ACTA OPHTHALMOLOGICA SCANDINAVICA 2004

Acupuncture treatment in
patients with keratoconjunctivitis
sicca: a pilot study
Marita Andersson Grönlund,1 Ulf Stenevi1 and Thomas
Lundeberg2
1
Institute of Clinical Neuroscience, Section of Ophthalmology, Sahlgrenska Academy
at Gothenburg University, Gothenburg, Sweden
2
Department of Physiology II, Karolinska Institute, Stockholm, Sweden

ABSTRACT.
Aim: To evaluate the effects of acupuncture in patients with keratoconjunctivitis dry eye tests such as: tear break-up
sicca (KCS). time (BUT), indicating tear quality; the
Material and Methods: Twenty-five patients (20 women, five men) with KCS Schirmer-1 test (S1T), indicating tear
were randomly assigned to an acupuncture treatment group or a control group. production, and Rose-Bengal staining
The effects of acupuncture were evaluated by a questionnaire on symptoms, visual (RBS), indicating ocular surface disease
analogue scale recordings, registration of drop frequency, and dry eye tests. Ten (Paschides et al. 1989; Prause 1989;
acupuncture sessions were given. Follow-up was carried out after 2–3 weeks Klaassen-Broekema et al. 1992).
and again after a mean period of 8 months. Sjögren’s syndrome is an auto-
Results: Patients receiving acupuncture felt better at the first follow-up com- immune disease of unknown origin,
characterized by lymphocyte infiltra-
pared with the control group (p ¼ 0.036). However, no statistical significance
tion of exocrine glands and occurrence
could be found concerning any change, or difference, in the total number of
of auto-antibodies such as rheumatoid
subjective symptoms, dosage frequency or, as indicated by the dry eye tests, factor (RF), antinuclear antibodies
tear quality, tear secretion and ocular surface disease. (ANA), and SS-A and SS-B antibodies.
Conclusion: The results indicate that acupuncture has subjective beneficial The term ‘primary SS’ is used when the
effects in patients with KCS and could therefore be tried as a complement to simultaneous presence of xerostomia
ordinary treatment. and KCS are found. ‘Secondary SS’
is defined as KCS and/or xerostomia in
Key words: acupuncture – dry eye – keratoconjunctivitis sicca (KCS) – sensory nerve stimulation – association with another chronic inflam-
Sjögren’s syndrome (SS) matory connective tissue disease (e.g.
rheumatoid arthritis (RA), systemic
Acta Ophthalmol. Scand. 2004: 82: 283–290 lupus erythematosus (SLE), scleroderma
Copyright # Acta Ophthalmol Scand 2004. or polymyositis) (Manthorpe et al. 1986;
Kroneld et al. 1997). Worldwide, several
doi: 10.1111/j.1600-0420.2004.00254.x different systems of classification criteria
for SS are in use (Fox & Saito 1994;
Vitali et al. 1996).
deficiency dry eye (TDDE) and evap- The conventional treatment for KCS
Introduction orative dry eye (EDE). Tear deficiency today is symptomatic. Replacement
Keratoconjunctivitis sicca (KCS), the dry eye is again sub-divided into therapy consists of lubricating oint-
symptoms of which include foreign Sjögren’s syndrome (SS) tear deficiency, ments, ocular inserts and different
body sensation, burning, itching, red- which is immune, and non-Sjögren’s tear types of artificial tear drops with differ-
ness, photophobia and blurred vision, deficiency, which is non-immune (Lemp ent degrees of viscosity, ocular surface
can be caused by various diseases and 1995). Decreased tear production, affinity, and tonicity and toxicity levels
by disorders of the eye and eye-related decreased tear quality and damage to (Adams et al. 1992; Friedlaender 1992;
conditions (Lemp 1995). Keratocon- the ocular surface are seen in patients Grene et al. 1992; van Bijsterveld & van
junctivitis sicca, or dry eye, may be with KCS. Diagnosis is established by Hemel 1992; Ubels et al. 1995; Marner
divided into two major classes: tear history and clinical findings, including et al. 1996). Anti-inflammatory therapy

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ACTA OPHTHALMOLOGICA SCANDINAVICA 2004
(Laibovitz et al. 1993; Marsh &
Pflugfelder 1999; Sall et al. 2000), reti-
noid ointment (Gilbard et al. 1989), tear
stimulants (bromhexine) and adhesive
glycoproteins such as topical fibronectin
(Nelson et al. 1992) have been tried with
varying results. The humidity of the eye
may be preserved by punctal occlusion
(Vrabec et al. 1993; Friedlaender & Fox
1998; Tananuvat et al. 2001; Goto et al.
2003). Bandage contact lenses as well as
surgical procedures such as micro-
vascular submandibular gland transfer
(Macleod et al. 1990; Kumar et al. 1991)
and autologous serum drops combined
with or without corneal epithelial
stem-cell transplantation to treat severe
dry eyes (Tsubota et al. 1996; Tai et al.
2002) have also been tried. Unfortu-
nately, many of these treatments of
KCS are not sufficiently effective in all
patients and give only short-term relief.
In SS patients treated for xerostomia
with acupuncture Blom et al. (1992)
found some positive subjective results
regarding eye symptoms; however, the
effects were not measured qualitatively
or quantitatively. The aim of the pre-
sent study was to evaluate objective
and subjective effects of sensory nerve
stimulation (acupuncture) in patients
with KCS.
Material and Methods
A prospective, randomized study was
performed to compare patients with
KCS undergoing acupuncture treatment
as a complement to ordinary artificial
tear drops with patients receiving tear
substitutes only. Twenty-five patients
with KCS, 20 women and five men,
aged between 31 and 79 years (mean
56 years), were included in the study.
The patients were randomly assigned
to an acupuncture treatment group
(n ¼ 12) or a control group (n ¼ 13).
Medical history and medication
intake were recorded, as were pre-
viously performed measurements of
unstimulated salivary flow and salivary
gland biopsy results. Unstimulated
whole sialometry 1.5 ml/15 minutes
was considered abnormal and lower
lip biopsy showing focal sialoadenitis
with a focus score of lymphoplasmo-
cytic infiltrates >1 was regarded as
positive for SS. The subjective and
objective effects were evaluated by a
detailed ophthalmological examination
and included the following:
284
(1) A validated questionnaire based
upon Workshop’s achievements (1989)
and the results of the European
multicentre study by Vitali et al. (1993),
dealing with subjective symptoms such
as dryness (>3 months), foreign body
sensation, burning eyes, intolerance to
smoke, drafts and light, redness of eyes,
disturbed vision, sticky secretion and
increased tear flow when peeling onions.
(2) A visual analogue scale (VAS)
recording showing the degree of
discomfort in the eyes translated into
‘better’, ‘no change’ or ‘worse’.
(3) The dosage frequency of any tear
substitute used.
(4) Dry eye tests, for evaluating tear
quality, tear production (quantity) and
ocular surface, performed in the follow-
ing order, according to Workshop’s
achievements (1989): after installing
2.5 ml of 1% fluorescein, the tear film
stability (i.e. the BUT) was measured
by examining the patient with a slit-
lamp using cobalt blue light. The BUT
is defined as the time (in seconds) after
a complete blink for dry spots to
become visible on the cornea. A mean
of three measurements of each eye was
recorded (cut-off value 10 seconds).
The S1T, measuring tear production
over a period of 5 minutes, was per-
formed without local anaesthesia and
with the eyes closed. Finally, after
instilling 2.5 ml of 1% Rose-Bengal
solution, staining devitalized cells,
RBS was recorded according to a
method described by van Bijsterveld
(1969). A maximum total score of 9
was given, with 1–3 points for each of
three sections of the eye: the cornea,
and the lateral and nasal parts of the
bulbar conjunctiva.
Visual acuity (VA) tests, slit-lamp
examination and ophthalmoscopy were
also performed. According to the
Copenhagen criteria (Manthorpe et al.
1986), KCS was diagnosed when at least
two of the following criteria were met:
BUT  10 seconds; S1T  10 mm/5 min-
utes, or RBS  4. These criteria were
generally used for the diagnosis of
KCS in Sweden when this study began.
Before starting the acupuncture
treatment, the patients were informed
about the possibility of any side-effects,
such as tiredness, drowsiness, a fall in
blood pressure of short duration and
haemorrhage at the place of insertion
of the needles. Patients who had
received acupuncture for any reason at
any time during the year prior to the
beginning of this study were excluded.
Each patient in the acupuncture treat-
ment group received 10 acupuncture
sessions of 30 minutes each, once to
twice per week. The needles were placed
bilaterally at the following acupuncture
points selected according to traditional
Chinese medicine (Liangyue et al. 1987):
ST2, ST8, ST36, GB1, GB14, BL2 and
LI4, as shown in Fig. 1. Manual
stimulation was used, initially and
after 10, 20 and 30 minutes. All patients
were treated by the same doctor/
acupuncturist (MAG). Possible side-
effects were registered.
The dry eye tests were also per-
formed before and after acupuncture
sessions 2 and 8. Follow-up was carried
out 2–3 weeks after completing the
acupuncture treatment (follow-up 1)
and again after a mean period of
8 months (range 3–12 months) (follow-
up 2). The control group underwent the
same examinations over a correspond-
ing period of time. Figure 2 shows a
flow chart of the study design.
The study was approved by the
ethical committee at the University of
Gothenburg. Informed consent was
obtained from the patients participat-
ing in the study.
Statistical analyses
Fisher’s exact test and repeated
measures analysis of variance (ANOVA)
for testing hypotheses between groups
as well as between-subject effects
and within-subject effects were used
for statistical analyses. Test results
were considered to be significant if
p < 0.05.
Results
In the acupuncture group two patients
were discontinued from the study for
reasons unrelated to the acupuncture
treatment. In the control group one
patient did not fulfil the criteria for
the diagnosis of KCS at the initial
examination, one patient did not attend
the follow-up examination and one
patient dropped out of the study
because of intolerance to the dry eye
tests. Table 1 shows the composition
of the acupuncture treatment group
and the control group in terms of sex,
mean age, KCS classification, and
results of previously performed meas-
urements of unstimulated salivary flow
 ACTA OPHTHALMOLOGICA SCANDINAVICA 2004

Fig. 1. Location of the acupuncture points used in the study. ST2 (Sibai): in the depression at the infra-orbital foramen. With the patient looking
straight ahead, the pupil and ST2 are on the same vertical line. ST8 (Touwei): 3.5 cun (five fingers) above the supra-orbital ridge, 4.5 cun (six fingers)
lateral to the middle line. The point is located in the sulcus coronalis at the upper border of the media temporalis. ST36 (Zusanli): 3 cun (four fingers)
below the apex patellae, one finger’s width lateral to the crista anterior tibiae. GB1 (Tongziliao): lateral to the outer canthus, in the depression on the
lateral side of the orbit. GB14 (Yangbai): 1 cun (one thumb’s width) above the supra-orbital ridge. With the patient looking straight ahead GB14, ST2
and the pupil are on the same vertical line. BL2 (Zanzhu): at the nasal end of the eyebrow, on the supra-orbital notch. LI4 (Hegu): between the first
and second metacarpal bones, approximately in the middle of the second metacarpal bone on the radial side, on the highest point of margo interosseus
dorsalis when the thumb is adducted. The needles were placed bilaterally.

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ACTA OPHTHALMOLOGICA SCANDINAVICA 2004

KCS
(n=25)

Acupuncture treatment group Control group

(n=12) (n=13)

Drop-out Ophthalmologic examination Drop-out Ophthalmologic examination

n=1 n=1

Acupuncture 1 Ophthalmologic examination

Follow-up I

Dry eye tests

Drop-out
n=1

Acupuncture 2
Ophthalmologic examination
Follow-up II
Dry eye tests
(n=10)

Drop-out Acupuncture 3
n=1

Acpuncture 4

Acupuncture 5

Acupuncture 6

Acupuncture 7

Dry eye tests

Acupuncture 8

Dry eye tests

Acupuncture 9

Acupuncture 10

2 to 3 weeks

Ophthalmologic examination
Follow-up I

Mean 8 months

Ophthalmologic examination
Follow-up II
(n=10)

Fig. 2. Flow chart showing study design for 25 KCS patients randomly assigned to an acupuncture treatment group or to a control group.

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 ACTA OPHTHALMOLOGICA SCANDINAVICA 2004

Table 1. Composition of the study population with KCS who completed the study in the treatment group noted that they had felt
acupuncture treatment group and the control group, with regard to sex, mean age, classification of better for about 4 months after complet-
KCS, unstimulated salivary flow and salivary gland biopsy results. ing the acupuncture treatment but that
after this period the positive effect had
Characteristics Acupuncture treatment Control
group n ¼ 10 group n ¼ 10 declined.
The mean score of frequency of eye-
Mean age year (range) 61 (38–79) 57 (31–75) drop use at baseline and at follow-ups 1
Sex F/M 9/1 8/2 and 2 is shown in Table 4. No statistic-
KCS classification ally significant difference could be
1 SS 3 3
found between the groups.
2 SS 5 5
Dry eye not associated with SS 2 2
When evaluating the results of the
Unstimulated salivary flow dry eye tests, we compared the results
Low 7 5 for right eyes at baseline with those for
Normal 1 4 right eyes at different time-points, as
Not performed 2 1 well as between groups. Likewise,
Salivary gland biopsy results for left eyes at baseline were
SS 3 3 compared with results for left eyes at
Not SS 4 3
different time-points and between
Not performed 3 4
groups. A comparison between the
SS ¼ Sjögren’s syndrome; 1 SS ¼ primary Sjögren’s syndrome; 2 SS ¼ secondary Sjögren’s syndrome. two groups revealed that acupuncture
was no more effective than receiving a
tear substitute in increasing tear qual-
and salivary gland biopsy results in the examination only one patient in the ity, as indicated by the BUT, in increas-
two groups of patients. acupuncture treatment group reported ing tear secretion, as indicated by the
The results of the questionnaire on symptoms of red eyes, compared with S1T, or in decreasing ocular surface
subjective symptoms are presented in six patients in the control group. How- disease, as indicated by RBS. However,
Table 2. At the initial examination all ever, no statistical significance was seen the S1T showed a statistically significant
of the patients had experienced dryness in the change in the total number of positive effect for left, but not right, eyes
of the eyes for more than 3 months. subjective symptoms either within or over time (p ¼ 0.0131) (Table 4). No
The second most frequent symptom between the groups (Table 3). statistically significant change could be
was ‘foreign body sensation’ (n ¼ 16; According to the VAS recordings, six found concerning the measurements of
acupuncture group: 8; control group: 8). patients in the acupuncture treatment the dry eye tests just before and after
At the first follow-up examination group felt better after finishing the treat- acupuncture sessions 2 and 8.
only four patients in the acupuncture ment and no one felt worse. In the con- No adverse effects of the acupunc-
group reported foreign body sensation, trol group no patient felt better and two ture treatment per se were noted.
compared with nine patients in the con- patients felt worse over the same period
trol group. The symptom of red eyes of time (p ¼ 0.036) (Fig. 3). However, at
was seen in 12 patients (acupuncture follow-up 2, there was no statistic-
group: 6; control group: 6) before the ally significant difference between the
start of the study. At the first follow-up groups. Two patients in the acupuncture Discussion
Based on the patients’ subjective
Table 2. Number of patients with KCS in the acupuncture treatment group recording subjective recordings, we found that in this study
symptoms in the questionnaire, compared with controls at baseline and follow-ups 1 and 2. sensory nerve stimulation had benefi-
cial effects on patients with KCS
Subjective symptoms (Fig. 3). According to Lemp (1995),
Baseline Follow-up 1 Follow-up 2 the best way to evaluate clinical efficacy
may be to observe symptoms and func-
ATG CG ATG CG ATG CG tional lifestyle in patients with KCS by
n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 using a validated questionnaire because
n n n n n n clinical findings and subjective symp-
Dryness >3 months 10 10 10 10 10 10
toms do not always correlate with one
Foreign body sensation 8 8 4 9 6 9 another. However, it should be noted
Burning sensation 8 5 4 8 3 6 that subjective measures are more
Intolerance to smoke 7 6 4 5 7 8 susceptible to certain kinds of bias
Intolerance to drafts 6 6 4 6 5 7 (Vincent & Richardson 1986). The find-
Intolerance to light 7 7 7 8 8 7 ings in the current report differ from
Redness 6 6 1 6 3 6 those obtained in a previous study by
Disturbed vision 7 6 4 4 4 6
Nepp et al. (1998), who found acupunc-
Sticky sensation 2 6 3 4 4 6
Increased tear flow ture to have an objective effect when
when peeling onions 4 8 2 6 4 8 treating KCS, based on BUT and S1T
results as well as on dosage frequency
ATG ¼ acupuncture treatment group; CG ¼ control group. of artificial tears.

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ACTA OPHTHALMOLOGICA SCANDINAVICA 2004

Table 3. Mean score of frequency of eyedrop use and total number of subjective symptoms, treatment. However, any placebo effects
according to the questionnaire in the two groups at baseline and at follow-ups 1 and 2. of the manipulation per se cannot be
excluded. Moreover, Bjerrum (1996)
Mean score (range)
reported that the signs of KCS changed
Baseline Follow-up 1 Follow-up 2 from one ocular examination to another
in as many as 21% of eyes in patients
ATG CG ATG CG ATG CG with primary SS, which also confirms
n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 the difficulties in evaluating clinical
n n n n n n findings using acupuncture, particularly
Frequency of eyedrop use 2.4 2.3 3.3 3.9 1.6 3.8 in patients with KCS.
(0–10) (0–8) (0–15) (0–10) (0–5) (0–10) The participants in the present study
Total number of 6.5 6.8 4.7 6.6 5.7 7.3 were predominantly women. Their
subjective symptoms (2–10) (3–10) (2–8)* (4–9) (3–8) (3–10)* mean age was 56 years. According to
Talal (1986), primary SS occurs nearly
ATG ¼ acupuncture treatment group; CG ¼ control group; * n ¼ 9. 10 times more frequently in women
than in men. Bjerrum (1997) found
Evaluating the clinical effects of acu- (1986) have pointed out that some that KCS was most common in persons
puncture is not easy, especially in a standardization of the acupuncture aged 50–59 years but increased equally
group of patients with KCS. It is almost treatment procedures in a study is with age in men and women.
impossible to construct a double-blind desirable for research purposes. The pre- In the present study KCS was diag-
trial involving sensory nerve stimulation sent study was designed as a two-group, nosed using the Copenhagen criteria
(Vincent & Richardson 1986) and randomized, prospective study, where (Manthorpe et al. 1986), which were
cross-over studies may be inappropriate one group received a standardization of the criteria used in our clinic at the
because of possible longterm effects acupuncture treatment as a complement time the study was initiated. Bjerrum
(Lewith & Machin 1983). A single two- to their ordinary treatment of artificial (1996) suggested modifying the
group, randomized, prospective trial has drops and the other group, the control Copenhagen criteria by changing the
been proposed by Lewith & Machin group, received only their usual cut-off value of the S1T from 10 mm/
(1983) and Vincent & Richardson eyedrops without any other form of minute to 5 mm/minute, which is the
criterion used in our clinic today. If
8 we had used the modified Copenhagen
criteria at the time of diagnosis, all but
one patient (in the control group)
would have been diagnosed as KCS
7 sufferers. According to the European
Acupuncture classification of Sjögren’s syndrome
treatment (Vitali et al. 1996), the diagnosis of
6 group (n=10) KCS is based on a S1T cut-off value
of 5 mm/5 minutes and/or RBS 4
points; however, in persons over the
5 Control group age of 60 years, S1T results should not
(n=10) be considered as tear production often
decreases with age. All of our patients,
4 both in the acupuncture treatment
group and in the control group,
fulfilled the European criteria.
The innervation and regulation of the
3 cornea, lacrimal glands and meibomian
glands as well as tear secretion and the
tear film is complex (Dartt 1994, 2001;
2 Walcott et al. 1994; Nelson 1998; Müller
et al. 2003). Both hormones, such as
androgens and prolactin, and neural
1 factors, such as encephalines, neuropep-
tide Y (NPY), substance P (SP), vaso-
active intestinal polypeptide (VIP) and
0 calcitonin gene-related peptide (CGRP),
Better No Worse are involved. Although acupuncture has
been used for more than 2000 years as a
change technique for pain relief and curing dif-
Fig. 3. Results of the visual analogue scale recordings translated into ‘better’, ‘no change’ or ferent types of diseases, its mechanism
‘worse’ at the first follow-up examination comparing the acupuncture treatment group with the of action is still not entirely known. So
control group (p ¼ 0.036). far, we know that acupuncture reacts at

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 ACTA OPHTHALMOLOGICA SCANDINAVICA 2004

Table 4. Mean score of dry eye tests in the two groups at baseline and at follow-ups 1 and 2.

Mean score (range)

Baseline Follow-up 1 Follow-up 2

ATG ATG CG CG ATG ATG CG CG ATG ATG CG CG

OD OS OD OS OD OS OD OS OD OS OD OS
n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 n¼9 n¼9 n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10 n ¼ 10

BUT 6.6 6.9 6.9 7.1 7.0 7.2 7.7 8.8 7.3 7.0 7.2 7.1
(3–10) (3–10) (3–10) (2–10) (4–10) (4–10) (3–10) (4–10) (4–10) (4–10) (4–10) (3–10)
S1T 5.2 6.2 6.2 3.6 6.1 6.6 4.6 4.0 6.2 7.7 6.8 5.1
(0–22) (0.5–25) (0–19) (0–10) (0–34) (0–14) (0–12) (0–10) (0–24) (1–25) (1–30) (1–22)
RBS 3.1 4.1 4.6 4.2 3.4 4.2 5.1 3.9 2.7 2.9 3.2 3.0
(2–6) (2–6) (4–6) (1–7) (2–6) (2–8) (3–8) (1–6) (0–6)* (1–8)* (2–6)* (0–8)*

ATG ¼ acupuncture treatment group; CG ¼ control group; OD ¼ right eye; OS ¼ left eye; BUT ¼ break-up time; S1T ¼ Schirmer-1 test; RBS ¼ Rose-
Bengal staining; * n ¼ 9.

local, regional (spinal cord), and general
(brain) levels (Han & Terenius 1982;
Andersson 1992; Karavis 1997a,
1997b). One possible cause of the relief
achieved in these patients with KCS
might be a corneal pain-relieving effect
by the acupuncture treatment. Several
neuropeptides and neurotransmitters,
such as SP, CGRP, norepinephrine and
met-encephalin, function as stimulators
of corneal wound healing (Müller et al.
2003). Previous reports have shown that
acupuncture may affect the circulatory
system (Jansen et al. 1989a, 1989b) and
the immune system (Lundeberg et al.
1988, 1991; Lundeberg 1993) by acti-
vation of the autonomic nervous system.
Sensory nerve stimulation may give rise
to vasodilatation by releasing CGRP,
which also acts as an endogenous anti-
inflammatory factor. Acupuncture has
been shown to induce an increase in sal-
ivary flow and local blood flux in
patients with xerostomia caused by
Sjögren’s syndrome (Blom et al. 1992,
1993). The effects of sensory nerve stimu-
lation on salivary secretion and blood
flow are probably related to the release
of vasodilatory neuropeptides such as
VIP, NPY and CGRP (Lundeberg
1993; Dawidson et al. 1998a, 1998b).
In conclusion, although based on a
small number of patients, our results
indicate that sensory nerve stimulation
has subjective beneficial effects in
patients with KCS and therefore could
be tried as a complement to ordinary
treatment. However, further studies will
have to be performed to better determine
the mechanism of acupuncture in KCS
patients. Measuring different kinds of
neurotransmitters, neuropeptides and
anti-inflammatory components in the
tear film under the influence of sensory
nerve stimulation would be of great
interest, as neural factors are involved
in the innervation of the lacrimal glands
and cornea and in the regulation of tear
secretion.
Acknowledgements
This study was supported by grants from
the Gothenburg Medical Society and the
Medical Faculty of the University of
Gothenburg (LUA).
The results of this study were presented at
the annual meeting of the Swedish Ophthal-
mology Society, in Västerås, Sweden and at
the 100-year anniversary of Henrik Sjögren,
in Jönköping, Sweden, both in 1999.
The authors gratefully acknowledge Nibia
Aires of the Biostatistics Branch, Depart-
ment of Mathematics, Chalmers University
of Technology, Gothenburg, for her help
with the statistical analyses, and Anna-
Karin Larsson for taking photographs.
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Received on August 7th, 2003.
Accepted on January 23rd, 2004.
Correspondence:
Marita Andersson Grönlund MD
Department of Paediatric Ophthalmology
Queen Silvia’s Children’s Hospital
Sahlgrenska University Hospital/East
SE 416 85 Gothenburg
Sweden
Tel: þ 46 31 34 35 843
Fax: þ 46 31 84 89 52
Email: marita.gronlund@oft.gu.se