17 e-Letters

  • Beware of False Reassurances

    We commend the authors on the first substantial work in assessing such an issue. However, we believe that important metrics have been overlooked.

    Socioeconomic Class:
    This study’s supplementary dataset demonstrates that certain universities, namely Oxford, Cambridge, Imperial College London and University College London, have significantly higher number of graduates entering OST on their first attempt and passing the Fellow of the Royal College of Ophthalmologists (FRCOphth) Part 1 exam than other universities. These universities are known to accept a lower proportion of candidates in lower SEC and Participation Of Local Areas (POLAR) quintiles than average (1).
    Those offered a place on OST had significantly higher educational performance measure (EPM) which comprises of points for examination ranking and additional degrees and publications (2) . For a variety of societal or financial reasons, lower SEC students may be less likely to intercalate or pursue medicine as a graduate, reducing their EPM(3).
    Further, a potential financial barrier exists of up to £5,078 for additional opportunities to increase portfolio score when applying to OST (4).
    Whilst no difference in this paper was found on first application, many gain OST after multiple attempts which bring with it a lack of job security, which could deter lower SEC applicants due to dependants, financial or geographical obligations.

International medical graduates...

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  • Critical Appraisal in uveitis and eye diseases with fewer evidence-based clinical practice guidelines

    Dear Editor,

    Thank you for the opportunity to respond to the comments raised in the correspondence by Galvez-Olortegui et al. [1] regarding our recent publication "Systematic review of clinical practice guidelines for uveitis" [2]

    We thank the authors for a thoughtful and considered response to the paper and appreciate the interest shown in our work. The authors have highlighted additional factors beyond evidence when formulating recommendations for patient care, such as cost-effectiveness, feasibility, and equity.

    We agree with the point that although the Appraisal of Guidelines for Research and Evaluation (AGREE II) is a commonly used tool for critical appraisal of Clinical Practice Guidelines (CPGs), the exclusion of items in the evaluation process may limit the assessment of the entire CPG development process. We acknowledge the concern about the lack of consideration of applicability domain (domain 5) in the evaluation of CPGs. Indeed, a CPG with high methodological quality can score low in applicability domain, which can limit its implementation in specific environments.

    We also appreciate the suggestion of a more novel tool, the appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX), which focuses specifically on the quality of the recommendations of the CPG and its clinical credibility and implementability for health professionals, decision makers, and stakeholders. In combination with AGREE...

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  • Clinical Practice Guidelines and positions statements critical appraisal in Uveitis

    To the editor:
    We have carefully read the article “Systematic Review of Clinical Practice Guidelines for Uveitis” by Ghadiri et al., whose purpose is to present the results, including the quality and current state of evidence, of a systematic review of Clinical Practice Guidelines (CPG) for uveitis(1).

    CPG provides recommendations to optimize patient care, based on a systematic review of evidence and, although the evidence is critical; additional factors should be considered when formulating recommendations, such as benefits and risks, use of resources, cost-effectivity, values and preferences of the patient, feasibility and equity, before recommendations are considered ultimate (2). Currently, there are several ways to critical appraise a CPG, and the most used is the Appraisal of Guidelines for Research and Evaluation (AGREE II).

    AGREE II has 23 items, with 6 domains, for evaluating the rigor or methodological quality and transparency with which a guide is developed; thus, the aim is to assess the entire CPG development process. However, a CPG with high methodological quality (domain 3) can score low in applicability domain (domain 5), because of it is difficulty to implement or adapt to a specific environment if the recommendations are not robust, troublesome to apply or of uncertain clinical validity. Ghadiri et al. specifically used 9 items of the AGREE II and none of them correspond to domain 5 (applicability). The AGREE II user manual itself advi...

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  • Differential Attainment in Ophthalmology

    Dear Aditi Das, Daniel Smith and Rashmi Mathew,

    Thank you for your interesting and important article exploring predictors of career success in ophthalmology. It is vital that we examine the factors that both enable and hinder career progression in medicine and surgery, as these affect the wellbeing and retention of doctors, arguably two of the biggest issues currently afflicting our profession. In addition, tackling differential attainment in doctors' career success is a matter of ensuring our core values of equality, diversity and inclusion are upheld in healthcare. Resultantly, differential attainment has become a research priority for key stakeholders, including the national bodies of the General Medical Council (GMC), Health Education England, the British Medical Association and the Royal Colleges.

    Your article stated that for your study's cohort, there was no association between ethnicity and passing the FRCOphth Part 1 on the first attempt. Conversely, the Royal College of Ophthalmologists (RCOphth) announced that GMC data found a statistically significant variation in the percentage of doctors passing FRCOphth examinations on their first attempt, depending on place of primary medical qualification and ethnicity. White UK graduates had a 72% pass rate, while BAME (Black, Asian or minority ethnic) UK graduates had a 60% pass rate, reducing to 50% for international BAME graduates.(1) These results display one way in which differential attainmen...

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  • Authors’ response to: Tomoyuki Kawada, regarding the publication: “Relative selenium insufficiency is a risk factor for developing severe Graves’ orbitopathy: a case -control study”

    Dear Editor,
    We are thankful for the enriching comments on our article on the selenium (Se) insufficiency cut-off point value related to severe Graves’ orbitopathy (GO).

    We concur that the area under the ROC curve revealed an imperfect differentiation between mild and severe GO. Since GO is a multifactorial disease, a single trace element like selenium should be combined with other determinants in clinical practice. Nonetheless, finding from our study built upon the existing evidence on the association between selenium and GO by proposing a possible cut-off-point that should be further validated with a larger and/or different population. Also, future studies that include healthy individuals without orbitopathy will generate more obvious comparative evidence on the effects of Se on the disease course.

    Universal normal ranges of serum selenium (Se) levels have not been set because of the geographical variability in selenium levels. The ‘sufficient’ levels of serum selenium have been relative to clinical parameters, e.g., prevention of Keshan disease at > 21 mcg/l, the optimal activity of IDIs (iodothyronine 5’ deiodinase) at > 65 mcg/l (1). The cut-point identified in our study was compatible with at least three studies (90mcg/l, 95mcg/l, and 89 mcg/l) regarding plasma selenium needed to achieve the full expression of plasma GPx (glutathione peroxidase) (1-3).

    1. Thomson CD. Assessment of requirements for selenium and adequ...

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  • Re: Relative selenium insufficiency is a risk factor for developing severe Graves' orbitopathy

    Lumyongsatien et al. investigated the risk of relative selenium (Se) insufficiency for the development of disease severity in 100 patients with Graves' orbitopathy (GO) (1). Thirty-two patients had mild GO and 68 had severe GO, and the adjusted odds ratio (OR) (95% confidence interval [CI]) of Se level ≤93 µg/L for severe GO development was 8.14 (2.39 to 27.75). Abnormal thyroid status was also a risk factor for severe GO, presenting adjusted OR (95% CI) of 3.24 (1.04 to 10.04). The authors concluded that Se ≤93 µg/L was a risk factor for severe GO development, and I have a comment about their study.

    The authors conducted a receiver operating characteristic curve analysis to determine the cut-off point for detecting severe GO, but the area under the curve was not so large in Figure 1. In addition, 95% CI for the adjusted OR presented a wide range. This means that ability of differentiating severe GO from mild GO by using serum Se may not be high, although there was a statistical significance. In addition, there is a need of study to specify the dose-response relationship between serum Se levels and severity of GO by including Graves' disease without orbitopathy. Anyway, further study is needed to determine the appropriate cut-off point of serum Se for detecting severe GO.

    1. Lumyongsatien M, Bhaktikamala U, Thongtong P, et al. Relative selenium insufficiency is a risk factor for developing severe Graves' orbitopathy: a case-con...

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  • Altered healthcare-seeking behaviours during the COVID-19 pandemic and moving forward

    Dear Editor,
    The impact of the COVID-19 pandemic on the NHS and its patients is indisputably far reaching, and this study [1] provides a much-needed perspective into how healthcare seeking behaviours were influenced during this time. The Emergency Department Syndromic Survey System (EDISS) data showed Emergency departments (ED) across the country showed a 25-50% decrease in attendances [2], raising concerns that individuals with possibly, life-threatening illnesses were potentially avoiding hospitals rather than seeking medical attention in a timely manner [2]. By looking into how the general population evaluated the severity, urgency and impact of various eye symptoms [1], the authors provide us with a better understanding of the driving forces and barriers to seeking healthcare, by doing which, they shed light on areas for which nationwide public health messages might not be sufficiently educating people on the importance of accessing healthcare appropriately for conditions that can be life-threatening, or in this case sight-threatening.
    The WHO declared the SARS-CoV-2 infection a pandemic on 11th March 2020 [3]. Subsequently, the UK Government imposed a national lockdown on 23rd March 2020 [4], with the aim of reducing pressures on the NHS and curbing infection rates. “Vulnerable” individuals were advised to “shield” [5]. The NHS saw a transition from face-to-face consultations to increasingly more virtual consultations [6], with many elective procedures bei...

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  • Comment on "Ocular manifestations of RT-PCR-confirmed COVID-19 cases in a large database cross-sectional study"

    Dear editor,

    I must thank Sarkar et al for their insightful study into the COVID effect on ocular symptoms. Although the pandemic has been raging on for close to 2 years now, there is still limited information on the ocular manifestation in COVID patients.

    However, I would like to point out the lack of information on the demographic of their study group. Whilst Sarkar et al has provided information on the age group of participants, giving the readers the idea that the ocular manifestation is more prominent in higher age group, It failed to address the fact that gender plays an important factor too. As demonstrated in studies like Borrelli et al [1] and Nøland et al [2], symptoms such as dry eyes etc are much more common in the female population. Hence, the study would have been more convincing if the information on the gender of the participants were made available.

    In addition to the point above, I would like to highlight that this study did not address the variation of severity of COVID infection in group 1. As concluded in studies like Johansson et al [3] and Son et al [4], there is substantial variation in symptoms among patients with similar viral load. This would bring to question as to whether the manifestation of ocular symptoms is directly influenced by the level of viral load itself or the severity of systemic COVID symptoms from.

    Lastly, Sarkar et al should address if patients with severe COVID infection were excluded from the st...

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  • Re: Rapid assessment of prevalence of blindness and cataract surgery in Kabul Province, Afghanistan

    Dear editor,

    I appreciate that the time this study was conducted was during a political turmoil in the country, and I applaud the effort to recruit participants during this difficult time. This article has shed light on the differences in prevalence of visual impairment between the male and female population. Noticeably the number of male participants with complete blindness was 3832, in contrast with the female participants of 6015. Unfortunately, there is no breakdown of data for causes of blindness and visual impairment between the male and female population. Perhaps it would help explain the phenomenon.

    The article has addressed the issue that there was difficulty obtaining female participants for this study due to the lack of female eye health personnel. Could this also mean that there is a lack of access to eye care for women for prevention of blindness.

    The article begged a question as to where Afghanistan should focus its efforts when it comes to eye care. Perhaps a very important effort is to recruit more female ophthalmologist in the country to allow better access to eye care for the female population. Hopefully this will be taken into consideration in the country's effort to combat blindness when the political climate allows.

  • How to tame synthetic biodegradable materials in ophthalmology: the importance of medications An opinion from physiological viewpoints

    I read with interest the publication by Ramachandran et al, and offer the following comments.

    Synthetic Bioresorbable polyglycolic acid (PGA) sheets are widely used in surgery and have recently been applied to ulcers resulting from endoscopic submucosal dissection (ESD)in upper gastrointestinal endoscopy treatment[1]. In vivo, PGA sheets undergo nonenzymatic hydrolysis with the resulting glycolic acid being completely metabolized in about 15 weeks. Animal and human studies have shown that PGA implantation provokes acute and prolonged inflammation by foreign-body reaction and localized acidification. In only a few hours, degraded PGA and glycolic acid induce acute inflammation, as demonstrated by neutrophil infiltration [2].

    In the Ramachandran study, the safety of poly- lactic co- glycolic acid (PLGA) electrospun membranes as carriers for limbal tissue explants was demonstrated. The ocular surface remained clear with no epithelial defects in three in five subjects at 12 months. It should be noted that degradation of biosynthetic materials including PLGA triggers inflammatory reactions. Thereore in the package instructions and guidelines often recommends not to use these materials in ophthalmology. However, host inflammatory reactions could be controlled with adequate medications such as topical or systemic steroid administrations. Although in the article, no information on such medications was provided,I hope they would be providesd elsewhere. Then, The oph...

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