Letters to the Editor

the compromise made by taking the data for the body mass index and arterial hypertension from 2006 and for the retinal vein occlusion assessment from 2001, the results suggest that retinal vein occlusions in the Chinese examined in the Beijing Eye Study 2001 were associated with a high body mass index. It is in contrast to the Japanese Funagata Eye Study, in which subjects with a low body mass index had an increased prevalence of retinal vein occlusions. If future studies conrm the discrepancy in the association between retinal vein occlusions and body mass index between Japanese and Chinese and other populations, the questions arises, what are the reasons for it? One may speculate whether differences in the mean arterial blood pressure and its presumed associations with cerebrospinal uid pressure and intraocular pressure,13 in addition to possible differences in the anatomy and biophysical properties of the lamina cribrosa and peripapillary sclera between Japanese and other populations, may play a pathogenic role in the development of retinal vein occlusions. JOST JONAS, MD Mannheim, Germany LIANG XU, MD YA X. WANG, MD WEI W. LIU, MD Beijing, China
References 1. Mitchell P, Lee AJ, Wang JJ, Rochtchina E. Intraocular pressure over the clinical range of blood pressure: Blue Mountains Eye Study ndings. Am J Ophthalmol 2005;140:1312. 2. Klein BE, Klein R, Knudtson MD. Intraocular pressure and systemic blood pressure: longitudinal perspective: the Beaver Dam Eye Study. Br J Ophthalmol 2005;89:284 7. 3. Xu L, Wang H, Wang Y, Jonas JB. Intraocular pressure correlated with arterial blood pressure. The Beijing Eye Study. Am J Ophthalmol 2007;144:4612. References 1. Mandel Y, Grotto I, El-Yaniv R, et al. Season of birth, natural light, and myopia. Ophthalmology 2008;115:686 92. 2. Legault L, Green-Demers I, Pelletier L. Why do high school students lack motivation in the classroom? Toward an understanding of academic amotivation and the role of social support. J Educ Psychol 2006;98:567 82. 3. Bobak M, Gjonca A. The seasonality of life birth is strongly inuenced by socio-demographic factors. Hum Reprod 2001; 16:15127.

Bobak and Gjonca3 found that among mothers with higher education level there were 30% more births in March to May than in October to December in the Czech Republic. In our own yet unpublished study, we found similar trends in Tunisia, where the photoperiod is comparable to that in Israel. Odds of being born to a family of high ESCS between April and June is 1.248 (P 0.007, N 3168). Thus, the effect of season on the development of myopia can be mediated by the academic effort of the children, inuenced by parents ESCS. Unfortunately, such data are not available in Mandel et al.1 Mandel et al used data on siblings refractive states in the logistic regression analysis to attempt to distinguish familial effects and found that the model remained almost exactly as reported. Unfortunately, levels of signicance were not given for the modied model. Considering the geater condence intervals and smaller samples for the sibling data compared with the original analysis, it is very likely that the odds ratio is signicant, if at all, only for subjects born in the longest photoperiod category. As their nding of the possible effect of season of birth on the development of myopia is important, clarication of the issue would be useful. Whether the seasonal effect is mediated by the duration or the intensity of light exposure at this very early age remains to be seen. PETER KABAI, PHD JOZSEF BAKK, MSC Budapest, Hungary

Myopia Risk Factors

Dear Editor: Mandel et al1 found that being born in summer and education level independently increase the odds of developing myopia. There are several possible explanations for such ndings. First of all, education level expressed as years in school in their sample, in which the mean age was 17.3 years, with half a year of standard deviation, might correspond to age, rather than true academic achievement. As age alone is a risk factor for developing myopia, age should have been included in their model as a possible confounding factor. Second, as the potential educational achievement of the subjects is not known, their present educational effort (time spent reading, writing, looking at a computer monitor, etc.) inuencing myopia cannot be evaluated. Third, academic effort of children is known to be inuenced by the economic, social, and cultural status (ESCS) of their parents.2 Although the relation between ESCS of the family and seasonality of birth has not received much research attention, the few studies on this issue indicate that season of birth is biased by the ESCS of parents. For example,

Author reply Dear Editor: We have read Kabai and Bakks letter with careful attention and will try to address their criticisms. Although age is a risk factor for myopia, it is unlikely that age was a confounding factor in our analysis, because the largest difference in mean age between any 2 of the photoperiod categories was 27 days (unreported data). Nevertheless, in light of the criticism we carried out an additional analysis in which we added age as an independent variable to the other 4 risk factors reported in our article (photoperiod, gender, education, origin). The results showed that photoperiods odds ratios (ORs) were not affected by the addition of age as a risk factor. For example, ORs for high myopia were 1.09 (95% condence interval [CI], 1.021.17), 1.11 (1.04 1.19), and 1.237 (1.151.33) for photoperiod categories 2, 3, and 4, respectively. These ORs are identical to those we obtained with a model that did not include age. The analysis also showed that there was no interaction between age and photoperiod category in our

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model. Nevertheless, age was indeed found to be a strong risk factor for myopia in our subjects. This can be partially explained by selection bias, because subjects who were examined for army service at a later age than 16 to 18 years had different socioeconomic and educational characteristics. With regard to the effect of parental economic, social, and cultural status, we addressed the possibility that familial factors can serve as confounders because they might be associated both with myopia and with birth seasonality. This was done in two ways, which are broadly discussed in our article. In the rst analysis, we added siblings refractive state to the other 4 independent variables to control for familial effect. This analysis yielded ORs for the photoperiod similar to those obtained in the original analysis. The effect was statistically signicant for photoperiods 3 and 4 relative to photoperiod 1, the shortest (a 95% CI for an OR that does not include 1 is considered statistically signicant, and there is thus no need to report the P value). In the second analysis, we substituted the photoperiod of the siblings for that of the subjects and found that the association between photoperiod and myopia prevalence disappeared. If family planning was indeed a confounding factor for the association between photoperiod and myopia prevalence, siblings photoperiod should have been identiable as a risk factor. In conclusion, our results do not support familial factors as possible confounding factors, whereas at the same time they do not provide evidence for causality between earlylife light exposure and myopia. Further studies are needed to acquire such evidence for an association between the season of birth, light, and myopia. YOSSI MANDEL, MD, MHA Jerusalem, Israel URI POLAT, PHD MICHAEL BELKIN, MD, MS Ramat Gan, Israel ITAMAR GROTTO, MD, MPH Beer Sheva, Israel ities but minimal visual improvement. However, the main purpose of this surgery may not be to restore damage already present but to prevent additional secondary retinal damage by delaying or halting the progression of macular anatomical changes.1,3 The main problem in patient selection is that most X-linked juvenile retinoschisis patients show nonprogressive disease progression, with variable visual prognosis.4,5 Thus, it is difcult to predict visual prognosis in each individual X-linked juvenile retinoschisis patient, and no factors have been identied that predict visual outcome. Even foveal thickness and macular area of cystic changes in OCT did not correlate with visual acuity (VA).6 Foveal retinoschisis is not always related to the sudden decrement of VA, and it may sometimes resolve spontaneously. Visual loss usually occurs during the rst decade of life, with VA reported to stabilize after puberty.4,5 The report by Ikeda et al did not provide any detailed information about preoperative history.1 It is especially interesting that patient 1 was 26 years old, which is old enough to be visually stabilized. This report therefore did not provide a sufcient rationale for performing vitrectomy in patients old enough to be stabilized. In our previous report, we selected relatively younger patients, who were likely to be still experiencing deterioration, as well as patients who recently developed macular retinoschisis with some visual decrement.3 Use of a gas tamponade in macular hole surgery is expected to block uid passage through the macular hole, as well as provide the buoyant force that pushes the retina against the pigment epithelium. The buoyant effect of gas, however, may not always be needed in retinoschisis surgery, especially in patients with newly developed retinoschisis with no denite retinal tissue defect. Vitreous tractional force in eyes with retinoschisis is not much higher than that in age-matched normal eyes. Weak adhesion between retinal layers may yield to relatively smaller tractional forces and result in separation of the retina. In our previous report, we intended only to remove vitreous tractional forces without the aid of buoyant force in one patient, but retinoschisis resolved immediately after vitrectomy without gas injection.3 We hypothesized that the retina could be restored by intraocular pressure and retinal ow resistance. Separation of retinal layers in foveal retinoschisis is thought to take place usually within inner nuclear layers.6 The inner layer of retinoschisis may include the inner plexiform layer, a high-resistance barrier to uid ow through the retina.6,7 In addition, there may be a recoiling effect between retinal layers. Due to the relatively young age of these patients, gas injection has many potential risks, including aggravating the cataract. Moreover, it is very difcult to keep young patients in a facedown position. We therefore regard this as a rationale for initially performing vitrectomy without gas injection. If there is no improvement of retinoschisis after vitrectomy, however, pure gas injection can be used as an adjuvant. This management technique should be evaluated with caution, however, because of considerable potential risks and uncertain potential benets. Further studies, including early surgery before the development of secondary neural degeneration and long-term follow-up results, are necessary

X-Linked Retinoschisis
Dear Editor: We read with interest the article by Ikeda et al describing the resolution of retinoschisis after vitrectomy in patients with X-linked juvenile retinoschisis.1 We agree that a vitreous tractional element may contribute to the development and progression of foveal retinoschisis in X-linked juvenile retinoschisis. Wide phenotypic variation in X-linked juvenile retinoschisis patients, even in members of the same family, suggests that factors other than genetic mutation may be involved in the macular manifestations of this disease.2 Previously, we also reported the resolution of retinoschisis after the removal of the internal limiting membrane in 2 X-linked juvenile retinoschisis patients.3 Considering the relatively lower patient age and the potential complications related to vitrectomy, patient selection for such surgery is very important. In both reports, vitrectomy resulted in the restoration of anatomic abnormal-

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