VOLUME 81 - ISSUE 1

Purpose: To (a) determine the normative values for optical coherence tomography (OCT) parameters such as central macular thickness, retinal nerve fiber layer thickness, and choroidal thickness in healthy children; (b) investigate the relationships of these parameters with axial length, central corneal thickness, refractive errors, and intraocular pressure; and (c) determine interexaminer agreement for choroidal thickness measurements.
Methods: In this cross-sectional study, 120 healthy children aged 8-15 years underwent detailed ophthalmological examination and OCT measurements. Choroidal thickness was measured at three separate locations by two independent examiners.
Results: The mean global retinal nerve fiber layer thickness was 98.75 ± 9.45 µm (79.0-121.0). The mean central macular thickness was 232.29 ± 29.37 µm (190.0-376.0). The mean subfoveal choroidal thickness obtained by examiner 1 was 344.38 ± 68.83 µm and that obtained by examiner 2 was 344.04 ± 68.92 µm. Interexaminer agreement was between 99.6%-99.8% for choroidal thickness at three separate locations. Central macular thickness increased with axial length (r=0.245, p=0.007). Choroidal thickness increased with age (r=0.291, p=0.001) and decreased with axial length (r=-0.191, p=0.037). Global retinal nerve fiber layer thickness decreased with axial length (r=-0.247, p=0.007) and increased with central corneal thickness (r=0.208, p=0.022). Global retinal nerve fiber layer thickness positively correlated with choroidal thickness (r=0.354, p<0.001). Global retinal nerve fiber layer thickness (r=0.223, p=0.014) and choroidal thickness (r=0.272, p=0.003) increased with the spherical equivalent (D).
Conclusions: Optical coherence tomography parameters showed a wide range of variability in children. Retinal nerve fiber layer thickness, central macular thickness, and choroidal thickness were found to be either inter-related or correlated with age, central corneal thickness, axial length, and refractive errors. Furthermore, manual measurements of choroidal thickness showed high interexaminer agreement. Because normative values for optical coherence tomography parameters differed in children, the measurements should be interpreted according to an age-appropriate database.

Keywords: Optic nerve; Retina; Choroid; Macula lutea; Refractive errors; Tomography, optical coherence/methods; Reference values; Children

Purpose: Malignant lesions of the eyelid are the most common eye cancers. Although rarely lethal, late diagnosis can lead to serious visual morbidity. Definitive diagnosis of neoplastic lesions is pathological. Indications and types of eyelid lesions in a single high-volume ophthalmic reference center in Sao Paulo, Brazil, were analyzed.
Methods: The surgical pathological reports of patients who underwent eye removal procedures between January 2000 and December 2012 were retrieved from the electronic database of the Ophthalmology Department and retrospectively reviewed. Data regarding the final anatomopathological diagnosis, sex, and age were analyzed via the χ² test with Yates' correction.
Results: Of the 1,113 eyelid tumors resected over the 13-year study period, 324 (29%) lesions were malignant. The most prevalent lesions were basal cell, squamous cell, and sebaceous gland carcinomas. The median ages of patients (females, n=165, 51%; males, n=159, 49%) with a diagnosis of basal cell, squamous cell, and sebaceous gland carcinomas were 65, 75, and 70 years, respectively.
Conclusion: This is the largest retrospective cohort analysis of eyelid tumors in a Latin American population. These findings are in agreement with those from large centers in other countries and regions.

Keywords: Eyelid neoplasms; Basal cell carcinoma; Squamous cell carcinoma; Melanoma; Brazil

Purpose: To compare 0.5 mg and 0.625 mg of bevacizumab for treating aggressive posterior retinopathy of prematurity (AP-ROP).
Methods: The medical records of patients with AP-ROP who were administered intravitreal bevacizumab (IVB) as a primary treatment at a university clinic were evaluated retrospectively. Five eyes of three patients (Group 1) who received 0.625 mg/0.025 ml IVB and 10 eyes of another five patients (Group 2) who received 0.5 mg/0.02 ml IVB were evaluated. Laser photocoagulation was used as additional treatment after relapses. Anatomic results and complications were evaluated in both groups.
Results: We evaluated 15 eyes of eight patients (four girls and four boys) with a flat demarcation line at posterior zone 2 and plus disease or stage-3 disease in this study. The mean gestational age of the three babies in Group 1 was 26 ± 1 weeks and the mean birth weight was 835.33 ± 48.01 g. The corresponding values were 25.2 ± 1.6 weeks and 724 ± 139.03 g, respectively, for the five babies in Group 2. Retinal vascularization was completed at a mean postmenstrual duration of 53.6 ± 1.5 weeks without additional treatment in the five eyes in Group 1. Laser photocoagulation for relapse was administered to five of the 10 eyes in Group 2. Retinal vascularization was completed at a mean postmenstrual duration of 47.6 ± 1.5 weeks in the remaining five eyes. None of the patients developed complications such as cataract, glaucoma, retinal tear, retinal or vitreous hemorrhage, or retinal detachment.
Conclusion: Although lower IVB doses in the treatment of AP-ROP are expected to be safer in terms of local and systemic side effects in premature infants, these patients may require additional treatment with IVB or laser photocoagulation.

Keywords: Retinopathy of prematurity; Bevacizumab/administration & dosage; Light coagulation/methods; Vascular endothelial growth factor/antagonists & inhibitors

Purpose: To evaluate the correlation between weight reduction and visual outcome in overweight patients with idiopathic intracranial hypertension.
Methods: Thirty-nine newly diagnosed, overweight (body mass index >25 kg/m²⁾ patients with idiopathic intracranial hypertension were studied retrospectively. All patients underwent medical treatment with acetazolamide, and a weight reduction program was also offered. Patients were grouped according to their compliance with this weight reduction program into the diet-success (Group 1) and diet-failure groups (Group 2). Body mass index, papilledema, visual acuity, and perimetric mean deviation were compared at the end of the 6-month study period.
Results: Groups 1 and 2 did not differ regarding the baseline mean body mass index (32.63 ± 5.61, 32.35 ± 5.06 kg/m²⁾, visual acuity (0.080 ± 0.13, 0.130 ± 0.24 logMAR), perimetric mean deviation (-9.978 ± 0.68, -12.86 ± 8.91), or papilledema grade (2.94 ± 0.22, 2.90 ± 0.30), respectively (p>0.05). During the 6 months' follow-up, Group 1 patients, who complied with both medical and diet therapy, improved significantly in all parameters, including body mass index (p<0.001), visual acuity (p=0.001), perimetric mean deviation (p=0.016), and papilledema grade (p<0.001). Conversely, Group 2 patients, who only underwent medical therapy, improved only in papilledema grade (p<0.001). However, coincident development of optic disc pallor was observed in three patients. Further, they also had significant loss in visual acuity (p=0.047) during the study period.
Conclusion: Weight reduction combined with medical treatment is associated with significantly better improvement in visual acuity, visual field, and papilledema in idiopathic intracranial hypertension patients. Compliance with an efficient diet program should be encouraged in overweight patients with idiopathic intracranial hypertension.

Keywords: Obesity/complications; Intracranial hypertension; Body mass index; Weight loss; Visual acuity; Visual field

Purpose: To assess scientific production related to ophthalmology and vision in Latin America during the period from 2006 to 2015.
Methods: The PubMed, Lilacs (Bireme), Google Scholar, SciELO, and Medigraphic databases were evaluated for this retrospective, descriptive, and comparative study.
Results: A total of 1,510 articles was identified. Brazil was the leader in quantitative production in ophthalmology, averaging 85.4 articles per year. Mexico was in second place with 27.4, and Argentina was in third place with 11.1 articles per year. Forty-one percent of articles were published in English, 28.1% dealt with the subspecialty of the retina, and 63% were published by researchers affiliated with universities. The frequency of male first authors was 58.9%, and the journal Arquivos Brasileiros de Oftalmologia accounted for 36.42% of the identified articles.
Conclusions: Brazil stands in first place in Latin America in ophthalmologic scientific production. Nearly half of the researchers in ophthalmology in Latin America included in our study were listed in databases other than PubMed.

Keywords: Bibliometrics; Scientific and technical activities; Ophthalmology

Purpose: To describe a new method for measuring anomalous head positions by using a cell phone.
Methods: The photo rotation feature of the iPhone^® PHOTOS application was used. With the patient seated on a chair, a horizontal stripe was fixed on the wall in the background and a sagittal stripe was fixed on the seat. Photographs were obtained in the following views: front view (photographs A and B; with the head tilted over one shoulder) and upper axial view (photographs C and D; viewing the forehead and nose) (A and C are without camera rotation, and B and D are with camera rotation). A blank sheet of paper with two straight lines making a 32-degree angle was also photographed. Thirty examiners were instructed to measure the rotation required to align the reference points with the orthogonal axes. In order to set benchmarks to be compared with the measurements obtained by the examiners, blue lines were digitally added to the front and upper view photographs.
Results: In the photograph of the sheet of paper (p=0.380 and a=5%), the observed values did not differ statistically from the known value of 32 degrees. Mean measurements were as follows: front view photograph A, 22.8 ± 2.77; front view B, 21.4 ± 1.61; upper view C, 19.6 ± 2.36; and upper view D, 20.1 ± 2.33 degrees. The mean difference in measurements for the front view photograph A was -1.88 (95% CI -2.88 to -0.88), front view B was -0.37 (95% CI -0.97 to 0.17), upper view C was 1.43 (95% CI 0.55 to 2.24), and upper view D was 1.87 (95% CI 1.02 to 2.77).
Conclusion: The method used in this study for measuring anomalous head position is reproducible, with maximum variations for AHPs of 2.88 degrees around the X-axis and 2.77 degrees around the Y-axis.

Keywords: Smartphone; Strabismus; Nystagmusm physiologic; Head; Torticollis

Purpose: To compare postoperative changes in retinal nerve fiber layer thickness in patients with macular holes treated with vitrectomy with Brilliant Blue-assisted internal limiting membrane peeling.
Methods: Twenty-two eyes of 20 patients with macular holes were studied. Each eye was selected to undergo Brilliant Blue-assisted internal limiting membrane peeling. The circumferential retinal nerve fiber layer thickness was determined using spectral domain optical coherence tomography preoperatively and 2 months postoperatively. Mean overall and sectoral retinal nerve fiber layer thicknesses were obtained for each patient.
Results: There was no statistically significant difference (p≥0.05) between the pre- and post-treatment measurements in relation to each CFN variable, i.e., on average, pre-treatment measures were the same as post-treatment measures. Furthermore, despite the differences between the pre- and post-treatment measures always being positive (pre-post >0), they are not statistically significant.
Conclusions: This study showed no significant decrease in retinal nerve fiber layer thickness measurements after macular holes surgery, regardless of age or sex.

Keywords: Nerve fibers; Retinal perforations/surgery; Retinal nerve fiber layer thickness; Macular hole

Purpose: To report the results of high-resolution anterior segment optical coherence tomography of patients implanted with a type 1 Boston keratoprosthesis (KPro).
Methods: The retrospective study cohort included 11 eyes of 11 patients (average age, 58.4 years; range, 34-83 years). All subjects underwent anterior segment optical coherence tomography at a single posteoperative time point. The main outcome measures were retro-backplate and retro-optic membrane formation, thinning and gap formation of the corneal carrier graft (melting), and degree of angle closure.
Results: Preoperative diagnoses included chemical burn (55%), failed corneal transplant (36%), and Stevens-Johnson syndrome (9%). The mean postoperative follow-up duration was 38.5 (range, 12-72) months. The most frequent findings of anterior segment optical coherence tomography were retroprosthetic membrane formation (63%, 7/11), thinning of the corneal carrier graft (melting; 55%, 6/11), and a narrow or closed angle (91%, 10/11). Other less common findings were epithelial growth over the optic surface and periprosthetic cyst formation. Retroprosthetic membrane formation was observed in all patients with melting (6/11).
Conclusions: Detailed postoperative examination and visualization of subtle changes of keratoprosthesis implanted eyes by slit lamp biomicroscopy are often difficult. Anterior segment optical coherence tomography is a useful, noninvasive, and quantitative imaging technique that provides useful information to postoperatively monitor the anatomic stability of an implanted keratoprosthesis.

Keywords: Keratoprosthesis; Corneal diseases; Visual prosthesis; Optical coherence tomography; Anterior eye segment

Purpose: This study aimed to share the results of patients who underwent anterior tarsal flap rotation combined with anterior lamellar reposition because of cicatricial upper eyelid entropion, and to determine the effectiveness and reliability of this surgical technique.
Methods: Fifteen eyes of 11 patients (2 right eyes; 5 left eyes; and 4 bilateral eyes) on whom we performed anterior tarsal flap rotation surgery combined with anterior lamellar reposition because of cicatricial entropion were included in this study. The medical records of the patients were analyzed retrospectively, and the causes of cicatricial entropion as well as the preoperative and postoperative ophthalmic examination findings were recorded. Normal anatomical appearance and function of eyelid were considered to have been achieved.
Results: The mean age was 59.81 ± 18 years. The mean follow-up period was 21.72 ± 14 months (range, 5-43 months). The causes of cicatricial entropion were postoperative cicatrices development due to multiple electrolyzes for trichiasis and/or distichiasis in 7 eyes, trachoma in 6 eyes, and trauma in 2 eyes. Irritation and watering were detected in all patients preoperatively, whereas corneal opacity and erosion were detected in 10 patients and epithelial erosion was detected in one patient. Full anatomical and functional success was achieved for all patients.
Conclusion: Anterior tarsal flap rotation combined with anterior lamellar reposition in the repair of cicatricial entropion was found to be an effective and reliable alternative surgical procedure.

Keywords: Trachoma/complications; Eyelids/surgery; Entropion/surgery; Cicatrix; Surgical flaps; Ophthalmologic surgical procedures/methods

Purpose: To investigate the potential effects of chronic exposure to a nasal decongestant and its excipients on ocular tissues using an experimental rat model.
Methods: Sixty adult male Wistar rats were randomized into six groups. The first two groups were control (serum physiologic) and Otrivine^® groups. The remaining four groups received the Otrivine excipients xylometazoline, benzalkonium chloride, sorbitol, and ethylene diamine tetra acetic acid. Medications were applied into both nostrils twice a day for 8 weeks. Before the rats were sacrificed, epithelial staining, the Schirmer test, and intraocular pressure measurements were performed under ketamine/xylasine anesthesia (50 and 5 mg/kg, respectively).
Results: Epithelial defects and dry eye were common findings in all study groups. Cataracts developed in two cases clinically. Histopathological evaluation revealed many different pathological alterations in all parts of the ocular tissues such as corneal edema, polypoid proliferation and hyalinization of the vessel wall, cystic formation of the lens, retinal nerve fiber layer degeneration, and corpora amylacea formation of the lacrimal gland.
Conclusions: Prolonged usage of the nasal decongestant xylometazoline and its excipients may cause ophthalmic problems such as dry eyes, corneal edema, cataracts, retinal nerve fiber layer, and vascular damage in rats. Although these results were obtained from experimental animals, ophthalmologists should keep in mind the potential ophthalmic adverse effects of this medicine and/or its excipients and exercise caution with drugs containing xylometazoline, ethylene diamine tetra acetic acid, benzalkonium chloride and sorbitol for patients with underlying ocular problems.

Keywords: Nasal decongestants/adverse effects; Animal, model; Tissues/drug effects; Eye/drug effects; Rats

We report a case of central corneal perforation treated with an autologous lamellar scleral graft and histologic findings obtained after a subsequent penetrating keratoplasty. A corneal perforation within a large Pseudomonas ulcer in a 55-year-old male rigid gas permeable contact lens wearer was sealed by a lamellar scleral graft from the same eye, followed by an uneventful penetrating keratoplasty 6 months later. Histology of the excised button revealed that the well-apposed graft, which maintained the irregular arrangement of the scleral collagen fibers, was embedded in the corneal stroma over the deep blood vessels and a rupture in Descemet's membrane. The clinical and histologic findings showed that autologous lamellar scleral grafts can be successfully used for the emergency treatment of corneal perforation when a corneal transplant is not available. The distinctive scleral structure revealed by histology and the inadequate graft transparency indicate that visual rehabilitation of eyes with a central corneal perforation can be achieved only by a subsequent optic penetrating keratoplasty.

Keywords: Corneal injuries; Corneal transplantation; Sclera/transplantation; Transplantation, autologous; Keratoplasty, penetrating

This study reports the first case of intravitreal angiostrongyliasis in South America treated with posterior worm removal via pars plana vitrectomy. This was a retrospective, observational case study. Data from medical charts, wide-field digital imaging, ocular ultrasound, and visual evoked potential studies were reviewed. A 20-month-old boy presented with eosinophilic meningitis and right eye exotropia. Polymerase chain reaction analysis of the cerebrospinal fluid showed a positive result for Angiostrongylus cantonensis. Fundus examination revealed a pale optic disc, subretinal tracks, vitreous opacities, peripheral tractional retinal detachment, and a dead worm in the vitreous cavity. The patient underwent pars plana vitrectomy with worm removal. This case report illustrates the first case of intravitreal angiostrongyliasis in South America, possibly related to the uncontrolled spread of an exotic invasive species of snail.

Keywords: Angiostrongylus cantonensis; Eye diseases/parasitology; Vitrectomy; Case report; South America

We report intraoperative finding of Granular Corneal Dystrophy Type-1 (GCD1) deposits after stromal pneumodissection in deep anterior lamellar keratoplasty (DALK) in a 61-year-old female. Pneumodissection was performed from the center to the periphery of the cornea, characterizing a big bubble type 1 technique which dissects the deep stroma from the predescemetic layer. After stromal removal, persistence of whitish deposits inside the predescemetic layer was noted. During post-operative evaluation, anterior biomicroscopy and anterior segment optical coherence tomography showed granular opacities between the patient's Descemet's membrane and the donor cornea, suggesting possible involvement of the predescemetic layer in GCD1. This may require the surgeon's attention to choose between DALK keratoplasty or penetrating keratoplasty.

Keywords: Corneal dystrophies, hereditary; Corneal transplantation; Cornea; Corneal diseases; Descemet membranes

Recurrent idiopathic neuroretinitis is an inflammatory optic neuropathy characterized by optic nerve edema and macular star, associated with painless and recurrent episodes of visual loss, poor visual prognosis, and visual field defects related to nerve fiber layer injury. The disorder is sometimes mistaken for atypical optic neuritis. However, early diagnosis is important for visual recovery. Long-term immunosuppression has been shown to reduce the rate of recurrence and protect against severe and irreversible vision loss.

Keywords: Retinitis; Optic nerve diseases; Optic disk; Anti-inflammatory agents; Immunosuppression; Recurrence

Eye banks use sterile procedures to manipulate the eye, antiseptic measures for ocular surface decontamination, and rigorous criteria for donor selection to minimize the possibility of disease transmission due to corneal grafting. Donor selection focuses on analysis of medical records and specific post-mortem serological tests. To guide and standardize procedures, eye bank associations and government agencies provide lists of absolute and relative contraindications for use of the tissue based on donor health history. These lists are guardians of the Hippocratic principle "primum non nocere." However, each transplantation carries risk of transmission of potentially harmful agents to the recipient. The aim of the procedures is not to eliminate risk, but limit it to a reasonable level. The balance between safety and corneal availability needs to be maintained by exercising prudence without disproportionate rigor.

Keywords: Eye banks/standards; Corneal transplantation; Donor selection; Tissue and organ harvesting