LETTERS TO THE EDITOR
Childhood Vascular Risk Factors and Retinal Vessel Caliber
To the Editor: would like to comment on the article: ‘‘Comparison of Outcomes of Suprabrow Single-Stab and Three-Stab Incision Frontalis Sling Surgery’’ by Jacob and associates.1 The authors suggest an intuitive and interesting modification of a standard ptosis repair technique for patients with poor levator function of both congenital and acquired etiologies.2Y4 Their surgical modification centers upon utilizing 1 central forehead incision for the Fox pentagonal placement of a sling material, in this case, the silicone rod.5 This study finds that the use of a single incision offers cosmetic benefit while retaining similar functional improvements as compared with a control group in which a 3-incision approach in the forehead area is used. The
study is well designed. All procedures are performed by 1 surgeon, eliminating differences in technique or ability. The parameters of functional and cosmetic outcome are assessed based on a clear scoring system; which is used by a group of examiners blinded to surgical technique. Although certainly the benefits are well demonstrated by this study, there are some reservations that I have found in reviewing this article. Considering the purported benefits, certainly scarring will be lessened if only 1 brow incision is used. This is especially advantageous in presentation of this technique to parents of prospective pediatric patients. The reduction in the number of incisions should also minimize intraoperative and postoperative bleeding and postoperative edema. The brow and forehead are densely vascularized and are likely to bleed significantly into the subcutaneous tissues with stab incisions. Fewer incisions could speed the recovery period and provide a more rapid evaluation of final eyelid position. In addition, fewer incisions allow for a reduced chance of exposure or contamination and infection of the band material. Contamination and foreign body granuloma related to the silicone band material certainly have been reported and can be the cause for poor outcome or lead to explantation of the bands and surgical revision.6,7 While the authors have clearly identified reduced scarring as a cosmetic benefit of this technique, one of the features of cosmesis that has not been assessed in their scale of improvement is lid contour. Contour deformities such as peaking of the lid margin or flattening of the eyelid arch certainly affect aesthetic results in ptosis repair. The problem with a single rhomboid or single pentagon placement of sling material is that it is often difficult to retain an appropriate lid contour, and sometimes the contour of the lid can be somewhat squared off or flat relative to a normal lid contour. Placement of a double rhomboid or double triangle often offers improved contour.8,9 Obviously, this would require at least 2 brow incisions but could avoid the central forehead incision. The tension on these triangles could be individually adjusted and therefore provide a more natural eyelid contour while retaining some of the other functional improvements that are often offered by this procedure. Finally, a point is raised regarding the relative ease of application of this technique. The authors purport that there is a
Volume 1, Number 5, September/October 2012
319
To the Editor: heung and colleagues1 are to be commended for their large landmark study on the association between retinal vessel caliber and systemic vascular risk parameters in schoolchildren. They have convincingly shown that the associations between a reduced retinal arterial vessel caliber and arterial hypertension and obesity are also valid in children. They added low birth weight to the factors associated with thin retinal arterioles. One of the important implications of the study is to shed light onto the pathogenic pathways in the development, the consequences, and the causes of arterial hypertension. The question I would like to ask is how much the statistically highly significant association between retinal arterial vessel diameter and systemic vascular parameters can be transferred into daily clinical practice, or what the clinical significance is when single patients are examined. Based on the results of the study by Cheung and coworkers, what is the diagnostic precision to detect arterial hypertension by just assessing the retinal vascular status in a single patient?
C
our ability to determine the direction of the associations and to infer potential causality. Longitudinal data, which we are currently collecting from this cohort of children, are needed. Nonetheless, prospective data from studies of middle-aged to older adults are available and suggest that these specific variations in retinal vessel caliber are associated with subsequent risks of clinical hypertension, obesity, and cardiovascular events. Second, our study design does not allow us to assess the diagnostic value of measuring retinal vessel caliber for detecting clinical hypertension for a single patient. To do so, one must establish what reference range of retinal vessel caliber should be. We aim to address this in an ongoing project. Finally, besides a ‘‘snapshot’’ measurement of retinal vessel caliber, it remains unknown whether monitoring changes in retinal vessel caliber over time is of any clinical significance (eg, monitor therapeutic response of antihypertensive medications in reversing end-organ microvascular damage). This is another important area for future research. Ning Cheung, MD Seang-Mei Saw, PhD Tien-Yin Wong, MD, PhD Singapore Eye Research Institute The University of Singapore Singapore
Jost Jonas, MD Department of Ophthalmology Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg Mannheim, Germany
REFERENCE 1. Cheung N, Saw SM, Liew G, et al. Childhood vascular risk factors and retinal vessel calibre. Asia Pac J Ophthalmol. 2012;1:193Y197.
Childhood Vascular Risk Factors and Retinal Vessel Caliber: Author Reply To the Editor: e thank the reader for his/her interest in our study. Although our data suggest statistically significant associations between variations in retinal vessel caliber and childhood systemic vascular risk factors, the clinical relevance of these findings remains uncertain for several reasons. First, the cross-sectional data limited
W
Asia-Pacific Journal of Ophthalmology
&
Suprabrow Single-Stab and Three-Stab Incision Frontalis Sling Surgery
I
Copyright © 2012 by Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Childhood Vascular Risk Factors and Retinal Vessel Caliber
To the Editor: would like to comment on the article: ‘‘Comparison of Outcomes of Suprabrow Single-Stab and Three-Stab Incision Frontalis Sling Surgery’’ by Jacob and associates.1 The authors suggest an intuitive and interesting modification of a standard ptosis repair technique for patients with poor levator function of both congenital and acquired etiologies.2Y4 Their surgical modification centers upon utilizing 1 central forehead incision for the Fox pentagonal placement of a sling material, in this case, the silicone rod.5 This study finds that the use of a single incision offers cosmetic benefit while retaining similar functional improvements as compared with a control group in which a 3-incision approach in the forehead area is used. The
study is well designed. All procedures are performed by 1 surgeon, eliminating differences in technique or ability. The parameters of functional and cosmetic outcome are assessed based on a clear scoring system; which is used by a group of examiners blinded to surgical technique. Although certainly the benefits are well demonstrated by this study, there are some reservations that I have found in reviewing this article. Considering the purported benefits, certainly scarring will be lessened if only 1 brow incision is used. This is especially advantageous in presentation of this technique to parents of prospective pediatric patients. The reduction in the number of incisions should also minimize intraoperative and postoperative bleeding and postoperative edema. The brow and forehead are densely vascularized and are likely to bleed significantly into the subcutaneous tissues with stab incisions. Fewer incisions could speed the recovery period and provide a more rapid evaluation of final eyelid position. In addition, fewer incisions allow for a reduced chance of exposure or contamination and infection of the band material. Contamination and foreign body granuloma related to the silicone band material certainly have been reported and can be the cause for poor outcome or lead to explantation of the bands and surgical revision.6,7 While the authors have clearly identified reduced scarring as a cosmetic benefit of this technique, one of the features of cosmesis that has not been assessed in their scale of improvement is lid contour. Contour deformities such as peaking of the lid margin or flattening of the eyelid arch certainly affect aesthetic results in ptosis repair. The problem with a single rhomboid or single pentagon placement of sling material is that it is often difficult to retain an appropriate lid contour, and sometimes the contour of the lid can be somewhat squared off or flat relative to a normal lid contour. Placement of a double rhomboid or double triangle often offers improved contour.8,9 Obviously, this would require at least 2 brow incisions but could avoid the central forehead incision. The tension on these triangles could be individually adjusted and therefore provide a more natural eyelid contour while retaining some of the other functional improvements that are often offered by this procedure. Finally, a point is raised regarding the relative ease of application of this technique. The authors purport that there is a
Volume 1, Number 5, September/October 2012
319
To the Editor: heung and colleagues1 are to be commended for their large landmark study on the association between retinal vessel caliber and systemic vascular risk parameters in schoolchildren. They have convincingly shown that the associations between a reduced retinal arterial vessel caliber and arterial hypertension and obesity are also valid in children. They added low birth weight to the factors associated with thin retinal arterioles. One of the important implications of the study is to shed light onto the pathogenic pathways in the development, the consequences, and the causes of arterial hypertension. The question I would like to ask is how much the statistically highly significant association between retinal arterial vessel diameter and systemic vascular parameters can be transferred into daily clinical practice, or what the clinical significance is when single patients are examined. Based on the results of the study by Cheung and coworkers, what is the diagnostic precision to detect arterial hypertension by just assessing the retinal vascular status in a single patient?
C
our ability to determine the direction of the associations and to infer potential causality. Longitudinal data, which we are currently collecting from this cohort of children, are needed. Nonetheless, prospective data from studies of middle-aged to older adults are available and suggest that these specific variations in retinal vessel caliber are associated with subsequent risks of clinical hypertension, obesity, and cardiovascular events. Second, our study design does not allow us to assess the diagnostic value of measuring retinal vessel caliber for detecting clinical hypertension for a single patient. To do so, one must establish what reference range of retinal vessel caliber should be. We aim to address this in an ongoing project. Finally, besides a ‘‘snapshot’’ measurement of retinal vessel caliber, it remains unknown whether monitoring changes in retinal vessel caliber over time is of any clinical significance (eg, monitor therapeutic response of antihypertensive medications in reversing end-organ microvascular damage). This is another important area for future research. Ning Cheung, MD Seang-Mei Saw, PhD Tien-Yin Wong, MD, PhD Singapore Eye Research Institute The University of Singapore Singapore
Jost Jonas, MD Department of Ophthalmology Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg Mannheim, Germany
REFERENCE 1. Cheung N, Saw SM, Liew G, et al. Childhood vascular risk factors and retinal vessel calibre. Asia Pac J Ophthalmol. 2012;1:193Y197.
Childhood Vascular Risk Factors and Retinal Vessel Caliber: Author Reply To the Editor: e thank the reader for his/her interest in our study. Although our data suggest statistically significant associations between variations in retinal vessel caliber and childhood systemic vascular risk factors, the clinical relevance of these findings remains uncertain for several reasons. First, the cross-sectional data limited
W
Asia-Pacific Journal of Ophthalmology
&
Suprabrow Single-Stab and Three-Stab Incision Frontalis Sling Surgery
I
Copyright © 2012 by Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
