such patients being treated should be monitored for initial
and ongoing efﬁcacy of treatment.
While 20% of our patients showed an improvement in
visual acuity by seven letters or more in at least one eye, 13
(87%) out of 15 showed a substantial improvement in their
retinal thickness in at least one eye. Perhaps treatment at
an earlier stage of edema and with alternate day dosage
might have a more beneﬁcial effect on visual acuity and a
reduced incidence of recurrence, respectively.
Dr Guiffre offers a raw analysis of our data and concludes
that age plays a role in the response to topical dorzolamide.
Although, initially, we were tempted to offer a similar
conclusion, we ultimately were cautious in over-interpreting
the results from a small series of patients. Dr Guiffre points
out that, whereas all six of younger subjects had an improve-
ment of their edema without rebound, only three of the nine
older subjects showed an improvement of their CME by
optical coherence tomography (OCT). Actually, seven out of
nine older subjects initially showed an improvement, Tables
1 and 2 in the article.
However, four out of these seven
subjects who showed an initial improvement developed a
rebound increase in their edema. As we mentioned in the
article, the duration of the CME may play a signiﬁcant role in
the ultimate response to treatment. However, it would be
misleading to draw any statistical correlations between the
“duration” of macular edema and response to treatment. The
exact “duration” for macular edema in any of our patients was
unknown, since all patients in this series, when examined for
the ﬁrst time, already exhibited CME.
Finally, Dr Guiffre expresses concern about undesirable
side effects, such as ocular discomfort and a burning
sensation with topical application of the medication. We
believe that these “minor” side-effects are more acceptable
than the potential, more clinically signiﬁcant, side-effects
such as notable fatigue, loss of appetite, development of
kidney stones, and a severe form of anemia that have been
reported with the use of systemic forms of carbonic
Our ﬁndings justify the conclusion that patients of any
age with RP and CME, documented by ﬂuorescein angiog-
raphy and/or OCT, can be safely treated with topical
dorzolamide to reduce the amount of their macular edema,
as long as they are suitably monitored for any undesirable
side-effects and possible rebound of their edema.
SANDEEP GROVER, MD
MARSHA A. APUSHKIN, MD
GERALD A. FISHMAN, MD
1. Grover S, Apushkin MA, Fishman GA. Topical dorzolamide
for the treatment of cystoid macular edema in patients with
retinitis pigmentosa. Am J Ophthalmol 2006;141:850 – 858.
2. Weiner JM. Diuretics and other agents employed in the
mobilization of edema ﬂuid. In: Gilman AG, Rall TW, Nies
AS, Taylor P, editors. The pharmacological basis of therapeu-
tics. 8th ed. New York: MacMillan Publishing Co. Inc,
3. Kass MA, Kolker AE, Gordon M, et al. Acetazolamide and
urolithiasis. Ophthalmology 1981;88:261–265.
Bilateral Lateral Rectus Recession
vs Unilateral Recess-Resect
Procedure for Exotropia With a
THE PURPOSE OF THE STUDY BY JEOUNG AND ASSOCIATES
was to compare surgical outcomes of bilateral lateral rectus
(BLR) recession with unilateral recess-resect (RR) on the
nondominant eye for intermittent or constant exotropia.
Not many papers had shown such good semiology to
determine distance and near deviation. However, the
authors did not analyze the main concern regarding exo-
tropia surgery: the instability of surgical results, what
increases late recurrences.
It would be important to
know the progression of deviation changes in each group
after the ﬁrst day, ﬁrst week, ﬁrst month, and six months
post surgery. Comparing the mean deviation change of
both groups at six months would help to indicate better the
most beneﬁcial procedure.
In 1982, we started studying the instability of surgical
results in exotropia. We observed that most patients
showed an exo imbalance of the dominant eye under
general anesthesia. This ﬁnding, in theory, could explain
the increased frequency of late recurrences when the
dominant eye is not included in the surgical plan. Ratio-
nally, if the mechanical exo imbalance of the ﬁxing eye is
not corrected, it can act as a fuel which increases the exo
imbalance of the nondominant eye. Only a good fusion
would help it from happening. This observation was also
veriﬁed by Jampolsky.
There is literature agreement with
these considerations: a systematic review of longer follow
ups indicates that BLR recession provides better than or
the same results as unilateral RR for basic and simulated
divergence excess exotropia.
The last Cochrane review
also indicates that bilateral surgery may be the most
effective surgical procedure for intermittent exotropia.
In summary, we believe that the conclusion reached by
Jeoung and associates,
favoring unilateral procedure,
might change if the mean deviation changes at six months
after surgery would be compared between the groups.
EDSON PROCIANOY, MD, P
LETICIA PROCIANOY, MD
Porto Alegre, Brazil