Letters to the Editor Internet Eye Questions Dear Editor: Each day tens of millions of people visit internet healthcare websites and forums. Until recently 1,2 there have been no published ophthalmic studies based on data derived from internet eye forums. In order to try to understand why people visit eye health websites, we are categorizing ques- tions posted at the 2 eyecare forums sponsored by the American Academy of Ophthalmology (AAO) at Medhelp. org (www.medhelp.org). Medhelp.org, founded in 1994, is the largest internet health forum website and among the top 10 health information web- sites. 3 Each month about 8 million visits are made to more than 300 different forums. In 2007, the AAO assumed control of the “Ask a Doctor Ophthalmology” and “Eye Care Community” forums. 4 At present, these 2 ophthalmology forums are visited more than 260,000 times each month. Questions are answered by the authors and Sandy Feldman, MD, FAAO, and Ray Oyakawa, MD, FAAO. In the 1-year period between March 1, 2008 and March 1, 2009, the 4 of us answered 9006 questions and at least twice that number of additional follow-up ques- tions and clarifications. Khaled Hassounah of MedHelp.org assembled all ques- tions posted on the 2 eye forums in the 6-month period between September 1, 2008 and March 1, 2009. There were 1087 postings on the “Doctor” forum and 3432 on the “Eye Community” forum. Questions to the Doctor forum are electronically restricted in the number that can be posted in a 24-hour period, while the latter forum has no restrictions. The authors reviewed each heading and/or posting content to categorize it. If there was ambiguity, we looked at the AAO ophthalmologists’ response to see how it was an- swered. If there still was doubt, we decided how we would direct the person posting if we were responding. Some postings were not categorized as they were to the wrong forum, duplicates, or blank. We categorized a total of 4485 postings, 3423 on the Community forum, and 1062 on the Doctor forum. We com- pared the 2 forums, and they were similar so we present our findings combined in descending frequency: retina-vitreous 886 (19.7%), cornea-external disease-anterior chamber 860 (19.2%), cataract-intraocular lens 584 (13%), neuro- ophthalmology 448 (10%), pediatrics-strabismus 408 (9.1%), oculoplastic 191 (4.3%), miscellaneous 177 (4.1%), eye pain or discomfort not associated with other category 170 (3.8%), glasses-refraction 144 (3.2%), glau- coma 140 (3.1%), trauma 128 (2.9%), blurred vision not associated with other category 123 (2.7%), refractive surgery 96 (2.1%), contact lens 91 (2%), insurance or procedure costs 39 (0.9%). We believe this is a first literature report of question categories posted on internet eye forums. We also note that every posting was of a problem, complaint, or dissatisfac- tion. People without problems do not post, and clinical studies based on eye forum websites must factor in this selection bias. Nevertheless, we feel that further clinical research using internet healthcare websites is appropriate and beneficial. The MedHelp.org–AAO eye forums provide free and timely advice to a large and growing number of internet users. From frequent grateful postings, we know that we have di- rected to ophthalmologists many people with the complete spectrum of major eye disease. This includes at least 2 children with undiagnosed retinoblastomas (EyeNet magazine, Internet Advice: When Patients Go on Line, May 2009). The AAO is currently seeking additional qualified, mo- tivated Fellows of the Academy to assist in the MedHelp. org program. Interested ophthalmologists should contact John Gallagher of the AAO Public Relations department (jgallagher@aao.org). JOHN C. HAGAN, III, MD, FAAO, FACS Kansas City, Missouri MICHAEL J. KUTRYB, MD, FAAO Titusville, Florida References 1. Hagan JC III, Kutryb MJ. Cataract and intraocular implant surgery concerns and comments posted at two internet eye care forums. Mo Med 2009;106:78 – 82. 2. Hagan JC III, Kutryb MJ. Internet forums track patients’ IOL concerns. Rev Ophthalmol 2009;16:52–5. 3. 20 Most Popular Health Websites April 2009. http://www. ebizmba.com/articles/health. 4. Hagan JC III. Oh say can you see? Using internet health forums to study cataract surgery. Mo Med 2009;106:4 –5. Keratoconus Dear Editor: In the article entitled, “Refractive, Topographic, Tomo- graphic, and Aberrometric Analysis of Keratoconic Eyes Undergoing Corneal Cross-Linking,” by Vinciguerra et al, 1 I noted the authors’ success in stabilizing the pro- gression of keratoconus (KCN) by strengthening the cor- nea through collagen cross-linking. Given the increased attention and effort directed toward methods and merits of strengthening the ectatic cornea, I would like to ele- vate awareness of external mechanical factors that appear to accelerate the progression of KCN. These factors are preventable, yet they frequently escape the clinician’s attention. While eye rubbing and allergy are recognized associations with KCN, their precise relationship and contribution to disease progression remain poorly under- stood. Clinical observation alone makes it difficult to evaluate the contribution that eye rubbing is making to disease progres- sion in an individual patient. Nevertheless, I believe that the following personal observations serve to alert the clinician to the types of patients who may benefit from reduced external injury from eye rubbing. 1. Although unproven, eye rubbing appears to accelerate progression of KCN, and in my experience, eye rubbing is the most consistent finding associated with disease asym- 2036