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.
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.
Ethnicity:
International medical graduates (IMGs) comprise over 30% of UK registered doctors(5). Black and minority ethnic (BME) doctors, IMG or UK trained, are less likely than their white counterparts to progress in their careers (6). Differential attainment is shown in university applications, postgraduate examinations results and outcomes of annual review of competence progression. The 2022 RCOphth Differential Attainment paper (7) reported that 70 % of white UK graduates pass their FRCOphth Part 1 first time, compared to 60% of BME UK graduates, 45% white IMGs and 50% BME IMGs, and similarly for EEA graduates. Similar results are reflected by a British Medical Assiciation (BMA) report into ethnic minority doctor barriers across all medical postgraduate exams(8). The authors claim that ethnicity does not influence success in OST whilst omitting doctors with non-UK PMQs which total a significant 24% of candidates sitting the FRCOphth Part 1. This RCOphth report also noted that in 2021, the Black trainee doctor population vs OST applicants and offers holders were 6.4%, 6.2% and 4.5% respectively. Whereas, white offer holders compared to applicants were 35.4% and 25.6% respectively.
Gender:
Whilst the authors state gender does not influence OST success, of 2021 applicants with recorded gender data, 55% were male and 39% female. However, of successful applicants, 74% were male and 16% female. The ratio of male to female doctors in training generally in the UK that year was 43.6% and 56.4% respectively. These findings demonstrate overrepresentation of men in OST year compared to females both in the application process and compared to the trainee population (7). Ophthalmology is second only to surgery as the speciality with the lowest proportion of female trainees(9).
Such work as done by the authors is important, but we feel the criteria and datasets used risk that creating a false reassurance that bias does not exist. We believe the subsequent publication of the RCOphth Differential Attainment Report does not support the authors’ claims regarding OST recruitment. Though not the methodology of their paper, to truly assess the impact of SEC, gender and ethnicity on career success, progress through the training programme itself, as well as subsequent consultant recruitment should also be investigated. Qualitative impact on trainee’s experiences would also buttress the quantitative data. We must remember that our ophthalmology workforce is much more than UK trained graduates who succeeded at their first attempt.
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...
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 II, this can be a useful way to evaluate the clinical credibility and implementability of CPGs. Within the context of this paper, the use of AGREE II was principally to ensure that this review would correspond to the other reviews within the umbrella of the WHO Guideline Review Committee Secretariat and the WHO Package of Eye Care Interventions [3]
Finally, we agree with your statement that the methodology used by Ghadiri et al. is applicable to eye diseases with a high number of evidence-based CPGs, and we appreciate your insights into the challenges of identifying and including consensus-based recommendations and panels of experts in the selection process. It is indeed unfortunate that the coverage of uveitis in CPGs is low, which can lead to challenges in guiding decision-making for optimum patient care. I appreciate the authors' efforts to identify gaps in evidence and propose strategies to handle them through systematic review, and thank you for your contribution to the discussion on improving the evaluation of CPGs for uveitis and other eye diseases.
Once again, we appreciate the comments made by the authors and thank BMJ Ophthalmology for the opportunity to respond. We hope that our work will contribute to further research in this area and improve patient outcomes.
References:
[1] Galvez-Olortegui J, Burgueño-Montañes C, Zavaleta-Mercado M, Galvez-Olortegui T and Adan A "Clinical Practice Guidelines and positions statements critical appraisal in Uveitis." Rapid Response to: "Systematic review of clinical practice guidelines for uveitis" BMJ Open Ophthalmol. 2023;8(1):e001091. Doi: http://dx.doi.org/10.1136/bmjophth-2022-001091
[2] Ghadiri N, Reekie IR, Gordon I, Safi S, Lingham G, Evans JR, et al. Systematic review of clinical practice guidelines for uveitis. BMJ Open Ophthalmol. 2023;8(1):e001091. Doi: http://dx.doi.org/10.1136/bmjophth-2022-001091
[3] Keel S, Evans JR, Block S, et al. Strengthening the integration of eye care into the health system: methodology for the development of the who package of eye care interventions. BMJ Open Ophthalmol 2020;5:e000533.doi:10.1136/bmjophth-2020-000533pmid:http://www.ncbi.nlm.nih.gov/pubmed/32821853PubMedGoogle Scholar
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...
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 advise against the exclusion of items in the evaluation process.
Recently, a new tool has been developed, the appraisal of Guidelines for Research and Evaluation-Recommendations Excellence (AGREE-REX), focused specifically on the quality of the recommendations of the CPG when evaluating clinical credibility and implementability for health professionals, decision makers and stakeholders. It comprises 9 items, grouped in 3 categories: clinical applicability, values and preferences, and implementability (3,4). The use of the AGREE-REX tool as a complement to AGREE II, might help to perform a better evaluation of the CPGs and to support the development of the Package of Eye Care Interventions (PECI) of the WHO (5).
Uveitis has been identified as one of the fifteen priority ocular pathologies for inclusion in the PECI, and through systematic reviews it is sought to determine gaps in evidence and propose strategies to handle them. We agree with Ghadiri et al. in the low coverage of the uveitis in the CPG, with the implications that this has to guide the decision making for the optimum patient care. We also consider that the methodology used by Ghadiri et al., is applicable to eye diseases with a high number of evidence-based CPG. The majority of articles with recommendations for the diagnosis and management of uveitis (a broad group of multidiciplinary or heterogeneous pathologies), are recommendations based on consensus, panel of experts, etc.; many of which were eliminated during authors selection process.
In summary, Ghadiri et al, performed an important analysis, which must be replicated mainly in eye diseases with a large number of CPG; however, not using AGREE-REX, in the context of few GPC in Uveitis, can lead to a rigor bias, excluding relevant content that point out evidence gaps that would allow the stablishment of strategies and future lines of research according to the objectives of the PECI.
References:
1. Ghadiri N, Reekie IR, Gordon I, Safi S, Lingham G, Evans JR, et al. Systematic review of clinical practice guidelines for uveitis. BMJ Open Ophthalmol. 2023;8(1):e001091. Doi: http://dx.doi.org/10.1136/bmjophth-2022-001091
2. Wachholz PA, Stein AT, Melo DO de, Mello RGB de, Florez ID. Recommendations for the development of Clinical Practice Guidelines. Geriatr Gerontol Aging. 2022;16:e0220016. Doi: http://dx.doi.org/10.53886/gga.e0220016
3. Brouwers MC, Spithoff K, Kerkvliet K, Alonso-Coello P, Burgers J, Cluzeau F, et al. Development and Validation of a Tool to Assess the Quality of Clinical Practice Guideline Recommendations. JAMA Netw Open. 2020;3(5):e205535. Doi: http://dx.doi.org/10.1001/jamanetworkopen.2020.5535
4. Florez ID, Brouwers MC, Kerkvliet K, Spithoff K, Alonso-Coello P, Burgers J, et al. Assessment of the quality of recommendations from 161 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation–Recommendations Excellence (AGREE-REX) instrument shows there is room for improvement. Implement Sci. 2020;15(1):79. Doi: https://doi.org/10.1186/s13012-020-01036-5
5. Keel S, Evans JR, Block S, Bourne R, Calonge M, Cheng CY, et al. Strengthening the integration of eye care into the health system: methodology for the development of the WHO package of eye care interventions. BMJ Open Ophthalmol. 2020;5(1):e000533. Doi: http://dx.doi.org/10.1136/bmjophth-2020-000533
Funding Sources
The authors declare no financial support for the performance of this study.
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...
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 being cancelled during this time [7].
With these structural and logistical changes, came changes to healthcare-seeking behaviours of the British population. With the reduction in ED attendances [2] comes the major risk of harm to patients who perceive COVID-19 as a barrier to seeking help. As described by the authors [1], the Rosenstock health belief model [8] outlines factors that influence an individual’s decision to seek medical help, of which COVID-19 and the lockdown presents as a barrier to the patient seeking medical attention in times when they think they require it. A study from an Emergency Eye Department (EED) at a tertiary eye centre in Leicester found a shocking 53% reduction in attendances during the 1st lockdown in March 2020 [9]. Furthermore, they noted a higher proportion of macula-off retinal detachment, a late sign of retinal tears, suggesting they may have resulted from possible delayed presentations to the emergency department. They observed a 60% reduction in the number of retinal tear cases presenting to ED [9], of which some could have progressed to retinal detachment.
The change in healthcare seeking behaviours attributed to COVID-19 is likely multifactorial, including perceived risk of contracting COVID-19 infection in higher risk environments such as hospitals, challenges associated with travel arrangements to point of care, reduced support from friends and family to aid appropriate contact with healthcare services. This is an area that requires further study to better understand the individual factors impacting decision-making in this context.
Somewhat independent of COVID-19, this survey identifies the need for individuals to be able to assess severity of their symptoms and seek help accordingly [1]. It has been previously identified that knowledge of eye disease is lacking amongst the general population [10]. This results in a significant barrier to accessing healthcare and can skew the risk assessment undertaken by individuals when deciding on how to act based on their symptoms. In a way, COVID-19 has shown a clear need for more effective communication of public eye health messages prompting people to access services when required with appropriate urgency. Moreover, the survey indicated that non-white individuals reported a reduced perception of severity and urgency of medical attention [1], suggesting an inadequacy in the way our healthcare messages are communicated to all groups of society.
Despite there being a larger emphasis for vulnerable individuals and those above the age of 70 to shield during the pandemic [5], the Leicester EED did not find any significant differences in the average age of patients pre-COVID-19 and during the pandemic. The survey noted that people of greater age were more likely to consider symptoms to be of greater seriousness [1], which may offset the perceived risk of COVID -19 infections. However, more data would be required to understand this relationship better.
COVID-19 has elucidated the need for a better understanding of healthcare seeking behaviours, not only during a pandemic, but also as we return to a more “normal” state of affairs, and this study provides a much-needed glimpse into factors affecting patients’ decision-making and ways in which they can be empowered to access healthcare as we continue to tackle the pandemic, and beyond.
References:
1. Butt GF, Hodson J, Wallace GR, et al. Public perceptions of eye symptoms and hospital services during the first UK lockdown of the COVID-19 pandemic: a web survey study. BMJ Open Ophthalmology 2021;6:e000854. doi: 10.1136/bmjophth-2021-000854
2. Thornton, J . Covid-19: A&E visits in England fall by 25% in week after lockdown. BMJ 2020; 369: m1401
3. WHO . Rolling updates on coronavirus disease (COVID-19), https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-a... (Accessed 19 Dec 2021)
4. UK Government . Number of coronavirus (COVID-19) cases and risk in the UK, https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public (Accessed 19 Dec 2021)
5. UK Government . Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19, https://www.gov.uk/government/publications/guidance-on-shielding-and-pro... (Accessed 19 Dec 2021)
6. Gilbert AW, Billany JCT, Adam R, et al. Rapid implementation of virtual clinics due to COVID-19: report and early evaluation of a quality improvement initiative. BMJ Open Quality 2020;9:e000985. doi: 10.1136/bmjoq-2020-000985
7. Dunn P, Allen L, Cameron G, Alderwick H. COVID-19 policy tracker. Available from: https://www.health.org.uk/news-and-comment/charts-and-infographics/covid.... (Accessed 19 Dec 2021)
8. Rosenstock, I.M., 2000. Health Belief Model.
9. Poyser A, Deol SS, Osman L, et al. Impact of COVID-19 pandemic and lockdown on eye emergencies. European Journal of Ophthalmology. 2021;31(6):2894-2900
10. Irving EL, Sivak AM, Spafford MM. “I can see fine”: patient knowledge of eye care. Ophthalmic Physiol Opt 2014;34:38-45.
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...
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 attainment affects doctors within ophthalmology.
Indeed, differential attainment has been known to exist for over two decades and the body of new evidence continues to grow.(2) There is now a collective agreement among the aforementioned key stakeholders that efforts must concentrate on constructing and executing action plans to effect change.(2-6) RCOphth have responded with the introduction of a reverse mentoring scheme to support both trainees and trainers, in order to reduce the inequalities faced by doctors in training.(1)
In conclusion, the GMC strategy for 2021-2025 includes focusing on doctors’ wellbeing; staff retention; and promoting a more supportive, fair and inclusive environment to improve our workforce and healthcare system.(7) Differential attainment is inextricably linked to all of these factors and is therefore a vital component to address. The focus should now be on piloting and evaluating interventions to tackle differential attainment, as well as sharing subsequent learning so that doctors may benefit across all branches of medicine and surgery.
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.
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...
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 study as they were too unwell to participate in ocular examination. If so, this would downplay the data on ocular symptoms among COVID patients.
References
1. Borrelli M, Frings A, Geerling G, Finis D. Gender-Specific Differences in Signs and Symptoms of Dry Eye Disease. Curr Eye Res. 2021;46(3):294-301. doi:10.1080/02713683.2020.1801758
2. Tellefsen Nøland S, Badian RA, Utheim TP, et al. Sex and age differences in symptoms and signs of dry eye disease in a Norwegian cohort of patients. Ocul Surf. 2021;19:68-73. doi:10.1016/j.jtos.2020.11.009
3. Johansson MA, Quandelacy TM, Kada S, et al. SARS-CoV-2 Transmission From People Without COVID-19 Symptoms. JAMA Netw Open. 2021;4(1):e2035057. doi:10.1001/jamanetworkopen.2020.35057
4. Son, Kyung-Bok, Lee, Tae-jin & Hwang, Seung-sik. (2021). Disease severity classification and COVID-19 outcomes, Republic of Korea. Bulletin of the World Health Organization, 99 (1), 62 - 66. World Health Organization.
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).
References
1. Thomson CD. Assessment of requirements for selenium and adequ...
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).
References
1. Thomson CD. Assessment of requirements for selenium and adequacy of selenium status: a review. Eur J Clin Nutr 2004;58:391-402.
2. Duffield AJ, Thomson CD, Hill KE, et al. An estimation of selenium requirements for new Zealanders. Am J Clin Nutr 1999;70:896-903.
3. Thaomson CD, Robinson MF, Butler JA, et al. Long-Term supplementation with selenate and selenomethionine: selenium and glutathione peroxidase (EC 1.11.1.9) in blood components of New Zealand women. Br J Nutr 1993;69:577-88
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.
References
1. Lumyongsatien M, Bhaktikamala U, Thongtong P, et al. Relative selenium insufficiency is a risk factor for developing severe Graves' orbitopathy: a case-con...
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.
References
1. Lumyongsatien M, Bhaktikamala U, Thongtong P, et al. Relative selenium insufficiency is a risk factor for developing severe Graves' orbitopathy: a case-control study. BMJ Open Ophthalmol 2021;6(1):e000713.
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...
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 ophthalmology community might improve its understanding of clinically available biodegradable materials, including mechanisms of action and response in the human body.
Reference
[1] Murakami, Daisuke; Harada, Hideaki; Amano, Yuji; Yamato, Masayuki:
Do polyglycolic acid sheets really prevent bleeding after endoscopic submucosal dissection? An opinion from physiological viewpoints
Endoscopy; Issue 01, 2020
[2] Ceonzo K, Gaynor A, Shaffer L et al. Polyglycolic
acid-induced inflammation: role of hydrolysis
and resulting complement activation.
Tissue Eng 2006; 12: 301–308
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.
Ethnicity:
Show MoreInternational medical graduates...
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...
Show MoreTo 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...
Show MoreDear Editor,
Show MoreThe 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...
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...
Show MoreDear 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.
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...
Show MoreDear 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).
References
Show More1. Thomson CD. Assessment of requirements for selenium and adequ...
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.
References
Show More1. Lumyongsatien M, Bhaktikamala U, Thongtong P, et al. Relative selenium insufficiency is a risk factor for developing severe Graves' orbitopathy: a case-con...
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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