VOLUME 89 - ISSUE 5

PURPOSE: To evaluate the agreement between optic nerve head structural parameters obtained using swept-source optical coherence tomography and the Laguna ONhE software.
METHODS: This retrospective cross-sectional study included 353 eyes from healthy individuals, glaucoma suspects, ocular hypertensive patients, and patients with glaucoma. Optic nerve head parameters — including disc area, vertical and area cup-to-disc ratios, and rim volume — were measured using swept-source optical coherence tomography and Laguna ONhE. Agreement between methods was assessed using Bland–Altman analysis. A regression-based calibration model was developed for disc area measurements.
RESULTS: Laguna ONhE systematically underestimated disc area (p < 0.001) and cup-to-disc ratios (p<0.001) and overestimated rim volume (p=0.0002) compared with swept-source optical coherence tomography. After applying the calibration equation for disc area, agreement improved substantially, with no statistically significant bias (p=0.3).
CONCLUSION: Laguna ONhE provides structural estimates comparable with those obtained with swept-source optical coherence tomography after calibration, suggesting it may serve as a practical and cost-effective alternative for glaucoma evaluation.

Keywords: Glaucoma; Optic nerve head; Laguna ONhE; Optical coherence tomography; Agreement

PURPOSE: This study aimed to evaluate the serum levels of thrombospondin-1, growth differentiation factor-15, resolvin D1, and resolvin E1 in patients with keratoconus.
METHODS: Thirty-five patients with keratoconus and 35 control subjects of similar age and sex were evaluated. The keratoconus group was divided into four stages according to the modified Krumeich classification. Commercial kits were used to determine thrombospondin-1, growth differentiation factor-15, resolvin D1, and resolvin E1 levels in serum samples using enzyme-linked immunosorbent assay (ELISA). Serum thrombospondin-1, growth differentiation factor-15, resolvin D1, and resolvin E1 levels were compared between the patient and control groups.
RESULTS: The keratoconus group consisted of 14 females and 21 males, and the control group consisted of 14 females and 21 males, with mean ages of 29.4±8.8 and 30.0±7.8 yr, respectively. There were significant differences in serum thrombospondin-1, growth differentiation factor-15, resolvin D1, and resolvin E1 levels between the serum of the keratoconus and control groups (p=0.006, p<0.001, p<0.001, and p=0.001, respectively). No significant correlations were found between keratoconus stage and serum thrombospondin-1, growth differentiation factor-15, resolvin D1 and resolvin E1 levels (r=−0.025, p=0.892; r=−0.019, p=0.913; r=−0.036, p=0.838; and r=−0.108, p=0.538, respectively).
CONCLUSION: Serum levels of thrombospondin-1, growth differentiation factor-15, resolvin D1, and resolvin E1 were significantly lower in patients with keratoconus. These results suggest that these parameters may be associated with the pathogenesis of keratoconus.

Keywords: Keratoconus/pathology; Thrombospondin 1/blood; Growth differentiation factor 15/blood; Docosahexaenoic acids/blood; Eicosapentaenoic acid/blood; Inflammation mediators

PURPOSE: To determine the indications and epidemiological characteristics of corneal transplant recipients at a referral center in Amazonas, Brazil, and to evaluate postoperative visual outcomes.
METHODS: This retrospective, descriptive, observational study included adult patients who underwent corneal transplantation performed by a single surgeon at the Instituto de Oftalmologia de Manaus between 2013 and 2023. Demographic characteristics, occupation, comorbidities, surgical indications, graft type, and best-corrected visual acuity at baseline and 12 months postoperatively were analyzed.
RESULTS: A total of 413 corneal transplantations were performed, predominantly in male patients (64.4%) aged 41–70 years (43.3%). Leucoma was the most common indication (26.2%), followed by perforated corneal ulcers (21.1%), bullous keratopathy (17.9%), and keratoconus (10.7%). Penetrating keratoplasty accounted for 94.9% of all procedures. Optical keratoplasty was the most frequently performed procedure (76.3%), followed by tectonic (22.0%) and therapeutic (1.7%) keratoplasty. At 12 months postoperatively, visual improvement was greatest among patients who underwent optical keratoplasty, particularly those with keratoconus, bullous keratopathy, and leucoma. Functional vision (≤0.3 logMAR) was achieved in 32.6% of eyes overall and in 40.3% of eyes that underwent optical keratoplasty. The number of transplantations declined after 2019, coinciding with the COVID-19 pandemic.
CONCLUSIONS: This study represents the largest retrospective series of corneal transplantations in Amazonas and one of the few such studies from Northern Brazil. The predominance of leucoma and infectious corneal perforation reflects regional socioeconomic and occupational vulnerabilities. Although visual outcomes improved significantly after transplantation, visual recovery was limited by the advanced stage of disease at presentation. These findings underscore the need to expand access to early diagnosis, strengthen eye banking and donor tissue procurement systems, and increase the adoption of lamellar keratoplasty techniques to optimize visual outcomes in the Amazon region.

Keywords: Corneal transplantation; Corneal opacity; Eye infections; Keratoplasty; Epidemiology; Visual acuity; Amazonas; Brazil

PURPOSE: Neuro-ophthalmology is a highly specialized subspecialty at the interface of neurology and ophthalmology. Globally, workforce shortages and geographic maldistribution limit access to neuro-ophthalmic care. Although Brazil has a large ophthalmology workforce, regional disparities may restrict access to subspecialty services. The national distribution of neuro-ophthalmologists has not previously been quantified. This study aimed to characterize the geographic distribution of neuro-ophthalmologists in Brazil and identify potential gaps in access to neuro-ophthalmic care.
METHODS: This cross-sectional, population-based study used data from the registry of the Brazilian Neuro-Ophthalmology Association (Associação Brasileira de Neuro-Oftalmologia [ABNO]) to identify practicing neuro-ophthalmologists (data extracted on January 1, 2026). Municipal- and state-level population estimates were obtained from the Brazilian Institute of Geography and Statistics. Specialist density was calculated as the number of neuro-ophthalmologists per million inhabitants. States were classified according to the presence or absence of at least one specialist and were further grouped into Brazil's five macroregions for comparative analyses. Descriptive statistical analyses were performed.
RESULTS: A total of 66 neuro-ophthalmologists were identified across 14 of Brazil's 27 states. Thirteen states had no registered neuro-ophthalmologists, representing approximately 49.4 million people (23.2% of the national population). Five states—São Paulo (n=31), Rio de Janeiro (n=6), Minas Gerais (n=6), Pernambuco (n=4), and Paraná (n=4)—accounted for more than two-thirds of all specialists. Specialist density ranged from 0 to more than 0.7 per million inhabitants, with higher concentrations in the Southeast and no specialists in several states in the North and Northeast. The distribution was highly clustered in metropolitan areas.
CONCLUSION: Brazil exhibits marked geographic maldistribution of neuro-ophthalmologists, with nearly one-quarter of the population lacking local access to specialized care. The concentration of specialists in urban and economically developed regions mirrors international trends and may exacerbate inequities within the public health system. Expanding the workforce and integrating teleophthalmology into neuro-ophthalmic services may help reduce regional disparities and improve access to specialized care.

Keywords: Ophthalmologists; Public health; Health policy; Workforce; Professional practice location; Telemedicine; Teleophthalmology; Brazil

PURPOSE: This study aimed to evaluate the agreement between the internal astigmatism axis obtained using the optical path difference-Scan III (NIDEK Co., Japan) and conventional slit-lamp biomicroscopic measurements for determining the toric intraocular lens axis in non-dilated eyes.
METHODS: This retrospective study included 56 eyes that underwent toric intraocular lens implantation and were evaluated at postoperative week 6. The toric intraocular lens axis was measured using the optical path difference-derived internal astigmatism axis under mesopic conditions without pharmacologic pupil dilation and compared with slit-lamp biomicroscopic measurements obtained after pharmacologic dilation. Agreement between the two methods was assessed using Bland–Altman analysis, the intraclass correlation coefficient, angular error analysis, and the distribution of clinically relevant deviations. Subgroup analyses were performed for plate-haptic and C-loop haptic intraocular lens.
RESULTS: The mean signed angular difference between the two methods was 0.00º (95% CI:, −0.41º to +0.41º), with 95% limits of agreement ranging from −2.99º to +2.99º. No systematic or proportional bias was observed. The mean absolute angular error was 1.21º±0.91º, and no eye demonstrated an intermethod discrepancy exceeding 5º. The difference between the two methods was ≤1º in 73.2% of eyes, ≤3º in 98.2%, and ≤5º in all eyes. Excellent agreement was observed between the two techniques (intraclass correlation coefficient >0.99, p<0.001). Comparable agreement was also observed in both the plate-haptic and C-loop haptic intraocular lens subgroups.
CONCLUSIONS: Optical path difference-derived internal astigmatism axis measurements demonstrated excellent agreement with conventional slit-lamp biomicroscopic assessment for postoperative evaluation of toric intraocular lens alignment. The low angular error, narrow limits of agreement, and absence of clinically meaningful discrepancies suggest that this technique may serve as a reliable alternative for determining the toric intraocular lens axis in non-dilated eyes with adequate pupil size.

Keywords: Internal astigmatism; OPD scan III; Rotation; Toric intraocular lens axis; Haptic design

PURPOSE: To evaluate the efficacy of autologous fat grafting for treating enophthalmos in anophthalmic sockets.
METHODS: In this prospective interventional case series, consecutive patients with anophthalmic sockets and enophthalmos were enrolled between August 2013 and July 2025. Clinical ophthalmologic examination, Hertel exophthalmometry, and orbital computed tomography scans were performed. Enophthalmos was assessed clinically and radiologically before and after orbital lipofilling with autologous fat. Fat was harvested from the inner thigh and injected into the inferolateral orbital compartment. The volume of injected fat was determined according to the degree of enophthalmos measured by Hertel exophthalmometry. Follow-up ranged from 2 to 60 months (median, 7 months).
RESULTS: Thirteen patients (13 sockets) underwent orbital autologous fat grafting using Coleman's technique. The injected fat volume ranged from 3.7 to 6 mL per procedure (median, 4.2 mL). Clinically, a reduction in enophthalmos of 1–5 mm was observed in 12 cases (median, 2 mm), which was associated with a decrease in prosthesis thickness. One patient developed a fat cyst due to anterior fat migration, and three patients required repeat grafting because of undercorrection. Computed tomography scans, available for nine patients, demonstrated a 6.8%–10.8% increase in intraorbital volume, particularly in the inferolateral quadrant. Conclusions: Clinical and radiological assessments demonstrated that lipofilling is an effective technique for restoring orbital volume in anophthalmic sockets with enophthalmos.

Keywords: Anophthalmos; Enophthalmos; Orbital volumetry; Fat grafting; Orbital reconstruction

PURPOSE:To investigate tomographic and biomechanical screening artifacts associated with primary pterygium that may mimic keratoconus-like patterns before and after surgical excision.
METHODS: Twenty-five eyes with primary pterygium underwent Scheimpflug corneal tomography and dynamic corneal response analysis before surgery and 3 months after excision. Tomographic and biomechanical (parameters were compared using paired analyses. The proportions of eyes exceeding established screening thresholds (Tomographic Biomechanical Index ≥0.29; Corvis Biomechanical Index ≥0.5) were compared using McNemar’s test.
RESULTS: BAD-D decreased significantly after surgery (1.69±1.22 vs. 1.36±0.90; Wilcoxon, p=0.027). Pentacam irregularity indices also improved significantly, including ISV (51.16±44.21 vs. 36.88±42.94; p<0.001) and IVA (0.39±0.29 vs. 0.30±0.32; p=0.006). No significant changes were observed in maximum keratometry, corneal astigmatism. The mean CBI decreased significantly (0.494±0.353 vs. 0.384±0.298; p=0.048), and the proportion of CBI-positive eyes (≥0.5) declined from 48% (12/25) to 28% (7/25). In contrast, the mean tomographic Biomechanical Index did not change remained unchanged (0.519±0.313 vs. 0.534±0.323; p=0.909), and the proportion of Tomographic Biomechanical Index-positive eyes (≥0.29) remained 76% (19/25). The number of topographic keratoconus classification positive eyes decreased from 8 (32%) to 3 (12%). Integrated Radius showed no significant postoperative change (p=0.131).
CONCLUSIONS: Primary pterygium was associated with tomographic and biomechanical screening abnormalities that mimicked keratoconus-like patterns. Following surgical excision, anterior tomographic parameters improved, and the proportion of Corvis biomechanical index-positive eyes decreased. In contrast, Tomographic Biomechanical Index remained elevated in most eyes, and stiffness-related biomechanical parameters showed no significant change. These findings demonstrate a differential postoperative response among screening indices and suggest that pterygium-induced anterior corneal surface distortion may increase false-positive keratoconus screening rates, particularly for Tomographic Biomechanical Index, which may remain elevated even after lesion removal.

Keywords: Pterygium; Cornea; Corneal topography; Biomechanical phenomena; Tomography; Keratoconus; Refractive surgical procedures

PURPOSE:To evaluate ocular findings in children born to mothers who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy.
METHODS: This prospective observational study was conducted in Brasília, Brazil, between October 2020 and 2021. Children born to mothers with laboratory-confirmed SARS-CoV-2 infection during pregnancy were included and compared with a control group of nonexposed children. All participants underwent a comprehensive ophthalmological examination performed by pediatric ophthalmologists, including assessment of ocular motility, slit-lamp biomicroscopy, cycloplegic refraction, intraocular pressure measurement, central corneal pachymetry, indirect ophthalmoscopy, and retinal imaging. Maternal and neonatal clinical data were also collected. Ocular parameters were compared between the exposed and control groups.
RESULTS: A total of 84 children were evaluated, including 70 exposed to maternal SARS-CoV-2 infection and 14 nonexposed controls. The mean gestational age was 38.3±1.8 weeks, and the mean birth weight was 3,192±492 g. No significant differences were observed between the groups in terms of ocular motility, anterior or posterior segment findings, intraocular pressure, central corneal thickness, or refractive status. Isolated findings, including epicanthus and congenital ptosis, were observed in a small number of children but were not significantly associated with maternal SARS-CoV-2 infection.
CONCLUSIONS: In this prospective cohort, no significant ocular abnormalities were identified in children exposed in utero to maternal SARS-CoV-2 infection compared with nonexposed controls. However, the relatively small and unbalanced control group limits the strength of these findings, which should not be interpreted as evidence that maternal SARS-CoV-2 infection does not affect ocular development. Larger prospective studies with adequately sized and balanced comparison groups are warranted to further investigate the potential ocular effects of prenatal SARS-CoV-2 exposure.

Keywords: COVID-19; SARS-CoV-2; Pregnancy; Infants; Ocular findings; Vertical transmission; Ophthalmology

PURPOSE:To evaluate the short-term safety and efficacy of bovine pericardium as a patch graft in glaucoma drainage implant surgery.
METHODS: We included 10 eyes from 10 patients with glaucoma. All patients underwent glaucoma drainage implant surgery using a bovine pericardial patch graft. The pericardial membrane was trimmed to 5 × 7 mm and used to cover the tube’s scleral track. Intraocular pressure, best-corrected visual acuity, and the number of antiglaucoma medications were assessed preoperatively and postoperatively on Days 1, 7, 14, 28, 45, 60, 75, and 90. Conjunctival hyperemia and intraocular inflammation were clinically graded postoperatively. Symptoms, including foreign body sensation, itching, and tearing, as well as postoperative complications, were recorded. Surgical failure was defined as tube exposure resulting from erosion of the overlying patch graft and conjunctiva.
RESULTS: The mean patient age was 63.4±15.6 years (range, 45–87 years). The most common postoperative symptom was foreign body sensation. During follow-up, three eyes developed asymptomatic thinning of the pericardial graft overlying the tube; in one of these eyes, the thinning progressed to tube exposure (10.0%; 95% CI, 0.3–44.5). No cases of endophthalmitis were observed.
CONCLUSIONS: In this short-term follow-up study, bovine pericardium may be a viable alternative for coverage of glaucoma drainage implants. Larger studies with longer follow-up periods are warranted to confirm these findings.

Keywords: Glaucoma; Drainage; Glaucoma drainage implants; Foreign body; Visual acuity; Intraocular pressure; Antiglaucoma agents; Conjunctiva; Pericardium; Bovine

PURPOSE:To determine the frequency and clinical characteristics of ophthalmologic manifestations in children aged ≤16 years with autism spectrum disorder who were evaluated at a private academic healthcare network and a public tertiary hospital.
METHODS: This retrospective descriptive study was conducted through a review of the medical records of children aged <16 years with autism spectrum disorder who were examined between 2023 and 2024. Demographic characteristics, visual function testability, refractive errors, strabismus, and prescribed treatments were analyzed. Dynamic retinoscopy was used to objectively assess the binocular accommodative response. Statistical analyses included 95% confidence intervals (Wilson score method) and exploratory multivariate logistic regression.
RESULTS: A total of 144 children were included; 79.2% were male, and the mean age was 6.3±2.7 years. Refractive errors were identified in 81.9% of children, of whom 63.2% had clinically significant errors requiring optical correction. Strabismus was diagnosed in 32.6% of cases, with exotropia being the most prevalent type. Stereopsis was successfully assessed in 72.2% of children. Notably, dynamic retinoscopy demonstrated perfect agreement (κ=1.000, p<0.001) with the presence of clinically significant refractive errors. Multivariate regression showed that increasing age was strongly associated with successful visual acuity testing, whereas neurological comorbidities and greater autism spectrum disorder severity significantly increased the odds of non-testability. Among children who continued follow-up, 63.9% experienced significant improvement in visual acuity. Although optical correction was generally well tolerated, adherence to occlusion therapy was notably low (6.8%), and 42.4% of the cohort was lost to follow-up.
CONCLUSIONS: Ophthalmologic abnormalities, particularly refractive errors and strabismus, are highly prevalent among children with autism spectrum disorder. Given the limited reliability of subjective visual assessment in this population, objective measures, particularly dynamic retinoscopy and cycloplegic refraction, are essential for accurate diagnosis. The substantial loss to follow-up further highlights the need for adapted clinical strategies to ensure continuity of ophthalmologic care in this population.

Keywords: Autism spectrum disorder; Pediatric ophthalmology; Refractive errors; Strabismus

Corneal blindness affects more than 12 million individuals worldwide; however, the availability of human donor corneas meets only a small fraction of the demand. Porcine corneal xenotransplantation represents a promising alternative because of the cornea's immune privilege and the anatomical similarities between human and porcine corneas. However, the galactose-α1,3-galactose antigen expressed on porcine cells induces hyperacute rejection through the activation of human anti-Gal antibodies, complement pathways, and innate immune cell infiltration. This review summarizes the mechanisms underlying corneal immune privilege and contrasts them with galactose-α1,3-galactose-mediated rejection pathways. In addition, it evaluates five major mitigation strategies: GGTA1-knockout pigs, enzymatic α-galactosidase treatment, RNA interference, decellularization, and immunosuppressive approaches, including CD40-CD154 blockade and topical tacrolimus. Preclinical studies have demonstrated that GTKO corneas can maintain transparency for longer than 1 year, whereas decellularized matrices preserve corneal architecture while exhibiting low antigenicity. These findings support the future clinical translation of porcine corneal xenotransplantation.

Keywords: Corneal transplantation; Xenotransplantation; Graft rejection; Galactose; Immunosuppressive agents.