Dear Editor
We respond to the comments by Solomon regarding our manuscript entitled “Sore eyes as the most significant ocular symptom experienced by people with COVID-19: a comparison between pre-COVID-19 and during COVID-19 states” http://dx.doi.org/10.1136/bmjophth-2020-000632 as follows:
1. The assertion that CVS causes sore eyes is true. However, as the author suggests, CVS syndrome causes other eye symptoms including photophobia, tearing, itching eye and red eye. Our study examined these symptoms too and compared pre-COVID states to during-COVID states. Apart from sore eyes – no significant differences were shown in our study. In fact, the reported prevalence of dry eye which is the most commonly reported symptom of CVS as people ‘forget’ to blink, actually reduced during COVID state. In addition, participants reported the duration of the eye symptoms - usually between 1-3 weeks - which tallied with the experience of other COVID-19 symptoms such as dry cough and fever. Therefore it is not likely that the sore eyes symptoms were caused by CVS.
2. Regarding the transmission – it may be possible that virus spreads from the oropharynx through the lacrimal canal to the conjunctiva (as mentioned by the author of the letter as a personal opinion [1]) - or it may indeed be from the conjunctival into the nasal meatus as shown for SARS virus [2]. Unless more evidence is available it is not possible t...
Dear Editor
We respond to the comments by Solomon regarding our manuscript entitled “Sore eyes as the most significant ocular symptom experienced by people with COVID-19: a comparison between pre-COVID-19 and during COVID-19 states” http://dx.doi.org/10.1136/bmjophth-2020-000632 as follows:
1. The assertion that CVS causes sore eyes is true. However, as the author suggests, CVS syndrome causes other eye symptoms including photophobia, tearing, itching eye and red eye. Our study examined these symptoms too and compared pre-COVID states to during-COVID states. Apart from sore eyes – no significant differences were shown in our study. In fact, the reported prevalence of dry eye which is the most commonly reported symptom of CVS as people ‘forget’ to blink, actually reduced during COVID state. In addition, participants reported the duration of the eye symptoms - usually between 1-3 weeks - which tallied with the experience of other COVID-19 symptoms such as dry cough and fever. Therefore it is not likely that the sore eyes symptoms were caused by CVS.
2. Regarding the transmission – it may be possible that virus spreads from the oropharynx through the lacrimal canal to the conjunctiva (as mentioned by the author of the letter as a personal opinion [1]) - or it may indeed be from the conjunctival into the nasal meatus as shown for SARS virus [2]. Unless more evidence is available it is not possible to confirm.
3. We agree that conjunctivitis is a general term that describes "inflammation of conjunctiva". As mentioned in our paper we wanted to further describe the most commonly reported symptoms that are experienced during COVID-19 state as ‘conjunctivitis’ in a very general term as it includes symptoms such as gritty eyes and muco-purulent discharge (associated with bacterial conjunctivitis) which were not reported in our participants infected with COVID-19.
References:
1. Solomon A. Eye Involvement and Care during COVID – 19 Pandemic. Medical Research Archives 2020;8. doi:10.18103/mra.v8i7.2158
2. Tong TR, Lam BH, Ng T, et al. Conjunctiva-Upper Respiratory Tract Irrigation for Early Diagnosis of Severe Acute Respiratory Syndrome. Journal of Clinical Microbiology 2003;41:5352–5352. doi:10.1128/JCM.41.11.5352.2003
Professor Shahina Pardhan
Dr Havovi Chichger
Megan Vaughan
(on behalf of the authors)
Sore eyes is a symptom which can be found in a large population with no COVID-19 involvement. It is a very common symptom in a large population starting from early child age to older age above 60 years. The modern life, which force people to use virtual screens in their every day work , and the exposure to the mobilescreen, in an epidemic form, are the cause of sore eyes and photophobia too. A new eye disease appeared ,in our modern world , about three decades ago. The disease is called Computer Visual Syndrome (CVS). It is presented by sore eye,photophobia,tearing, itchinh, red eye . It is the result of diminish of blinking during screen work and creating dry eye condition. The population presented in this article included young to old age people. Many people may have already CVS with no sore eye at the begining.When examining them , the conjunctiva is red and smoothness is lost. We may hypotise that many people included in the presented study did have already CVS whic was agravated by COVID-19.
Regarding the transmition of COVID-19 through conjunctiva. We must take in consideration that the tight connection of the conjunctiva to the oropharinx space through the lacrimal canal might be a source of infection of the conjunctiva from that site. The first days, the persons who are already contaminated by COVID-19 are with no symptoms. The virus may spread from the oropharinx through the lacrimal canal to the conjunctiva and starts the conjunctival reaction. ...
Sore eyes is a symptom which can be found in a large population with no COVID-19 involvement. It is a very common symptom in a large population starting from early child age to older age above 60 years. The modern life, which force people to use virtual screens in their every day work , and the exposure to the mobilescreen, in an epidemic form, are the cause of sore eyes and photophobia too. A new eye disease appeared ,in our modern world , about three decades ago. The disease is called Computer Visual Syndrome (CVS). It is presented by sore eye,photophobia,tearing, itchinh, red eye . It is the result of diminish of blinking during screen work and creating dry eye condition. The population presented in this article included young to old age people. Many people may have already CVS with no sore eye at the begining.When examining them , the conjunctiva is red and smoothness is lost. We may hypotise that many people included in the presented study did have already CVS whic was agravated by COVID-19.
Regarding the transmition of COVID-19 through conjunctiva. We must take in consideration that the tight connection of the conjunctiva to the oropharinx space through the lacrimal canal might be a source of infection of the conjunctiva from that site. The first days, the persons who are already contaminated by COVID-19 are with no symptoms. The virus may spread from the oropharinx through the lacrimal canal to the conjunctiva and starts the conjunctival reaction.
Conjunctivitis is a general term which describes "inflammation of conjunctiva" and it can be used here also as COVID-19 conjunctivitis. Many reports, about such type of conjunctivits, were already published.It seems that the cases are 1,5% - 3% of the total the COVID-19 diagnosed people who were hospitalizedand according to which demographic origin is the report.
We read with great interest the recent publication by Stellwagen et al titled 'Personal hygiene risk factors for contact lens-related microbial keratitis'.[1] Findings by Stellwagen et al mirror patterns of modifiable behavioural risk factors for contact lens-related keratitis seen in our practice. We recently evaluated the prevalence of behavioural risk factors, as well as contact lens-related education given to our patients.
We recruited 100 consecutive patients referred with contact lens-related keratitis to an acute ophthalmology clinic at a tertiary eye hospital in Edinburgh, UK. A set questionnaire covering contact lens hygiene and recall of contact lens related education was used as part of the history taking process on presentation.
98 out of 100 patients were soft contact lens wearers, with 34% purchasing contact lenses online. 61 out of 100 reported receiving advice regarding contact lens usage and hygiene on initial purchase only and none thereafter. Seven percent did not recall receiving any contact lens-related advice at all. Contact lenses (excluding extended wear contact lenses) were worn for a median duration of 12 hours per day (Range 4.5-18). 27 out of 100 reported wearing contact lenses longer than prescribed for their specified lens type (eg. monthly or fortnightly disposable contact lenses) and 27 out of 100 reported swimming in their contact lenses. Excluding extended wear contact lens users, 17 out of 84 report...
We read with great interest the recent publication by Stellwagen et al titled 'Personal hygiene risk factors for contact lens-related microbial keratitis'.[1] Findings by Stellwagen et al mirror patterns of modifiable behavioural risk factors for contact lens-related keratitis seen in our practice. We recently evaluated the prevalence of behavioural risk factors, as well as contact lens-related education given to our patients.
We recruited 100 consecutive patients referred with contact lens-related keratitis to an acute ophthalmology clinic at a tertiary eye hospital in Edinburgh, UK. A set questionnaire covering contact lens hygiene and recall of contact lens related education was used as part of the history taking process on presentation.
98 out of 100 patients were soft contact lens wearers, with 34% purchasing contact lenses online. 61 out of 100 reported receiving advice regarding contact lens usage and hygiene on initial purchase only and none thereafter. Seven percent did not recall receiving any contact lens-related advice at all. Contact lenses (excluding extended wear contact lenses) were worn for a median duration of 12 hours per day (Range 4.5-18). 27 out of 100 reported wearing contact lenses longer than prescribed for their specified lens type (eg. monthly or fortnightly disposable contact lenses) and 27 out of 100 reported swimming in their contact lenses. Excluding extended wear contact lens users, 17 out of 84 reported sleeping and 40 out of 84 showering whilst wearing contact lenses. 18 respondents reported using tap water to clean contact lenses. 42 out of 100 had experienced at least one previous microbial keratitis requiring treatment while wearing contact lenses. Worryingly, the proportion of patients partaking in at least one behavioural risk factor was similar in those with (70.6%) and without (67.4%) previous infections, indicating inadequacy of secondary preventative measures.
Our findings highlights that a large proportion of patients are exposed to risk factors increasing the risk of contact lens retailed complications as described by Stellwagen et al. We agree strongly with the authors that patient education is therefore essential to reduce contact lens-related infections, as this was lacking in a significant proportion of our patients. Educating prescribers of contact lenses and opportunistic contact lens education in clinics is needed to improve patient awareness of risk factors. Purchase of contact lenses online poses further challenges to patient education. Findings by Stellwagen et al will give clinicians valuable tools in quantifying risks of certain risk factors when discussing these with patients and hopefully lead to improved concordance with contact lens advice.
1. Stellwagen A, MacGregor C, Kung R, et al Personal hygiene risk factors for contact lens-related microbial keratitis BMJ Open Ophthalmology 2020;5:e000476. doi: 10.1136/bmjophth-2020-000476
Bradley and Delaffon conducted a literature review regarding diabetic retinopathy screening (DRS) in people with severe mental illness (SMI) (1). People with SMI have reduced attendance at DRS, because of poorer compliance with general diabetic care. The authors verified that anxiety and depression were barriers in attending DRS and strategies of preventative health programs such as DRS should be developed and prepared for people with SMI. I want to present two information.
Chen and Lu reviewed the association between diabetic retinopathy (DR) and depression (2). Depression in patients with DR had a negative effect on the condition of DR, and they recommended psychiatric therapies for depression to achieve optimal prognosis in patients with DR and depression. Diabetes control is closely related to keeping good lifestyles including nutrition, exercise, resting and stress management. Taken together, diabetes supporting system in patients with depression could be developed by comprehensive medical and health care strategies.
Khoo et al. specified that severity of DR, diabetic macular edema (DME) and vision loss were significantly associated with poor psychosocial outcomes (3). Bi-directional associations might be existed and increased incidence and progression of DR was predominant in subjects with depression or depressive symptoms. Based on a systematic review, they proposed two actions. First, prevention of poor psychological outcomes is needed by delaying pro...
Bradley and Delaffon conducted a literature review regarding diabetic retinopathy screening (DRS) in people with severe mental illness (SMI) (1). People with SMI have reduced attendance at DRS, because of poorer compliance with general diabetic care. The authors verified that anxiety and depression were barriers in attending DRS and strategies of preventative health programs such as DRS should be developed and prepared for people with SMI. I want to present two information.
Chen and Lu reviewed the association between diabetic retinopathy (DR) and depression (2). Depression in patients with DR had a negative effect on the condition of DR, and they recommended psychiatric therapies for depression to achieve optimal prognosis in patients with DR and depression. Diabetes control is closely related to keeping good lifestyles including nutrition, exercise, resting and stress management. Taken together, diabetes supporting system in patients with depression could be developed by comprehensive medical and health care strategies.
Khoo et al. specified that severity of DR, diabetic macular edema (DME) and vision loss were significantly associated with poor psychosocial outcomes (3). Bi-directional associations might be existed and increased incidence and progression of DR was predominant in subjects with depression or depressive symptoms. Based on a systematic review, they proposed two actions. First, prevention of poor psychological outcomes is needed by delaying progression of DR/DME. Second, early detection and management of poor psychological functioning is needed by improving screening tools and medical/health care systems for patients. Diabetes and its complication management have some difficulties even in patients without SMI. As there is a limitation in personal effort, improvement of accessibility to medical/health care system is needed in patients with SMI.
References
1. Bradley ER, Delaffon V. Diabetic retinopathy screening in persons with mental illness: a literature review. BMJ Open Ophthalmol 2020;5(1):e000437.
2. Chen X, Lu L. Depression in Diabetic Retinopathy: A Review and Recommendation for Psychiatric Management. Psychosomatics 2016;57(5):465-471. doi:10.1016/j.psym.2016.04.003
3. Khoo K, Man REK, Rees G, Gupta P, Lamoureux EL, Fenwick EK. The relationship between diabetic retinopathy and psychosocial functioning: a systematic review. Qual Life Res 2019;28(8):2017-2039. doi:10.1007/s11136-019-02165-1
Thank-you to the authors for sharing their departmental protocol based current international research and recommendations [1]. We have put in place many of the precautions outlined however wished to share our recent experience with regard to intravitreal injections (IVI), and additional measures put in place as a result.
IVIs have continued in our service for sight threatening pathology throughout the UK government lockdown of the past 8 weeks. Patients have self-isolated for 7 days prior to their procedure and are screened for symptoms of COVID19 or contacts before attendance. Arriving at our facility they wash their hands, don a surgical mask and have their temperature, oxygen saturations and blood pressure checked. Social distancing is maintained in waiting areas by blocking alternate seats as mentioned.
For the procedure itself the patient is draped and injectors wear sterile gloves, a theatre gown and a fluid resistant surgical mask as per national guidance [2].
There was no protocol to routinely test patients attending for IVI at our units for coronavirus, however tests were performed on four consecutive injection lists on 4th and 5th May. 48 patients were tested with a mean age of 76 years (range 54-92). 2 (4%) tested positive despite being asymptomatic. They were asked not to attend and will be rescheduled. 4 (13%) decided not to attend voluntarily.
As mentioned by the authors retinal services tend to serve an elderly population with a...
Thank-you to the authors for sharing their departmental protocol based current international research and recommendations [1]. We have put in place many of the precautions outlined however wished to share our recent experience with regard to intravitreal injections (IVI), and additional measures put in place as a result.
IVIs have continued in our service for sight threatening pathology throughout the UK government lockdown of the past 8 weeks. Patients have self-isolated for 7 days prior to their procedure and are screened for symptoms of COVID19 or contacts before attendance. Arriving at our facility they wash their hands, don a surgical mask and have their temperature, oxygen saturations and blood pressure checked. Social distancing is maintained in waiting areas by blocking alternate seats as mentioned.
For the procedure itself the patient is draped and injectors wear sterile gloves, a theatre gown and a fluid resistant surgical mask as per national guidance [2].
There was no protocol to routinely test patients attending for IVI at our units for coronavirus, however tests were performed on four consecutive injection lists on 4th and 5th May. 48 patients were tested with a mean age of 76 years (range 54-92). 2 (4%) tested positive despite being asymptomatic. They were asked not to attend and will be rescheduled. 4 (13%) decided not to attend voluntarily.
As mentioned by the authors retinal services tend to serve an elderly population with a high prevalence of co-morbidities. This puts them at high risk of significant morbidity and mortality from COVID-19. Although a small opportunistic sample our observations suggest that simply isolating and screening symptomatic patients cannot guarantee a list free from the risk of potential transmission amongst this at risk population.
As a result of the above and in addition to the measures outlined we feel we should now swab test all patients 3 days prior to their attendance.
Furthermore, given the close contact inherent in performing injections and in line with recommendations from our Hong Kong colleagues based on experience from the SARS outbreak [3] we feel that IVIs should be considered high risk procedure for transmission and staff supported in wearing personal protective equipment that makes them feel safe. This is generally felt to be a filtering face piece (FFP3) mask and a protective visor in addition to a surgical gown and gloves.
We look forward to hearing from colleagues elsewhere as to how they approach this issue.
References:
[1] Safadi K, Kruger J, Chowers I, Solomon A, Amer R, Aweidah H et al. Ophthalmology practice during the COVID-19 pandemic. BMJ Open Ophthalmology. 2020;5(1):e000487.
[2] Public Health England. Recommended PPE for healthcare workers by secondary care inpatient clinical setting, NHS and independent sector. 2020 p. 33.
[3] Chan W, Liu D, Chan P, Chong K, Yuen K, Chiu T et al. Precautions in ophthalmic practice in a hospital with a major acute SARS outbreak: an experience from Hong Kong. Eye. 2005;20(3):283-289.
Article Title: Complement factors and reticular pseudodrusen in intermediate age-related macular degeneration staged by multimodal imaging BMJ Open Ophthalmology Jan 2020, 5 (1) e000361; DOI: 10.1136/bmjophth-2019-000361
E-letter sender: Anne M Lynch, Brandie D Wagner, Alan G Palestine, Jennifer L Patnaik, Ashley A Frazier-Abel, Marc T Mathias, Frank S Siringo, V. Michael Holers, Naresh Mandava
E-Letter Title: Response to letter entitled “The Controversial Role of Inhibitory Complement Factors in Age-Related Macular Degeneration”
February 12, 2020
Dear Editor,
We appreciate the comments from Shiwani et al. regarding our manuscript entitled “Complement factors and reticular pseudodrusen in intermediate age-related macular degeneration staged by multimodal imaging.” As reported in the manuscript, (1) we found significantly elevated levels of C3a, Ba, C5a and C2 in cases with the intermediate phenotype of age-related macular degeneration (AMD) compared with cataract controls without AMD. We also found significantly lower levels of Factor B, Factor H, Factor I, C1q, iC3b/C3b, and C5 in the AMD cases compare...
Article Title: Complement factors and reticular pseudodrusen in intermediate age-related macular degeneration staged by multimodal imaging BMJ Open Ophthalmology Jan 2020, 5 (1) e000361; DOI: 10.1136/bmjophth-2019-000361
E-letter sender: Anne M Lynch, Brandie D Wagner, Alan G Palestine, Jennifer L Patnaik, Ashley A Frazier-Abel, Marc T Mathias, Frank S Siringo, V. Michael Holers, Naresh Mandava
E-Letter Title: Response to letter entitled “The Controversial Role of Inhibitory Complement Factors in Age-Related Macular Degeneration”
February 12, 2020
Dear Editor,
We appreciate the comments from Shiwani et al. regarding our manuscript entitled “Complement factors and reticular pseudodrusen in intermediate age-related macular degeneration staged by multimodal imaging.” As reported in the manuscript, (1) we found significantly elevated levels of C3a, Ba, C5a and C2 in cases with the intermediate phenotype of age-related macular degeneration (AMD) compared with cataract controls without AMD. We also found significantly lower levels of Factor B, Factor H, Factor I, C1q, iC3b/C3b, and C5 in the AMD cases compared with controls.
All of our complement results were corrected for multiple comparisons testing using the false-discovery rate (FDR). The FDR approach to multiple comparisons is a commonly used method and is typically less conservative than a Bonferroni correction. The Bonferroni adjustment controls the familywise type I error rate, whereas the FDR controls the type I error rate only amongst those null hypotheses that were rejected. Both approaches assume complete independence between tests and are therefore more conservative than needed given the tests for complement factors are likely correlated (2). In response to the questions raised by Shiwani et al, we completed the analysis using the Bonferroni statistical correction. Following the application of the Bonferroni statistical correction, we found C2 was no longer significant and Factor B was now of borderline statistical significance (see Table 1).
We agree with Shiwani et al that the low levels of the complement inhibitors need further investigation and as stated in the manuscript, we would hope to explore this finding further when we examine genetic polymorphisms of the complement pathways in this cohort. We also hope that moving forward there will be more investigation of the role of the complement system in patients with the early or intermediate phenotype of AMD so that interventions can be introduced before the patient develops the advanced stages of AMD.
References
1. Lynch AM, Palestine, A.G, Wagner, B.D, Patnaik, J.L, Frazier-Abel, A.A, Mathias, M.T, Siringo, F.S, Holers, V.M, Mandava, N. Complement factors and reticular pseudodrusen in
intermediate age-related macular degeneration staged by multimodal imaging. BMJ Open Ophthalmology Jan 2020, 5 (1) e000361; DOI: 10.1136/bmjophth-2019-000361
2. Westfall, P. and S. Young (1993). Resampling Based Multiple Testing. New York, John Wiley and Sons, Inc.
Table 1. Complement Levels for Cases with Intermediate AMD Versus Controls.
* OR corresponding to change in 10 units of complement factor
†OR = Odds ratio from the multivariable logistic regression with 95% Confidence Intervals (CI) after adjusting for age and family history of AMD.
‡ P-values obtained from multivariate logistic regression including age and family history of AMD and adjusted for multiple comparisons using FDR
§ P-values obtained from multivariate logistic regression including age and family history of AMD and adjusted for multiple comparisons using the Bonferroni statistical correction
We read with interest the role of complement in age-related macular degeneration (AMD) explored by Lynch and colleagues1. The authors have expertly examined the numerous components of the complement system and provided much novel data, particularly in the context of intermediate AMD.
Their results are congruent with that of the literature, especially with regard to lower levels of C3a, C5a and Ba in the setting of AMD2. Furthermore, the results of the FILLY trial have shown positive effects of the inhibition of C3 in limiting geographic atrophy and thus lend an element of support to the conclusions of this study3. We hope that the subsequent phase 3 trials – DERBY and OAKS – will lend further support and allow research such as this to translate to clinical benefit for patients4.
However, we do feel that there may be an element of multiple hypothesis testing evident in this study that increases the risk of generating some erroneous results. We feel a Bonferroni statistical correction would have been an appropriate tool to add further robustness to the positive findings that have been demonstrated. We especially feel that the results relating to the inhibitory factors of the complement system do not tend to correlate with some of the findings in the literature. Although Lynch et al have identified lower levels of Factor B, Factor H and Factor I in the AMD arm of the study, there are numerous reports in the literature reporting the opposite...
We read with interest the role of complement in age-related macular degeneration (AMD) explored by Lynch and colleagues1. The authors have expertly examined the numerous components of the complement system and provided much novel data, particularly in the context of intermediate AMD.
Their results are congruent with that of the literature, especially with regard to lower levels of C3a, C5a and Ba in the setting of AMD2. Furthermore, the results of the FILLY trial have shown positive effects of the inhibition of C3 in limiting geographic atrophy and thus lend an element of support to the conclusions of this study3. We hope that the subsequent phase 3 trials – DERBY and OAKS – will lend further support and allow research such as this to translate to clinical benefit for patients4.
However, we do feel that there may be an element of multiple hypothesis testing evident in this study that increases the risk of generating some erroneous results. We feel a Bonferroni statistical correction would have been an appropriate tool to add further robustness to the positive findings that have been demonstrated. We especially feel that the results relating to the inhibitory factors of the complement system do not tend to correlate with some of the findings in the literature. Although Lynch et al have identified lower levels of Factor B, Factor H and Factor I in the AMD arm of the study, there are numerous reports in the literature reporting the opposite results where levels of these factors are higher in AMD patient populations, albeit not in settings with identical severity of disease2,5,6.Whether the results presented in this study constitute a true finding in the setting of intermediate AMD or whether this represents a statistical type 1 error, it would be difficult to ascertain.
Overall, this study shines more light on this intricate topic with clinically significant results. We hope this will stimulate further research and discussion in the field.
References
1. Lynch AM, Palestine AG, Wagner BD, et al. Complement factors and reticular pseudodrusen in intermediate age-related macular degeneration staged by multimodal imaging. BMJ Open Ophthalmol 2020;5:e000361. doi:10.1136/bmjophth-2019-000361
2. Scholl HPN, Issa PC, Walier M, et al. Systemic Complement Activation in Age-Related Macular Degeneration. Toland AE, ed. PLoS One 2008;3:e2593. doi:10.1371/journal.pone.0002593
3. Apellis Pharmaceuticals. Apellis Pharmaceuticals Announces That APL-2 Met Its Primary Endpoint in a Phase 2 Study in Patients with Geographic Atrophy, an Advanced Form of Age-Related Macular Degeneration Statistically Significant Slowing of Disease Progression Seen at 12 Months. 2017. Accessed January 26, 2020.
4. Apellis Pharmaceuticals. Recruiting patients with geographic atrophy secondary to AMD for phase 3 trials | Apellis APL-2 Opthalmic Trial. . Accessed January 26, 2020.
5. Hecker LA, Edwards AO, Ryu E, et al. Genetic control of the alternative pathway of complement in humans and age-related macular degeneration. Hum Mol Genet 2010;19:209-215. doi:10.1093/hmg/ddp472
6. Silva AS, Teixeira AG, Bavia L, et al. Plasma levels of complement proteins from the alternative pathway in patients with age-related macular degeneration are independent of Complement Factor H Tyr402His polymorphism. Mol Vis 2012;18:2288-2299.
Dear Editor
Show MoreWe respond to the comments by Solomon regarding our manuscript entitled “Sore eyes as the most significant ocular symptom experienced by people with COVID-19: a comparison between pre-COVID-19 and during COVID-19 states” http://dx.doi.org/10.1136/bmjophth-2020-000632 as follows:
1. The assertion that CVS causes sore eyes is true. However, as the author suggests, CVS syndrome causes other eye symptoms including photophobia, tearing, itching eye and red eye. Our study examined these symptoms too and compared pre-COVID states to during-COVID states. Apart from sore eyes – no significant differences were shown in our study. In fact, the reported prevalence of dry eye which is the most commonly reported symptom of CVS as people ‘forget’ to blink, actually reduced during COVID state. In addition, participants reported the duration of the eye symptoms - usually between 1-3 weeks - which tallied with the experience of other COVID-19 symptoms such as dry cough and fever. Therefore it is not likely that the sore eyes symptoms were caused by CVS.
2. Regarding the transmission – it may be possible that virus spreads from the oropharynx through the lacrimal canal to the conjunctiva (as mentioned by the author of the letter as a personal opinion [1]) - or it may indeed be from the conjunctival into the nasal meatus as shown for SARS virus [2]. Unless more evidence is available it is not possible t...
Sore eyes is a symptom which can be found in a large population with no COVID-19 involvement. It is a very common symptom in a large population starting from early child age to older age above 60 years. The modern life, which force people to use virtual screens in their every day work , and the exposure to the mobilescreen, in an epidemic form, are the cause of sore eyes and photophobia too. A new eye disease appeared ,in our modern world , about three decades ago. The disease is called Computer Visual Syndrome (CVS). It is presented by sore eye,photophobia,tearing, itchinh, red eye . It is the result of diminish of blinking during screen work and creating dry eye condition. The population presented in this article included young to old age people. Many people may have already CVS with no sore eye at the begining.When examining them , the conjunctiva is red and smoothness is lost. We may hypotise that many people included in the presented study did have already CVS whic was agravated by COVID-19.
Show MoreRegarding the transmition of COVID-19 through conjunctiva. We must take in consideration that the tight connection of the conjunctiva to the oropharinx space through the lacrimal canal might be a source of infection of the conjunctiva from that site. The first days, the persons who are already contaminated by COVID-19 are with no symptoms. The virus may spread from the oropharinx through the lacrimal canal to the conjunctiva and starts the conjunctival reaction.
...
We read with great interest the recent publication by Stellwagen et al titled 'Personal hygiene risk factors for contact lens-related microbial keratitis'.[1] Findings by Stellwagen et al mirror patterns of modifiable behavioural risk factors for contact lens-related keratitis seen in our practice. We recently evaluated the prevalence of behavioural risk factors, as well as contact lens-related education given to our patients.
Show MoreWe recruited 100 consecutive patients referred with contact lens-related keratitis to an acute ophthalmology clinic at a tertiary eye hospital in Edinburgh, UK. A set questionnaire covering contact lens hygiene and recall of contact lens related education was used as part of the history taking process on presentation.
98 out of 100 patients were soft contact lens wearers, with 34% purchasing contact lenses online. 61 out of 100 reported receiving advice regarding contact lens usage and hygiene on initial purchase only and none thereafter. Seven percent did not recall receiving any contact lens-related advice at all. Contact lenses (excluding extended wear contact lenses) were worn for a median duration of 12 hours per day (Range 4.5-18). 27 out of 100 reported wearing contact lenses longer than prescribed for their specified lens type (eg. monthly or fortnightly disposable contact lenses) and 27 out of 100 reported swimming in their contact lenses. Excluding extended wear contact lens users, 17 out of 84 report...
Bradley and Delaffon conducted a literature review regarding diabetic retinopathy screening (DRS) in people with severe mental illness (SMI) (1). People with SMI have reduced attendance at DRS, because of poorer compliance with general diabetic care. The authors verified that anxiety and depression were barriers in attending DRS and strategies of preventative health programs such as DRS should be developed and prepared for people with SMI. I want to present two information.
Chen and Lu reviewed the association between diabetic retinopathy (DR) and depression (2). Depression in patients with DR had a negative effect on the condition of DR, and they recommended psychiatric therapies for depression to achieve optimal prognosis in patients with DR and depression. Diabetes control is closely related to keeping good lifestyles including nutrition, exercise, resting and stress management. Taken together, diabetes supporting system in patients with depression could be developed by comprehensive medical and health care strategies.
Khoo et al. specified that severity of DR, diabetic macular edema (DME) and vision loss were significantly associated with poor psychosocial outcomes (3). Bi-directional associations might be existed and increased incidence and progression of DR was predominant in subjects with depression or depressive symptoms. Based on a systematic review, they proposed two actions. First, prevention of poor psychological outcomes is needed by delaying pro...
Show MoreThank-you to the authors for sharing their departmental protocol based current international research and recommendations [1]. We have put in place many of the precautions outlined however wished to share our recent experience with regard to intravitreal injections (IVI), and additional measures put in place as a result.
IVIs have continued in our service for sight threatening pathology throughout the UK government lockdown of the past 8 weeks. Patients have self-isolated for 7 days prior to their procedure and are screened for symptoms of COVID19 or contacts before attendance. Arriving at our facility they wash their hands, don a surgical mask and have their temperature, oxygen saturations and blood pressure checked. Social distancing is maintained in waiting areas by blocking alternate seats as mentioned.
For the procedure itself the patient is draped and injectors wear sterile gloves, a theatre gown and a fluid resistant surgical mask as per national guidance [2].
There was no protocol to routinely test patients attending for IVI at our units for coronavirus, however tests were performed on four consecutive injection lists on 4th and 5th May. 48 patients were tested with a mean age of 76 years (range 54-92). 2 (4%) tested positive despite being asymptomatic. They were asked not to attend and will be rescheduled. 4 (13%) decided not to attend voluntarily.
As mentioned by the authors retinal services tend to serve an elderly population with a...
Show MoreDear Editor,
We read with interest the role of complement in age-related macular degeneration (AMD) explored by Lynch and colleagues1. The authors have expertly examined the numerous components of the complement system and provided much novel data, particularly in the context of intermediate AMD.
Their results are congruent with that of the literature, especially with regard to lower levels of C3a, C5a and Ba in the setting of AMD2. Furthermore, the results of the FILLY trial have shown positive effects of the inhibition of C3 in limiting geographic atrophy and thus lend an element of support to the conclusions of this study3. We hope that the subsequent phase 3 trials – DERBY and OAKS – will lend further support and allow research such as this to translate to clinical benefit for patients4.
However, we do feel that there may be an element of multiple hypothesis testing evident in this study that increases the risk of generating some erroneous results. We feel a Bonferroni statistical correction would have been an appropriate tool to add further robustness to the positive findings that have been demonstrated. We especially feel that the results relating to the inhibitory factors of the complement system do not tend to correlate with some of the findings in the literature. Although Lynch et al have identified lower levels of Factor B, Factor H and Factor I in the AMD arm of the study, there are numerous reports in the literature reporting the opposite...
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