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Editors Selection IGR 9-4

Clinical Forms of Glaucoma: Echocardiography in PES

Comment by Josef Flammer on:

46383 Assessment of myocardial ischaemia using tissue Doppler imaging in pseudoexfoliation syndrome, Demir N; Ulus T; Yucel OE et al., Eye, 2011; 25: 1177-1180

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This is an interesting study, linking pseudoexfoliation syndrome (32 patients) with echocardiographically (tissue Doppler) traceable changes in heart function. With tissue Doppler, velocities of moving tissue at certain points can be assessed allowing the detection of subtle changes of systolic as well as diastolic heart function. With this study by Demir et al. (1429) the authors demonstrate a significant reduction in systolic velocities at the level of the septal, lateral, anterior and inferior mitral anulus compared to an age and sex-matched control population. Whereas these results are certainly of interest, the conclusion that there 'may be an association between pseudoexfoliation syndrome and subclinical myocardial ischemia' and 'that ophthalmologists should consider informing their patient's general practitioners about a possible cardiac risk' might be exaggerated in the context of this study. Several limitations have to be taken into account: The fact that a slight reduction in systolic velocities has been detected does not automatically imply (subclinical) myocardial ischemia. Furthermore, no information whether the study was performed operator-blinded is given in the manuscript, a condition which is crucial for the validity of the results, especially because the method is not very reproducible and the sample error (where in the tissue does the operator place the Doppler probe) is very high. Another intriguing point is the fact that although the systolic velocities were significantly reduced, global ejection fraction was not and, furthermore, subclinical ischemia is detected already at rest, a fact pointing towards a higher degree of ischemia. Thus for future studies it would be interesting to see whether an increase in energy demand (e.g., exercise) leads to a further decrease in systolic velocities. In conclusion, with this interesting finding the authors opened a challenging discussion whether pseudoexfoliation syndrome has an impact on myocardial function, but did not provide a clear answer. In the future other (blinded) studies with more validated methods are needed.

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