In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
The article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge i...
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
The article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge in ophthalmology. Over the years, the number of doctors unsure in dealing with the most basic eye problems increases. Therefore, we should focus on basic ophthalmology education so that doctors working in the primary care of the population can routinely refer patients to ophthalmologists.
The use of artificial intelligence may be another alternative that can identify ophthalmic diseases with as good accuracy as experts. Artificial intelligence algorithms can be used in telemedicine programs to serve populations of countries that have an irregular distribution of ophthalmologists on their territory, facilitating access to eye examinations with consequent early identification of disease.3
REFERENCE
1. Resnikoff S, Lansingh VC, Washburn L, Felch W, Gauthier TM, Taylor HR, Eckert K, Parke D, Wiedemann PEstimated number of ophthalmologists worldwide (International Council of Ophthalmologyupdate): will we meet the needs? Br J Ophthalmol. 2019 Jul 2. pii: bjophthalmol-2019-314336.
2. Quillen DA, Harper RA, Haik BG. Medical student education in ophthalmology: Crisis and opportunity. Ophthalmology. 2005;112(11):1867–8.
3. Surendran TS, Raman R. Teleophthalmology in diabetic retinopathy. J
Diabetes Sci Technol. 2014; 8: 262-6.
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Although the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of the...
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Although the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of these services will make for more efficient productivity at referral centers, and the patients will avoid having to spend the time and expense to travel to secondary and tertiary centers for basic eye care.3 Practical training of primary care providers is needed to ensure the transfer of skills, but for this training to have long-term impact on service delivery, primary health centers need to be properly equipped and training programs need to be well integrated into the health systems and, in particular, the referral networks, to ensure that patients with more serious conditions are accessing specialists.3-5
Health systems, therefore, need to have adequate financing available, but the costs of universal eye health are a barrier to remote and resource-limited communities in nearly all countries. For example, the burden of out-of-pocket costs of cataract surgery hits the middle-class populations of higher income countries the hardest.6 Innovative, cost-effective solutions must be employed to better tailor the universal access of eye care to a local population. In developing countries, the provision of phacoemulsification and the maintenance of the required equipment are too expensive for most of the patients and facilities. In these settings, manual small-incision cataract surgery (MSICS) is the more appropriate surgical technique, having the same advantages of phaco in terms of outcomes and faster surgical time and recovery, but MSICS also has a shorter learning curve and drastically lower costs.7-9
At the primary care level, cost-effective technology, such as the use of artificial intelligence and smart phones in telemedicine for the purposes of examination and diagnosis, appears to be an appropriate solution to overcoming financial barriers, again saving patients both the time and the expense of traveling to secondary and tertiary care centers.10-13 The diagnostic accuracy of telemedicine models has been validated; however, for the models to work, attention is again placed on the referral network, which has to be strengthened to be able to manage the increase in caseload.12
References
1. Resnikoff S, Lansingh VC, Washburn L, et al. Estimated number of ophthalmologists worldwide (International Council of Ophthalmology Update): will we meet the needs? Br J Ophthalmol 02 July 2009. doi:10.1136/bjophthamol-2019-314336 [Epub ahead of print]
2. World Health Organization. Universal eye health: a global action plan 2014–2019. [A66/11 – 28 March 2013]. 2013. Available: http://www.who.int/blindness/EyeHealthActionPlanWHA66.pdf. [Accessed September 5, 2019].
3. Mafwiri MM, Jolley E, Hunter J, Gilbert CE, Schmidt E. Mixed methods evaluation of a primary eye care training programme for primary health workers in Morogoro Tanzania. BMC Nurs 2016;15:41.
4. Jolley E, Mafwiri M, Hunter J, Schmidt E. Integration of eye health into primary care services in Tanzania: a qualitative investigation of experiences in two districts. BMC Health Serv Res 2017;17(1):823.
5. Yip JLY, Bright T, Ford S, Mathenge W, Faal H; Rwanda Primary Eye Care Process evaluation group. Process evaluation of a National Primary Eye Care Programme in Rwanda. BMC Health Serv Res 2018;18:950.
6. Lansingh VC, Carter MJ, Eckert KA, Winthrop KL, Furtado JM, Resnikoff S. Affordability of cataract surgery using the Big Mac prices. Rev Mex Oftalmol 2015;89:21–30.
7. Singh K, Misbah A, Saluja P, Singh AK. Review of manual small-incision cataract surgery. Indian J Ophthalmol 2017;65:1281–88.
8. Gogate P, Optom JJ, Deshpande S, Naidoo K. Meta-analysis to compare the safety and efficacy of manual small incision cataract surgery and phacoemulsification. Middle East Afr J Ophthalmol 2015;22:362–9.
9. Ruit S, Gurung R, Vyas S. The role of small incision suture-less cataract surgery in the developed world. Curr Opin Ophthalmol 2018;29:105–9.
10. Delgoshaei B, Mobinizadeh M, Mojdekar R, Afzal E, Arabloo J, Mohamadi E. Telemedicine: a systematic review of economic evaluations. Med J Islam Repub Iran 2017;31:113.
11. Shi L, Wu H, Dong J, Jiang K, Lu X, Shi J. Telemedicine for detecting diabetic retinopathy: a systematic review and meta-analysis. Br J Ophthalmol 2015;99:823–31.
12. Wong TY, Sabanayagam C. Strategies to tackle the global burden of diabetic retinopathy: from epidemiology to artificial intelligence. Ophthalmologica. 2019 Aug 13:1-12. doi: 10.1159/000502387. [Epub ahead of print]
13. Mohammadpour M, Heidari Z, Mirghorbani M, Hashemi H. Smartphones, tele-ophthalmology, and VISION 2020. Int J Ophthalmol 2017;10:1909–18.
We read with interest Babu’s report on ‘Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high volume vitreoretinal surgery centres: a pilot study’.1 As the first unit in the United Kingdom to purchase and use the NGENUITY 3D Visualization System (Alcon Laboratories, Fort Worth USA), we would like to share our experience. We assessed DAVS against analogue microscope (AM), from the Consultant surgeons’, trainees and the scrub nurses’ perspective. In our group there was a rapid adaption to the altered colours, head position and stereo vision offered by the DAVS for macular disease, with slower uptake for complex retinal detachments and trauma. In particular, we found the view and quality of image colour in macular cases to be sharp, even at high magnification, making for easier and safer membrane peels. DAVS provided a tangibly improved image quality and ease of description and teaching never previously experience by everyone present in theatre. Surgical trainees particularly benefited from better anatomical and a 3D view of the vitreoretinal pathology. Anecdotally, we tend to agree with Babu et al’s findings that the limitations lie in complex anterior segment cases, particularly with a poor red reflex, where we found the view of the posterior capsule to be compromised compared to the AM. Also, the presence of a sizeable disparity in contrast between immediately adjacent structures in the posterior segment (e.g. colobomas, asteroid hyal...
We read with interest Babu’s report on ‘Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high volume vitreoretinal surgery centres: a pilot study’.1 As the first unit in the United Kingdom to purchase and use the NGENUITY 3D Visualization System (Alcon Laboratories, Fort Worth USA), we would like to share our experience. We assessed DAVS against analogue microscope (AM), from the Consultant surgeons’, trainees and the scrub nurses’ perspective. In our group there was a rapid adaption to the altered colours, head position and stereo vision offered by the DAVS for macular disease, with slower uptake for complex retinal detachments and trauma. In particular, we found the view and quality of image colour in macular cases to be sharp, even at high magnification, making for easier and safer membrane peels. DAVS provided a tangibly improved image quality and ease of description and teaching never previously experience by everyone present in theatre. Surgical trainees particularly benefited from better anatomical and a 3D view of the vitreoretinal pathology. Anecdotally, we tend to agree with Babu et al’s findings that the limitations lie in complex anterior segment cases, particularly with a poor red reflex, where we found the view of the posterior capsule to be compromised compared to the AM. Also, the presence of a sizeable disparity in contrast between immediately adjacent structures in the posterior segment (e.g. colobomas, asteroid hyalosis) impacted on DAVS image quality. What we were not expecting was the difficulty our scrub nurses would have with the DAVS. They found that the polarised glasses rendered normal stereo vision more difficult, and the tinted lenses were a challenge when working in a dimmed ambient lighting. While the surgeons quickly adapted to the novel viewing system, our nursing colleagues found it less easy to use and took longer to adapt.
Reference:
1. Babu N, Kohli P, Jena S, et al. Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high-volume vitreoretinal surgery centre: a pilot study. British Journal of Ophthalmology 2020;104:432-436.
We read with interest the BMJ Editorial Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear1. This highlights the need for risk mitigation in the context of commonplace eye examinations using the slit-lamp biomicroscope and direct ophthalmoscope, both requiring very close proximity manoeuvres within a few centimetres of the patients’ eye, nose and mouth. Droplet spread during eye examination likely increases during these prolonged direct examination techniques. Those at most risk are trainees working in accident and emergency, opticians or acute care settings who are required to see patients presenting with “red eye” for which conjunctivitis is a common cause.
Patients with conjunctivitis can be safely manged by the non-specialist using simple observation and history enquiry2 supplemented by a phone captured image. Remote-site consultation allows further discussion allowing an eye image and clinical details to be scrutinised without the requirement for on-site attendance. Currently, clinicians use mobile phone consultations to supplement and enhance care provision and it would seem prudent to adopt this more widely to minimise risk of Covid-19 transmission which might be acquired through public transport travel, waiting room exposure or face to face consultation. Notwithstanding confidentiality issues of commonly used freeware with private image messaging capabilities e.g Whatsap...
We read with interest the BMJ Editorial Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear1. This highlights the need for risk mitigation in the context of commonplace eye examinations using the slit-lamp biomicroscope and direct ophthalmoscope, both requiring very close proximity manoeuvres within a few centimetres of the patients’ eye, nose and mouth. Droplet spread during eye examination likely increases during these prolonged direct examination techniques. Those at most risk are trainees working in accident and emergency, opticians or acute care settings who are required to see patients presenting with “red eye” for which conjunctivitis is a common cause.
Patients with conjunctivitis can be safely manged by the non-specialist using simple observation and history enquiry2 supplemented by a phone captured image. Remote-site consultation allows further discussion allowing an eye image and clinical details to be scrutinised without the requirement for on-site attendance. Currently, clinicians use mobile phone consultations to supplement and enhance care provision and it would seem prudent to adopt this more widely to minimise risk of Covid-19 transmission which might be acquired through public transport travel, waiting room exposure or face to face consultation. Notwithstanding confidentiality issues of commonly used freeware with private image messaging capabilities e.g Whatsapp, secure ophthalmology data transmission, for example “Attend Anywhere” have been evaluated in Scotland (Livingstone I personal communication) and might be usefully adopted more widely3.
Ophthalmology is one of the highest patient volume specialties with an elderly patient demographic attending for chronic age-related eye diseases often with systemic co-morbidities rendering them a high-risk vulnerable group. To our knowledge there is no consistent UK-wide policy for protecting patients or professionals from Covid-19 transmission in the eye care setting. In the current climate of escalating Covid-19 numbers we suggest remote-site diagnosis using external eye image capture and/or video-consultation to be rapidly adopted by ophthalmologists as a risk mitigating, cost-effective approach to efficient triage and remote site management for all patients with the symptoms and signs of conjunctivitis who should not be referred to on-site hospital eye services.
References
1. Li J, Lam D, Chen Y, et al. Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear. Br J Ophthalmol 2020;104(3):297-298
2. Timlin H, Butler L, Wright M. The accuracy of the Edinburgh Red Eye Diagnostic Algorithm. Eye (Lond) 2015; 29(5): 619–624
3. Poyser O, Livingstone I, Ferguson A, et al. Real-Time Tele-Ophthalmology in the Emergency Department.) Invest. Ophthalmol. Vis. Sci. 2019;60(9):6124
I read with interest the article by Kern et al: Implementation of a cloud-based referral platform in ophthalmology making telemedicine services a reality in eye care. I agree entirely that this is a way forward in ophthalmology, and increasing cooperation between optometrists and ophthalmologists is vital and in the best interests of the patient as well as the NHS.
However, there is an important sentence in the introduction which is incorrect:
'The Opticians Act 1989 obligates UK optometrists to refer any incidental eye abnormality detected during an NHS eye test to a Hospital Eye Services (HES) unless they provide a sufficient disease description including medical advice to the patient.7 '
The obligation on an optometrist to refer a person who appears to be suffering from an injury or disease of the eye applied to any consultation, whether NHS or private. However, this was removed on 1 January 2000 when the General Optical Council’s Rules relating to Injury or Disease of the Eye (1999) came into force. Optometrists now have discretion as to whether or not to refer patients, and indeed many such patients are successfully managed in primary care as a result.
There is no unified consensus in the peripheral nerve literature regarding the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple well-designed peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives to nerve autografts at various gap lengths [1-3]. While there are no trials directly comparing the use of ANAs to nerve autografts in corneal neurotization, Avance® allografts have now become “on label” for corneal neurotization given the successful clinical outcomes reported by several tertiary care centers [4].
In comparing the study by Catapano et al. to the study by Leyngold et al. it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al. were under 18 years of age vs. 14% in the paper by Leyngold et al. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al. noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. The reported CCS at 6 months postoperatively was only 30.0±26.8mm with a significant number (44%) of patients in their study having CCS at or below 10mm and peripheral corneal sensation (PCS) at or below 30mm at that...
There is no unified consensus in the peripheral nerve literature regarding the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple well-designed peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives to nerve autografts at various gap lengths [1-3]. While there are no trials directly comparing the use of ANAs to nerve autografts in corneal neurotization, Avance® allografts have now become “on label” for corneal neurotization given the successful clinical outcomes reported by several tertiary care centers [4].
In comparing the study by Catapano et al. to the study by Leyngold et al. it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al. were under 18 years of age vs. 14% in the paper by Leyngold et al. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al. noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. The reported CCS at 6 months postoperatively was only 30.0±26.8mm with a significant number (44%) of patients in their study having CCS at or below 10mm and peripheral corneal sensation (PCS) at or below 30mm at that time. Among the three patients (43%) reported by Leyngold et al. who had corneal sensation measurements under 35mm one had a follow up of only 3 months, second patient achieved an improvement of 34mm at 10 months after surgery despite multiple medical comorbidities and extensive conjunctival scarring, and the last patient was shown to have corneal nerve regeneration on in vivo confocal microscopy, improved ocular surface and visual acuity despite a small improvement in average corneal sensation. Also, four patients in the study by Catapano et al. were found to have persistent epithelial defects (PEDs) 24 months after the surgery (21%) compared to only 1 patient (14%) reported by Leyngold et al. at 1 month postoperatively.
Finally, the authors state that they “have yet to encounter a suboptimal neurotization outcome with use of nerve autografts to route sensory axons of the great auricular nerve to the cornea” based on only two of their published cases [7]. Such a small number of cases is not sufficient to draw significant conclusions regarding clinical outcomes of their reported technique.
References:
1. Brooks DN, Weber RV, Chao JD, et al. Processed nerve allografts for peripheral nerve reconstruction: A multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions. Microsurgery. 2012 Jan; 32(1)
2. Zuniga JR, Williams F, Petrisor D. A case-and-control, multi-site, positive controlled, prospective study of the safety and effectiveness of immediate inferior alveolar nerve processed nerve allograft reconstruction with ablation of the mandible for benign pathology. J Oral Maxillofac Surg. 2017 Dec; 75(12): 2669-2681.
3. Rinker BD, Zoldos J, Weber RV, et al. Use of processed nerve allografts to repair nerve injuries greater than 25 mm in the hand. Ann Plast Surg. 2017 Jun; 78(6S Suppl 5): S292-S295. 10.1097/SAP.0000000000001037
4. Leyngold IM, Yen MT, Tian J, et al. Minimally invasive corneal neurotization with acellular nerve allograft: surgical technique and clinical outcomes. Ophthalmic Plast Reconstr Surg 2019;35:133–40.
5. Catapano J, Fung SSM, Halliday W, et al. Treatment of neurotrophic keratopathy with minimally invasive corneal neurotisation: long-term clinical outcomes and evidence of corneal reinnervation. British J Ophthalmol. 2019:bjophthalmol-2018-313042.
6. Park J, Charlson E, Leyngold IM, et al. Corneal neurotization: A review of pathophysiology and outcomes. Ophthalmic Plast Reconstr Surg. 2020; Jan 8. doi: 10.1097/IOP.0000000000001583. [Epub ahead of print]
7. Jowett N, Pineda II R. Corneal neurotisation by great auricular nerve transfer and scleral-corneal tunnel incisions for neurotrophic keratopathy. Br J of Ophthalmol. 2018 Nov 23. pii: bjophthalmol-2018-312563
It has been seventeen years since the emergence of Severe Acute Respiratory Syndrome (SARS -CoV)1 and in 2004, we reported the presence of SARS-CoV in human tears and highlighted the possibility of human transmission through tears2.
A new strain of coronavirus (2019-nCoV) has emerged recently in China.3 A recent report highlighted the possibility of transmission through tears.4 This thus serves as a timely reminder for ophthalmologists and healthcare professionals to take necessary precautions in the clinic. Furthermore, asymptomatic patients are potentially infective.3
As ophthalmologists, we sit eye-to-eye with our patients and this close proximity puts us at high risk of being exposed to such infections. When measuring intraocular pressure under topical anaesthesia, our fingers are in contact with the periocular skin or fluorescein-stained tears and it is conceivable that poor hand hygiene increases risk of disease transmission. The tips of reusable bottles of anaesthesia may also come into contact with tear fluid or eyelashes of patients at risk. Also, the use of Schirmer’s test for dry eyes or research purposes, might be sources of infection if the tear samples are not stored properly. It is thus important to ensure good hand hygiene, to wear surgical masks, and if handling infected patients, to don personal protective equipment (PPE) and goggles. It is also important to ensure proper disinfection of reusable equipment (such as tonometer tips). Alternat...
It has been seventeen years since the emergence of Severe Acute Respiratory Syndrome (SARS -CoV)1 and in 2004, we reported the presence of SARS-CoV in human tears and highlighted the possibility of human transmission through tears2.
A new strain of coronavirus (2019-nCoV) has emerged recently in China.3 A recent report highlighted the possibility of transmission through tears.4 This thus serves as a timely reminder for ophthalmologists and healthcare professionals to take necessary precautions in the clinic. Furthermore, asymptomatic patients are potentially infective.3
As ophthalmologists, we sit eye-to-eye with our patients and this close proximity puts us at high risk of being exposed to such infections. When measuring intraocular pressure under topical anaesthesia, our fingers are in contact with the periocular skin or fluorescein-stained tears and it is conceivable that poor hand hygiene increases risk of disease transmission. The tips of reusable bottles of anaesthesia may also come into contact with tear fluid or eyelashes of patients at risk. Also, the use of Schirmer’s test for dry eyes or research purposes, might be sources of infection if the tear samples are not stored properly. It is thus important to ensure good hand hygiene, to wear surgical masks, and if handling infected patients, to don personal protective equipment (PPE) and goggles. It is also important to ensure proper disinfection of reusable equipment (such as tonometer tips). Alternatively, the use of disposable equipment such as tonometer probes/cover, single-use equipment, disposable contact lenses for procedures, might eliminate the risk of viral transmission.
The emergence of this current strain coincides with the lunar new year, and we are likely to see massive people movement within China and around the world. This facilitates disease transmission and it is thus imperative to remind all healthcare professionals to practice caution when handling patients in the clinic.
References
1. World Health Organization. Severe acute respiratory syndrome (SARS): summary table of SARS cases by country on Aug 15, 2003. Available at: http://www.who.int/csr/sars/country/en/country2003_08_15.pdf. Accessed on January 24th, 2020.
2. Loon SC, Teoh SCB, Oon LLE, Se-Thoe SY, Leo YS. The severe acute respiratory syndrome coronavirus in tears. Br J Ophthalmol 2004;88:861-863.
Given the lack of level 1 evidence there is no unified consensus among peripheral nerve experts on the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives for peripheral nerve reconstruction at various gap lengths [1-3]. Moreover, as the authors correctly point out in their correspondence, no trials exist comparing the use of ANAs to nerve autografts in corneal neurotization, nullifying their claim of nerve autograft superiority for this procedure. Of note, Avance® allografts have become “on label” for corneal neurotization since my last correspondence.
In comparing the study by Catapano et al to the study by Leyngold et al it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al were under 18 years of age. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. Catapano et al reported mean CCS at 30.0±26.8mm at 6 months postoperatively, with a significant number (44%) of patients in their study having CCS at or below 10...
Given the lack of level 1 evidence there is no unified consensus among peripheral nerve experts on the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives for peripheral nerve reconstruction at various gap lengths [1-3]. Moreover, as the authors correctly point out in their correspondence, no trials exist comparing the use of ANAs to nerve autografts in corneal neurotization, nullifying their claim of nerve autograft superiority for this procedure. Of note, Avance® allografts have become “on label” for corneal neurotization since my last correspondence.
In comparing the study by Catapano et al to the study by Leyngold et al it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al were under 18 years of age. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. Catapano et al reported mean CCS at 30.0±26.8mm at 6 months postoperatively, with a significant number (44%) of patients in their study having CCS at or below 10mm and peripheral corneal sensation (PCS) at or below 30mm at that time. Among the three patients (43%) reported by Leyngold et al who had corneal sensation measurements under 35mm one had a follow up of only 3 months, second patient achieved an improvement of 34mm at 10 months after surgery despite multiple medical comorbidities, and the last patient was shown to have corneal nerve regeneration on in vivo confocal microscopy, improved ocular surface and visual acuity. Also, four patients in the study by Catapano et al were found to have persistent epithelial defects (PEDs) 24 months after the surgery (21%) compared to only 1 patient (14%) reported by Leyngold et al at 1 month postoperatively.
Finally, the authors state that they “have yet to encounter a suboptimal neurotization outcome with use of nerve autografts to route sensory axons of the great auricular nerve to the cornea” based on only two of their published cases [7]. This quantity of cases is not sufficient to draw any conclusions regarding clinical outcomes of this technique.
References:
1. Brooks DN, Weber RV, Chao JD, et al. Processed nerve allografts for peripheral nerve reconstruction: A multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions. Microsurgery. 2012 Jan; 32(1)
2. Zuniga JR, Williams F, Petrisor D. A case-and-control, multi-site, positive controlled, prospective study of the safety and effectiveness of immediate inferior alveolar nerve processed nerve allograft reconstruction with ablation of the mandible for benign pathology. J Oral Maxillofac Surg. 2017 Dec; 75(12): 2669-2681.
3. Rinker BD, Zoldos J, Weber RV, et al. Use of processed nerve allografts to repair nerve injuries greater than 25 mm in the hand. Ann Plast Surg. 2017 Jun; 78(6S Suppl 5): S292-S295. 10.1097/SAP.0000000000001037
4. Catapano J, Fung SSM, Halliday W, et al. Treatment of neurotrophic keratopathy with minimally invasive corneal neurotisation: long-term clinical outcomes and evidence of corneal reinnervation. British J Ophthalmol. 2019:bjophthalmol-2018-313042.
5. Leyngold IM, Yen MT, Tian J, et al. Minimally invasive corneal neurotization with acellular nerve allograft: surgical technique and clinical outcomes. Ophthalmic Plast Reconstr Surg 2019;35:133–40.
6. Park J, Charlson E, Leyngold IM, et al. Corneal neurotization: A review of pathophysiology and outcomes. Ophthalmic Plast Reconstr Surg. 2020; Jan 8. doi: 10.1097/IOP.0000000000001583. [Epub ahead of print]
7. Jowett N, Pineda II R. Corneal neurotisation by great auricular nerve transfer and scleral-corneal tunnel incisions for neurotrophic keratopathy. Br J of Ophthalmol. 2018 Nov 23. pii: bjophthalmol-2018-312563
The authors would like to thank Dr. MAYURI BORGOHAIN et al. for their interest on our study ‘Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial’, and appreciate their insightful comments.
First, in this study, for “Combined Subconjunctival Injection of Dexamethasone”, we means combination subconjunctival injection of Dexamethasone with anti-glaucoma drug (such as topical pilocarpine, beta-blocker, brinzolamide, and alpha-2 agonists).
Second, for better investigating the effectiveness of injection of dexamethasone, the control group was designed to not subjected to any topical anti-inflammatory drug. Moreover, Patients that were excluded with a usage of topical anti-inflammatory drugs (including NASIDs and steroids), which was mentioned in the method part.
Third, the range of intraocular pressure (IOP) in those 42 eyes was 27-60 mmHg.
Fourth, to study the window period from onset of acute attack for maximum efficacy of subconjunctival dexamethasone injection, we performed correlation analysis between the duration before recruitment with the decrease of IOP (IOPbaseline – IOP24h)，and found that the decrease of IOP was corelated with the duration before recruitment (r = -0.481, p = 0.002). Moreover, about one half of patients that the duration less than 5 days had more efficacy of subconjunctival dexamethasone injection.
Dr. Leyngold states we ‘fail to support [our] viewpoint with peer reviewed studies.’ Our position against the use of acellular nerve allografts (ANAs) in corneal neurotisation was grounded on robust evidence from basic science literature demonstrating their inferior performance relative to autografts for large gap nerve repair. No clinical trial comparing the two techniques exists, and in our opinion there lacks the necessary equipoise to perform such a study.
The regeneration-restrictive properties of long-segment ANAs renders them unsuitable for use in directing sensory axons to the cornea. The largest single-centre study on Avance® ANA use for peripheral nerve repair demonstrated meaningful recovery in only 54% of cases where allografts longer than 50 mm were employed [1]. Remarkably, exploitation of the suboptimal capacity of ANAs to support nerve regeneration has been proposed as a means to inhibit axon growth in the surgical management of painful neuromas [2].
In his defence of off-label use of Avance® allografts in corneal neurotisation, Dr. Leyngold cites his case-series wherein sensory improvement of 35 mm or more was documented in two of seven eyes (29%). In contrast, Catapano et al. noted sensory improvement of 35 mm or more in 16 of 18 cases (89%) where nerve autografts were employed to route healthy trigeminal sensory axons to anaesthetic corneas [3]. In our own experience, we have yet to encounter a suboptimal neurotization outcome with use of n...
Dr. Leyngold states we ‘fail to support [our] viewpoint with peer reviewed studies.’ Our position against the use of acellular nerve allografts (ANAs) in corneal neurotisation was grounded on robust evidence from basic science literature demonstrating their inferior performance relative to autografts for large gap nerve repair. No clinical trial comparing the two techniques exists, and in our opinion there lacks the necessary equipoise to perform such a study.
The regeneration-restrictive properties of long-segment ANAs renders them unsuitable for use in directing sensory axons to the cornea. The largest single-centre study on Avance® ANA use for peripheral nerve repair demonstrated meaningful recovery in only 54% of cases where allografts longer than 50 mm were employed [1]. Remarkably, exploitation of the suboptimal capacity of ANAs to support nerve regeneration has been proposed as a means to inhibit axon growth in the surgical management of painful neuromas [2].
In his defence of off-label use of Avance® allografts in corneal neurotisation, Dr. Leyngold cites his case-series wherein sensory improvement of 35 mm or more was documented in two of seven eyes (29%). In contrast, Catapano et al. noted sensory improvement of 35 mm or more in 16 of 18 cases (89%) where nerve autografts were employed to route healthy trigeminal sensory axons to anaesthetic corneas [3]. In our own experience, we have yet to encounter a suboptimal neurotization outcome with use of nerve autografts to route sensory axons of the great auricular nerve to the cornea [4].
When counselling patients on corneal neurotisation, surgeons need be aware of the considerable evidence pointing to a higher risk of procedural failure where ANAs are substituted for nerve autografts. Articles supporting ANA use should be scrutinized for declared or undeclared conflicts of interest that may influence perception of the surgical outcome.
References:
1. Leckenby JI, Furrer C, Haug L, Juon Personeni B, Vogelin E. A retrospective case series reporting the outcomes of Avance nerve allografts in the treatment of peripheral nerve injuries. Plast Reconstr Surg 2019 doi: 10.1097/prs.0000000000006485[published Online First: Epub Date]|.
2. Hong T, Wood I, Hunter DA, et al. Neuroma Management: Capping Nerve Injuries With an Acellular Nerve Allograft Can Limit Axon Regeneration. Hand 2019:1558944719849115 doi: 10.1177/1558944719849115[published Online First: Epub Date]|.
3. Catapano J, Fung SSM, Halliday W, et al. Treatment of neurotrophic keratopathy with minimally invasive corneal neurotisation: long-term clinical outcomes and evidence of corneal reinnervation. British Journal of Ophthalmology 2019:bjophthalmol-2018-313042 doi: 10.1136/bjophthalmol-2018-313042[published Online First: Epub Date]|.
4. Jowett N, Pineda Ii R. Corneal neurotisation by great auricular nerve transfer and scleral-corneal tunnel incisions for neurotrophic keratopathy. Br J Ophthalmol 2019;103(9):1235-38 doi: 10.1136/bjophthalmol-2018-312563[published Online First: Epub Date]|.
In the response to the article titled “Estimated number of ophthalmologists worldwide (International Council of Ophthalmology update): will we meet the needs?.” published in your esteemed journal, which is a well thought off and written paper, I would like to raise few points regarding this study.
Show MoreThe article concluded that the estimated global ophthalmologist workforce appears to be growing, but, the appropriate distribution of the eye care workforce and the development of comprehensive eye care delivery systems are needed to ensure that eye care needs are universally met.1
However, we can see that better population care requires more complex solutions than just increasing the number of ophthalmologists. Ophthalmologists need complex devices to perform diagnostics and surgery. That way, they end up in places with the necessary infrastructure for it. This problem does not affect the population of countries with good public transport infrastructure that allows people in small towns to access hospitals with ophthalmic care. However, this is not the reality of most of the world's population. In this way, other solutions must be considered.
The teaching of ophthalmology in medical schools has been gradually reduced. The number of colleges in countries such as the United States, which have a compulsory formal internship in ophthalmology, has dropped from 68% in 2000 to 30% in 2004.2 Consequently, training has been ineffective in building basic knowledge i...
We appreciate the comment provided by Dr. Martins regarding our recent estimates of the global number of ophthalmologists, and we agree wholeheartedly with his points, which are encapsulate in the conclusion of our article.1 We appreciate the opportunity to further elaborate.
Show MoreAlthough the global ophthalmologist workforce appears to be continuously growing, our most important finding is that the numbers alone are not sufficient to ensure universal eye health coverage, with no relationship observed between national prevalence of blindness and ophthalmologist density.1 We believe the appropriate distribution, and deployment of ophthalmologist and eye care teams, combined with outreach services where appropriate are important solutions to increasing access of eye care among remote populations. However, we especially stress that the integration of comprehensive eye care into the health care system is critical to universal eye health coverage.2 We emphasize the need for different models of care and service-delivery and the role of the eye care professional cadres, including optometrists and allied ophthalmic personnel, particularly in task-shifting refraction and basic eye care services.
Comprehensive eye care begins at the primary care level,2 and we agree that more ophthalmology education is needed as part of medical education. If primary care providers are able to provide basic eye care services at the community level, then it is assumed that task-shifting of the...
Dear Sir
We read with interest Babu’s report on ‘Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high volume vitreoretinal surgery centres: a pilot study’.1 As the first unit in the United Kingdom to purchase and use the NGENUITY 3D Visualization System (Alcon Laboratories, Fort Worth USA), we would like to share our experience. We assessed DAVS against analogue microscope (AM), from the Consultant surgeons’, trainees and the scrub nurses’ perspective. In our group there was a rapid adaption to the altered colours, head position and stereo vision offered by the DAVS for macular disease, with slower uptake for complex retinal detachments and trauma. In particular, we found the view and quality of image colour in macular cases to be sharp, even at high magnification, making for easier and safer membrane peels. DAVS provided a tangibly improved image quality and ease of description and teaching never previously experience by everyone present in theatre. Surgical trainees particularly benefited from better anatomical and a 3D view of the vitreoretinal pathology. Anecdotally, we tend to agree with Babu et al’s findings that the limitations lie in complex anterior segment cases, particularly with a poor red reflex, where we found the view of the posterior capsule to be compromised compared to the AM. Also, the presence of a sizeable disparity in contrast between immediately adjacent structures in the posterior segment (e.g. colobomas, asteroid hyal...
Show MoreWe read with interest the BMJ Editorial Novel Coronavirus disease 2019 (COVID-19): The importance of recognising possible early ocular manifestation and using protective eyewear1. This highlights the need for risk mitigation in the context of commonplace eye examinations using the slit-lamp biomicroscope and direct ophthalmoscope, both requiring very close proximity manoeuvres within a few centimetres of the patients’ eye, nose and mouth. Droplet spread during eye examination likely increases during these prolonged direct examination techniques. Those at most risk are trainees working in accident and emergency, opticians or acute care settings who are required to see patients presenting with “red eye” for which conjunctivitis is a common cause.
Patients with conjunctivitis can be safely manged by the non-specialist using simple observation and history enquiry2 supplemented by a phone captured image. Remote-site consultation allows further discussion allowing an eye image and clinical details to be scrutinised without the requirement for on-site attendance. Currently, clinicians use mobile phone consultations to supplement and enhance care provision and it would seem prudent to adopt this more widely to minimise risk of Covid-19 transmission which might be acquired through public transport travel, waiting room exposure or face to face consultation. Notwithstanding confidentiality issues of commonly used freeware with private image messaging capabilities e.g Whatsap...
Show MoreI read with interest the article by Kern et al: Implementation of a cloud-based referral platform in ophthalmology making telemedicine services a reality in eye care. I agree entirely that this is a way forward in ophthalmology, and increasing cooperation between optometrists and ophthalmologists is vital and in the best interests of the patient as well as the NHS.
However, there is an important sentence in the introduction which is incorrect:
'The Opticians Act 1989 obligates UK optometrists to refer any incidental eye abnormality detected during an NHS eye test to a Hospital Eye Services (HES) unless they provide a sufficient disease description including medical advice to the patient.7 '
The obligation on an optometrist to refer a person who appears to be suffering from an injury or disease of the eye applied to any consultation, whether NHS or private. However, this was removed on 1 January 2000 when the General Optical Council’s Rules relating to Injury or Disease of the Eye (1999) came into force. Optometrists now have discretion as to whether or not to refer patients, and indeed many such patients are successfully managed in primary care as a result.
There is no unified consensus in the peripheral nerve literature regarding the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple well-designed peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives to nerve autografts at various gap lengths [1-3]. While there are no trials directly comparing the use of ANAs to nerve autografts in corneal neurotization, Avance® allografts have now become “on label” for corneal neurotization given the successful clinical outcomes reported by several tertiary care centers [4].
In comparing the study by Catapano et al. to the study by Leyngold et al. it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al. were under 18 years of age vs. 14% in the paper by Leyngold et al. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al. noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. The reported CCS at 6 months postoperatively was only 30.0±26.8mm with a significant number (44%) of patients in their study having CCS at or below 10mm and peripheral corneal sensation (PCS) at or below 30mm at that...
Show MoreIt has been seventeen years since the emergence of Severe Acute Respiratory Syndrome (SARS -CoV)1 and in 2004, we reported the presence of SARS-CoV in human tears and highlighted the possibility of human transmission through tears2.
A new strain of coronavirus (2019-nCoV) has emerged recently in China.3 A recent report highlighted the possibility of transmission through tears.4 This thus serves as a timely reminder for ophthalmologists and healthcare professionals to take necessary precautions in the clinic. Furthermore, asymptomatic patients are potentially infective.3
As ophthalmologists, we sit eye-to-eye with our patients and this close proximity puts us at high risk of being exposed to such infections. When measuring intraocular pressure under topical anaesthesia, our fingers are in contact with the periocular skin or fluorescein-stained tears and it is conceivable that poor hand hygiene increases risk of disease transmission. The tips of reusable bottles of anaesthesia may also come into contact with tear fluid or eyelashes of patients at risk. Also, the use of Schirmer’s test for dry eyes or research purposes, might be sources of infection if the tear samples are not stored properly. It is thus important to ensure good hand hygiene, to wear surgical masks, and if handling infected patients, to don personal protective equipment (PPE) and goggles. It is also important to ensure proper disinfection of reusable equipment (such as tonometer tips). Alternat...
Show MoreGiven the lack of level 1 evidence there is no unified consensus among peripheral nerve experts on the optimum type of interposition nerve graft for target tissue reinnervation. There are multiple peer reviewed studies by leading experts in peripheral nerve surgery supporting the use of acellular nerve allografts (ANAs) as viable alternatives for peripheral nerve reconstruction at various gap lengths [1-3]. Moreover, as the authors correctly point out in their correspondence, no trials exist comparing the use of ANAs to nerve autografts in corneal neurotization, nullifying their claim of nerve autograft superiority for this procedure. Of note, Avance® allografts have become “on label” for corneal neurotization since my last correspondence.
In comparing the study by Catapano et al to the study by Leyngold et al it is important to note that the average follow up in the former was 24 months whereas it was only 6 months in the latter [4,5]. In addition, 88% of the patients in the paper by Catapano et al were under 18 years of age. As stated in my previous correspondence, Park et al has shown that pediatric age is correlated to improved results in corneal neurotization irrespective of the technique [6]. Catapano et al noted continued improvement in central corneal sensation (CCS) up to two years postoperatively. Catapano et al reported mean CCS at 30.0±26.8mm at 6 months postoperatively, with a significant number (44%) of patients in their study having CCS at or below 10...
Show MoreThe authors would like to thank Dr. MAYURI BORGOHAIN et al. for their interest on our study ‘Combined subconjunctival injection of dexamethasone for the management of acute primary angle closure: a randomised controlled trial’, and appreciate their insightful comments.
First, in this study, for “Combined Subconjunctival Injection of Dexamethasone”, we means combination subconjunctival injection of Dexamethasone with anti-glaucoma drug (such as topical pilocarpine, beta-blocker, brinzolamide, and alpha-2 agonists).
Second, for better investigating the effectiveness of injection of dexamethasone, the control group was designed to not subjected to any topical anti-inflammatory drug. Moreover, Patients that were excluded with a usage of topical anti-inflammatory drugs (including NASIDs and steroids), which was mentioned in the method part.
Third, the range of intraocular pressure (IOP) in those 42 eyes was 27-60 mmHg.
Fourth, to study the window period from onset of acute attack for maximum efficacy of subconjunctival dexamethasone injection, we performed correlation analysis between the duration before recruitment with the decrease of IOP (IOPbaseline – IOP24h)，and found that the decrease of IOP was corelated with the duration before recruitment (r = -0.481, p = 0.002). Moreover, about one half of patients that the duration less than 5 days had more efficacy of subconjunctival dexamethasone injection.
Dr. Leyngold states we ‘fail to support [our] viewpoint with peer reviewed studies.’ Our position against the use of acellular nerve allografts (ANAs) in corneal neurotisation was grounded on robust evidence from basic science literature demonstrating their inferior performance relative to autografts for large gap nerve repair. No clinical trial comparing the two techniques exists, and in our opinion there lacks the necessary equipoise to perform such a study.
The regeneration-restrictive properties of long-segment ANAs renders them unsuitable for use in directing sensory axons to the cornea. The largest single-centre study on Avance® ANA use for peripheral nerve repair demonstrated meaningful recovery in only 54% of cases where allografts longer than 50 mm were employed [1]. Remarkably, exploitation of the suboptimal capacity of ANAs to support nerve regeneration has been proposed as a means to inhibit axon growth in the surgical management of painful neuromas [2].
In his defence of off-label use of Avance® allografts in corneal neurotisation, Dr. Leyngold cites his case-series wherein sensory improvement of 35 mm or more was documented in two of seven eyes (29%). In contrast, Catapano et al. noted sensory improvement of 35 mm or more in 16 of 18 cases (89%) where nerve autografts were employed to route healthy trigeminal sensory axons to anaesthetic corneas [3]. In our own experience, we have yet to encounter a suboptimal neurotization outcome with use of n...
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