VOLUME 64 - ISSUE 6

Purpose: To analyze the incidence, type, management and evolution of complications in laser in situ keratomileusis (LASIK). Methods: Retrospective non-comparative case series. LASIK was performed in 1000 eyes using the Hansatome® or the Automated Corneal Shaper® microkeratomes, and the VISX 20/20B or the Chiron Technolas 217C excimer lasers. Intraoperative, early and late postoperative complications were reviewed. Results: Mean preoperative spherical equivalent (SE) was -4.29 ± 3.20D. Average follow-up was 6.05 ± 6.69 months. There were 5 (0.5%) intraoperative microkeratome-related flap complications (3 thin flaps, 1 buttonhole and 1 small flap). The most frequent early postoperative complication was microwrinkled flaps (6.4%), followed by interface debris (4.1%), the non-diffuse intralamellar keratitis (1.1%), haze (0.4%), interface epithelial ingrowth (0.4%) and dislocated flaps (0.3%). Most of these reported events were successfully managed. Late refraction-related complications were analyzed in 655 eyes with a minimum follow-up of 3 months. At the last examination, mean SE was -0.26 ± 0.76D. Eight per cent were undercorrected by more than -1.00D and 1.67% was overcorrected by more than +1.00D. Reoperation was necessary in 28 eyes (4.27%). Five cases (0.76%) lost 2 or more lines of best spectacle corrected visual acuity. There were no sight-threatening complications. Conclusion: LASIK is a safe refractive procedure with few complications.

Keywords: Laser in situ keratomileusis; Laser in situ keratomileusis; Refractive errors; Prospective studies; Intraoperative complications; Postoperative complications

Purpose: To determine an eventual relationship between human lens thickness and age. Methods: Lens thickness and diameter were assessed by pachymetry and stereoscopic microscopy in 108 eyes donated for corneal graft. Results: Mean lens thickness was 3.73 mm with standard deviation of 0.73 mm and mean diameter was 8,96 mm with standard deviation of 0.41 mm. Sixty-three lenses (58.3%) were from female subjects and forty-five (41.7%) were from male subjects. There was no significant difference of lens diameter and thickness between genders. Age and lens thickness presented a significant direct correlation with a 54.86 mm mean increase between ages ten and ninety. This correlation was not observed in relation to the lens diameter. Conclusion: With age, lens thickness presented a significant increase among all studied age groups.

Keywords: Lens; crystalline; Age factors; Human

Purpose: To study high intravitreal dosage of ganciclovir (2000 or 4000 micrograms) in acquired immunodeficiency syndrome (AIDS) and cytomegalovirus retinitis. Methods: Prospective study for high dose intravitreal ganciclovir (2000 or 4000 micrograms) between 1996 and 1998 at the Federal University of São Paulo - Paulista Medical School in patients with diagnosis of AIDS, herpetic cytomegalovirus and intolerance to intravenous or oral treatment. Results: Of 1950 patients examined, 21 (1.07%) were intolerant to systemic treatment (ganciclovir or foscarnet). Of those, 21 with 37.1 years average age, corresponding to 31 eyes were treated with intravitreous medication. Seventeen patients (81%) were male. Of the 21 patients, 11 (14 eyes) received 2000 µg intravitreous medication and 10 (17 eyes) received 4000 µg. In the beginning of the treatment 100% of the patients showed low vision. At the end of the treatment (22 weeks on average), group I (intravitreous medication 2000 µg) showed increase of visual acuity (VA) in 35.7%, the same VA in 50% and decrease of VA in 14.3% due to retinal detachment. In the group II (intravitreous medication 4000 µg) 58.8% had increased VA, 23.5% had the same VA and 17.6% had decrease of VA due to cataract and retinal detachment. Conclusions: Intravitreous injection of a high dose (2000 or 4000 micrograms/0,1 ml) of ganciclovir for the treatment of a CMV retinitis is satisfactory. The adverse effects are cataract and retinal detachment. The retinal detachment could not be conclusively attributed to the injections and was probably a secondary complication of cytomegalovirus retinitis.

Keywords: Acquired immunodeficiency syndrome; Cytomegalovirus retinitis; Ganciclovir; Injections; Vitreous body; Prospective studies

Purpose: Discuss the most important forms of treatment available nowadays and to report our experience with the surgical treatment of chronic canaliculitis. Methods: Retrospective study with 7 cases assisted at the Clínica Oftalmológica of HC-FMUSP in the last 3 years. Results: All the patients submitted to surgical treatment had complete cure of the signs and symptoms. Conclusions: We should always remember the possibility of canaliculitis in patients with epiphora and chronic secretion in the lacrimal punctum so that the appropriate surgical treatment can be established.

Keywords: Eye infection, bacterial; Actinomycetales infections; Lacrimal apparatus diseases; Chronic diseases

Purpose: Retrospective study of surgical results of the correction of horizontal strabismus in a University Hospital. Methods: In selected cases of comitant eso- and exotropias, without signs of oculomotor paralyses or restricted ocular rotations, surgeries of: recessions of both medial recti (group A), or both lateral recti (group C) were performed, recession-resection for esotropias (group B) or for exotropias (group D), with or without transpositions of the respective muscular insertions. Results: The number of esotropias was greater than that of exotropias (nA = 66; nB = 28; nC = 27; nD = 22) as well as surgeries in which transpositions were done (96) surpassed surgeries without transpositions (47). The distributions of the preoperative angles (m = 42.49D, s= 11.68D for esotropias; m= 35.38D, s= 9.93D for exotropias) and of the respective obtained corrections (m = 38.95D, s = 13.57D for esotropias; m = 31.64D, s = 14.58D for exotropias) were practically equivalent. In addition, high correlations were observed between the pre-op angles and the amount of the respective operations. However, the correlations between the pre-op angles and the proportional results of the surgeries (given in D/mm) were always low. The amount of corrections when residual angles of ±5D, ±10D and ±15D were considered reached respectively 31.9%, 62.8% and 80.8% for esotropias, and 40.8%, 55.1% and 73.5% for exotropias. Conclusions: Although the surgical plans and the respective operations give satisfactory results in a general analysis, the individual outcomes are highly unpredictable.

Keywords: Oculomotor muscles; Strabismus; University hospitals; Retrospective studies; Ophthalmologic surgical procedures; Eye movements

Purpose: To determine the importance of oblique muscle dysfunctions in the etiopathogeny of alphabetic syndromes ("A" and "V"); to determine which oblique dysfunction is more often associated with each alphabetic syndrome. Methods: 178 patients with eso/exodeviations and alphabetic syndromes ("A" or "V"), with or without oblique muscle dysfunctions, were retrospectivelly studied. Patients with special forms of strabismus (syndromes and paresis) and patients with previous strabismus surgery were excluded from the study. Results: 78 patients with "A" pattern were studied: 44 women and 34 men; 61 patients were 20 years old or younger and 17 patients were older; 59 eso- and 19 exodeviations; 58 patients with an "A" pattern of 30 prismatic diopters or smaller, 12 patients with "A" pattern diagnosed by the corneal reflex only and 8 patients with the variation greater than 30; oblique muscle dysfunctions were observed in 70 of the 78 patients studied (bilateral superior oblique overaction associated with bilateral inferior oblique underaction (31 cases) and isolated bilateral superior oblique overaction (12 cases) were more frequently found.One hundred patients with "V" pattern were studied: 58 women and 42 men; 77 patients were 10 years old or younger; 65 eso- and 34 exodeviations and 1 orthotropia; 71 patients with "V" ranging from 10 to 30 prismatic diopters; oblique muscle dysfunctions were found in 93 patients and isolated bilateral inferior oblique overaction (33 cases) and bilateral inferior oblique muscle overaction associated with bilateral superior oblique muscle underaction (30 cases) were more frequently observed. Conclusions: The results of this study confirm the importance of oblique muscle dysfunctions in the etiopathogeny of alphabetic syndromes.

Keywords: Oculomotor muscles; Anisotropy; Strabismus

Purpose: To evaluate the ocular alterations due to cataract surgery with IOL implant in leprosy patients and compare them with patients without leprosy. Methods: In this study, 122 leprosy patient eyes and 71 eyes from patients without leprosy underwent extracapsular cataract surgery and/or phacoemulsification with IOL implant and were examined periodically after the operation. Results: Ocular alterations due to surgery and IOL presence were found more often in leprosy patients. Conclusions: IOL used in leprosy patient is an appropriate procedure when we face patients with the disease handicaps.

Keywords: Lenses, intraocular; Cataract extraction; Leprosy

Purpose: To evaluate the efficacy of a product which is normally used for cleaning of contact lenses (CompleteÒ: polyhexamethylene biguanide (Tris ChemTM), Tyloxapol, USP, Tromethamine, USP, and Edetate disodium, USP, in sterile isotonic solution) in the disinfection of the cone of the applanation tonometer. Methods: The cone remained immersed in the solution for an average period of 28 minutes. A container for cleaning the contact lenses and a polystyrene support were used. At the end of each day, for 22 days, cultures for fungi and bacteria were carried out as well as direct examinations for fungi and Gram bacterioscopies for S. aureus. The bactericide and fungicide power of the product for S. aureus ATCC#25923, E. coli ATCC#25922, P. aeruginosa ATCC#27853, C. albicans ATCC#76615 and A. niger ATCC# 16404 was verified in vitro. Results: In the cultures, in the direct examination for fungi and in the bacterioscopy by Gram, microorganisms were not identified. In the study in vitro, 48 hours were necessary for the complete elimination of all studied bacteria. Conclusions: Bacteria and fungi were not found in any of the examinations carried out in the solution and in the receptacle despite the fact that the tests in vitro had demonstrated that the time of immersion of the head in the solution (average of 28 minutes) was insufficient for the complete elimination of the microorganisms, what makes the use of this product impractical in the disinfection of the plastic cone of the applanation tonometer.

Keywords: Tonometry; Disinfection; Equipment contamination; Disinfectants

Objectives: The present study compares the results obtained with single zone PRK versus multiple zones PRK for treating low myopia. Methods: Nineteen patients presenting spherical equivalent up to 6.00 diopters of myopia, were submitted to PRK using two different approaches. Ramdomly one eye received a 6.0 mm spherical ablation (SZ) while the fellow eye was treated with two optical zones, 6.0 mm and 6.5 mm (MZ). All the procedures aimed to correct total spherical equivalent. Follow-up was carried out for at least 6 months. Results: The multizone group (MZ) presented a preoperative mean spherical equivalent of -2.87 diopters, ranging from -1.25 to -4.62D. In the single zone group, the mean spherical equivalent was -2.78 diopters, ranging from -1.37 to -4.62D. No significant difference was observed between the two groups considering final spherical equivalent (p=0.391). In the first postoperative month, 84% of the patients in the MZ group and 95% in the SZ group presented uncorrected visual acuity equal to or better than 20/40. No difference was detected regarding time necessary to achieve best uncorrected vision. Conclusion: Results obtained using different ablation profiles were similar in regard to spherical equivalent, induced astigmatism and complications. A better final uncorrected visual acuity trend was observed in the SZ group but it was not considered clinically significant. We believe that any of the evaluated approaches are valued methods for treating low myopia.

Keywords: Keratectomy; Photorefractive; Excimer laser; Myopia

Purpose: This study was designed to evaluate the most frequent indications, as well as the results of final visual acuity (VA) after penetrating keratoplasty (PK), performed by residents. Methods: A consecutive series of 159 cases of PK was followed during the period from January 1991 to October 1998, at the Medical School of São Jose do Rio Preto - "Hospital de Base", in terms of indication for penetrating keratoplasty and final visual acuity. The minimum follow-up to assess the final visual acuity was 6 months. The cases of penetrating keratoplasty were divided into 6 groups of preoperative diagnosis for better comparison and statistical analysis of the final visual acuity. Such groups were: keratoconus, pseudophakic bullous keratopathy, aphakic bullous keratopathy, Fuchs' endothelial distrophy, band keratopathy and leukomas. All surgeries were performed by residents under supervision. Results: Keratoconus was the group that reached the highest average increase of postoperative lines of visual acuity (7.55 ± 2.83) and band keratopathy the smallest one (0.33 ± 3.20). A significant difference was observed among the indications for penetrating keratoplasty when compared to developed countries, where keratoconus is the most predominant indication. Our analysis revealed that the most important indications for penetrating keratoplasty in decreasing order were: leukoma, pseudophakic bullous keratopathy, keratoconus, Fuchs' endothelial distrophy, aphakic bullous keratopathy and band keratopathy. Conclusion: Keratoconus showed significant difference of final visual acuity levels (p value < 0,05) when compared to the other 5 groups of penetrating keratoplasty indications.

Keywords: Corneal opacity; Penetrating keratoplasty; Visual acuity; Developing countries; Hospital medical staff

Purpose: An experimental study to evaluate the behavior of polytetrafluoroethylene (Gore-Tex®) compared with human sclera, in scleral perforations induced in rabbits eyes was performed. Methods: Twenty-two eyes of rabbits were submitted to scleral perforation followed by Gore-Tex® graft in the left eye and human sclera graft in the right eye respectively. During one month the postoperative evolution was analyzed every day: intensity of hyperemia, presence of infection, secretion, rejection and tonicity of the eyes. Results: No cases of secretion, infection or rejection were observed. The histological sections showed fibrosis in the eyes with Gore-Tex®, good adhesion and epithelization. Conclusion: The Gore-Tex® showed to be a plausible material to be used as graft in scleral defects with some advantages such as easy obtention, good handling and durability.

Keywords: Sclera; Polytetrafluoroethylene; Sclera; Sclera; Rabbits

Background: Idiopathic juxtafoveolar retinal telangiectasis (IJT) group 2A occurs in the 5th or 6th decade of life and affects both sexes. The visual loss is associated with characteristic fundus findings that include pigment deposition in the macula. Purpose: To describe two cases with uncommon macular pigmentation. Method: Case report and discussion. Results: We demonstrated heavy pigment deposition in the macula of two patients who were previously misdiagnosed as having macular corioretinal scar. Pigment deposition enhancement was shown in the follow-up period of eight years in one patient. Conclusion: Group 2A IJT diagnosis may be difficult and should be considered based on the clinical features of the pigment deposits in the macula.

Keywords: Telangiectasis; Fovea centralis; Macula lutea; Pigment epithelium of eye; Retinal neovascularization; Fluorescein angiography; Fundus oculi; Differential diagnosis; Case report

Purpose: To describe the clinicopathological findings of a case of Melkersson-Rosenthal syndrome with monosymptomatic presentation. Methods: Review of the clinical chart and histopathological slides of the case. Results: The clinical diagnosis of Melkersson-Rosenthal syndrome was suspected by the presence of unilateral bipalpebral edema. The orbital computed tomography disclosed tissue thickening of both superior lids. Granulomatous lymphangitis was demonstrated histopathologically. The granulomas were present in the neighborhood and in the lumen of the lymphatic vessels. Conclusions: Melkersson-Rosenthal syndrome can occur in a monosymptomatic presentation. The histopathological demonstration of granulomatous lymphangitis confirmed the diagnosis. Systemic steroid therapy was efficient reducing the edema of the lids.

Keywords: Melkersson-Rosenthal syndrome; Melkersson-Rosenthal syndrome; Edema; Eyelids; Lymphangitis; X-ray tomography computed; Adrenal cortex hormones

The authors describe a case of Moebius syndrome associated with arthrogryposis multiplex congenita, a rare presentation, with no previous reports in the South American literature. The Moebius syndrome consists of VII and VI cranial nerves paralysis, usually associated with other musculoskeletal anomalies, often situated in the extremities. Arthro- gryposis multiplex congenita is generally characterized by rigidity and contracture of multiple joints and sometimes is associated with other congenital anomalies. The patient was a 3-year-old boy, presenting with convergent strabismus, ophthalmoplegia, VII cranial nerve paralysis and tongue musculature deficiencies, alterations consistent with Moebius syndrome. Associated with these alterations, musculoskeletal abnormalities consistent with arhrogryposis were found: hands and forearms in flexion and scapular muscular dystrophy. Surgical treatment was performed in order to correct convergent strabismus, with good follow-up. The authors suggest arthrogryposis investigation in all patients that present with Moebius syndrome, because this association is possibly being underdiagnosed.

Keywords: Moebius syndrome; Arthrogryposis; Strabismus; Ophthalmoplegia; Case report

Purpose: To report a patient with leishmaniasis with eyelid lesion and dilated lacrimal excretory system. Case report: This patient had mucocutaneous leishmaniasis with multiple skin lesions, ectropium of the inferior eyelid and alterations in the lacrimal excretory system. Discussion: Even though the eyelid and lacrimal ducts are infrequently affected in patients with leishmaniasis, the authors emphasized the necessity of preventing measures against the vector and early treatment.

Keywords: Leishmaniasis; cutaneous; Eyelids; Lacrimal apparatus; Case report

To describe the clinical and surgical therapeutic modalities in age-related macular degeneration (ARMD).

Keywords: Photochemoterapy; Macular degeneration; Porphyrins; Choroidal neovascularization; Age of onset

Kayser-Fleischer (K-F) rings are characterized by copper deposition on Descemet's membrane, mainly near the limbus. They are strongly associated with Wilson's disease and are the most common ocular finding in this disease. There is an association between the presence of the rings and the time of disease. The K-F rings are composed of small copper granulations of different sizes on the cornea. Wilson's disease is characterized by an accumulation of copper in the body, primarily in the liver. The occurrence of pigmented rings on the cornea not associated with Wilson's disease have been reported and must be differentiated from the K-F rings. They occur most often in hepatobiliary diseases, multiple myeloma and ocular copper containing foreign bodies. The purpose of this paper is to review the K-F rings and Wilson's disease.

Keywords: Hepatolenticular degeneration; Corneal diseases; Pigmentation disorders; Descemet's membrane