VOLUME 64 - ISSUE 5

Purpose: To establish the prevalence of refractive errors and ocular disorders in preschool and schoolchildren of Ibiporã, Brazil. Methods: A survey of 6 to 12-year-old children from public and private elementary schools was carried out in Ibiporã between 1989 and 1996. Visual acuity measurements were performed by trained teachers using Snellen's chart. Children with visual acuity <0.7 in at least one eye were referred to a complete ophthalmologic examination. Results: 35,936 visual acuity measurements were performed in 13,471 children. 1.966 children (14.59%) were referred to an ophthalmologic examination. Amblyopia was diagnosed in 237 children (1.76%), whereas strabismus was observed in 114 cases (0.84%). Cataract (n=17) (0.12%), chorioretinitis (n=38) (0.28%) and eyelid ptosis (n=6) (0.04%) were also diagnosed. Among the 614 (4.55%) children who were found to have refractive errors, 284 (46.25%) had hyperopia (hyperopia or hyperopic astigmatism), 206 (33.55%) had myopia (myopia or myopic astigmatism) and 124 (20.19%) showed mixed astigmatism. Conclusions: The study determined the local prevalence of amblyopia, refractive errors and eye disorders among preschool and schoolchildren.

Keywords: Eye infections; Refractive errors; Blindness; Amblyopia; Preschool child; Visual acuity

Objective: To evaluate the effect of the deep lamellar keratoplasty technique in preserving Descemet's membrane and the patient's endothelial cells, using corneoscleral donor button. Methods: 14 lamellar keratoplasties were performed with viscodissection of the receptor's Descemet's membrane using 4% chondroitin sulphate and 3% sodium hyaluronate. Ten (10) patients presented advanced keratoconus, 3 had herpes simplex leucoma and 1 had corneal irregularity due to a previous radial keratotomy. Postoperative follow-up varied from 12 to 48 months (average 24 ± 10.5 months). Results: After all sutures had been removed, the spherical equivalent on the last ophthalmic examination was -2.0 ± 3.6 diopters (D) (-10,3 D to +4,74 D). Final astigmatism varied from -6,0 CD to -0,75 CD with an average of -3,3 ± 1,9 CD. Twelve of 14 patients presented a best spectacle corrected visual acuity of 20/40 or better on the last examination. All patients gained Snellen lines. Postoperatively there was no corneal edema, endothelial decompensation, rejection, interface opacity nor deposits. Two patients developed Descemet's folds accounting for low visual acuity. Conclusion: In spite of technical difficulties related to lamellar keratoplasty and viscodissection of Descemet's membrane, we believe that this is a procedure of choice in patients whose endothelial cells population is preserved. This technique results in better final visual acuity when compared to the traditional lamellar transplant, and less immunologic reaction when compared to penetrating keratoplasty. Because the receptor's endothelium was preserved, surgeries resulted in transparent corneas, regardless of the donor's tissue quality.

Keywords: Corneal transplantation; Descemet's membrane

Purpose: To evaluate the possible alterations of the retinal nerve fiber layer (RNFL), as detected by scanning laser polarimetry (SLP), that may occur in patients with migraine with aura. Methods: Twenty patients with migraine with aura and twenty normal subjects were studied. Inclusion criteria for the two groups included age of at least 18 years, no history of any ocular disease except refractive error or strabismus, and no family history of ocular hypertension or glaucoma. Potential subjects underwent a comprehensive eye examination. Exclusion criteria included refractive error greater than 5 DS and/or 2 DC, best-corrected visual acuity less than 20/40, intraocular pressure greater than 21 mmHg, abnormal optic discs, cup-to-disc ratio (C/D) greater than 0.5 or asymmetry between C/D of the two eyes greater than 0.2, or any other concomitant retinal pathology. The patients were submitted to a Humphrey Field (30-2) examination and RNFL analysis using the GDx Nerve Fiber Analyzer. One eye from each patient was randomly selected for statistical analysis. Results: None of our controls had any visual field defects. Nine eyes (45%) from migraine patients had visual-field abnormalities beyond 95% normal confidence limits, as indicated by MD, CPSD or GHT. The retardation values of the superior nerve fiber layer of migraine patients were significantly lower than values in normal patients (p=0.005). No significant differences were observed in global, inferior, temporal and nasal measurements between the two groups. Conclusions: In this study, the RNFL measurements were significantly lower in the superior retina of migraine patients, indicating that these patients might have migraine-related ischemic damage of nerve fibers.

Keywords: Nerve fibers; Retina; Migraine, classic; Lasers

Purpose: Identification of the perception that teachers belonging to the public education system have concerning the refractive errors in the eye occurring at school age in order to subside training programs for teachers aiming at the detection of, and subsequent assistance to, ophthalmic problems in schoolchildren. Methods: A transversal study carried out with a population of first-degree elementary school teachers, covering all public schools of the southern region of São Paulo, Brazil. A structured questionnaire based on an exploratory story was handed out. Results: The population comprised 545 subjects distributed among 120 elementary schools. The average age of the population was 37.8 years, with an average length of teaching time of 13.2 years. The majority of them (67.4%) did not receive orientation on ocular health in the last three years. The teachers distinguished more accurately the symptoms of myopia (70.8%) than those of hyperopia (42.9%) and astigmatism (40.9%). A significant number (48.5%) of them pointed out signals and behaviors indicative of the presence myopia in schoolchildren; 40.9% indicated difficulties in reading and writing in hyperope children without optical correction. "Blurred vision" (45.4%) and disinterest for activities demanding visual effort (40.9%) were the most indicated manifestations in astigmatic children. All refractive errors in the eye were classified as very serious disorders by the teachers. Conclusion: Distorted and/or insufficient knowledge was disclosed among elementary school teachers, about refractive errors occuring at school age.

Keywords: Refractive errors; Ophthalmology; Visual acuity; School health; Health promotion; School health services

Purpose: There are few Brazilian studies about canaliculus obstruction etiology. To analyze the various etiologies of the obstruction was the goal in the present study. Methods: The study was carried out on 63 lacrimal apparatus of 59 patients who were submitted to external examination, biomicroscopy, Jones' I and II tests and canaliculus measurement. Results: The most important etiologies were chronic dacryocystitis and failure of dacryocystorhinostomy (53.9%) followed by traumatisms caused by aggression, car accidents and a dog bite. Agenesis contributed with 9.5% and less frequent were canaliculus inflammations and infections, surgeries, radiotherapy and idiopathic obstructions. Conclusions: There is no diference between the findings of this study and those re-ported in the international literature.

Keywords: Lacrimal duct obstruction; Lacrimal duct obstruction; Dacryocystitis; Dacryocystorhinostomy; Eye injuries

Purpose: To compare the efficacy of three types of treatment for strabismus: surgery, unilateral and bilateral botulinum toxin injections. Methods: To compose groups I and II, a prospective study was carried out observing the pretreatment measurement of the deviation, repeated after 7, 30 and 90 days after the injection. To compose group III, a retrospective study was carried out. Results: The percentage of horizontal deviation correction for distance, in 3 months, was: group I = 50.9%; group II = 55.8%, and group III = 77.0%; for near, 48.6%, 49.2% and 72.8% respectively.The therapeutic success rate, defined as residual deviation of 10 PD (prism diopter) or less, was: group I = 57.1%; group II = 68.4% and group III = 72.4%.Conclusions: There were no statisticaly significant differences between the percentage of deviation correction and success rate between the three types of treatment studied.

Keywords: Strabismus; Botulinum toxin type A; Case report

Purpose: To determine the efficacy of the diode laser and its complications in treating retinopathy of prematurity, at stage 3, threshold. Methods: One hundred and fifty-two children, out of 348 premature infants examined at the Ophthalmologic Clinic of the Getúlio Vargas Hospital and Instituto de Olhos do Piauí, in Teresina - Piauí, from July '89 to March '99, had retinopathy of prematurity. Those with retinopathy of prematurity at stage 3, threshold, were submitted to application of diode indirect laser to the retina. Results: Twenty children (38 eyes) received diode laser. Twelve patients showed regression of retinopathy and three children developed stage 5. No ocular complications were observed. Five children had respiratory failure due to anesthesia. Conclusions: The diode laser treatment was successful in 80.0% of the patients. The complications were possibly related to the general anesthesia.

Keywords: Retinopathy of prematurity; Light coagulation; Lasers; Infant, newborn; Infant, premature

Purpose: To evaluate and compare the efficacy and tolerance to the topical use of 0.05% ketotifen fumarate and 0.1% olopatadine hydrochloride in the treatment of patients with allergic conjunctivitis. Methods: A masked, randomized clinical study was performed in order to compare the efficacy, safety and side effects of the use of 0.05% ketotifen fumarate and 0.1% olopatadine hydrochloride ophthalmic solutions for the alleviation of symptoms and signs in patients with allergic conjunctivitis. Thirty-four patients, fulfilling the inclusion criteria of the protocol were divided into two groups and received a flask with the masked drug, instilling one drop twice daily in each eye for 30 days. Signs and symptoms of these patients were evaluated on a visit before treatment and on five visits during the treatment (days 1, 2, 7, 14 and 30). Results: Severity of allergic conjunctivitis was the same in both studied groups. Both ketotifen and olopatadine were equivalent and efficient regarding decrease in itching, burning and lacrimation symptoms. Bulbar conjunctival hyperemia was attenuated in both groups. Evaluation of adverse reactions showed the occurrence of burning on administration of both drugs and ketotifen led to occurrence of itching. No hypersensitivity reaction to the studied drugs was observed. Conclusions: This study evidences that 0.05% ketotifen fumarate and 0.1% olopatadine hydrochloride ophthalmic solutions, when instilled twice daily for 30 days, were efficient and safe regarding alleviation of the main symptoms and signs of allergic conjunctivitis.

Keywords: Ketotifen; Dibenzoxepins; Ophthalmic solutions; Conjunctivitis, allergic

Purpose: To determine ultrasonographic findings in patients with clinical diagnosis of endophthalmitis, a severe purulent inflammatory reaction confined to the interior of the eye. Methods: Ultrasound examination was performed (10MHz transducer, UltraScan® ALCON), during the period of 1997 to 1999. Results: We analyzed 25 eyes with a clinical diagnosis of endophthalmitis (23 exogenous, 2 endogenous). Twelve (12/23) were post-surgery (7 post-cataract surgery, 4 post-glaucoma surgery and 1 post-keratoplasty). Six followed penetrating trauma and 4 were after corneal ulcer. One patient had corneal suture and cataract surgery after penetrating trauma. Two of them presented low-reflectivity echoes, similar to the normal vitreous, and endophthalmitis was ruled out at that time. Twenty-three cases presented (at different degrees) vitreous involvement with low-mobility dense membranes, vitreous organization and vitreous cavitation. Diffuse choroidal thickening (12 cases), choroidal and/or retinal detachment (8 and 5 cases) and orbital abscess (1 case) were found. Conclusions: Ultrasound examination is important to help in clinical suspected endophthalmitis in order to determine the involvement of the posterior segment.

Keywords: Endophthalmitis; Eye infections; Ultrasonics

Purpose: To evaluate contact lens (CL) adaptation and sales in optician stores of 4 cities in São Paulo State, Brazil. Methods: A study was performed in view of the answers to a questionnaire applied by four medical students to optician stores selling contact lenses in four cities of the state of São Paulo. The researchers evaluated the need of medical prescriptions for contact lens sales, the specialist in charge of selling and/or adapting contact lenses, the types of lenses sold/adapted, the equipment used in the contact lens tolerance test, the patient's behavior facing contact lens complications during adaptation or during its use; the information given about possible signs and symptoms of risk and the patient's hygiene, as well as the number of hours of contact lens wear and their wearing during sleep. Results: Of the 198 investigated optician stores, 121 (61.11%) sell contact lenses. In 112 (92.56%) of the stores, medical prescription was not required for the purchase of lenses. In these stores, the contact lens degrees were determined by measuring glass lenses in 69 (61.61%) of the cases and by verbal report in 28 (25.00%) cases. Concerning equipment, 102 (91.07%) of the stores had lensometers, 41 (36.61%) had keratometers and 14 (12.50%) had slit lamp. Soft disposable contact lenses were displayed for sale/adaptation in 66 (54.55%) of the stores, so were soft extended and daily use contact lenses in 68 (56.20%) stores and hard contact lenses, in 54 (44.63%) stores. In 103 (85.12%) stores, tolerance test was done, and the responsible persons for seeing the patient and for monitoring were professionals who called them selves contact lens fitters in 78 (64.46%) of these stores, the shop assistant in 20 (16.53%), the optician in 12 (9.92%) and the ophthalmologist in 9 (7.44%). As to complications due to contact lens adaptation, 66 (54.55%) stores mentioned that they would happen only if they happened on the tolerance test; in 35 (28.93%) stores, an ophthalmologist was advised for treatment and in 20 (16.53%) stores, a return was suggested for information on treatment. Only in 15 (13.39%) stores, professionals warned about possible risk symptoms and in 13 (11.61%) stores, they were concerned about diseases, which contraindicate contact lens wear. In 105 (93.75%) of the stores, professionals did not pay full attention to contact lens hygiene, wearing hours and lens wearing during sleep. Conclusion: Of the 198 investigated stores, 61.11% sell contact lenses, and 92.56% did not require medical prescription; 14.88% did not perform any kind of tolerance test and the remaining 85.12% performed tests which are normally not sufficient to detect alterations induced by contact lenses. There was no concern about contraindications, risk signs and symptoms, evaluation of possible complications resulting from contact lens wear. Neither was there concern about the least hygiene care during the tolerance test. Professionals, who call themselves contact lens fitters, shop assistants, opticians and ophthalmologists, which were responsible for adaptation give no appropriate instructions about contact lens wear and, in many cases, none about contact lens hygiene.

Keywords: Contact lenses; Contact lenses; Extended-wear contact lenses; Hydrophilic contact lenses; Cornea; Disposable equipment; Accomodation, ocular; Optician stores; Questionnaires

Methods: Four eyes of 4 patients presenting post-trabeculectomy with mitomycin-A complications (leaking blebs, 3 eyes, and inadvertent filtering bleb, 1 eye) underwent bleb reconstruction with amniotic membrane. Results: Mean follow-up time was 5.75 months (range, 2 to 9 months). Complete resolution was achieved in all cases. In one case it was necessary to add cyanoacrylate tissue adhesive and place a therapeutic contact lens. The epithelialization occurred within 14.75 days (range, 8 to 21 days). Visual acuity improved in 1 patient and did not change in the other 3 cases. Intraocular pressure remained under control in all patients with the additional use of topical antiglaucomatous medication. Conclusions: The use of amniotic membrane seems to represent a viable option for the treatment of post-trabeculectomy leaking and inadvertent filtering blebs that were resistant to conventional therapy. More cases are necessary for further analysis and to refine the technique.

Keywords: Biological dressings; Trabeculotomy

Purpose: To evaluate the changes due to aging in normal human lens density and thickness, and in anterior chamber depth. Methods: Using Scheimpflug image processing, 120 eyes of 60 patients were examined. The patients were divided into 6 groups, namely, Group I, 10 to 19 years old; Group II, 20 to 29 years old; Group III, 30 to 39 years old; Group IV, 40 to 49 years old; Group V, 50 to 59 years old; and Group VI, 60 to 69 years old. Anterior chamber depth, density and thickness of lens were analyzed. The densitometry was performed dividing the lens into five areas: anterior capsular (area 1), anterior cortical (area 2), nuclear (area 3), posterior cortical (area 4) and posterior capsular (area 5). These were correlated with age. Results: The anterior chamber depth decreased and the lens thickness increased with age. The lens density also increased with age, except in area 5, where values decreased. There was a strong positive correlation between increasing age and the density in all lens areas (area 1: r = 0.78, p<0.001; area 2: r = 0.87, p<0.001; area 3: r = 0.88, p<0.001; and area 4: r = 0.70, p<0.001) except in the posterior capsular area, where correlation was negative (area 5: r = -0.62; p<0.001). In addition, there was a significant correlation between increasing age and lens thickness (r = 0.73; p<0.001). Correlation between age and anterior chamber depth (r= -0.34; p<0.001) was negative. The correlation coefficient for lens thickness and anterior chamber depth was also negative (r = -0.60; p<0.001). Conclusions: This study shows changes due to aging in human lens density and thickness as well as in anterior chamber depth using Scheimpflug system. These findings should be considered when studying anticataractogenic drugs, cataractogenic potential of drugs and cataract patients.

Keywords: Anterior chamber; Crystalline lens; Aging; Cataract; Photography; Anterior eye segment

Purpose: To describe the clinical and social profile of recipient patients of transplanted corneas, and to evaluate main indications for corneal transplants, waiting time for donor tissue, and percentages of success, rejection and failure of penetrating keratoplasty. Methods: Retrospective chart review of 87 patients submitted to penetrating keratoplasty at the Santa Casa of Porto Alegre, between January, 1990 and December, 1998 totalling 91 eyes. Fifty-six of these patients were called at the time of data analysis, for a clinical evaluation of the graft. Results: Of the 91 keratoplasties in 87 patients, 53 (60.9%) were performed in males and 34 (39%) in females. The age of these patients varied between 3 and 89 years, with an average of 42.3±19.8 years. The main indications for penetrating keratoplasty at this Ophthalmology Department was keratoconus in 32 (35%) eyes, bullous keratopathy (after cataract extraction, Fuchs dystrophy, etc) in 24 (26.4%), mechanical trauma in 9 (9.9%), infection in 9 (9.9%), chemical burn in 2 (2.2%), thermal burn in 1 (1.1%) and other causes in 14 (15.6%) patients. The waiting time for donor tissue was 17.3±9.9 months. Of the 91 studied keratoplasties, 25 (27.5%) presented with rejection and 12 (13.2%) patients presented corneal graft failure. Conclusions: This study showed the epidemiology of patients submitted to penetrating keratoplasties. It was not possible to analyze postoperative results and to compare them with other studies since there were no available data due to premature discharge or loss of follow-up of patients.

Keywords: Cornea; Corneal transplantation; Penetrating keratoplasty; Corneal transplantation; Graft survival; Organ donors

Purpose: To identify the principal reactions of children facing strabismus surgery information as a result of its immediate and recent indication on medical consultation. Methods: Intervention/Action during Research; interview after surgery indication. Results: Anxiety and fear were the most important feelings encountered. They were sustained by partial concepts formed about surgery due the different levels of cognitive development of the children. The motivation for the surgery itself was only recognized among subjects older than 9 years. Children with less age had their surgery motivation mixed with the adults' purposes, especially parents, around them. Conclusions: The special meaning of this data seems to be that the symbolic function should be considered to psychologically prepare children for the surgery, in both directions: cognitive and emotional representation.

Keywords: Strabismus; Strabismus; Anxiety; Fear; Cognition; Parent-child relations; Child behavior disorders; Patient participation

The authors report the case of a 27-year-old male patient with Alport syndrome. Prior to the surgical treatment of the visual deficit by phacoemulsification of the lens and IOL implantation, the patient had been submitted to renal transplantation with total recovery of renal function. Visual acuity post-surgery was 20/20 in both eyes. The authors present a short description of the etiopathology, clinical signs and diagnostic criteria of the syndrome.

Keywords: Hereditary nephritis; Hereditary nephritis; Hereditary nephritis; Visual acuity; Case report

The authors report a case of an adult patient infected with the human immunodeficiency virus (HIV) who presented with retinal toxicity due to didanosine. Didanosine is a reverse transcriptase inhibitor used in AIDS treatment. The association of didanosine and retinal toxicity is well established in children although it is very rare in adults.

Keywords: Retinal diseases; Retinal diseases; Acquired immunodeficiency syndrome; HIV infection; Didanosine

The authors report a case of a 2-year-old child with a probable diagnosis of congenital left VI nerve palsy. Surgical correction was performed OS: large medial rectus recession and large lateral rectus resection were carried out. Findings during surgery and final outcome support the diagnosis of congenital VI nerve palsy.

Keywords: Paralysis; Cranial nerve diseases; Differential diagnosis; Case report

The autors present a confirmed case of diffuse unilateral subacute neuroretinitis (D.U.S.N.) with identification of the worm in a 6-year-old child with symptoms of cutaneous larva migrans, as well as analysis of 7 other cases of D.U.S.N. and association with cutaneous larva migrans or positive sorology for Toxocara canis. This is the first described case in the literature of the association between D.U.S.N. and cutaneous larva migrans in its active form.

Keywords: Optic neuritis; Retinitis; Eye infections; parasitic larva migrans; Ancylostoma

Myasthenia gravis is a chronic disease characterized by abnormal fatigability of striated muscles which may involve isolated muscle groups or become generalized. The authors report a case of generalized congenital myasthenia gravis and partial ophthalmoplegia involving a 10-year-old boy with systemic symptoms of absence of adduction, abduction and elevation in both eyes and with bilateral palpebral ptosis, and reduced infraversion function. The patient was diagnosed at two years and six months of age, when treatment with pyridostigmine was started at subtherapeutic doses, with no significant changes in clinical signs and symptoms. At four years of age, the patient was taken to this institution and the dose of his medication was adjusted, with significant improvement of systemic motor systems, partial improvement of palpebral ptosis, and no change in external ophthalmoplegia.

Keywords: Myasthenia gravis; Myasthenia gravis; Pyridostigmine bromide; Ophthalmoplegia; Blepharoptosis; Case report