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January 2012

 
Letters
 
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Testing for Toxicity 

In his October letter, Lee R. Duffner, MD, reminded us that color vision testing has in the past been used as a screening tool for hydroxychloroquine toxicity (and that it must be done properly).

However, the Academy committee that revised the screening recommendations—Revised Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy1—felt strongly that color abnormalities are too nonspecific (and sensitive to other pathology) to serve as a primary screening tool. Dr. Duffner’s data do not resolve these concerns: Although he found some cases of toxicity with color testing, we don’t know whether more might have been found with modern objective testing. And if his assumption of toxicity was not validated with other tests, a valuable drug might have been stopped unnecessarily.

It is quite acceptable to use color as a supplementary screening test, but it should not supplant careful 10-2 field testing and the use of sensitive objective tests such as spectral domain optical coherence tomography (SD-OCT) and multifocal electroretinography (mfERG).

Michael F. Marmor, MD   
Palo Alto, Calif.   

___________________________

1 Marmor MF et al. Ophthalmology. 2011;118:415-422.


Bevacizumab for ROP Data Clarification 

I read the October story “Study of Bevacizumab for ROP Sparks Controversy” (Clinical Update, October with great interest, in part because the writer attributed the initiation of the “intense debate” to my New England Journal of Medicine editorial.1

My editorial was an objective assessment of the efficacy, safety and practicality of intravitreal bevacizumab (IVB) for ROP based on pharmacokinetic data, previous small case series and the BEAT-ROP trial.2 While the latter multicenter, randomized trial had flaws, it was nonetheless superior to previous work and underwent rigorous review by the NEJM editorial staff. From this information IVB is obviously practical, and it appears at least as safe for the eye as conventional laser therapy (CLT). I also noted the unknown systemic safety of this treatment and pointedly stated that such concerns were “potentially profound.”

However, the efficacy of IVB over CLT was dramatic, especially for zone I ROP. The BEAT-ROP trial looked at recurrence rate of disease following treatment and reported that data in terms of infants and not eyes. The results were as follows:

Recurrence Rate

   

CLT

IVB

P Value

Overall

26%

6%

0.002

Zone I

42%

6%

0.003

Posterior zone II

12%

5%

0.27

Unfortunately, the Eye-Net article mentioned only the overall results as listed in the abstract, but mistakenly referred to them as the zone I results. This mischaracterization of the treatment effect dramatically undervalues the true efficacy difference in zone I and, by association, undervalued the basis for my editorial opinion. IVB is practical, safe for the eye, and dramatically more efficacious for true zone I ROP. The speculative systemic safety issues do not offset the major improvement in preventing blindness in zone I ROP. We have much to learn about IVB, and I support more research and more evidence-based results.

James D. Reynolds, MD   
Buffalo, N.Y.   

___________________________

1 Reynolds JD. N Engl J Med. 2011;364:677-678.
2 Mintz-Hittner HA, et al. N Engl J Med. 2011;364:603-615.
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EyeNet regrets this error.

Heard on the Web

The IOP Question: Experts Discuss Fluctuation
JUNE, FEATURE

“Looking forward to home IOP measuring device and all the data we could glean from it. I think it could also be a powerful positive feedback tool to increase patient compliance with drops.”

—Melissa O. Ajunwa, MD   

Hydroxycholoroquine-Induced Retinal Toxicity
JUNE, OPHTHALMIC PEARLS

“One of the best and most succinct summaries on the topic of Plaquenil I have ever read. Inclusion of recent OCT discovery and actual normative body habitus information will be crucial in early detection clinically going forward for us clinicians.”

—Harold E. Reaves, MD   

Rieger Syndrome
APRIL, BLINK

“Excellent unforgettable clinical image. Thanks EyeNet.

—Thomas Mathew, MD   


The comments above are published with permission from their respective contributors.


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