Ophthalmology Volume 105, Number 6, June I998
The only disadvantage of this technique is the uncer- minimize thermal damage at the specimen border and to
tainty of the histopathologic evaluation. We have to ac-
cept that we lose the possibility of histopathologic evalua-
tion of the peripheral 2 mm of tissue. However, since the
rate of recurrence appears to be similar with both meth-
ods, the above described drawback may have no clinical
significance.
G. RAD~, MD
St. Pdten, Austria
References
I. Radb G, Klemen UM. Langzeitergebnisse nach CO2 Laser
Excision. Spektrum Augeheilkd 1995; 163-4.
2. Verschueren Rcj. The Cob2s laser in tumor surgery. Assen:
Van Gorcum, 1976;47-52.
Authors’ reply
Dear Editor:
Dr. Rad6 offers some important comments about the laser
surgical method for treating eyelid margin tumors.
The reasons for the choice of the microscope-mounted
system in surgical oncology were fully reported in a previ-
ous paper.’ In the specific anatomic area of the eyelid
margins, we believe that the microsurgical method can
allow proper intraoperative definition of the lesion bor-
ders. Magnification of the surgical field up to 12x in-
creased the precision of the resection and maximized
healthy tissue conservation. Moreover, since the total ex-
cursion of the micromanipulator in a small surgical field
did not require position change of the operating micro-
scope, the entire surgical system was of satisfactory stabil-
ity. This advantage balanced the apparent reduction of
freedom during the surgical procedure while eliminating
the variable due to the gross incision direction of the
hand-held surgical system.
The super-pulse mode of laser emission may be prefera-
ble for the reduced carbonization zone, especially when
incising lateral borders. Less advantages of the mode are
experienced at the deep resection border, where an in-
creased coagulation capability is required, and when using
the laser for adjunctive peripheral vaporization. In the
latter case, the continuous mode of laser emission can
offer the desired surgical result with no potential risk of
tumor cell particle spreading due to the acoustic effect.2
Even though we initially used postoperative antibiotic
treatment for all patients, we now agree with Dr. Rad6 that
it is not necessary. Rarely, indications for prophylactic
antibiotic treatment remain for elderly or diabetic patients.
In our opinion, the histopathologic limitations in speci-
men evaluation at the eyelid resection margin should be
reduced to a minimum, mostly by adequately selecting
the patients and then by laser incising the critical margin
with minimal thermal injury. Laser excision of primary
superficial tumors with an “anterior” location usually
gives specimens with histologically assessable tumor-free
margins.” Conversely, when dealing with an “intermedi-
ate” location of the lesion, extended to the intermarginal
space (but not reaching the conjunctival border), a specific
ability is required for complete removal of the lesion to
946
avoid cosmetic or functional complications. The latter
subgroup of lesions therefore requires the most accurate
preoperative selection and intraoperative microsurgical
precision.
GAETANO BANDIERAMONTE, MD
PAOLO LEPERA, MD
Milano, Italy
References
BandieramonteG, ChiesaF, Lupi M, DiPietroS. The useof
laserin microsurgicaloncology. Microsurgery 1986;7:95-
101.
EsenalievRO, OraevskyAA, Letokhov VS, et al. Studies
of acousticaland shockwavesin the pulsedlaserablation
of biotissue.LasersSurg Med 1993; l3:470-84.
BandieramonteG, LeperaP, Moglia D, et al. Lasermicro-
surgery for superficialTl-T2 basal-cellcarcinomaof the
eyelid margins.Ophthalmology 1997;104:1179-84.
Prism Adaptation Study
Dear Editor:
Repka, Connett, and Scott point out in their reply to
Greenwald (Ophthalmology 1997; 104:1725-6) that
comparison of overall successrates in the Prism Adapta-
tion Study (Ophthalmology 1996:103:922-S) is a bit
complicated. While I agree with their estimate of the net
benefit of prism adaptation, I believe that without correc-
tion for continuity their P value is too generous, even at
only 0.17.
Imputing the same successrate for the 63 prism re-
sponderswho underwent entry angle surgery asthat found
for the prism responderswho received adapted angle sur-
gery and normalizing for the number of actual (not im-
puted) observations gives a successrate of 98/121 (8 l%,
in agreement with the authors) for prism adaptation versus
90/121 (74%) for conventionally treated patients. Using
these numbers, with the appropriate correction for conti-
nuity, z, = 1.08, which gives a two-tailed P = 0.28.
Alternatively, Fisher’s exact test also gives P = 0.28.
This significance level falls well short of the cx= 0.05
specified in the original study design. Therefore, each
surgeon will have to decide whether the effort and ex-
pense necessary for prism adaptation are worth a l-year
motor outcome that does not meet the usual statistical
criteria for being significantly different from conventional
management.If clinicians are inclined to accept the trend
found in the Prism Adaptation Study even at this signifi-
cance level, they should recognize that there is consider-
able uncertainty associated with the sample estimate of
7% benefit. The true benefit of prism adaptation-if the
customary 95% confidence interval is applied-may be
anywhere from -3% to +17%.
STEVEN M. ARCHER, MD
Ann Arbor, Michigan
Authors’ reply
Dear Editor:
Dr. Archer proposesan alternative analysis of the l-year
 Letters
data from the Prism Adaptation Study (PAS) based on
the use of a continuity-corrected z-statistic or a Fisher’s
exact test. His use of these methods is applied to imputed
data. The imputation is done by computing a weighted
average of the rates of motor success in two groups of
patients: (1) the prism responders, who received enhanced
surgery determined by their adapted angle (success rate,
.53/59), and (2) the prism nonresponders (success rate, 391
62). The former rate is given twice the weight of the
latter, and the combination yields an estimated 97.8 (ap-
proximately 98) successes out of 121 patients in the
prism-adapted surgery group. This is compared to a suc-
cess rate of 90/121 in the conventional group.
The Fisher’s exact test and the test based on a continu-
ity-corrected z-statistic are established statistical pro-
cedures for data that are counts in 2 X 2 contingency
tables. However, their properties are not established for
estimated or imputed counts based on weighted averages.
The Fisher’s test in particular assumes a hypergeomet-
ric distribution for cell counts, assuming that row and
column margins are fixed. In the analysis of the PAS, the
imputed data are not counts, and some of the margins
(estimated counts of successes in the various groups)
should be regarded as random variables rather than fixed
values. Continuity-corrected or uncorrected z-statis-
tics based simply on comparing 98/121 versus 90/121
have the defect that the estimated variances in the denomi-
nator are incorrect since they do not take the weightings
of the component estimates into account. Thus, we do
not feel that the results of such a test can be regarded as
valid for data derived in this way.
An alternative approach to the analysis we provided
in our earlier letter (Ophthalmology 1997; 104: 1725-d)
to the Editor
is possible: Assuming the null hypothesis, we are inter-
ested in computing the probability that the differences in
estimated success rates between the two treatments would
be as large as that observed in the PAS. The appropriate
null hypothesis would assume common rates of success
in those patients assigned to the conventional group as in
those assigned to prism adaptation. PAS data indicate that
stratification is necessary because prism responders and
nonresponders have different rates of success, and they
are represented unequally in the two groups. Maximum
likelihood methods, using all of the PAS data, can be
used to estimate the common rates for responders and
nonresponders under the null hypothesis; they are 0.8 16
and 0.623, respectively. Using these common success
rates and the observed counts of 59 patients in the prism-
adapted enhanced surgery group, 62 patients in the nonre-
sponder group, and 12 1 patients in the conventional treat-
ment group, we performed 10,000 computer simulations
of the PAS trial. We counted the number of times that
the absolute value of the estimated difference in success
rates exceeded that observed in the PAS (the observed
difference was 0.81 - 0.74 = 0.07). The observed differ-
ence was exceeded 1944 times, yielding an estimated two-
sided P value of 0.194. (The standard error for this esti-
mate is approximately 0.004.) This method, which has
the merit of not relying on a normal approximation or
other assumptions about distribution, thus yields a proba-
bility estimate that happens to be closer to our P value
of 0.17 than to Dr. Archer’s estimate of 0.28.
JOHN E. CONNETT, PhD
MICHAEL X. REPKA, MD
WILLIAM E. SCOTT, MD
Baltimore, Maryland
947