VOLUME 80 - ISSUE 5

Purpose: To investigate human beta-defensins (HBDs) and cathelicidin LL-37 (LL-37) expressions in patients with pterygium. Methods: In this retrospective consecutive case series, 26 pterygium specimens and 15 normal conjunctival specimens of 15 control subjects were in vestigated. Expressions of HBD-1, HBD-2, HBD-3, and LL-37 were assessed using immuno histochemical staining. A brown color in the cytoplasm and/or nuclei of epithelial cells indicated positive staining for HBDs and LL-37. For each antibody, the intensity of the reaction (negative [-], weak [1+], moderate [2+], or strong [3+]) was determined to describe the immunoreactions. Results: The median age was 52 years in both groups. There were no significant differences in age and sex between the groups (p=0.583, p=0.355, respectively). Of the 26 pterygium specimens, 15 (57.7%) (14 weak, 1 moderate staining) showed HBD-2 expression, which was not observed in any of the control specimens. One (3.8%) pterygium and one (6.7%) control specimen demonstrated weak staining for HBD-3. HBD-2 expression was significantly higher in the pterygium specimens than in the controls (p=0.002). None of the tissue specimens had positive staining for HBD-1 or LL-37 in either group (both; p=1.00). Conclusions: HBD-2 expression was higher in pterygium specimens than in the controls. HBD-2 expression that might be stimulated by inflammatory cytokines may be related to inflammation and fibrovascular proliferation and may play a role in pterygium pathogenesis.

Keywords: Cathelicidins; Beta-defensins; Immunohistochemical; Inflammation; Pterygium/pathology

Purpose: To identify the causes of a diffuse lamellar keratitis (DLK) outbreak using a systematic search tool in a case-control analysis. Methods: An Ishikawa diagram was used to guide physicians to determine the potential risk factors involved in this outbreak. Coherence between the occurrences and each possible cause listed in the diagram was verified, and the total number of eyes at risk was used to calculate the proportion of affected eyes. Multivariate analysis was performed using logistic regression to determine the independent effect of the risk factors, after controlling for confounders and test interactions. Results: All DLK cases were reported in 2007 between June 13 and December 21; during this period, 3,698 procedures were performed. Of the 1,682 flap-related procedures, 204 eyes of 141 individuals presented with DLK. No direct relationship was observed between the occurrence of DLK and the presence of any specific factors; however, flap-lifting enhancements, procedures performed during the morning shift, and non-use of therapeutic contact lenses after the surgery were significantly related to higher occurrence percentages of this condition. Conclusions: The Ishikawa diagram, like most quality tools, is a visualization and knowledge organization tool. This systematization allowed the investigators to thoroughly assess all the possible causes of DLK outbreak. A clear view of the entire surgical logistics permitted even more rigid management of the main factors involved in the process and, as a result, highlighted factors that deserved attention. The case-control analysis on every factor raised by the Ishikawa diagram indicated that the commonly suspected factors such as biofilm contamination of the water reservoir in autoclaves, the air-conditioning filter system, glove powder, microkeratome motor oil, and gentian violet markers were not related to the outbreak.

Keywords: Keratitis/epidemiology; Keratomileusis, laser in situ; Corneal injury; Refractive surgical procedure; Cornea

Purpose: To determine the relationship between anterior segment and optic nerve head (ONH) parameters. Methods: Two hundred healthy subjects were enrolled in this study. The par­ticipants underwent measurement of anterior segment parameters with a Pentacam Scheimpflug system and imaging of the optic disc with confocal scanning laser ophthalmoscopy. Pearson’s correlation coefficient was calculated to assess the associations between ONH and anterior segment parameters. Multivariate regression analyses controlling for age and disc area as confounding factors were also conducted. Results: There were significant negative relationships between optic disc area and corneal thickness (p=0.03, r=-0.217) and volume (p=0.017, r=-0.239). Corneal refractive power was significantly correlated with cup area, rim area, rim volume, and cup/disc ratio (p<0.05 for all). An increase of 1 diopter in anterior corneal refractive power corresponded to a decrease of 0.022 in cup/disc ratio. Rim volume was negatively correlated with anterior chamber depth and anterior chamber volume (p<0.05 for both). A 1-mm3 increase in anterior chamber depth corresponded to a 0.154-mm3 decrease in rim volume. Mean and maximum cup depth measurements were not associated with any of the anterior segment parameters. Conclusions: In nonglaucomatous eyes, the dimensions and shape of the ONH may be related to anterior segment morphology. Therefore, it may be helpful to take anterior segment parameters into consideration in evaluating the OHN.

Keywords: Anterior eye segment; Cornea; Glaucoma; Optic disc

Purpose: To evaluate the changes in several ocular parameters, including choroidal thickness, during and after hemodialysis. Methods: Twenty-seven eyes of 27 patients with chronic renal failure undergoing hemodialysis were included. The patients underwent an ophthalmic examination, including intraocular pressure, central corneal thickness, iridocorneal angle, subfoveal choroidal thickness, and blood pressure, just before a hemodialysis session, during the second hour of the session, and half an hour after the end of the session. Body weight was measured before and after the session, and ultrafiltration volume was noted after the session. Central corneal thickness, intraocular pressure, and subfoveal choroidal thickness were measured by optical coherence tomography. Results: In comparison with baseline levels, mean intraocular pressure and central corneal thickness increased significantly during the second hour of hemodialysis (p=0.001 and p=0.011, respectively) and showed no significant changes after hemodialysis (p=0.844 and p=0.246, respectively). Mean iridocorneal angle did not significantly change during the second hour of hemodialysis (p=0.101) and after hemodialysis (p=0.589). Mean subfoveal choroidal thickness was significantly lower during the second hour of hemodialysis (p<0.001) and after hemodialysis (p<0.001). Conclusions: Mean intraocular pressure and central corneal thickness increased and subfoveal choroidal thickness decreased during the second half of the hemodialysis session. During the second half of the session, intraocular pressure and central corneal thickness had a trend toward reduction, while subfoveal choroidal thickness had a relatively steady course. Because of possible fluctuations in the values, it would be reasonable to evaluate the changes not only from before to after hemodialysis but also during hemodialysis when analyzing the ocular effects of dialysis.

Keywords: Cornea; Choroid; Intraocular pressure; Iris; Renal dialysis

Purpose: To estimate the prevalence of external punctal stenosis (EPS) in the elderly population and investigate associated factors. Methods: A total of 278 patients ≥65 years of age were evaluated for evidence of EPS from January to July 2016. Associated systemic, ocular, demographic, and lifestyle factors were investigated. Multiple logistic regression analyses were applied to evaluate the factors related to having EPS. P values <0.05 were considered statistically significant. Results: The prevalence of EPS in this study population was 63.3%, with a mean age of 70.67 ± 7.85 (65-92 years). The ocular factor that was most commonly related to EPS was chronic blepharitis (48.9%). EPS was also associated with taking glaucoma medications (95% CI, 0.08-0.96, p=0.043), smoking history (95% CI, 0.13-0.84, p=0.021), ectropion (95% CI, 0.004-0.26, p=0.001), complaints of tearing (95% CI, 1.11-3.52, p=0.02), and outdoor occupational activity (95% CI, 3.42-9.97, p<0.05). Conclusions: EPS is more common in elderly patients than in the general population. Outdoor occupational activity, taking antiglaucomatous medications, ectropion, and smoking are significantly associated with EPS. In addition, surgical treatment decisions should be made after complete evaluation and interviewing the patients.

Keywords: Lacrimal apparatus; Lacrimal duct obstruction; Blepharitis; Dry eye syndromes; Aged; Turkey/epidemiology

Purpose: To compare the aqueous humor (AH) concentrations of moxifloxacin 0.5% and gatifloxacin 0.3% solutions alone or when treatment was combined with steroids, and to correlate these concentrations with the minimum inhibitory concentrations (MIC) for the most common endophthalmitis-causing organisms. Methods: Patients undergoing phacoemulsification were enrolled to receive one drop of one of the following solutions: moxifloxacin (G1), moxifloxacin + dexamethasone (G2), gatifloxacin (G3), or gatifloxacin + c (G4), every 15 min, 1h before surgery. AH samples were collected before surgery and analyzed using HPLC-tandem mass spectrometry. Results: The mean antibiotic concentrations in the AH were: G1= 1280.8 ng/mL; G2= 1644.3 ng/mL; G3= 433.7 ng/mL; and G4= 308.1 ng/mL. The mean concentrations statistically differed between G1 and G2 (p=0.01), and G3 and G4 (p=0.008). All samples achieved the MIC for Staphylococcus epidermidis; 100% of the samples from G1 and G2, and 97% from G3 and G4 reached the MIC for fluoroquinolone-sensitive Staphylococcus aureus; 100% of the samples from G1 and G2, 88% from G3, and 72% from G4 reached the MIC for enterococci (p<0.001); and 100% of samples from G1 and G2, 59% from G3, and 36% from G4 reached the MIC for Streptococcus pneumoniae (p<0.001). For fluoroquinolone-resistant S. aureus, 23% from G1, 44% from G2, and no samples from G3 or G4 achieved the MIC (p<0.001). Conclusions: Moxifloxacin + dexamethasone demonstrated a higher concen­tration in the AH than the moxifloxacin alone. Gatifloxacin + steroids demonstrated less penetration into the anterior chamber than gatifloxacin alone. Moxifloxacin was superior to gatifloxacin considering the MIC for enterococci, S. pneumoniae, and fluoroquinolone-resistant S. aureus.

Keywords: Aqueous humor; Ophthalmic solutions; Antibiotic prophylaxis; Fluoroquinolones; Steroids; Adrenal cortex hormones; Anti-bacterial agents; Comparative study

Purpose: To investigate differences in the palpebral fissure eyelid position in Japanese subjects and in Brazilian subjects of European descent over 50 years of age. Methods: A cross-sectional study evaluating 50 Japanese subjects and 50 Bra­­­zilian subjects of European descent over 50 years of age was performed to evaluate the effect of aging on eyelid position. Digital photographs were taken with the eyes in the primary position and transferred to a computer to be processed by Scion imaging software for evaluation of palpebral fissure width, height, and margin reflex distance (MRD). The data were statistically analyzed according to sex, age, and race. Results: The width of the eyelid fissure in Japanese subjects was higher than that in Brazilian subjects, whereas the height of the eyelid fissure and the MRD1 was higher in Brazilians than in Japanese (p<0.01). Width, height, and MRD1 were linearly associated with age only in the Japanese group (p<0.05); this association was observed only with width in the Brazilian group (p<0.05). There were no differences according to laterality in either group (p>0.05). Conclusion: There are racial differences in age-related changes in the eyelids, which are more marked in Japanese subjects.

Keywords: Eyelids/anatomy and histology; Eyelids/pathology; Asian Continental Ancestry Group; Brazilian; Age factors; Image processing,computer-assisted

Purpose: To evaluate the corneal biomechanical features and central corneal thickness in ankylosing spondylitis patients and to evaluate correlations of these parameters with disease activity. Methods: The study included 51 patients diagnosed with ankylosing spondylitis (mean age, 40.80 ± 13.15 years; range, 18-72 years) and 34 age- and sex-matched healthy controls (mean age, 42.00 ± 12.32 years; range, 18-60 years). All underwent a complete ophthalmological and physical examination, including visual acuity testing and biomicroscopic anterior and posterior segment examinations. Corneal hysteresis, corneal resistance factor, Goldmann-correlated intraocular pressure, and corneal compensated intraocular pressure were evaluated with an ocular response analyzer, and the central corneal thickness was measured with Sirius® corneal tomography. The Bath Ankylosing Spondylitis Disease Activity Index, Functional Index, and Metrology Index scores were recorded. Results: In the ankylosing spondylitis patients, the mean disease duration was 7.73 ± 6.05 (range, 1-30) years. There was no statistically significant difference between the patients and controls in the corneal biomechanical features. The Goldmann-correlated intraocular pressure and corneal compensated intraocular pressure both showed positive correlations with age (p=0.003 and p=0.001, res­pectively). There was a negative correlation between corneal hysteresis and disease duration (p=0.002), and between central corneal thickness and the Bath Ankylosing Spondylitis Metrology Index score (p=0.003). Conclusion: This study demonstrated a significant negative correlation between corneal hysteresis and disease duration in ankylosing spondylitis patients. Furthermore, the central corneal thickness value decreased with an increase in Bath Ankylosing Spondylitis Metrology Index score, which may result in an underestimate of intraocular pressure readings and thus an inaccurate risk assessment of glaucoma.

Keywords: Spondylitis, ankylosing; Corneal biomechanics; Corneal tomography; Severity of illness index

Objective: The aim of this study was to determine the central corneal thickness (CCT) and intraocular pressure (IOP) in full-term newborns and to correlate these values with the following variables: weight, sex, and post-conception age (PCA). Methods: IOP and CCT were determined in 52 full-term newborns with a mean gestational age of 39.43 ± 1.03 weeks and a mean birth weight of 3,273 ± 558 g. The mean age of the neonates at the time of taking the measurements was 1.15 ± 1.38 days after birth. IOP was determined with a Tono-Pen, and CCT was determined using a handheld ultrasound pachymeter. Results: The mean overall IOP was 14.0 ± 2.91 mmHg, and the mean IOP in male and female newborns was 13.77 ± 2.88 mmHg and 14.32 ± 3.05 mmHg, respectively. The mean overall CCT was 605.87 ± 62.98 µm, and the mean CCT in male and female newborns was 626.70 ± 67.46 µm and 577.45 ± 45.50 µm, respectively; the mean CCT was higher in male newborns than in female newborns. PCA was negatively associated with CCT, IOP, and weight; however, only the correlation with CCT was statistically significant. Comparisons between the sexes showed significant differences for two variables: weight and CCT. Conclusions: No relationship was found between CCT and IOP; however, we found a positive association between weight and CCT.

Keywords: Glaucoma/genetics; Cornea topography; Intraocular pressure; Tonometry, ocular; Humans; Infant, newborn

Purpose: To investigate the effects of pterygium on corneal endothelial cell density in patients with unilateral pterygium. Methods: We performed a cross-sectional analysis of data from patients with unilateral pterygium who were selected from September 1, 2015 to July 31, 2016 at Hospital de Base do Distrito Federal to assess the corneal endothelial cell density, coefficient of variation in the cell area, hexagonality, and corneal pa­chymetric results. In all patients, noncontact specular microscopy was performed in both eyes and a minimum endothelial cell count of 75 cells/mm2 was required for inclusion in the study. The contralateral eye served as the control. Results: Sixty-one patients were included in the study. Twenty-nine (47.5%) patients were men and 32 (52.5%) were women (mean age, 50.84 ± 13.8). The percentage of pterygium that invaded the cornea ranged from 4.87% to 24.59% (median, 9.70% ± 4.99%). The mean corneal endothelial cell density (cells/mm) was lower in the pterygium eyes than in the controls (2451.83 ± 284.96 vs. 2549.95 ± 268.94, respectively; p=0.04). No differences in the mean coefficients of variation of cell size, hexagonality, and corneal pachymetric results were observed between the patients and controls. The Pearson correlation test showed a significant negative linear relationship between pterygium invasion and endothelial cell density [p<0.001, n=61, r=-0.553 (95% CI, -0.34 to -0.73)]. Conclusion: Compared with the contralateral eyes, those of patients with unilateral pterygium were associated with a decrease in corneal endothelial cell density.

Keywords: Pterygium; Corneal endothelial cell; Endothelium; corneal; Microscopy/methods

This report presents multimodal imaging of a 27-year-old woman diagnosed with benign familial fleck retina (OMIM 228980), an uncommon disorder. Fundus photographs revealed retinal flecks that affected her post-equatorial retina but spared the macular area. Fundus autofluorescence and infrared imaging demonstrated a symmetrical pattern of yellow-white fleck lesions that affected both eyes. Her full-field electroretinogram and electrooculogram were normal. An optical coherence tomography B-scan was performed for both eyes, revealing increased thickness of the retinal pigmented epithelium leading to multiple small pigmented epithelium detachments. The outer retina remained intact in both eyes. Spectral-domain optical coherence tomography angiography with split-spectrum amplitude decorrelation algorithm and 3 × 3 mm structural en face optical coherence tomography did not show macular lesions. Benign familial fleck retina belongs to a heterogenous group of so-called flecked retina syndromes, and should be considered in patients with yellowish-white retinal lesions without involvement of the macula.

Keywords: Eye diseases, hereditary/genetics; Eye diseases, hereditary/diagnosis; Retinal diseases/diagnosis; Retinal diseases/genetics; Tomography, optical coherence

We report a case of cortical blindness secondary to posterior leukoencephalopathy syndrome, which was successfully treated by blood pressure management. A 66-year-old white man presented at the emergency room complaining of severe frontal headache, disorientation, and progressive blurred vision. The initial physical examination disclosed a blood pressure of 200/176 mmHg. One hour later the patient exhibited mental confusion and bilateral blindness. Computed tomography and magnetic resonance imaging were performed, and a systemic workup was conducted, resulting in a diagnosis of posterior leukoencephalopathy syndrome. This syndrome is a rare manifestation of systemic hypertension that requires proper diagnosis and management to avoid irreversible brain damage. Early recognition of this condition and prompt control of the patient’s blood pressure are essential because they may bring about a reversal of the syndrome, which may otherwise result in permanent brain damage.

Keywords: Blindness; Hypertensive encephalopathy; Hypertension; Posterior leukoencephalopathy syndrome; Humans; Case reports

We report a case of a 49-year-old female who presented to the emergency department with blurred vision and vomiting, hours after taking two tablets of 250 mg of acetazolamide. The anterior chamber was bilaterally flat, with normal intraocular pressure in both eyes. An ultrasound biomicroscopic (UBM) examination showed bilateral ciliary effusion and complete appositional angle closure in all quadrants. Acetazolamide-induced bilateral angle closure was diagnosed. Steroid and cycloplegic therapy were initiated, and acetazolamide was discontinued. The following day, the anterior chamber had regained its volume without substantial change in the effusion size. Three weeks later, complete resolution of the ciliary effusion was verified by means of a third UBM scan.

Keywords: Acetazolamide/toxicity; Myopia/etiology; Humans; Case report

A 37-year-old female presented with severe apraxia of lid opening (ALO) affecting the right upper lid associated with Becker congenital myotonia (MC). The patient had a history of right upper lid ptosis for 25 years that was exacerbated over the previous month with severe incapacity to open her right eye. No other associated neurological or ophthalmic symptoms were observed. The patient was treated with botulinum toxin (BoNT-A) injection into the pretarsal and lateral canthus region of the orbicularis oculi of the affected eyelid. Treatment with BoNT-A is an effective method of managing ALO in Becker MC. This is the first case of unilateral ALO in the course of Becker MC that was successfully treated with injections of botulinum toxin.

Keywords: Myotonia congenita; Botulinum toxins, type A; Apraxias; Oculomotor muscles; Humans; Case reports

Standardization of terminologies and methods is increasingly important in all fields including ophthalmology, especially currently when research and new technology are rapidly driving improvements in medicine. This review highlights the range of notations used by vision care professionals around the world for vision measurement, and the challenges resulting from this practice. The global community is urged to move toward a uniform standard.

Keywords: Visual acuity; Vision screening; Vision tests; logMAR; ETDRS