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Letters to the Editor References 1. Zamir E, Read RW, Rao NA. Self-inflicted anterior scleritis. Ophthalmology 2001;108:192–5. 2. Jordan DR, Nerad J, Tse D. An unusual case of orbital cellulitis [review]. Can J Ophthalmol 1990;25:4:210 –2. 3. Diagnostic and Statistical Manual of Mental Disorders: DSMIV, 4th ed. Washington DC: American Psychiatric Association 1994;471–5, 683.
DAVID R. JORDAN, MD, FACS Ottawa, Ontario, Canada Author reply Dear Editor: We agree with Dr. Jordan in emphasizing the differences between factitious disorders and malingering. This difference was similarly discussed in our article. The term “factitious,” as explained in the Discussion of our article is used in two different ways. The strict psychiatric meaning of “factitious,” as it appears in the DSM-IV, refers to selfinflicted conditions in which the patient is deceptive and has psychologic motives (such as assuming the sick role). This is in contrast to malingering, in which the patient is seeking secondary gain and has no underlying psychiatric illness. Despite these definitions, the term “factitious” has been used more liberally in the medical literature to describe all sorts of self-inflicted conditions.1,2 In our cases, one patient was obviously malingering, whereas the other probably had a factitious problem of psychiatric origin. To avoid confusing the readers, we have reverted to the broader term, “self-inflicted anterior scleritis,” which we think is appropriate for both patients presented. References 1. Ugurlu S, Bartley GB, Otley CC, Baratz KH. Factitious disease of periocular and facial skin. Am J Ophthalmol 1999;127:196 – 201. 2. Braude L, Sugar J. Chronic unilateral inferior membranous conjunctivitis (factitious conjunctivitis). Arch Ophthalmol 1994;112:1488 –9.
EHUD ZAMIR, MD NARSING A. RAO, MD Los Angeles, California
Improvement in UCVA does not directly demonstrate resolution of optical aberrations caused by central islands or decentration. For example, an eye can have improvement of UCVA from 20/100 to 20/30 as a result of the correction of a ⫺2 diopter (D) residual myopia, but still suffer from the same BCVA of 20/30 because of unresolved central island or newly introduced secondary aberrations. Because the authors report that BCVA was measured in the Methods section, it is puzzling that BCVA data were entirely omitted in the Results section. BCVA is the most important basic parameter in this type of study and should be revealed. Symptoms of ghosting, halo, glare, and night driving disability are problems that often afflict patients with central islands and decentration, causing them to seek further treatment. I wonder whether the authors found that their treatments resolved these symptoms. Because these complaints should be routinely charted, perhaps it would be possible for the authors to report these findings. The laser used for the treatment is important data for anyone who may wish to reproduce the technique. I request that the authors report which laser was used. Although they reported that either a Summit ExciMed or a VISX was used in previous treatments, the laser used for the treatment of central islands and decentration was not specified. There are some inconsistencies in the results that would be helpful to clear up. The article reported the mean spherical equivalent before retreatment was ⫺2.3 D but gave a range of ⫺0.5 to 3.63 D, which is contradictory. After the first procedure, 14.4% of eyes required more than 30 days for the epithelium to heal. That is well outside of the normal range and may indicate complications or pathogens that should be explained. I look forward to the additional information, so I can assess whether to assimilate the authors’ eminently logical technique. Reference 1. Rachid MD, Yoo SH, Azar DT. Phototherapeutic keratectomy for decentration and central islands after photorefractive keratectomy. Ophthalmology 2001;108:545–52.
DAVID HUANG, MD, PHD Cleveland, OH
Central Island and Decentration Correction Dear Editor: Rachid, Yoo, and Azar described a simple and elegant method for correcting central islands and decentration.1 However, the article did not provide some key data needed to assess the effectiveness of their technique, which combines transepithelial phototherapeutic keratectomy with photorefractive keratectomy enhancement. I request that the authors disclose the following information. Best-corrected visual acuity (BCVA) is a routinely measured parameter that is particularly important for assessing central islands and decentered laser treatment, which causes decreased quality of vision that cannot be corrected by spectacles. Although the authors report improved uncorrected visual acuity (UCVA) after their treatments, this can be simply due to correction of residual refractive error.
Author reply Dear Editor: We are grateful for Dr. Huang’s request for additional data regarding the outcome of our three-step (phototherapeutic keratectomy [PTK], transepithelial photorefractive keratectomy [PRK], PTK) surgical technique to treat central islands and decentration after PRK.1 Best corrected visual acuity (BCVA). BCVA was not routinely measured on our patients before and after retreatment. However, spectacle-corrected visual acuity (SCVA) was measured before and after retreatment in 12 of 14 patients. As can be seen from the Figure, 3 of 12 patients gained ⱖ1 line of SCVA, and none lost ⱖ1 line of SCVA. We believe that the improvements of SCVA may be due to either improved surface topography or the reduction in
1935
DAVID R. JORDAN, MD, FACS Ottawa, Ontario, Canada Author reply Dear Editor: We agree with Dr. Jordan in emphasizing the differences between factitious disorders and malingering. This difference was similarly discussed in our article. The term “factitious,” as explained in the Discussion of our article is used in two different ways. The strict psychiatric meaning of “factitious,” as it appears in the DSM-IV, refers to selfinflicted conditions in which the patient is deceptive and has psychologic motives (such as assuming the sick role). This is in contrast to malingering, in which the patient is seeking secondary gain and has no underlying psychiatric illness. Despite these definitions, the term “factitious” has been used more liberally in the medical literature to describe all sorts of self-inflicted conditions.1,2 In our cases, one patient was obviously malingering, whereas the other probably had a factitious problem of psychiatric origin. To avoid confusing the readers, we have reverted to the broader term, “self-inflicted anterior scleritis,” which we think is appropriate for both patients presented. References 1. Ugurlu S, Bartley GB, Otley CC, Baratz KH. Factitious disease of periocular and facial skin. Am J Ophthalmol 1999;127:196 – 201. 2. Braude L, Sugar J. Chronic unilateral inferior membranous conjunctivitis (factitious conjunctivitis). Arch Ophthalmol 1994;112:1488 –9.
EHUD ZAMIR, MD NARSING A. RAO, MD Los Angeles, California
Improvement in UCVA does not directly demonstrate resolution of optical aberrations caused by central islands or decentration. For example, an eye can have improvement of UCVA from 20/100 to 20/30 as a result of the correction of a ⫺2 diopter (D) residual myopia, but still suffer from the same BCVA of 20/30 because of unresolved central island or newly introduced secondary aberrations. Because the authors report that BCVA was measured in the Methods section, it is puzzling that BCVA data were entirely omitted in the Results section. BCVA is the most important basic parameter in this type of study and should be revealed. Symptoms of ghosting, halo, glare, and night driving disability are problems that often afflict patients with central islands and decentration, causing them to seek further treatment. I wonder whether the authors found that their treatments resolved these symptoms. Because these complaints should be routinely charted, perhaps it would be possible for the authors to report these findings. The laser used for the treatment is important data for anyone who may wish to reproduce the technique. I request that the authors report which laser was used. Although they reported that either a Summit ExciMed or a VISX was used in previous treatments, the laser used for the treatment of central islands and decentration was not specified. There are some inconsistencies in the results that would be helpful to clear up. The article reported the mean spherical equivalent before retreatment was ⫺2.3 D but gave a range of ⫺0.5 to 3.63 D, which is contradictory. After the first procedure, 14.4% of eyes required more than 30 days for the epithelium to heal. That is well outside of the normal range and may indicate complications or pathogens that should be explained. I look forward to the additional information, so I can assess whether to assimilate the authors’ eminently logical technique. Reference 1. Rachid MD, Yoo SH, Azar DT. Phototherapeutic keratectomy for decentration and central islands after photorefractive keratectomy. Ophthalmology 2001;108:545–52.
DAVID HUANG, MD, PHD Cleveland, OH
Central Island and Decentration Correction Dear Editor: Rachid, Yoo, and Azar described a simple and elegant method for correcting central islands and decentration.1 However, the article did not provide some key data needed to assess the effectiveness of their technique, which combines transepithelial phototherapeutic keratectomy with photorefractive keratectomy enhancement. I request that the authors disclose the following information. Best-corrected visual acuity (BCVA) is a routinely measured parameter that is particularly important for assessing central islands and decentered laser treatment, which causes decreased quality of vision that cannot be corrected by spectacles. Although the authors report improved uncorrected visual acuity (UCVA) after their treatments, this can be simply due to correction of residual refractive error.
Author reply Dear Editor: We are grateful for Dr. Huang’s request for additional data regarding the outcome of our three-step (phototherapeutic keratectomy [PTK], transepithelial photorefractive keratectomy [PRK], PTK) surgical technique to treat central islands and decentration after PRK.1 Best corrected visual acuity (BCVA). BCVA was not routinely measured on our patients before and after retreatment. However, spectacle-corrected visual acuity (SCVA) was measured before and after retreatment in 12 of 14 patients. As can be seen from the Figure, 3 of 12 patients gained ⱖ1 line of SCVA, and none lost ⱖ1 line of SCVA. We believe that the improvements of SCVA may be due to either improved surface topography or the reduction in
1935