Acta Ophthalmologica 2014

to the nerve fibre layer [NFL] and the ganglion cell layer [GCL] to the IPL) and further analysed in the same way. The photoreceptor outer segment (PROS) length at the fovea was also evaluated manually using a B-scan. In MEWDS eyes, mean logMAR best-corrected visual acuity and mean deviation values on Humphrey perimetry significantly ameliorated (P = 0.01 for both, Wilcoxon’s signed-rank test) with improvements in retinal outer morphology. Compared with baseline data, the whole retinal thickness did not change significantly at any time-point measured (P = 0.17 for both). The inner retinal layer (ILM-IPL) thickness significantly decreased at 1 month and later (P = 0.01 for both, Fig. 1B). Notably, the ILM-NFL thickness significantly declined at 1 month and later (P = 0.01 for both, Fig. 1C), whereas the GCL-IPL thickness was unaltered at any time-point measured (P = 0.17, P = 0.32). In MEWDS eyes, the inner layer and ILM-NFL thicknesses were significantly greater than in unaffected fellow eyes at baseline (P = 0.01 and 0.02, respectively; Fig. 1B,C), but the GCL-IPL thickness was not (P = 0.60). Accordingly, the responsible layer for the increased inner thickness in the acute phase was thought to be the NFL, which harbours retinal venules. Retinal periphlebitis has been reported in some MEWDS cases (Jampol et al. 1984). Macular focal electroretinography revealed a significant reduction in not only a-waves but also b-waves in MEWDS eyes (Horiguchi et al. 1993). These observations suggest that inner retinal layers were subclinically involved in MEWDS eyes in parallel with outer retinal damage, and inflammation may play a role in its pathogenesis. Outer layer thickness significantly increased at 3 months (P = 0.02, Fig. 1D). Moreover, PROS length significantly increased at 1 month and later (P = 0.01 for both, Fig. 1E). At 3 months, BCVA significantly correlated with the elongated PROS length (R = 0.75, P = 0.03, Spearman’s rank correlation coefficient). However, there was no significant change in any retinal layer thickness in the unaffected eyes (Fig. 1B–D). This study is the first to show a close link between visual recovery and PROS elongation in MEWDS. Because the outer layer thickening and the inner layer thinning cancelled each other out, the whole retinal thickness


appeared unchanged with regression of MEWDS.

References Hashimoto Y, Saito W, Saito M et al. (2014): Retinal outer layer thickness increases after vitrectomy for epiretinal membrane and visual improvement positively correlates with photoreceptor outer segment length. Graefes Arch Clin Exp Ophthalmol, 252: 219–226. Horiguchi M, Miyake Y, Nakamura M et al. (1993): Focal electroretinogram and visual field defect in multiple evanescent white dot syndrome. Br J Ophthalmol 77: 452–455. Jampol LM, Sieving PA, Pugh D et al. (1984): Multiple evanescent white dot syndrome. I. Clinical findings. Arch Ophthalmol 102: 671–674. Li D & Kishi S (2009): Restored photoreceptor outer segment damage in multiple evanescent white dot syndrome. Ophthalmology 116: 762–770.

Correspondence: Wataru Saito, MD, PhD Department of Ocular Circulation and Metabolism Hokkaido University Graduate School of Medicine Nishi 7, Kita 15, Kita-ku Sapporo 060-8638, Japan Tel: +81 11 706 5944 Fax: +81 11 706 5948 Email: [email protected]

The influence of glaucoma medications on ocular surface disease in primary open-angle glaucoma patients with and without conjunctivochalasis Sibel Kocabeyoglu, Mehmet C. Mocan and Murat Irkec Department of Ophthalmology, School of Medicine, Hacettepe University, Ankara, Turkey doi: 10.1111/aos.12425

Editor, cular surface disease (OSD), one of the major side-effects of longterm use of antiglaucoma drugs, is thought to develop secondary to


reduced tear production, corneal epithelial damage, decreased number of subbasal nerves and corneal sensitivity, reduced number of goblet cells and damage to the mucous layer of the tear film resulting in tear film instability (Pisella et al. 2002). OSD in elderly is also associated with several conditions including conjunctivochalasis (CCh), a frequently overlooked ocular surface problem of the ageing population characterized by looseness and redundancy of inferior bulbar conjunctiva between the globe and the eyelid, which causes OSD symptoms by inducing tear film instability, delayed tear clearance and ocular surface inflammation (Liu 1986; Di Pascuale et al. 2004). The aim of this study was to evaluate whether the effect of CCh on ocular surface parameters differs according to the type of topical antiglaucoma medication in primary open-angle glaucoma patients. A total of 190 eyes of 190 subjects with or without CCh were included in this prospective study. Participants were divided into three groups: Group I was composed of patients treated with prostaglandin (PG) analogues (n = 46); Group II was composed of patients treated with beta-adrenergic antagonists (n = 45); Group III (control group) was composed of healthy subjects (n = 99). The subjects were categorized into two subgroups according to the presence or the absence of CCh. The tear break-up time (BUT), lissamine green (LG) staining and Schirmer test were performed and ocular surface disease index (OSDI) questionnaire scores were noted for each subject. Mann–Whitney U test, Kruskal–Wallis test and one-way ANOVA were used for statistical analysis. All ocular surface parameters were found worse in each group with CCh. Patients with CCh in Group I had significantly lower Schirmer test values and higher LG grading and OSDI scores than those of patients with CCh in Group II and Group III (p < 0.05; Table 1). Ocular surface parameters of patients with grade 2 CCh were significantly different than those of grade 1 CCh in all groups (p < 0.05). Both beta-blockers and PG analogues increase the inflammatory marker expression and decrease MUC5AC-related mucin production in epithelial cells compared with normal subjects (Pisella et al. 2004). These

Acta Ophthalmologica 2014

Table 1. Comparison of ocular surface parameters of subjects with and without conjunctivochalasis as evaluated with Kruskal–Wallis test. b-blocker group

PG group CCh (+) (n = 23) BUT (second) LG staining (grade) Schirmer test (mm) OSDI score (points)

7.9 1.5 7.5 17.3


2.6 0.9 3.1 15.3

CCh () (n = 23) 9.3 0.3 11.9 6.5


1.6 0.4 3.0 4.3


CCh (+) (n = 20)


The influence of glaucoma medications on ocular surface disease in primary open-angle glaucoma patients with and without conjunctivochalasis.

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