We refer Dr Grzybowski to Table 2 in our study, which did demonstrate the complication rates between patients taking selective alpha-antagonists, nonselective alphaantagonists, and no medication that experienced IFIS. We mentioned that other studies have shown effective management of IFIS with pupillary expansion rings.2 However, regarding our study, we reported what we observed: a more frequent use of devices in patients with selective alphaantagonists. We did not address the effectiveness on the management of IFIS and could not make recommendations on this based upon these findings. We agree with Dr Grzybowski that more evidence-based medicine reports and scientific evidence are needed to assess the management of IFIS. DAVID E. VOLLMAN
St. Louis, Missouri LUIS GONZALEZ-GONZALEZ
Jamaica Plain, Massachusetts AMY CHOMSKY
Nashville, Tennessee MARY K. DALY
Jamaica Plain, Massachusetts ELIZABETH BAZE
Houston, Texas MARY G. LAWRENCE
Bethesda, Maryland CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article for any disclosures of the authors.
REFERENCES
1. Vollman D, Gonzalez-Gonzalez LA, Chomsky A, Daly M, Baze E, Lawrence M. Intraoperative floppy iris and prevalence of intraoperative complications: results from Ophthalmic Surgery Outcomes Database. Am J Ophthalmol 2014;157(6): 1130–1135. 2. Blouin MC, Blouin J, Perreault S, Lapointe A, Dragomir A. Intraoperative floppy-iris syndrome associated with alpha1adrenoreceptors: comparison of tamsulosin and alfuzosin. J Cataract Refract Surg 2007;33(7):1227–1234.
shadows, and crescents following laser peripheral iridotomy, linear dysphotopsia seems to be the most specific symptom pertaining to laser peripheral iridotomies, and certainly the most problematic. We suspect that the magnitude of this problem may actually be underreported, as patients are not often asked specifically about visual symptoms that developed after laser peripheral iridotomy is performed. From our own experience, the number of patients reporting linear dysphotopsia has risen over the years. We applaud the authors’ efforts in conducting a prospective, randomized, and masked study directly comparing temporal and superior laser peripheral iridotomy position and the prevalence of linear dysphotopsia. Differing opinions regarding the role of lid position in causing visual symptoms following laser peripheral iridotomy have previously been expressed. While Congdon and associates,2 in their recent paper, reported that stray light and prevalence of visual symptoms did not differ between subjects regardless of lid coverage, Spaeth and associates3 have suggested that visual symptoms are more likely in patients with partially or fully exposed laser peripheral iridotomies. Current clinical guidelines in our hospital state that laser peripheral iridotomies should be placed as close to the 12 o’clock meridian, as peripherally as possible in order to ensure that the iridotomies are entirely covered by the upper lids. Following this randomized controlled trial, we are now considering a change in clinical practice to have all laser peripheral iridotomies placed as temporally as possible. While laser peripheral iridotomy is a routinely common procedure for ophthalmologists, we feel that little thought is currently given to the potentially debilitating effects that linear dysphotopsia might have on previously asymptomatic patients undergoing this prophylactic procedure. If linear dysphotopsia rates are as high as the 10.7% mentioned in Dr Vera’s study, patients need to be carefully counseled before undergoing prophylactic laser peripheral iridotomy. WEN WEI WOO NICHOLAS KLOSTER WRIDE SCOTT GEORGE FRASER
Sunderland Eye Infirmary, United Kingdom
Dysphotopsia After Temporal Versus Superior Laser Peripheral Iridotomy: A Prospective Randomized Paired Eye Trial
THE AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors have no financial disclosure to make and declare that no payment or services from a third party have been received for any aspect of the submitted work. No funding has been received for preparation and submission of this manuscript.
EDITOR: WE READ WITH INTEREST THE IMPORTANT ARTICLE BY VERA
and associates1 reporting that temporally placed laser peripheral iridotomies are less likely to cause linear dysphotopsia compared to ones placed superiorly. We agree with the authors that while patients can experience a variety of visual symptoms including haloes, VOL. 158, NO. 4
REFERENCES
1. Vera V, Naqi A, Belovay GW, Varma DK, Ahmed II. Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective randomized paired eye trial. Am J Ophthalmol 2014;157(5):929–935.
CORRESPONDENCE
849
2. Congdon N, Yan X, Friedman DS, et al. Visual symptoms and retinal straylight after laser peripheral iridotomy: The Zhongshan Angle-Closure Prevention Trial. Ophthalmology 2012; 119(7):1375–1382. 3. Spaeth GL, Idowu O, Seligsohn A, et al. The effects of iridotomy size and position on symptoms following laser peripheral iridotomy. J Glaucoma 2005;14(5):364–367.
REPLY WE APPRECIATE THE INTEREST AND POSITIVE FEEDBACK OF
Woo and associates. When an iridotomy is placed superiorly, lid coverage is not necessarily protective of visual symptoms, for reasons we discussed in our paper.1 The superior tear film at the lid margin results in a base-up prism refracting stray light onto the peripheral retina that can result in dysphotopsia. Furthermore, as the lid and tear film is dynamic, visual symptoms may vary considerably. We agree that linear dysphotopsia is an underreported and potential debilitating complication after laser peripheral iridotomy. Proper informed consent is important for any patient undergoing peripheral iridotomy, and we strongly recommend the iridotomy be placed away from the lid margin to reduce the incidence of dysphotopsia. Thus, we prefer the temporal or nasal location in most cases. VANESSA VERA IQBAL IKE K. AHMED
Toronto, Ontario, Canada CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article for any disclosures of the authors.
emergency evaluation of these patients is necessary.2 Lee and associates make the following points in the discussion of their study:1 ‘‘Recent guidelines from the AHA/ASA recommend that all patients with suspected brain or retinal ischemia should undergo immediate brain imaging and etiological work-ups.3 However, physicians seem to be reluctant to follow these recommendations. According to a recent survey, only 35% of ophthalmologists and 73% of neurologists refer patients with CRAO to the emergency room for extensive etiologic evaluation.4’’ In the reference cited, the American Heart Association and American Stroke Association do not recommend immediate brain imaging and etiological work-ups of patients with suspected brain or retinal ischemia.3 On the contrary, these guidelines specifically state, ‘‘The setting of specific recommendations for the timing and type of diagnostic workup for patients with TIA or stroke is beyond the scope of these guidelines.’’3 The survey referenced by the authors, which found that 35% of ophthalmologists refer patients with central retinal artery occlusion to the emergency room, was a study regarding emergency treatment of acute central retinal artery occlusion with thrombolytics.4 The survey was not aimed at evaluating the referral of patients with central retinal artery occlusion for etiological evaluation. Patients with suspected brain or retinal ischemia usually present with symptoms of transient ischemic attack or with signs of acute branch or central retinal artery occlusion. Do the authors have evidence that these patients should be immediately referred for emergency etiological evaluation? STEVEN COHEN
Clearwater, Florida REFERENCE
1. Vera V, Naqi A, Belovay GW, Varma DK, Ahmed II. Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective randomized paired eye trial. Am J Ophthalmol 2014;157(5):929–935.
THE AUTHOR HAS COMPLETED AND SUBMITTED THE ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. The author indicates no funding support.
REFERENCES
Co-occurrence of Acute Retinal Artery Occlusion and Acute Ischemic Stroke: Diffusion-Weighted Magnetic Resonance Imaging Study EDITOR: IN THEIR ARTICLE, ‘‘CO-OCCURRENCE OF ACUTE RETINAL
artery occlusion and acute ischemic stroke: Diffusionweighted magnetic resonance imaging study,’’ Lee and associates recommend emergent evaluation of patients with suspected brain or retinal ischemia.1 The accompanying editorial, in the wording of its title, ‘‘Acute retinal arterial ischemia: An emergency often ignored,’’ also suggests that 850
1. Lee J, Kim SW, Lee SC, et al. Co-occurrence of acute retinal artery occlusion and acute ischemic stroke: diffusionweighted magnetic resonance imaging study. Am J Ophthalmol 2014;157(6):1231–1238. 2. Biousse V. Acute retinal arterial ischemia: an emergency often ignored. Am J Ophthalmol 2014;157(6):1119–1120. 3. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:227–276. 4. Atkins EJ, Bruce B, Newman NJ, Biousse V. Translation of clinical studies to clinical practice: survey on the treatment of central retinal artery occlusion. Am J Ophthalmol 2009;148(1):172–173.
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER 2014
St. Louis, Missouri LUIS GONZALEZ-GONZALEZ
Jamaica Plain, Massachusetts AMY CHOMSKY
Nashville, Tennessee MARY K. DALY
Jamaica Plain, Massachusetts ELIZABETH BAZE
Houston, Texas MARY G. LAWRENCE
Bethesda, Maryland CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article for any disclosures of the authors.
REFERENCES
1. Vollman D, Gonzalez-Gonzalez LA, Chomsky A, Daly M, Baze E, Lawrence M. Intraoperative floppy iris and prevalence of intraoperative complications: results from Ophthalmic Surgery Outcomes Database. Am J Ophthalmol 2014;157(6): 1130–1135. 2. Blouin MC, Blouin J, Perreault S, Lapointe A, Dragomir A. Intraoperative floppy-iris syndrome associated with alpha1adrenoreceptors: comparison of tamsulosin and alfuzosin. J Cataract Refract Surg 2007;33(7):1227–1234.
shadows, and crescents following laser peripheral iridotomy, linear dysphotopsia seems to be the most specific symptom pertaining to laser peripheral iridotomies, and certainly the most problematic. We suspect that the magnitude of this problem may actually be underreported, as patients are not often asked specifically about visual symptoms that developed after laser peripheral iridotomy is performed. From our own experience, the number of patients reporting linear dysphotopsia has risen over the years. We applaud the authors’ efforts in conducting a prospective, randomized, and masked study directly comparing temporal and superior laser peripheral iridotomy position and the prevalence of linear dysphotopsia. Differing opinions regarding the role of lid position in causing visual symptoms following laser peripheral iridotomy have previously been expressed. While Congdon and associates,2 in their recent paper, reported that stray light and prevalence of visual symptoms did not differ between subjects regardless of lid coverage, Spaeth and associates3 have suggested that visual symptoms are more likely in patients with partially or fully exposed laser peripheral iridotomies. Current clinical guidelines in our hospital state that laser peripheral iridotomies should be placed as close to the 12 o’clock meridian, as peripherally as possible in order to ensure that the iridotomies are entirely covered by the upper lids. Following this randomized controlled trial, we are now considering a change in clinical practice to have all laser peripheral iridotomies placed as temporally as possible. While laser peripheral iridotomy is a routinely common procedure for ophthalmologists, we feel that little thought is currently given to the potentially debilitating effects that linear dysphotopsia might have on previously asymptomatic patients undergoing this prophylactic procedure. If linear dysphotopsia rates are as high as the 10.7% mentioned in Dr Vera’s study, patients need to be carefully counseled before undergoing prophylactic laser peripheral iridotomy. WEN WEI WOO NICHOLAS KLOSTER WRIDE SCOTT GEORGE FRASER
Sunderland Eye Infirmary, United Kingdom
Dysphotopsia After Temporal Versus Superior Laser Peripheral Iridotomy: A Prospective Randomized Paired Eye Trial
THE AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors have no financial disclosure to make and declare that no payment or services from a third party have been received for any aspect of the submitted work. No funding has been received for preparation and submission of this manuscript.
EDITOR: WE READ WITH INTEREST THE IMPORTANT ARTICLE BY VERA
and associates1 reporting that temporally placed laser peripheral iridotomies are less likely to cause linear dysphotopsia compared to ones placed superiorly. We agree with the authors that while patients can experience a variety of visual symptoms including haloes, VOL. 158, NO. 4
REFERENCES
1. Vera V, Naqi A, Belovay GW, Varma DK, Ahmed II. Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective randomized paired eye trial. Am J Ophthalmol 2014;157(5):929–935.
CORRESPONDENCE
849
2. Congdon N, Yan X, Friedman DS, et al. Visual symptoms and retinal straylight after laser peripheral iridotomy: The Zhongshan Angle-Closure Prevention Trial. Ophthalmology 2012; 119(7):1375–1382. 3. Spaeth GL, Idowu O, Seligsohn A, et al. The effects of iridotomy size and position on symptoms following laser peripheral iridotomy. J Glaucoma 2005;14(5):364–367.
REPLY WE APPRECIATE THE INTEREST AND POSITIVE FEEDBACK OF
Woo and associates. When an iridotomy is placed superiorly, lid coverage is not necessarily protective of visual symptoms, for reasons we discussed in our paper.1 The superior tear film at the lid margin results in a base-up prism refracting stray light onto the peripheral retina that can result in dysphotopsia. Furthermore, as the lid and tear film is dynamic, visual symptoms may vary considerably. We agree that linear dysphotopsia is an underreported and potential debilitating complication after laser peripheral iridotomy. Proper informed consent is important for any patient undergoing peripheral iridotomy, and we strongly recommend the iridotomy be placed away from the lid margin to reduce the incidence of dysphotopsia. Thus, we prefer the temporal or nasal location in most cases. VANESSA VERA IQBAL IKE K. AHMED
Toronto, Ontario, Canada CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article for any disclosures of the authors.
emergency evaluation of these patients is necessary.2 Lee and associates make the following points in the discussion of their study:1 ‘‘Recent guidelines from the AHA/ASA recommend that all patients with suspected brain or retinal ischemia should undergo immediate brain imaging and etiological work-ups.3 However, physicians seem to be reluctant to follow these recommendations. According to a recent survey, only 35% of ophthalmologists and 73% of neurologists refer patients with CRAO to the emergency room for extensive etiologic evaluation.4’’ In the reference cited, the American Heart Association and American Stroke Association do not recommend immediate brain imaging and etiological work-ups of patients with suspected brain or retinal ischemia.3 On the contrary, these guidelines specifically state, ‘‘The setting of specific recommendations for the timing and type of diagnostic workup for patients with TIA or stroke is beyond the scope of these guidelines.’’3 The survey referenced by the authors, which found that 35% of ophthalmologists refer patients with central retinal artery occlusion to the emergency room, was a study regarding emergency treatment of acute central retinal artery occlusion with thrombolytics.4 The survey was not aimed at evaluating the referral of patients with central retinal artery occlusion for etiological evaluation. Patients with suspected brain or retinal ischemia usually present with symptoms of transient ischemic attack or with signs of acute branch or central retinal artery occlusion. Do the authors have evidence that these patients should be immediately referred for emergency etiological evaluation? STEVEN COHEN
Clearwater, Florida REFERENCE
1. Vera V, Naqi A, Belovay GW, Varma DK, Ahmed II. Dysphotopsia after temporal versus superior laser peripheral iridotomy: a prospective randomized paired eye trial. Am J Ophthalmol 2014;157(5):929–935.
THE AUTHOR HAS COMPLETED AND SUBMITTED THE ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. The author indicates no funding support.
REFERENCES
Co-occurrence of Acute Retinal Artery Occlusion and Acute Ischemic Stroke: Diffusion-Weighted Magnetic Resonance Imaging Study EDITOR: IN THEIR ARTICLE, ‘‘CO-OCCURRENCE OF ACUTE RETINAL
artery occlusion and acute ischemic stroke: Diffusionweighted magnetic resonance imaging study,’’ Lee and associates recommend emergent evaluation of patients with suspected brain or retinal ischemia.1 The accompanying editorial, in the wording of its title, ‘‘Acute retinal arterial ischemia: An emergency often ignored,’’ also suggests that 850
1. Lee J, Kim SW, Lee SC, et al. Co-occurrence of acute retinal artery occlusion and acute ischemic stroke: diffusionweighted magnetic resonance imaging study. Am J Ophthalmol 2014;157(6):1231–1238. 2. Biousse V. Acute retinal arterial ischemia: an emergency often ignored. Am J Ophthalmol 2014;157(6):1119–1120. 3. Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:227–276. 4. Atkins EJ, Bruce B, Newman NJ, Biousse V. Translation of clinical studies to clinical practice: survey on the treatment of central retinal artery occlusion. Am J Ophthalmol 2009;148(1):172–173.
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER 2014
