. There
are several excellent texts that illustrate how to conduct an ANOVA using
a repeated measures design in the SPSS environment....
We read with interest Jackson and Morris's response to our letter.
The author's indicated that it was not possible to conduct a repeated
measures ANOVA using SPSS. However, SPSS provides several ways to analyze
repeated measures ANOVA through the general linear model command. There
are several excellent texts that illustrate how to conduct an ANOVA using
a repeated measures design in the SPSS environment.
Second, they posed a question about whether it was reasonable to
assume that the data collected 18 months post surgically was specifically
related to data collected previously. To answer, yes, any time several
measurements are collected over time on the same subject, the data points
within each subject are related. Therefore the use of statistical
procedures that account for this clustering must be used. The fact that
the study was exploratory in nature does not preclude the application of
basic statistical principles. On the other hand, the authors correctly
noted that they had also analyzed the data using a 2x3 design. This
approach is reasonable. Unfortunately, the actual p-values were not
provided for the readers in the original article or in their response to
our editorial.
We read with great interest the case report of severe vision loss by
ostrich pecking trauma and would like to bring readers attention to a case
we recently reported about an adult farm worker who lost his vision due to
an ostrich attack [1]. In our case, a 34-year-old male was attacked by
the giant bird with consequent severe pain and immediate loss of vision to
no light perception. On examination, pati...
We read with great interest the case report of severe vision loss by
ostrich pecking trauma and would like to bring readers attention to a case
we recently reported about an adult farm worker who lost his vision due to
an ostrich attack [1]. In our case, a 34-year-old male was attacked by
the giant bird with consequent severe pain and immediate loss of vision to
no light perception. On examination, patient’s right eye had significant
proptosis with severe limitations of the globe in all directions and
irregular full-thickness lacerations of the skin. Exploration of the wound
revealed two fragments of bony-like tissue but no fractures. Ultrasound
examination and CT-scan of the orbits revealed a disorganized right globe
with multiple scleral ruptures without any bony fractures. Microscopic
examination of bony fragments was consistent with avian rostrum.
Human eye injuries caused by pecking of birds are uncommon and are
usually labeled as humorous or incidental, and, consequently, most go
unreported. Serious injuries to humans caused by birds have been sparsely
reported in the English literature. In the non-English literature, Kuhl
reviewed a series of 14 patients with severe eye injuries from 1875
through 1970 caused by birds [2]. All were penetrating ocular injuries,
and some caused permanent visual injuries and/or blindness.
In general, birds are viewed as presenting less of a danger because
of the assumption that the bird will take flight if frightened. On the
contrary, some birds show aggressive behaviors related to territoriality
or breeding. The male ostrich (a flightless bird) is known to establish
territory, display aggressive territorial behavior, and may attack
potential predators [3]. These two reports of an ostrich attack causing
permanent visual loss in adult humans are first in the ophthalmic
literature and emphasize the potential for serious ocular injuries from
birds. People living in rural areas and those who work or plan to visit
farms should be aware that territorial behavior of many domestic animals
and birds may be a potential risk factor.
Imtiaz A. Chaudhry, M.D., Ph.D, FACS
Abdulrahman M. Al-Sharif, M.D
Mohammad Hamdi, M.D
King Khaled Eye Specialist Hospital
PO Box 7191
Riyadh 11462, Saudi Arabia
Tele: 966 (1) 482 1234 ext: 3771
e-mail: orbitdr@hotmail.com
References
(1) Chaudhry IA, Al-Sharif AM, Hamdi M. Severe ocular and periocular
injuries caused by an ostrich. Ophthal Plast Reconstr Surg. 2003;19:246-7.
(2) Kuhl W. Augen verletzungen durch Vogel [Eye injuries caused by
birds].Klin Monatsbl Augenheilkd. 1970;157:810-5.
(3) Deeming DC, Bubier NE. Behavior in natural and captive
environments. In: Deeming DC, ed. The Ostrich: Biology, Production and
Health. Cambridge: University Press; 1999:83-103.
We would like to thank the authors Hornby and Gilbert for their
interesting letter referring to our case report of bilateral colobomatous
microphthalmos with orbital cyst.[1] Their remarks and view are relevant
and demand further clarification.
Because our intention was to investigate more in depth the origin of
the cyst fluid and wall and because of space limitations, we were not able
to...
We would like to thank the authors Hornby and Gilbert for their
interesting letter referring to our case report of bilateral colobomatous
microphthalmos with orbital cyst.[1] Their remarks and view are relevant
and demand further clarification.
Because our intention was to investigate more in depth the origin of
the cyst fluid and wall and because of space limitations, we were not able
to provide additional data about the documented vitamin A deficiency (VAD)
during pregnancy in our histopathologic case report.[2] We will provide
these here. The mother had a history of a biliopancreatic diversion
(Scopinaro procedure) which resulted in a diminished absorption in order
to induce weight loss. However, this operation is associated with a risk
to develop nutritional deficiencies, especially of fat-soluble vitamins
(A,D,E,K), and this in up to 6 percent of cases.[3] In our case, from the
16th week of gestation onwards, the vitamin A status of the mother had
been monitored along with other nutritional parameters (Table 1).
Subsequently, she had been hospitalized for intravenous administration of
a multivitamin preparation, extra vitamin B12 and iron, together with oral
suppletion of folic acid and multivitamins. Despite such maximal repletion
there had been a documented hypovitaminosis A at least from week 16 until
the 24th week of gestation. From week 28 of gestation she had been
hospitalized for parenteral nutrition to further support her vitamin
status. The father was healthy, and no consanguinity was present. History
of any eye abnormalities in the family was negative. It is very likely
that a depletion of vitamin A during conception and the first weeks of
pregnancy was present because vitamin A has a depot within the liver, as
such preventing an acute drop in its plasma level. Futhermore plasma
vitamin A level do not decrease during pregnancy under normal physiologic
conditions. Therefore, ocular development probably occurred in the
context of a vitamin A deficiency.
Previous research done by Hornby et al. pointed out a possible link
between VAD during pregnancy and an increased incidence of microphthalmos
in newborns, in particular in cases with a genetic recessive
predisposition to the teratogenic effects of varying degrees of VAD during
pregnancy.[4] Cools et al. reported the presence of bilateral congenital
microphthalmos in two newborns in a series of nine cases of
biliopancreatic diversion–related adverse neonatal outcome.[3] In one
of them, VAD occurred during pregnancy. Excess as shortage of vitamin A
during gestation may result in an anomalous development of the organism
(e.g. teratogenicity of vitamin A analogues such as isotretinoin),
especially of the eyes.[5] Accumulating data are providing further
evidence to support a possible link between VAD and congenital
microphthalmos and consider vitamin A level as a possible nutritional risk
factor for abnormal development such as folic acid in the prevention of
neural tube defects. This may have implications in preconceptional
evaluation, especially for women with a history of bypass surgery.
Parenteral nutrition as preconceptional treatment may be sufficient to
replete vitamin and nutrient stores in these cases.
References
1. Hornby SJ, Gilbert C. Vitamin A deficiency and possible link with
colobomatous malformations. Br J Ophthalmol July 2007 eLetter
2. Decock, C. E., Breusegem, C. M., Van Aken, E. H, and Leroy, B. P.
High beta-trace protein concentration in the fluid of an orbital cyst
associated with bilateral colobomatous microphthalmos. Br.J Ophthalmol.
91(6), 836-837. 2007.
3. Cools M, Duval ELIM, Jespers A. Adverse neonatal outcome after
maternal biliopancreatic diversion operation: report of 9 cases. Eur J
Pediatr 2006;165:199-202
4. Hornby SJ, Ward SJ, Gilbert CE. Eye birth defects in humans may be
caused by a recessively-inherited genetic predisposition to the effects of
maternal vitamin A deficiency during pregnancy. Med Sci Monit.
2003;9(11):HY23-6.
5. Dickman ED, Thaller C, Smith SM. Temporally-regulated retinoic
acid depletion produces specific neural crest, ocular and nervous system
defects. Development 1997;124:3111-21.
Dr Cho and colleagues present data on a very small cohort of patients
with wet AMD that have switched treatment from either bevacizumab or
ranibizumab to aflibercept. Of note, this subgroup comprised approximately
8% of the total number of patients switched to aflibercept.
Any retrospective review is likely to be heavily biased by the
anticipated 'treatment benefit' of a new therapy particularly if, as in
this ca...
Dr Cho and colleagues present data on a very small cohort of patients
with wet AMD that have switched treatment from either bevacizumab or
ranibizumab to aflibercept. Of note, this subgroup comprised approximately
8% of the total number of patients switched to aflibercept.
Any retrospective review is likely to be heavily biased by the
anticipated 'treatment benefit' of a new therapy particularly if, as in
this case, the readers of retinal optical coherence tomography (OCT) scans
have the ability to manually correct and alter data that were originally
generated by semi-automated methods. In this study, the magnitude of
change observed in central foveal thickness was of marginal clinical
relevance (7.8% reduction from Baseline) after 1 injection and was further
attenuated by 6 months; these results suggest that the retinal OCT scan
reader was an important source of bias. This view is further supported by
the observation that visual acuity, which may be less liable to
investigator related bias, remained unchanged throughout.
Retrospective reviews are of scientific value when conducted in a
rigourous and independent manner. Selective reporting of data from this
study inevitably undermines any clinical conclusions regarding the
relevance of switching patients from anti-VEGF therapies to aflibercept.
Conflict of Interest:
I have consulted for a number of pharmaceutical companies including Novartis, the MAH of ranibizumab in the EU.
We congratulate the authors Ghazi-Nouri et al. to their recently
published study “Visual function and quality of life following vitrectomy
and epiretinal peel surgery”. It mainly confirms our results on a very
similar consecutive cohort of 20 patients followed for three months which
was published August 2005 in the Medline indexed German “Ophthalmologe”
[1] and therefore represents the first paper...
We congratulate the authors Ghazi-Nouri et al. to their recently
published study “Visual function and quality of life following vitrectomy
and epiretinal peel surgery”. It mainly confirms our results on a very
similar consecutive cohort of 20 patients followed for three months which
was published August 2005 in the Medline indexed German “Ophthalmologe”
[1] and therefore represents the first paper on this subject. The first
oral presentation was at the 2004 annual meeting of the German
Ophthalmological Society (DOG).
For assessing the benefit in visual quality of life after
vitreoretinal surgery for epiretinal membranes, we used the commonly
accepted Visual Function 14 (VF-14) test. A larger patient series using
the NEI-VFQ 25 is ongoing. Similarly as in the recent study of Ghazi-Nouri
et al., a significant increase in visual quality of life 3 months after
surgery was observed. The VF-14 values increased significantly from 72.8
preoperatively to 83.3 postoperatively (p<0.05) - although the fellow
eye had good visual acuity (visual acuity of –logMAR 0.2 or better was an
inclusion criteria), so that every patient underwent surgery on the worse
seeing eye. In contrast to Ghazi-Nouri et al., visual acuity increased
significantly from –logMAR 0.55 to 0.4 (p=0.018), which is approximately
1.5 Snellen lines and consistent with most previously reported results in
the literature (2, 3). However, all surgery had been performed by only one
experienced surgeon.
We performed statistic analyses on the data in order to isolate
predictive factors for surgery. When splitting our 20 patients in the two
halves with lowest and highest preoperative VF-14 values, it could be
shown that patients with preoperatively low VF-14 values benefited from
surgery in visual quality of life, while those with preoperatively high VF
-14 values did not. In an analysis of variance model it could be further
shown, that the increase in visual quality of life could better be
estimated than the increase of visual acuity. If in such modelling only
the preoperative VF-14 values and preoperative visual acuity were used to
assess the increase in visual quality of life, those two parameters had a
surprisingly high predictive value (R2=0.80). Cataract surgery did not
influence results significantly. Thus in addition to the later published
results of Ghazi-Nouri et al., we can give practical recommendations for
patient selection: a patient with preoperatively low VF-14 values (i.e.
the patient is highly bothered by the visual performance) and a
preoperatively low visual acuity is very likely to benefit from surgery.
Together with the information that the increase in visual acuity will
probably be not very high, this allows for best consulting and patient
selection for epiretinal membrane surgery.
C. Hirneiss, MD
A.S. Neubauer, MD
A. Kampik, MD
Dept. of Ophthalmology
Ludwig-Maximilians University
Mathildenstr. 8
80336 Muenchen
Germany
References
1. Hirneiss C, Rombold F, Kampik A, Neubauer AS. Visual quality of
life after vitreoretinal surgery for epiretinal membranes. Ophthalmologe
2005 Aug 3 [Epub ahead of print]
2. Michels RG. Vitrektomy for macular pucker. Ophthalmology
1984;91:1384-1388
3. Haritoglou C, Eibl K, Schaumberger M et al. Functional outcome
after trypan blue-assisted vitrectomy for macular pucker: a prospective,
randomized, comparative trial. Am J Ophthalmol 2004;138:1-5
The work by Habib et al [1] is a timely one with the increasingly
important role of assessment and monitoring of the quality of health
service delivery and outcomes. As they indicate, little work exists in
ophthalmology on the associations between surgical volume and outcomes.
This may partly be due to the low rate of serious complications with
ophthalmic surgery such as cataract extraction. However...
The work by Habib et al [1] is a timely one with the increasingly
important role of assessment and monitoring of the quality of health
service delivery and outcomes. As they indicate, little work exists in
ophthalmology on the associations between surgical volume and outcomes.
This may partly be due to the low rate of serious complications with
ophthalmic surgery such as cataract extraction. However, with large
numbers of patients undergoing cataract surgery, ophthalmologists cannot
afford to become complacent as even relatively low complication rates have
the potential to harm many in the community. Currently, in Western
Australian hospitals, phacoemulsification with intraocular lens insertion
is the most commonly performed surgical procedure.
The lack of significant associations between an individual surgeon’s
surgical volume and complication rate in contrast to that shown for the
pooled data [1] may be due to less statistical power in the former group
and is a limitation with any single centre study. Our population-based
work into endophthalmitis after cataract surgery showed marked differences
in endophthalmitis incidence across different surgical centres. However,
we did not find any association between cataract surgery volume and
endophthalmitis risk either before [2] or after adjustment for case-mix
[3].
These contrasting results highlight the importance of selecting valid
outcome measures when the monitoring of clinician performance is being
considered. Should we choose a surrogate measure, a clinical endpoint or
both? The degree to which any complication is within the control of the
surgeon will vary. If a complication is multifactorial, such as
endophthalmitis, then the entire system of care is just as important as a
surgeon’s technical expertise.
Despite highly publicised failures of care [4], it is important that
we do not succumb to a simplistic populist model of “someone to blame”.
Although monitoring surgeon performance is an important aspect of any
quality improvement effort, equally important is a better understanding
and attention to the operating environment and prevailing organisational
culture.
References
(1) Habib M, Mandal K, Bunce CV, Fraser SG. The relation of volume
with outcome in phacoemulsification surgery. Br J Ophthalmol 2004;88:643-
646.
(2) Morlet N, Li J, Semmens JB, Ng J. The Endophthalmitis Population
Study of Western Australia (EPSWA): First Report. Br J Ophthalmol
2003;87:574-576.
(3) Li J, Morlet N, Ng JQ, Semmens JB, Knuiman MW. Significant
nonsurgical risk factors for endophthalmitis after cataract surgery: EPSWA
fourth report. Invest Ophthalmol Vis Sci 2004;45:1321-1328.
(4) Smith R. One Bristol, but there could have been many. BMJ
2001;323:179-180
I commend the authors for yet another treatment for this potentially
disabling and common affliction.
I note that one important component of this treatment requires the mapping
of the site of the erosion during an attack with this area being singled
out for the localised 4-6mm of treatment. However, in most patients that
I have treated over the years the area of erosion is healed by the time
they seek...
I commend the authors for yet another treatment for this potentially
disabling and common affliction.
I note that one important component of this treatment requires the mapping
of the site of the erosion during an attack with this area being singled
out for the localised 4-6mm of treatment. However, in most patients that
I have treated over the years the area of erosion is healed by the time
they seek ophthalmic care (microerosions) and at the most there may be
left some intraepithelial microcysts but no epithelial defect. I would
have thought that this would make it difficult to ascertain where the
treatment should be applied in these cases. The patients who present with
a large epithelial defect (macro-erosions), in whom the mapping of
involved epithelium is possible, are in the minority in my practice.
Perhaps the authors are seeing a selection bias in their cases and it
would be interesting if they could indicate whether they would treat these
“microerosions” and if so where on the cornea.
They also describe using a dry surgical sponge to debride the treated area
resulting in a single sheet removal of the treated area. In my
experience, attempted removal of the loose sheet of epithelium in a
recurrent erosive patient most often results in removal of the entire
corneal epithelium which can be seen to be non-adherent out to the limbus
in all directions. It would be useful if the authors could indicate how
they restrict the removal of the treated epithelium only without ending up
removing the entire corneal epithelium.
As an ophthalmologist for many years, I continue to find the
diagnosis of dry eye difficult unless it is severe. I have spoken to
colleagues who have the same experience. As detailed in this paper there
are many things going on in the pathophysiology of which dryness may be
one.
Can I suggest it might be helpful to our understanding and approach to
sore eyes, to be less dogmatic about attributing dryness as the reason f...
As an ophthalmologist for many years, I continue to find the
diagnosis of dry eye difficult unless it is severe. I have spoken to
colleagues who have the same experience. As detailed in this paper there
are many things going on in the pathophysiology of which dryness may be
one.
Can I suggest it might be helpful to our understanding and approach to
sore eyes, to be less dogmatic about attributing dryness as the reason for
discomfort in these eyes. The discomfort may be caused by a host of
factors which may or may not include dryness.
Dear Editor,
We read with interest the paper by Hamada et al 1, which draws a number of conclusions from a five year follow up study of 69 periocular BCCs treated by conventional surgery, and in particular suggests that there is no place for Mohs micrographic surgery (MMS) in patients with periocular BCCs. MMS is the serial saucerisation excision with mapped horizontal tissue sections examining 100% of the surg...
We read with interest Jackson and Morris's response to our letter.
The author's indicated that it was not possible to conduct a repeated measures ANOVA using SPSS. However, SPSS provides several ways to analyze repeated measures ANOVA through the general linear model command. There are several excellent texts that illustrate how to conduct an ANOVA using a repeated measures design in the SPSS environment....
Dear Editor
We read with great interest the case report of severe vision loss by ostrich pecking trauma and would like to bring readers attention to a case we recently reported about an adult farm worker who lost his vision due to an ostrich attack [1]. In our case, a 34-year-old male was attacked by the giant bird with consequent severe pain and immediate loss of vision to no light perception. On examination, pati...
Dear Editor,
We would like to thank the authors Hornby and Gilbert for their interesting letter referring to our case report of bilateral colobomatous microphthalmos with orbital cyst.[1] Their remarks and view are relevant and demand further clarification.
Because our intention was to investigate more in depth the origin of the cyst fluid and wall and because of space limitations, we were not able to...
Dr Cho and colleagues present data on a very small cohort of patients with wet AMD that have switched treatment from either bevacizumab or ranibizumab to aflibercept. Of note, this subgroup comprised approximately 8% of the total number of patients switched to aflibercept.
Any retrospective review is likely to be heavily biased by the anticipated 'treatment benefit' of a new therapy particularly if, as in this ca...
Dear Editor,
We congratulate the authors Ghazi-Nouri et al. to their recently published study “Visual function and quality of life following vitrectomy and epiretinal peel surgery”. It mainly confirms our results on a very similar consecutive cohort of 20 patients followed for three months which was published August 2005 in the Medline indexed German “Ophthalmologe” [1] and therefore represents the first paper...
Dear Editor
The work by Habib et al [1] is a timely one with the increasingly important role of assessment and monitoring of the quality of health service delivery and outcomes. As they indicate, little work exists in ophthalmology on the associations between surgical volume and outcomes. This may partly be due to the low rate of serious complications with ophthalmic surgery such as cataract extraction. However...
Dear Editor
I commend the authors for yet another treatment for this potentially disabling and common affliction. I note that one important component of this treatment requires the mapping of the site of the erosion during an attack with this area being singled out for the localised 4-6mm of treatment. However, in most patients that I have treated over the years the area of erosion is healed by the time they seek...
As an ophthalmologist for many years, I continue to find the diagnosis of dry eye difficult unless it is severe. I have spoken to colleagues who have the same experience. As detailed in this paper there are many things going on in the pathophysiology of which dryness may be one. Can I suggest it might be helpful to our understanding and approach to sore eyes, to be less dogmatic about attributing dryness as the reason f...
Dear Dr. Watson,
I wish to share that I have adopted your technique of limbal sparing LK for keratoglobus patients and am happy with the results.
Dr.Sitalakshmi
Director
Cornea Services
Sankara Nethralaya
Chennai
India
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