VOLUME 79 - ISSUE 4

Purpose: To investigate the effects of the Valsalva maneuver (VM) on optic disc morphology, choroidal thickness, and anterior chamber parameters. Methods: This prospective observational study included 60 eyes of 60 healthy subjects. The anterior chamber parameters, including central corneal thickness (CCT), anterior chamber depth (ACD), anterior chamber angle (ACA), anterior chamber volume (ACV), pupil diameter (PD), axial length (AL), subfoveal and peripapillary choroidal thickness, optic disc parameters, and intraocular pressure (IOP), were measured at rest and during VM. Results: VM did not have any significant influence on AL, subfoveal and peripapillary choroidal thickness, optic disc area, rim area, cup area, cup-to-disc area ratio, vertical cup-to-disc ratio, rim volume, cup volume, and nerve head volume measurements (for all; p >0.05). IOP and PD significantly increased during VM (for both; p <0.001). VM significantly decreased CCT, ACD, ACA, and ACV values (for all; p <0.001). Moreover, the optic nerve cup volume decreased and the horizontal cup-to-disc ratio significantly increased during VM (for both; p <0.05). Conclusions: VM may cause transient changes in IOP, optic disc morphology, and anterior chamber parameters.

Keywords: Valsalva maneuver; Optic disc/anatomy & histology; Choroid/anatomy & histology; Intraocular pressure; Anterior chamber

Purpose: To evaluate variations in choroidal thickness (CT) during the water drinking test (WDT) in emmetropic eyes (EE) and highly myopic eyes (ME) using spectral-domain optical coherence tomography (SD-OCT). Methods: Clinical trial performed at a tertiary care hospital comprising 30 randomly selected eyes. The WDT and SD-OCT macular scans were performed 10 and 45 min after water ingestion in 15 myopic and 15 EE of 15 healthy patients in each group. Primary study outcomes were average macular CT measured by SD-OCT and intraocular pressure (IOP) during the WDT. Results: The mean spherical equivalent refraction was 0.15 ± 0.24 D in emmetropic and -7.1 ± 1.75 D in ME (p<0.001). No statistical differences between EE and ME were observed during the WDT response. EE had higher CT compared with ME at the fovea (361.4 ± 55.4 vs 257.9 ± 95.3; p<0.001), 3 mm nasal to the fovea (158.0 ± 71.8 vs 122.5 ± 54.5; p =0.047), and 3 mm temporally to the fovea (310.6 ± 52.4 vs 247.6 ± 90.1; p=0.05). Regarding CT variation, significant differences in foveal CT at 10 min after water ingestion were observed in both EE and ME, with no statistically significant difference observed between groups. A moderate correlation between IOP peak during the WDT and CT was demonstrated in ME (r=0.52; p=0.04). Conclusions: No statistically significant differences in CT variation during the WDT were observed between EE and ME, indicating similar behavior of the choroidal bed during the WDT in both groups. Further, CT was thinner in highly ME, with CT variation unable to explain elevations in IOP observed during the WDT.

Keywords: Myopia; Choroid; Tomography; Optical coherence; Axial length; Eye; intraocular pressure; Water; drinking; Osmosis

Purpose: To evaluate the results and complications of phacoemulsification surgery in eyes with posterior polar cataracts and compare the techniques of viscodissection and hydrodissection. Methods: The medical records of 29 consecutive patients (16 males, 13 females) with posterior polar cataracts (44 eyes) who had undergone cataract surgery were retrospectively reviewed. Patients were divided into two groups according to the technique used; viscodissection was applied to the experimental group (group 1) and hydrodissection to the control group (group 2). Results: The postoperative best corrected visual acuity (BCVA) was 0.19 ± 0.22 logMAR (mean ± standard deviation) (range 0.00-0.70) in group 1 and 0.25 ± 0.18 logMAR (range 0.00-0.70) in group 2. Although the mean postoperative BCVA in group 1 was greater than that in group 2, the difference was not statistically significant (p=0.165). The mean postoperative BCVA was significantly greater than the mean preoperative BCVA in both groups (p=0.00). Intraoperatively, posterior capsular rupture occurred during the removal of the cortex in three eyes (13%) of group 1 patients, with vitreous loss and anterior vitrectomy in one eye only. In group 2, six eyes (28.5%) presented posterior capsular rupture, and anterior vitrectomy was performed because of vitreous loss in three eyes. Although the percentage of posterior capsular rupture was greater in group 2, the difference was not statistically significant (p=0.207). Conclusions: Complications in posterior polar cataract surgeries can be overcome by being careful throughout the surgery and using proper techniques. Viscodissection may be better for avoiding posterior capsular rupture than hydrodissection.

Keywords: Phacoemulsification/methods; Vitreous body/surgery; Dissection/methods; Visual acuity

Purpose: To evaluate lenticular oxidative stress in rat menopausal models. Methods: Forty Wistar female albino rats were included in this study. A total of thirty rats underwent oophorectomy to generate a menopausal model. Ten rats that did not undergo oophorectomy formed the control group (Group 1). From the rats that underwent oophorectomy, 10 formed the menopause control group (Group 2), 10 were administered a daily injection of methylprednisolone until the end of the study (Group 3), and the remaining 10 rats were administered intraperitoneal streptozocin to induce diabetes mellitus (Group 4). Total oxidant status (TOS), total antioxidant capacity (TAC), and oxidative stress index (OSI) measurements of the crystalline lenses were analyzed. Results: The mean OSI was the lowest in group 1 and highest in group 4. Nevertheless, the difference between the groups was not statistically significant in terms of OSI (p >0.05). The mean TOS values were similar between the groups (p >0.05), whereas the mean TAC of group 1 was significantly higher than that of the other groups (p <0.001). Conclusions: Our results indicate that menopause may not promote cataract formation.

Keywords: Menopause; Cataract; Oxidative stress; Lens, crystalline

Purpose: To evaluate the Abbreviated National Eye Institute Visual Function Questionnaire (NEI VFQ 9), which is shorter than those previously published, as a tool for assessing vision-related quality of life in patients with ptosis and dermatochalasis. Methods: This is a cohort study of 46 patients who underwent blepharoptosis and/or upper eyelid blepharoplasty surgery by a single surgeon (CN) in 2013 in a public, academic, ambulatory care referral center. Patients included 29 who underwent blepharoplasty, 11 who underwent ptosis surgery, and 6 who underwent combined surgery. The NEI-VFQ 9 was administered pre- and postoperatively, and the composite scores were compared using Student's t-test. Survey duration was timed in a subset of patients. The hypothesis was that the NEI VFQ 9 could detect a statistically significant improvement in composite score after surgical intervention. Results: The mean pre- and postoperative NEI VFQ 9 composite scores were 74.9 and 86.8, respectively, in the blepharoplasty-only group (P<0.0001), 72.07 and 86.41, respectively, in the ptosis-only group (P=0.004), and 75.8 and 87.2, respectively, in the combined group (P=0.022). There was no correlation between the gain in composite score and the change in upper eyelid margin to reflex distance. Twenty-five patients were timed filling out the survey, and the mean was 2.3 min. Conclusions: The NEI VFQ 9 consistently demonstrates a significant increase in visual function for blepharoptosis and dermatochalasis patients. Thus, it may be a useful tool for assessing vision-related quality of life in patients with ptosis and dermatochalasis.

Keywords: National Eye Institute (U.S.); Blepharoptosis; Eyelids; Disability evaluation; Quality of life; Visual acuity

Purpose: To assess the effect of hemodialysis on retinal and choroidal thicknesses using spectral-domain optical coherence tomography (SD-OCT). Methods: In this prospective interventional study, 25 hemodialysis patients (17 male, 8 female) were enrolled. All participants underwent high-speed, high-resolution SD-OCT (λ=840 mm; 26.000 A-scans/s; 5 µm resolution) before and after hemodialysis. Choroidal thickness was measured perpendicularly from the outer edge of the retinal pigment epithelium to the choroid-sclera boundary at the fovea and at five additional points: 500 µm and 1000 µm nasal to the fovea and 500 µm, 1000 µm, and 1500 µm temporal to the fovea. Two masked physicians performed the measurements. Choroidal and retinal thicknesses before and after hemodialysis were compared. Results: The median choroidal thicknesses before and after hemodialysis were 182 µm (range, 103-374 µm) and 161 µm (range, 90-353 µm), respectively (P<0.001). The median retinal thicknesses were 246 µm (range, 179-296 µm) before and 248 µm (range, 141-299 µm) after hemodialysis (P>0.05). Systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, heart rate, and ocular perfusion pressure significantly decreased after hemodialysis (P<0.001). Intraocular pressure did not vary significantly (P=0.540). Conclusion: Hemodialysis seems to cause a significant decrease in choroidal thickness, whereas it has no effect on retinal thickness. This significant decrease in choroidal thickness might be due to the extensive fluid absorption in hemodialysis, which could result in decreased ocular blood flow.

Keywords: Choroidal thickness; Hemodialysis; Optical coherence tomography

Purpose: To compare therapeutic outcomes between trabeculectomy and medical therapy in patients with open-angle glaucoma. Methods: In the present retrospective comparative study, the medical charts of 284 patients (eyes) newly diagnosed with open-angle glaucoma who had received conventional medications (n=188) or undergone fornix-based trabeculectomy (n=96) at a teaching eye hospital were reviewed. Results: At a mean follow-up of 6.6 years, post-treatment changes in intraocular pressure (IOP), visual field (VF), best spectacle-corrected visual acuity (BSCVA), and number of required drugs were significantly more favorable in the surgical group (P<0.001 for all comparisons). However, the frequency of clinically desirable IOP (≤21 mmHg) at the endpoint was comparable between the surgical and medical groups (87.2% vs. 82.3%; P=0.26). The rate of conversion to surgical therapy was 34% in the medical group. A greater baseline requirement for anti-glaucoma drugs (two or more) was the only independent predictor of treatment failure in the present study. Conclusions: Although more severe cases naturally receive trabeculectomy, the surgical approach had greater efficacy than conventional medical therapy in patients with open-angle glaucoma. An initial requirement for two or more anti-glaucoma drugs may predict failure of medical therapy.

Keywords: Glaucoma, open-angle/drug therapy; Glaucoma, open-angle/surgery; Trabeculectomy; Visual acuity

Purpose: To develop 27 short sentence optotypes for the Portuguese version of the Radner Reading Charts. Methods: Thirty-four Portuguese sentences were constructed following the concept of the Radner Reading Charts to obtain highly comparable sentences in terms of lexical difficulty, syntactical complexity, word length, number of syllables, and position of words. A long text (106 words) at the 5th grade reading level was also tested to assess the validity of the reading speeds obtained with the short sentences. The short sentences and long text were tested in 50 volunteers with similar educational backgrounds (mean age 30.98 years ± 6.99 years, range 19-47 years). Reading speeds were measured with a stop-watch and reported as words per minute (wpm). The reading time for each of the short sentences to be selected for the chart was defined as falling within the range of the mean ± 0.40 × standard deviation (SD). Results: The overall mean reading speed for each of the short sentences was 235.43 ± 36.39 wpm. The 27 sentences with a mean between 220.8 and 250.0 wpm (overall mean ± 0.40 × SD) were selected for construction of the reading charts. The mean reading speed for the long text was 212.42 ± 26.20 wpm. Correlation between the selected short sentences and long text was high (r =0.86). Reliability analysis yielded an overall Cronbach's alpha coefficient of 0.97. Conclusions: The 27 short Portuguese sentences were highly comparable in terms of syntactical structure, number, position and length of words, lexical difficulty, and reading length. This reading test can overcome the limitations of the current tests for homogeneity and comparability, reducing subjectivity in the evaluation of the functional outcomes of medical and surgical ophthalmologic treatments.

Keywords: Reading; Vision tests/methods; Visual acuity; Feasibility studies

Purpose: The objective of this study was to evaluate subfoveal choroidal thickness (SFCT) using enhanced depth imaging optical coherence tomography (EDI-OCT) in patients with naïve branch retinal vein occlusion (BRVO) before and after intravitreal dexamethasone implant (Ozurdex®) injection. Methods: Thirty-nine patients with unilateral BRVO and 35 healthy subjects were included in this prospective study. Choroidal thickness was evaluated by EDI-OCT at baseline and 1 month after dexamethasone implant. Results: The mean SFCT measured in 39 patients with BRVO was 299.41 ± 55.86 µm, significantly greater than that in contralateral eyes (283.76 ± 57.44 µm; p=0.009) and control eyes (276.14 ± 39.06 µm; p=0.044). The mean SFCT after the treatment was 279.64 ± 50.96 µm, significantly thinner than that before intravitreal dexamethasone therapy (p=0.004). Conclusions: SFCT in treatment-naive BRVO eyes was significantly greater than that in contralateral eyes and healthy eyes and decreased significantly after intravitreal dexamethasone implantation.

Keywords: Choroid/pathology; Intravitreal injections; Retinal vein occlusion; Tomography, optical coherence; Macular edema; Dexamethasone/administration and dosage; Visual acuity

Purpose: Evaluation of the nerve fiber thicknesses of the macula, choroid, and retina using the apnea-hypopnea index in individuals with obstructive sleep apnea syndrome (OSAS) without systemic components. Methods: Prospective, controlled study. The central macular, choroidal, and retinal nerve fiber layer (RNFL) thicknesses were evaluated using enhanced depth imaging-spectral domain optical coherence tomography in individuals with OSAS. In people with severe OSAS who had received treatment, posterior ocular structures were examined over 3 months (4th and 12th weeks), and changes were evaluated. Only the right eyes of the participants were evaluated in the study. Results: A total of 72 people were involved in the study, with 18 in the control group and 19 with mild, 16 with moderate, and 19 with severe OSAS. No significant difference was found among the groups in terms of demographic measures. No significant differences were found among the groups in terms of the measures of central macular, central subfoveal choroidal (CSCT), temporal choroidal, nasal choroidal, and RNFL thicknesses. In severe OSAS cases in which treatment was administered, although subjective clinical recovery was observed, statistically significant thinning was detected during the 3-month follow-up period in the CSCT, general RNFL, as well as in the inferior and superior nasal quadrants, and temporal superior quadrant (p=0.005, p=0.009, p=0.039, p=0.003, and p=0.02, respectively). Conclusion: In the group with severe OSAS, thinning in some posterior ocular tissues was observed. Although patients with severe OSAS may experience clinical recovery, we recommend that they would be followed up in terms of ocular ischemic injury.

Keywords: Sleep apnea syndromes; Macula; Choroid; Tomography, optical coherence; Nerve fibers; Retina

Our patient was a 34 year-old male who presented with a painless conjunctival mass that had developed 3 months before his first visit. On performing slit-lamp biomicroscopy, a lobulated pink-yellowish solid mobile mass was observed on the nasal bulbar conjunctival surface of his left eye. The tumor was excised, and histopathologic examination of the tumor revealed a sebaceous adenoma. Systemic examination was normal. No recurrence was observed during the 24-month follow-up period. Sebaceous adenoma of the bulbar conjunctiva is an extremely rare benign tumor, which may be observed to be isolated in the absence of malignancy.

Keywords: Adenoma/pathology; Adenoma/surgery; Conjunctival neoplasms/surgery; Adenocarcinoma, sebaceous/pathology

A 51-year-old patient underwent posterior vitrectomy with perfluoropropane gas injection, phacoemulsification, and implantation of an Oft Cryl® hydrophilic acrylic intraocular lens (IOL) because of traumatic retinal detachment and cataract in the right eye. On the first postoperative day, gas was filling the anterior chamber because of patient's non-compliance in terms of head positioning, and was reabsorbed within one week. Eight months later, the patient returned complaining of a significant decrease in vision. IOL opacification was noticed by slit-lamp examination. The lens was explanted to undergo gross and light microscopic analysis. The lens was also stained with the alizarin red method for calcium identification. Light microscopic analysis confirmed the presence of granular deposits, densely distributed in an overall circular pattern in the central part of the lens optic. The granules stained positive for calcium. This is the first case of the opacification of this type of hydrophilic lens. Surgeons should be aware of this potential postoperative complication, and the use of hydrophilic IOLs should be avoided in procedures involving intracameral gas because of the risk of IOL opacification.

Keywords: Vitrectomy; Intraocular lens; Lens implantation; Hydrophilic contact lens; Capsule opacification

To our knowledge, we report the first case of an extraconal orbital cystic schwannoma in Brazilian literature. The tumor grew slowly and progressively and was associated with minimal eccentric proptosis and diplopia. The radiologic study (orbital computed tomography) revealed a rounded, encapsulated, and extraconal cystic mass in the superior medial region of the right orbit in the supraorbital and supratrochlear nerve topography. An anterior orbitotomy with full excision of the tumor was performed, and the histopathology examination revealed that the tumor was a schwannoma. After the surgery, the patient experienced total remission of his symptoms.

Keywords: Neurilemmoma diagnosis; Neurilemmoma surgery; Orbital neoplasms; Exophthalmos; X-ray computed tomography

Conjunctival ulceration accompanied with secretion and pain was observed in a 30-year-old male, 3 days after a perforating corneal trauma. Cultures of conjunctival ulcer samples grew Fonsecaea pedrosoi, a major causative agent of chromoblastomycosis that is typically transmitted during trauma. The conjunctival ulcer was successfully treated with amphotericin B, itraconazole, and fluconazole. This case report summarizes the diagnosis and treatment of a conjunctival ulcer due to F. pedrosoi, which is a rare complication of contaminated ocular trauma. To the best of our knowledge, this is the first reported case of F. pedrosoi causing acute conjunctival ulceration in the literature.

Keywords: Chromoblastomycosis; Ascomycota/isolation & purification; Conjunctival disease; Eye injuries, penetrating; Eye infections, fungal

We report two cases of suspicious asymmetric bow tie and inferior steepening on topographic evaluations with reflection (Placido) and projection (Scheimpflug). Rotating Scheimpflug corneal and anterior segment tomography (Oculus Pentacam HR, Wetzlar, Germany)® was performed in the first case, with a maximal keratometric value (Kmax) of 43.2 D and an overall deviation value from the Belin/Ambrósio Enhanced Ectasia Display (BAD-D) of 1.76, which was observed in the study eye (OD). BAD-D was 6.59 in the fellow eye, which had clinical findings that were consistent with keratoconus stage 2. The second case presented with a Kmax of 45.3 D and BAD-D of 0.76 in OD and 1.01 in OS. This patient had discontinued wearing soft contact lens less than 1 day prior to examination. Corneal tomographic data enabled us to distinguish mild or forme fruste keratoconus from contact lens-induced corneal warpage, and similar findings were observed on curvature maps.

Keywords: Tomography; Corneal topography; Keratoconus; Ectasia/diagnosis; Corneal diseases

We describe an unusual case of acquired anterior staphyloma in a patient addicted to crack cocaine. At the beginning of his crack cocaine abuse, he noticed redness and irritation of his eyes. Over the next 4 months, the patient also noticed the onset of decreasing visual acuity in his right eye (OD). Initially, his visual acuity was light perception in OD, and slit-lamp examination revealed a corneal infiltrate with a peripheral perforation and an iris prolapse. The patient was hospitalized to ensure compliance with the prescribed treatment and was advised to undergo therapeutic keratoplasty; however, the patient left the hospital against medical advice and was lost to follow-up for the next 6 months. He returned with complaints of photophobia and the inability to close his right eyelids. At this time, his cornea had developed an anterior staphyloma and required a sclerokeratoplasty. Following surgery, the patient was again lost to follow-up.

Keywords: Eye infection/etiology; Corneal ulcer/complications; Crack cocaine/adverse effects

Normal-tension glaucoma (NTG) is a progressive optic neuropathy with intraocular pressure (IOP) within the statistically normal range (≤21 mmHg). The prevalence of NTG varies widely among different population studies, being the most prevalent open-angle glaucoma subtype in some reports. The etiology of NTG possibly is multifactorial and still not well defined. Alternative treatments have been proposed based on pathogenesis details. However, in clinical practice, adequate reduction of IOP remains the keystone of managing patients with NTG. We review the pathogenesis of NTG and the available therapies for this optic neuropathy.

Keywords: Open-angle glaucoma; Intraocular pressure; Optic nerve diseases; Antihypertensive agents/therapeutic use