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MAILBOX Terdam Study 1394 Br J Ophthalmol 2001;85:1394–1395 Br J Ophthalmol: first published as 10.1136/bjo.85.11.1394b on 1 November 2001. Downloaded from coeYcient was calculated by us after digitalis- 5 Wolfs RC, Klaver CC, Vingerling JR, et al. Distri- ing the data points. It equals 0.51. According bution of central corneal thickness and its to Klemm,4 (page 97) the estimate of association with intraocular pressure: The Rot- MAILBOX terdam Study. Am J Ophthalmol 1997;123:767– regression is extremely unreliable and thus 72. useless at r <z0.6z. The data of Ehlers et al, 6 Watzlawick P. Wie wirklich ist die Wirklichkeit? therefore, are much more convincing than the Munich: Piper, 1976. data of Whitacre This fact does not 7 Bron AM, Creuzot-Garcher C, Goudeau- et al. Boutillon S, et al. Falsely elevated intraocular An “overtrained” ophthalmologist reduce the merit of Whitacre, who brought the pressure due to increased central corneal thick- responds problem of corneal influence on tonometry to ness. Graefes Arch Clin Exp Ophthalmol 1999; our notice. 237:220–4. 8 Stodtmeister R. Applanation tonometry and cor- EDITOR,—As one of the most “overtrained”(!) It escaped the attention of Bechmann et al 2 rection according to corneal thickness. Acta ophthalmologists in the United Kingdom at that figure 4 of Ehlers et al and figure 2 of Ophthalmol Scand 1998;76:319–24. the present time, I was delighted and stimu- Whitacre et al3 diVer fundamentally from 9 Shah S, Chatterjee A, Mathai M, et al. Relation- lated to read the excellent, erudite, and witty figure 2 in the paper by Wolfs et al.5 ship between corneal thickness and measured intraocular pressure in a general ophthalmology 1 Furthermore, regarding the results of the Rot- commentary by James Acheson. I think that clinic. Ophthalmology 1999;106:2154–60. the issue that lies at the heart of the matter is, terdam study, the ordinate of figure 4 of as Mr Acheson himself puts it, “It all depends Ehlers et al shows the correction value accord- on what you mean by training . .” Surely one ing to corneal thickness, and in figure 2 of Major orbital complications of of the driving reasons behind the length of all Whitacre et al the ordinate shows the measure- endoscopic sinus surgery specialist training in the UK has always been ment error according to corneal thickness. the high demands of the service commitment These two ordinates (Ehlers et al and Whita- EDITOR,—We read with interest the article by of the senior house oYcer and registrar grades cre et al)diVer by sign and show the result of Rene et al.1 We would like to clarify a few alike. Until the issue of doctors’ numbers can subtraction of intracamerally measured IOP points regarding endoscopic sinus surgery. begin to be tackled at a meaningful level in the and applanation tonometry values. The ordi- Endoscopic sinus surgery is considered by UK we shall forever have the push-pull nate in figure 2 of the Rotterdam study, how- many to be the most exciting development in politics of service versus training. It is still ever, shows the results of applanation tono- otolaryngology. The aim is to restore the natu- worth pointing out that we have the lowest metry. This is a fundamental diVerence that ral mucociliary clearance mechanism, drain- number of doctors per capita in the developed absolutely forbids a comparison. The Rotter- age, and aeration of the sinuses by a minimally world, bar only Greece and Albania. dam study does not provide a correlation invasive technique, maintaining as much of It is also very true that the standards of coeYcient of the data shown in figure 2, which the normal anatomy as possible.2 We agree ophthalmology training in the UK are re- may be interpreted as a cloud of points. We with the authors that the incidence of ocular garded very highly by trainees from oversees, have similar data and have calculated the coef- complications is low and similar to those who regularly come to the UK to complement ficient of correlation r = 0.17. Therefore, in reported by other non-endoscopic ap- and polish oV their training. However, they this case it may be concluded that the estimate proaches.3 The authors mentioned CT scan- come mainly for subspecialty training and of regression is playing with figures only 4 ning as a preoperative measure to reduce often go to superspecialist regional centres, (Klemm, page 97). complications; this is a well established In summary, the data of Ehlers where they act as fellows, often in a somewhat et al practice in all departments that practise endo- currently show the association of measurement privileged position. They are able to benefit scopic sinus surgery. Orbital complications are error and corneal thickness in the most from the high level of internationally re- more likely to occur in patients with extensive convincing way. Although Bechmann have nowned expertise in their chosen field that the et al polyposis especially those who had multiple (erroneously) seen a small influence of central UK is still able to provide. We in the UK face surgery; however, in a survey of British a rather unique situation, in that superspecial- corneal thickness in IOP measurement in the otolaryngologists4 the overall estimated com- ist fellowship training is quite rightly becom- literature they attribute an important part to plication rate was 0.24%. As a matter of fact ing the norm while still being outside the corneal thickness in the diagnosis and under- endoscopic sinus surgery techniques are being national Calman training programme. This standing of various types of glaucoma. It can used to treat orbital complications such as sends a very mixed message about its value to be concluded from the context that the authors malignant exophthalmos in thyroid eye dis- the powers that be. It is also far from easy for treat corneal thickness as a new quantity in the http://bjo.bmj.com/ ease.5 We believe that the key to avoiding such every trainee to find a suitable fellowship and diagnosis of glaucoma, comparable with optic complications is the adequate understanding funding. disc parameters. They have nicely shown of the nasal anatomy endoscopically, which is So, on the one hand the length of training diVerent values of corneal thickness in the could be shortened by tackling the issue of various types of glaucoma. However, they do only achieved through attending specialised service versus training demands, and on the not believe that corneal thickness influences workshops that are widely available through- other hand perhaps training could formally be applanation tonometry. Therefore, they have out the country; adequate haemostasis intra- lengthened to ensure that British ophthal- to explain their findings in a more complicated operatively is of paramount importance. If mologists are able to stay at the forefront of way. The psychologist and philosopher Watzla- complications are encountered then the im- 6 their chosen fields in the international arena. wick (page 67) states that we prefer declaring mediate termination of the procedure is on September 28, 2021 by guest. Protected copyright. We all await developments with interest! undeniable facts (which are inconsistent with recommended and an urgent ophthalmologi- our explanation) to be untrue or unreal instead cal opinion should be sought. MARCELA VOTRUBA of fitting our explanation to these facts. The Kellogg Eye Center, University of Michigan, Ann Arbor NIHAL B KENAWY MI, USA application of biometric knowledge in judging Bristol Eye Hospital the data of Whitacre et al3 and a reinterpreta- 5 MR OMAR M AYOU 1 Acheson J. Are ophthalmologists overtrained? Br tion of figure 2 of the Rotterdam study may fit University of Bristol J Ophthalmol 2001;85:383–4. the opinion of the authors to the most likely explanation7–9 that corneal thickness influences Correspondence to: Dr Kenawy [email protected] the results in applanation tonometry to a clini- Biometric aspects and comparison with cally relevant degree, and that recommends the published papers application of OCT in the diagnosis of 1 Rene C, Rose GE, Lenthall, et al. Major orbital glaucoma if available. complications of endoscopic sinus surgery. Br J EDITOR,—In their discussion on central cor- Ophthalmol 2001;85:598–603. neal thickness determined with optical coher- RICHARD STODTMEISTER 2 Stammberger H. Endoscopic endonasal surgery- ence tomography in glaucoma in the BJO, Turnstrasse 24, 66953 Pimasens, Germany new concepts in the treatment of recurrening Bechmann et al1 mention the results of Ehlers sinusitis. Part I. Anatomical and physiological 2 considerations. Otolaryngol Head Neck Surg et al. and compare them with the results of 1985;94:143–7. 3 1 Bechmann M, Thiel MJ, Roesen B, et al. Central Whitacre et al without regarding generally corneal thickness determined with optical co- 3 Mackay I S, Lund VJ. Surgical management of accepted principles of interpretation.4 Some herence tomography in various types of glau- sinusitis. In: Kerr AG, ed. Scott-Brown’s biometrical considerations will be found in the coma. Br J Ophthalmol 2000;84:1233–7. otolaryngology. 6th ed. Oxford: Butterworth- 2 Ehlers N, Bramsen T, Sperling S. Applanation Heinemann, 1997;4(12):1–29. following. tonometry and central corneal thickness. Acta 4 Cumberworth VL, Sudderick RM, Mackay IS. In the paper by Ehlers et al in figure 4 the Ophthalmol (Copenh) 1975;53:34–43. Major complications of functional endoscopic correlation coeYcient between the correction 3 Whitacre MM, Stein RA, Hassanein K. The sinus surgery. Clin Otolaryngol 1994;19:248–53. value and corneal thickness is 0.768 atn=29. eVect of corneal thickness on applanation 5 Kennedy DW, Goodstein ML, Miller NR, et al.
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