ly, our literature has referred to many problems that do not interfere with vision as "cosmetic." However, physicians should not refer to a problem as cosmetic in their charts or referral letters, for example, "I am referring you this patient with a cosmetic ptosis." If an insurance company receives such information in a second opinion or in requested records, the surgery will not be covered, regardless of what other information is provided. Therefore, it is important to avoid the term cosmetic and supplant it with reconstructive when referring to congenital or acquired deformities. We do our patients and ourselves a grave disservice when we refer to
reconstructive surgery as "cosmetic." This error is seldom made by general plastic surgeons, whose existence depends on this subtle but important distinction. We thank Small for further clarifying and emphasizing the problems in differentiating cosmetic and functional problems and their reimbursement, and for providing additional sug¬ gestions to help alleviate these problems. Richard L. Anderson, MD Salt Lake City, Utah John B. Holds, MD St Louis, Mo
secondary to a macular hole between Japan and the United
States may be attributed to the difference between the races. Our coauthor, Dr Ogino, reported a 27% incidence of associated frequencies of peripheral retinal tears with macular hole and a 13.1% incidence in patients with degenerative myopia.2 These data are in agreement with Dr Davidorf's comments. We evaluated retinal detachment due to macular holes in patients with high myopia and excluded those patients with peripheral retinal breaks, uveitis, and trauma. We are certain that no patients described in our article had peripheral retinal breaks. According to Dr Davidorf, however, some patients may have had peripheral retinal breaks. Even if this were true, we would initially recommend an intraocular gas tam¬ ponade alone in a patient with high myopia who had a retinal detachment due to a macular hole because this procedure alone has a good initial reattachment rate (59%) and causes less surgical damage. If the initial gas tamponade procedure fails, a scierai buckling procedure, such as Dr Davidorf recom¬ mends, may be considered as one of the reoperation
procedures.
Surgical Technique in Retinal Detachment due to a Macular Hole
To the Editor.\p=m-\In the article by Kuriyama et al1 in the November 1990 issue of the Archives, the authors report an unusually high number of retinal detachments due to macular holes. In fact, the largest series in the literature, to our knowledge, reports a 0.6% incidence of macular break as a cause of retinal detachment.2 In our institution, it is rare to see a retinal detachment secondary to a macular hole. On first impression, many detachments in patients with high myopia appear to have a hole in the macula. The detached macula in these patients is extremely thin at the fovea and gives the appearance of a full-thickness hole. Myopic retinal detachments frequently have very small peripheral tears that are difficult to see. The majority of the patients in the article by Kuriyama et al1 underwent scleral buckling procedures. The repair of the detachments could be attributed to the approximation of the peripheral tear with either a scleral buckle or intraocular tamponade. I recommend that the initial operation in a patient with high myopia who has a retinal detachment presumably due to a macular hole be a scierai buckling procedure with cryotherapy to the peripheral retina. I think Kuriyama et al1 will find that a surprisingly high percentage of patients will have successful reattachment of the retina. If the retinal detach¬ ment recurs with fluid accumulating in the posterior pole, then one can use a transvitreal approach such as the one described by Kuriyama et al. Frederick H. Davidorf, MD Columbus, Ohio 1. Kuriyama S, Matsumura M, Harada T, Ishigooka H, Ogino N. Surgical techniques and reattachment rates in retinal detachment due to macular hole. Arch Ophthalmol. 1990;108:1559-1561. 2. Margherio RR, Schepens CL. Macular breaks, I: diagnosis, etiology and observations. Am J Ophthalmol. 1969;4:24.
In Reply.\p=m-\Weappreciate Dr Davidorf's interest in our article and his comments regarding the initial operation in a patient with high myopia who has a retinal detachment presumably due to a macular hole. In Japan, it is not rare to see a patient with a retinal detachment due to macular hole. In fact, some Japanese ophthalmologists report a 10% incidence of macular hole causing a retinal detachment, which is much higher than the incidence reported by Margherio and Schepens.1 The difference in the incidence of retinal detachment
Shoji Kuriyama, MD Miyo Matsumura, MD Takafumi Harada, MD Hitoshi Ishigooka, MD Nobuchiki Ogino, MD
Kyoto, Japan
1. Margherio RR, Schepens CL. Macular breaks, I: diagnosis, etiology and observations. Am J Ophthalmol. 1969;4:24. 2. Ogino N. Retinal detachment with macular hole: statistical study of some characteristics. Acta Soc Ophthalmol Jpn. 1979;83:275-278.
Transferrin Receptor Expression by Retinal Pigment Epithelial Cells in Proliferative Vitreoretinopathy
To the Editor.\p=m-\Wewere interested in the study by Jaffe and associates,1 disclosing the potential use of immunotoxins to inhibit the growth of retinal pigment epithelial cells in patients with proliferative vitreoretinopathy (PVR). Exposing the proliferating retinal pigment epithelial cells to an immunotoxin composed of a monoclonal antibody directed against transferrin receptor and conjugated to ricin A chain, caused a significant decrease in the number of cells and affected their morphologic appearance. This study was based on the hypothesis that transferrin receptors, which are expressed at high density on various types of proliferating cells, could constitute a useful target for immunotoxins, whereby proliferating retinal pigment epithelial cells would be inhibited during PVR. This hypothesis, however, was investigated by studying the cells in vitro, not in vivo, so that it could be determined whether such antiproliferative agents might be used in patients with PVR. We have been studying PVR for a few years,2,3 looking for expression of various markers at the surface of proliferating retinal pigment epithelial cells. Since transferrin receptors are membrane antigens expressed by proliferating cells, we examined these markers on intra¬ vitreal cells and cells from subretinal fluid obtained surgically in eight patients with PVR. In the five vitreous and three subretinal fluids, immunocytologic procedures were performed using monoclonal antibod¬
ies to transferrin receptors (OKT9, Ortho Pharmaceutical Corp, Raritan, NJ). A strong immunoreactivity was present at the surface of 90% to 100% of the examined cells. These positive cells showed various morphologic patterns, such as heavily pigmented cells; large, poorly pigmented and unpigmented cells; and small unpigmented cells. Immunoreactivity to cytokeratin (KL1, Immunotech Co, Marseille, France) confirmed that these cells were derived from retinal pigment
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/17/2015
reconstructive surgery as "cosmetic." This error is seldom made by general plastic surgeons, whose existence depends on this subtle but important distinction. We thank Small for further clarifying and emphasizing the problems in differentiating cosmetic and functional problems and their reimbursement, and for providing additional sug¬ gestions to help alleviate these problems. Richard L. Anderson, MD Salt Lake City, Utah John B. Holds, MD St Louis, Mo
secondary to a macular hole between Japan and the United
States may be attributed to the difference between the races. Our coauthor, Dr Ogino, reported a 27% incidence of associated frequencies of peripheral retinal tears with macular hole and a 13.1% incidence in patients with degenerative myopia.2 These data are in agreement with Dr Davidorf's comments. We evaluated retinal detachment due to macular holes in patients with high myopia and excluded those patients with peripheral retinal breaks, uveitis, and trauma. We are certain that no patients described in our article had peripheral retinal breaks. According to Dr Davidorf, however, some patients may have had peripheral retinal breaks. Even if this were true, we would initially recommend an intraocular gas tam¬ ponade alone in a patient with high myopia who had a retinal detachment due to a macular hole because this procedure alone has a good initial reattachment rate (59%) and causes less surgical damage. If the initial gas tamponade procedure fails, a scierai buckling procedure, such as Dr Davidorf recom¬ mends, may be considered as one of the reoperation
procedures.
Surgical Technique in Retinal Detachment due to a Macular Hole
To the Editor.\p=m-\In the article by Kuriyama et al1 in the November 1990 issue of the Archives, the authors report an unusually high number of retinal detachments due to macular holes. In fact, the largest series in the literature, to our knowledge, reports a 0.6% incidence of macular break as a cause of retinal detachment.2 In our institution, it is rare to see a retinal detachment secondary to a macular hole. On first impression, many detachments in patients with high myopia appear to have a hole in the macula. The detached macula in these patients is extremely thin at the fovea and gives the appearance of a full-thickness hole. Myopic retinal detachments frequently have very small peripheral tears that are difficult to see. The majority of the patients in the article by Kuriyama et al1 underwent scleral buckling procedures. The repair of the detachments could be attributed to the approximation of the peripheral tear with either a scleral buckle or intraocular tamponade. I recommend that the initial operation in a patient with high myopia who has a retinal detachment presumably due to a macular hole be a scierai buckling procedure with cryotherapy to the peripheral retina. I think Kuriyama et al1 will find that a surprisingly high percentage of patients will have successful reattachment of the retina. If the retinal detach¬ ment recurs with fluid accumulating in the posterior pole, then one can use a transvitreal approach such as the one described by Kuriyama et al. Frederick H. Davidorf, MD Columbus, Ohio 1. Kuriyama S, Matsumura M, Harada T, Ishigooka H, Ogino N. Surgical techniques and reattachment rates in retinal detachment due to macular hole. Arch Ophthalmol. 1990;108:1559-1561. 2. Margherio RR, Schepens CL. Macular breaks, I: diagnosis, etiology and observations. Am J Ophthalmol. 1969;4:24.
In Reply.\p=m-\Weappreciate Dr Davidorf's interest in our article and his comments regarding the initial operation in a patient with high myopia who has a retinal detachment presumably due to a macular hole. In Japan, it is not rare to see a patient with a retinal detachment due to macular hole. In fact, some Japanese ophthalmologists report a 10% incidence of macular hole causing a retinal detachment, which is much higher than the incidence reported by Margherio and Schepens.1 The difference in the incidence of retinal detachment
Shoji Kuriyama, MD Miyo Matsumura, MD Takafumi Harada, MD Hitoshi Ishigooka, MD Nobuchiki Ogino, MD
Kyoto, Japan
1. Margherio RR, Schepens CL. Macular breaks, I: diagnosis, etiology and observations. Am J Ophthalmol. 1969;4:24. 2. Ogino N. Retinal detachment with macular hole: statistical study of some characteristics. Acta Soc Ophthalmol Jpn. 1979;83:275-278.
Transferrin Receptor Expression by Retinal Pigment Epithelial Cells in Proliferative Vitreoretinopathy
To the Editor.\p=m-\Wewere interested in the study by Jaffe and associates,1 disclosing the potential use of immunotoxins to inhibit the growth of retinal pigment epithelial cells in patients with proliferative vitreoretinopathy (PVR). Exposing the proliferating retinal pigment epithelial cells to an immunotoxin composed of a monoclonal antibody directed against transferrin receptor and conjugated to ricin A chain, caused a significant decrease in the number of cells and affected their morphologic appearance. This study was based on the hypothesis that transferrin receptors, which are expressed at high density on various types of proliferating cells, could constitute a useful target for immunotoxins, whereby proliferating retinal pigment epithelial cells would be inhibited during PVR. This hypothesis, however, was investigated by studying the cells in vitro, not in vivo, so that it could be determined whether such antiproliferative agents might be used in patients with PVR. We have been studying PVR for a few years,2,3 looking for expression of various markers at the surface of proliferating retinal pigment epithelial cells. Since transferrin receptors are membrane antigens expressed by proliferating cells, we examined these markers on intra¬ vitreal cells and cells from subretinal fluid obtained surgically in eight patients with PVR. In the five vitreous and three subretinal fluids, immunocytologic procedures were performed using monoclonal antibod¬
ies to transferrin receptors (OKT9, Ortho Pharmaceutical Corp, Raritan, NJ). A strong immunoreactivity was present at the surface of 90% to 100% of the examined cells. These positive cells showed various morphologic patterns, such as heavily pigmented cells; large, poorly pigmented and unpigmented cells; and small unpigmented cells. Immunoreactivity to cytokeratin (KL1, Immunotech Co, Marseille, France) confirmed that these cells were derived from retinal pigment
Downloaded From: http://archopht.jamanetwork.com/ by a University of Michigan User on 06/17/2015
