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Opaque Intraocular Lens Implantation Eye (2015) 29, 978–985 © 2015 Macmillan Publishers Limited All rights reserved 0950-222X/15 www.nature.com/eye Sir, CORRESPONDENCE Sir, Methodological remarks concerning the recent meta- Reply to ‘Lack of positive effect of intravitreal analysis on the effect of intravitral bevacizumab in bevacizumab in central serous chorioretinopathy: central serous chorioretinopathy meta-analysis and review’ We read with great interest the recent meta-analysis by We appreciate the interest of Sergentanis and Chatziralli 1 Chung et al, which reached important conclusions about in our published manuscript, ‘Lack of positive effect of the effect of intravitral bevacizumab in central serous intravitreal bevacizumab in central serous chorioretinopathy; nevertheless, some methodological chorioretinopathy: meta-analysis and review.’1 They have 1 issues need to be addressed concerning this meta-analysis. addressed methodological issues concerning meta- fi ‘ Speci cally, the authors state that The mean difference analysis because the SD of difference was not provided in and SD at the 6-month follow-up were calculated from the the manuscript. ’ data in the included studies. This seems an intriguing We absolutely agree that it would have been more fi statement that should be further clari ed by the authors to meaningful meta-analysis if we contacted the authors of substantiate the validity of the meta-analysis and guarantee each study, asking them to calculate de novo the difference the reproducibility of their results. The included studies as Sergentanis and Chatziralli have rightly pointed out. ± presented mean SD at baseline and at the 6-month time Alternatively, Hedges g formula for pooled SD was used point; the SD of the difference (with the latter representing a to estimate difference SD. And then, paired SD was new measure) was not provided by the included articles. − r – calculated, as follows, pooled SD × sqrt(2 × 1 )). Given that the variance of a an A B difference Although our meta-analysis failed to verify the positive inherently necessitates knowledge about the covariance effect of IVB in CSC, the outcome of this treatment is still (A, B), any attempt to estimate the SD of the difference unknown owing to many limitations, such as small would imply assumptions about the covariance; the latter sample sizes, clinical heterogeneity, and methodology. is not negligible and seems of corollary importance in — Therefore, further investigation including more studies light of the longitudinal nature of the baseline 6-month with larger scales and better methodologies will help to comparison. Therefore, the authors should disclose their clarify the uncertain relationship between CSC and IVB. assumptions regarding the calculation of covariance and provide the relevant formulas with the corresponding statistical references supporting their approach; critical discussion of any limitations potentially stemming from Reference such assumptions would be of interest. An alternative way would be contact with the authors 1 Chung YR, Seo EJ, Lew HM, Lee KH. Lack of positive effect of of each study, asking them to calculate de novo the intravitreal bevacizumab in central serous chorioretinopathy: – difference and provide the meta-analysts with the exact meta-analysis and review. Eye 2013; 27: 1339 1346. SD data. Nevertheless, Chung et al did not provide any statement disclosing contact with the authors of K Lee and Y-R Chung individual studies. In conclusion, thorough clarification of the methods Department of Ophthalmology, Ajou University used by Chung et al1 seems desirable, so as to further School of Medicine, Suwon, Republic of Korea solidify the validity of their approach. Reliable calculation E-mail: [email protected] of variance often represents a challenging notion in the field of meta-analysis. Eye (2015) 29, 978; doi:10.1038/eye.2015.5; published online 27 February 2015 Conflict of interest The authors declare no conflict of interest. Sir, Reference Opaque intraocular lens implantation 1 Chung YR, Seo EJ, Lew HM, Lee KH. Lack of positive effect of We read with interest the recent correspondence by Yusuf intravitreal bevacizumab in central serous chorioretinopathy: et al1 describing the factors influencing black intraocular meta-analysis and review. Eye 2013; 27: 1339–1346. lens (IOL) selection for intractable diplopia. We present retrospective data on our experience with TN Sergentanis1 and IP Chatziralli2 opaque IOLs over a span of 11 years (2003–2014) at our tertiary strabismus and vitreoretinal referral centre in 1Department of Epidemiology and Biostatistics, Scotland. Our findings are summarised in Table 1. University of Athens, Athens, Greece Five of our six patients were phakic, and underwent 2Second Department of Ophthalmology, routine phacoemulsification surgery, with insertion of a Ophthalmiatrion Eye Hospital, Athens, Greece custom-made Ophtec 0.0D black polycarbonate Ani II E-mail: [email protected] (‘no hole’) IOL into the capsular bag. This lens takes ~12–14 weeks to manufacture, and technical Eye (2015) 29, 978; doi:10.1038/eye.2015.8; published specifications are shown in Figure 1. Its 9-mm optic online 27 February 2015 diameter allows implantation in the capsular bag, and limits side illumination in scotopic conditions. However, as Correspondence 979 Table 1 Patient characteristics Case Age Gender Diagnosis resulting Previous Approximate duration of Preoperative Surgical Date of IOL Visual acuity Postoperative Follow-up (years) in intractable treatment occlusive therapy until lens status procedure surgery implant (VA) sequelae (months) diplopia IOL surgery (months) Preoperative Postoperative 1 38 Male Traumatic retinal Squint 10 Phakic Right July 2007 Ophtec Hand Light Mild 9 detachment surgery, phaco- Black Ani movements perception postoperative OCL, aspiration, II no hole uveitis occlusive IOL into (9.0 mm glasses capsular optic; bag (LA) overall length 13.75 mm) 2 45 Female Traumatic retinal Prism, 30 Phakic Left phaco- December Ophtec 6/9 Light Secondary 9 detachment; OCL, aspiration, 2008 Black Ani perception exotropia – decompensation pilocarpine IOL into II no hole requiring of phoria capsular squint surgery bag (GA) 3 41 Male Severe Squint 12 Phakic Left phaco- October Ophtec 6/60 ‘0’ (Final Removal of 28 anisomyopia and surgery x2, aspiration, 2009 Black Ani VA 6/60 black IOL, amblyopia OCL, IOL into II no hole with clear secondary patch capsular IOL) lens implant. bag (GA) Monocular diplopia 4 45 Female Intracranial Botulinum 7 Phakic Right September Ophtec 6/60 No light Worsening of Patient haemorrhage with Toxin A, phaco- 2011 Black Ani perception convergent demise at acquired patching aspiration, II no hole squint—listed 23 months nystagmus and IOL into for squint diplopia capsular surgery bag (LA) 5 49 Female Retinal OCL 9 Pseudo Left December Morcher 6/120 Light Side 1 detachment, phakic Secondary 2012 85F perception illumination full-thickness IOL (6.00 mm macular hole implant optic; into sulcus overall (LA) length 12 mm) 6 56 Male Microvascular OCL, 22 Phakic Right July 2013 Ophtec 6/12 Light Mild 2 third nerve palsy, patching phaco, IOL Black Ani perception postoperative Diabetes (no eye into II no hole uveitis disease) capsular bag (LA) Abbreviations: GA, general anaesthetic; IOL, intraocular lens; LA, local anaesthetic; OCL, occlusive contact lenses. it is not foldable, implantation requires a proportionately larger corneal incision, which could potentially prolong postoperative recovery and increase the risk of future infection and globe rupture. Whilst we have not formally tested for its near-infrared (NIR) properties, other opaque polycarbonate IOLs in use, such as Ophtec ‘pupil occluder’ iris claw IOLs, have been shown to be NIR-blocking, thereby providing total light occlusion and minimising the risk of treatment failure.1,2 Clinically, all five patients had good resolution of intractable diplopia, albeit with variable light perception. The absolute occlusion with consequent symptomatic reduction of field resulted in explantation of the opaque IOL in one patient. This highlights the importance of considering loss of visual field with complete occlusion, and subsequent poor adaptation to monocular vision. One patient had known Type II diabetes mellitus. Implantation of opaque IOLs in diabetics may be considered a relative contraindication,3 and has not Figure 1 Custom-made Ophtec Ani II 0.0 Dpt. Black. Poly- previously been described in the literature to our carbonate, nonfoldable, posterior chamber IOL (incision 49mm). knowledge. Systemic conditions like diabetes tend to Reformatted image, reproduced with permission from Ophtec BV. cause bilateral symmetrical ocular pathology.4 In the authors’ opinion, regular fundus surveillance of the from longer-term follow-up with posterior segment fellow eye provides a reasonable proxy that predicts imaging including optical coherence tomography, for development of diabetic eye disease in the occluded eye. example, those with choroidal naevi, suspicious discs, However, we concur that higher risk patients may benefit or lattice degeneration. Eye Correspondence 980 Conflict of interest The mechanism of light perception following black fl IOL implantation is a curious phenomenon and its The authors declare no con ict of interest. identification is critical to minimize the risk of treatment failure.4,5 High rates of postoperative satisfaction are reported in patients with NIR-transmitting black IOLs,6 Acknowledgements despite near universal postoperative light perception.5 We are grateful
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