VOLUME 66 - ISSUE 1

PURPOSE: To report the findings in patients with clinical suspicion of ocular cicatricial pemphigoid (OCP) and to present the results of direct immunofluorescence investigation. METHODS: Prospective study performed at the Federal University of São Paulo. Clinical examination and conjunctival biopsies were performed in thirteen patients (26 eyes) who presented clinical evidence of OCP without systemic immunosuppression therapy or topic anti-glaucoma drug use. Immunofluorescence was immediately performed after obtaining biopsies. RESULTS: According to Foster's staging system, the proportions of eyes classified as stage I to IV were 3.8%, 3.8%, 77% and 15.4%, respectively. Only three (3) of thirteen (13) patients (23%) were positive on performing immunofluorescence technique. CONCLUSION: This study shows that the diagnoses of ocular cicatricial pemphigoid were established at advanced stages of the disease and that direct immunofluorescence presented low sensitivity in detecting immunoreactant deposition along the basement membrane of the conjunctiva, when compared to the literature.

Keywords: Benign mucousmembrane pemphigoid; Vesiculobullous skin diseases; Basement membrane; Conjunctiva; Direct fluorescent antibody technique

PURPOSE: To analyze the effectiveness of the treatment with Botox® and to study the behavior of these patients after successive applications, giving attention to the possible effect of tolerance after the persistent use of this medication. METHODS: A prospective study of 16 patient with facial dystonia, was performed in the Ophthalmic Plastic Department, of the "Hospital das Clínicas" of São Paulo University, from April l 998 to March 1999. All patients were submitted to ophthalmic examination, neurological examination and computerized tomography scan. The patients with important symptoms of spasm were treated with botulinum A toxin (Botox®). Ten patients were female. The mean age was 64.75 years. RESULTS: Hemifacial spasm (8 patients) was the most common form of facial dystonia. Success rate was 87.5%, the mean duration of the effect after the treatment was between 30 and 90 days. CONCLUSION: Treatment of facial spasm with botulinum A toxin was effective in 87.5% of our patients.

Keywords: Botulism toxin type A; Blepharospasm; Dystonia; Facial muscles

PURPOSE: The primary ocular targets of chronic graft-versus-host disease (GVHD) are the lacrimal gland (LG) and the conjunctiva, and their involvement results in keratoconjunctivitis sicca (KCS). The purpose of the present study was to evaluate the frequency of signs and symptoms of KCS present in patients submitted to BMT, to identify the cellular phenotype of the conjunctival and lacrimal gland biopsies of these patients by immunohistochemistry and to correlate the findings with the presence of dry eye due to GVHD. METHODS: Forty-seven patients were clinically classified into two groups: Group I, with ocular GVHD, submitted to allogeneic BMT and Group II, without ocular GVHD, submitted to autologous and allogeneic BMT. Thorough eye examination, including clinical lacrimal function tests and biopsies of the conjunctiva and of the LG were performed in the pre- and posttransplantation period. The biopsies were submitted to immunohistochemical analysis using a panel of monoclonal antibodies. RESULTS: Of the 28 (82.4%) patients with chronic GVHD, 13 (46.4%) presented ocular GVHD. Of the six patients without GVHD, one (16.7%) presented ocular GVHD. None of those submitted to autologous BMT presented ocular GVHD and 14 (41.2%) of 34 patients with allogeneic BMT presented ocular GVHD. All patients with ocular GVHD (Group I) had symptoms and the most frequent were burning, foreign body sensation, blurred vision and dryness. The rose bengal test was one of the most sensitive in this study and slit lamp examination was very useful in the evaluation of corneal and conjunctival alterations, since these alterations were always present in patients with dry eye in our study. Neither symptoms and signs of dry eye nor significant immunologic reaction was observed in the conjunctiva and in the LG of patients without ocular GVHD (Group II). There was an increase in the T lymphocyte population, of T helper lymphocyte (Th/i) and T suppressor-cytotoxic lymphocyte (Ts/c) subpopulation in the conjunctiva and in the LG of patients with ocular GVHD after the transplantation. CONCLUSIONS: Patients submitted to allogeneic BMT may develop ocular GHVD characterized by KCS. The immunohistochemical study of the conjunctiva and lacrimal gland biopsies of these patients suggested that these tissues are the target of the T cell mediated immunological reaction.

Keywords: Immunohistochemistry; Conjunctiva; Lacrimal apparatus; Bone marrow transplantation; Graft vs host disease

PURPOSE: To evaluate complications of allergic keratoconjuctivitis that caused reduction in visual acuity to 0.6 or less and that could not solve with clinic treatment. METHODS: We analyzed retrospectively 186 charts and selected patients with visual acuity less than 0.6 on Snellen chart, associated with secondary anterior segment alterations. Data collected from the charts were: age, gender, kind of allergy, time of disease, time that complication appeared after treatment in our Service, side effects and ocular complications. RESULTS: Complications of anterior segment that caused reduction in visual acuity were: shield ulcers, 5 cases; cataract, 3 cases; corneal opacity, 6 cases; ocular perforation, 2 cases and keratoconus 13 cases. There were 7 surgeries: 2 tectonic penetrating keratoplasty, 4 optic keratoplasty, 4 optic penetrating keratoplasty and one superficial keratectomy. CONCLUSION: Patients with allergic keratoconjunctivitis should be treated in order to prevent ocular complications like keratitis, keratoconus, opacities and cataract.

Keywords: Conjunctivitis, allergic; anterior eye segment

PURPOSE: To evaluate the knowledge and attitudes of intensive care physicians concerning corneal transplantation. METHODS: A questionnaire was answered by 100 intensive care physicians. RESULTS: All physicians knew about the procedure and were in favor of cornea transplantation, but only 57% had ever asked for a donation. Forty-four (44%) of all physicians did not feel able of answering questions by possible donors and all the physicians said to be interested in having more information about corneal transplantation. CONCLUSION: Information and education about transplantation in Medical Schools must be improved, in order to provide better understanding for intensive care physicians, in such a way that they could act more effectively when facing such situations.

Keywords: Corneal transplantation; Organ procurement; Knowledge, attitudes, practice; Physician's role

PURPOSE: To evaluate the indications, techniques and findings of B-scan ultrasound after vitreoretinal surgery. METHODS: Retrospective study of 441 B-scan ultrasounds of 400 patients between 01/09/98 and 02/15/00. Of these, 55 examinations were performed to evaluate the postoperative status of vitreoretinal surgery. After exclusions, 50 ultrasounds were reviewed, all performed by the first author using the same equipment. The technique used to image these eyes was contact through the lids in 46 cases, immersion in 3 and both in 1 case. Other techniques such as different patient positioning was used in special cases. RESULTS: Of the 50 patients studied, 30 were males and 20 females. The ages varied between 1 and 82 years, mean of 44.74±21.09 years. Of the surgeries performed, 13 were scleral buckles and 37 were pars plana vitrectomies. The time when the examination was requested varied from the 1st to the 48th month after surgery, mean of 6.94±10.19 months. The main indications for the study were: impossible fundus examination in 16 cases (32%), vitreous hemorrhage in 17 cases (34%) and cataract in 9 cases (18%). Of the 50 studied eyes, 25 (50%) presented an attached retina and 24 (48%) presented a detached retina. Considering the 37 vitrectomized eyes, 26 (52%) had intraocular silicone oil, 8 had saline solution/aqueous, 1 (2%) had gas (C3F8), 1 (2%) had gas and residual perfluorocarbon and 1 had perfluorocarbon liquid. CONCLUSION: B-scan ultrasound enables a convenient, non invasive assessment to evaluate intraocular structures in situations of media opacity after vitreoretinal surgery.

Keywords: Ultrassonography; Vitreous body; Vitreous body; Postoperatie period; Evaluation studies

PURPOSE: To compare clinical characteristics and surgical out comes between keratoconus cases with and without acute hydrops (AH). METHODS: All keratoconus cases followed up at the Hospital Universitário Antônio Pedro - UFF and at Clinica Oftamológica Souza Pena between 1982 and 2000 were reviewed. Main analyzed outcome parameters were: visual acuity, follow-up time since diagnosis, type of visual correction, morphological and keratometric classification, and surgical results. RESULTS: The overall acute hydrops incidence was 5.8%. Gender, keratoconus family history, atopy did not differ significantly between the two groups. Among acute hydrops cases, 72.7% were classified as peripheral cones, against 21.4% of the control cases (p < 0.05). Overall, 19% of the patients needed penetrating keratoplasty (PK). Out of 1062 eyes that did not develop acute hydrops, 8.4% underwent PK, compared to 88.4 % of the acute hydrops eyes (p < 0.05). Surgical outcomes showed no significant difference between the two groups. CONCLUSION: Peripheral cones were more frequently related to acute hydrops, and consequently, to PK. Keratoconus surgical treatment results were similar in cases with and without acute hydrops.

Keywords: Keratoconus; Corneal edema; Penetrating keratoplasty; Visual acuity; Retrospective studies

PURPOSE: To present a preliminary report of homeopathic medicine in the treatment of vernal keratoconjunctivitis, at the Cornea service, of the São Geraldo Hospital. METHODS: Thirteen patients with vernal keratoconjunctivitis, examined from January 1998 to December 1999, were included in the present study.The mean age of patients was 9.5 years. Nine patients were males and four were females. All patients had already used or were using steroid eye drops. Before the beginning of homeopathic treatment, all patients were examined by one of the authors, and were monthly followed by the same doctor, during six months and each trimester, for another six months during the homeopathic treatment. The homeopathic treatment was accomplished through one single oral dose, according to the patient's symptomatic totality. RESULTS: The improvement rates of the patients' signals and symptoms were: tearing and ocular pain, 100%; ocular secretion, 92%; foreign body sensation, 86%; itching and photophobia, 84%; decrease or absence of discomfort during daily activities related to vernal keratoconjunctivitis, 84%; Trantas' dots, 62.5%; conjunctival hyperemia, 61%; epithelial erosions 58% and papillary hypertrophy of the upper tarsal conjunctiva, 8%. CONCLUSIONS: This study suggest that homeopathic medicines can be useful in the treatment of vernal keratoconjunctivitis, with improvement of the signals and symptomsrelatedto the disease. A double-masked study, with more patients should be done to confirm these findings.

Keywords: Conjunctivitis, allergic; Homeopathy

PURPOSE: To describe a new orbital implant, with an original shape, the surgical technique adapted for its implantation and preliminary results. METHODS: The authors describe the surgical technique performed in 22 patients, either as primary or secondary implants. The patients were evaluated in a prospective way to cosmesis (degree of upper lid sulcus and enophthalmos), implant mobility, volume and centralization. Follow-up ranged from 3 to 15 months (average 1 year). RESULTS: A good cosmetic result without cases of severe upper lid sulcus or enophthalmos and a good prosthesis mobility were observed. There was no implant infection, migration or extrusion. CONCLUSIONS: We conclude that the clinical results with the new implant can be compared to the usual coupled ones, but a multicentric study, with longer follow-up is necessary, for a better evaluation of its potential complications.

Keywords: Orbital implants; Orbit; Biomaterials, compatible

PURPOSE: To study the prevalence of superficial ocular trauma due to foreign bodies in patients during occupational activities. METHODS: Prospective study of patients with occupational ocular trauma diagnosed at the Hospital Getúlio Vargas (HGV) / Universidade Federal do Piauí (UFPI), from October 1997 to March 1999. The following data were obtained: age, gender, occupation, affected eye, activity performed at the time of the trauma, nature and localization of the foreign body and posterior complications. RESULTS: 713 patients were studied, of whom 686 (96.21%) were males and 27 (3.79%) were females. The patients were affected mainly in the third decade of life, corresponding to 312 patients (43.75%). In relation to the activity performed during the trauma, 158 patients (22.16%) were metallurgists, 153 (21.46%) locksmiths and 126 (17.67%) mechanics. Concerning the foreign body, 489 (68.58%) were iron and 47 (6.59%) were other metals. Regarding localization, 587 foreign bodies (81.64%) were in the cornea, 75 (10.43%) in the tarsal conjunctiva, 49 (6.81%) in the bulbar conjunctiva. In addition to the foreign bodies 361 (48.38%) patients presented corneo-conjunctival abrasion. CONCLUSION: The superficial foreign body is an important cause of occupational ocular trauma. The most frequent component was iron, and the patients were mainly metallurgists, locksmiths and mechanics, males in their thirties.

Keywords: Occupational accidents; Eye foreign bodies; Eye injuries; Protective devices; Cornea; Blindness

PURPOSE: To evaluate the frequency of different types of glaucoma at the Hospital das Clínicas of Campinas State University. METHODS: Cross-sectional study of 329 patients followed at the Glaucoma Service of Campinas State University from October 1 to December 20, 2000. The frequency of each type of glaucoma and the treatment were analyzed. RESULTS: There were 329 patients examined at the Glaucoma Service: 132 (40.1%) were referred to the service as glaucoma suspects and 197 (59.9%) as glaucoma patients. Ninety of the 132 glaucoma suspects had glaucoma (68.2%) and 42 are still under investigation (31.8%). Among the 329 patients, 283 (86%) had glaucoma, 42 (12.8%) were glaucoma suspects, 2 (0.6%) had ocular hypertension and 2 (0.6%) did not have glaucoma. There were 530 eyes with glaucoma: 298 (56.2%) with primary open angle glaucoma, 108 (20.4%) with chronic angle closure glaucoma, 21 (4%) with glaucoma following cataract surgery, 19 (3.6%) congenital glaucoma and 16 (3%) with low-tension glaucoma. All patients received initial clinical treatment with IOP-lowering medication. After a mean follow up of 10.5 months, 89 (16.8%) underwent laser therapy: 72 (13.6%) iridotomy, 7 (1.3%) trabeculoplasty and 10 (1.9%) panphotocoagulation. A hundred and seventy nine (33%) eyes required surgical treatment. CONCLUSION: The most frequent types of glaucoma were primary open angle and angle closure glaucoma. Low tension glaucoma and glaucoma associated with exfoliation syndrome were uncommon in this population.

Keywords: Glaucoma; Open angle glaucoma; Angle closure glaucoma; Open angle glaucoma; Angle closure glaucoma; Open angle glaucoma; Angle closure glaucoma; Trabeculectomy; Cross sectional studies

PURPOSE: To assess the quality of life in patients with Stevens-Johnson syndrome (SJS). METHODS: Fourteen patients with SJS were evaluated between 1998 and 1999 at the External Disease and Cornea Service of the Dept. of Ophthalmology of UNIFESP. We used a S.F. 36 questionnaire. The score for the seven subitems was given based on described formula. High scores mean a better life condition. The same questionnaire was repeated 4 times in a 3 months period. RESULTS: The means of the means of the 4 questionnaire values for the 14 patients were decreased in all S.F. 36 subitems (41.04±22.38 for physical aspects, 53.82±22.82 for social aspects, 26.24±22.46 for emotional aspects, 34.95±25.45 for functional aspects, 42.03± 31.85 for pain, 46.33±18.37 for vitality, 46.18±24.83 for mental health and 50.26±16.29 for general health). CONCLUSION: The S.F. 36 questionnaire is an important method to assess physical and emotional aspects of patients with low vision. It allowed us to detect important limitations in patients with SJS. More patients with a larger follow up are necessary to improve our analysis and further evaluate the effects of psychological intervention.

Keywords: Stevens-Johnson syndrome; Quality of life; Questionnaires

PURPOSE: To evaluate the use of amniotic membrane (AM) as an adjunct to the treatment of corneal and scleral thinnings. METHODS: Amniotic membrane was obtained at the time of cesarean section and was preserved at -80ºC in glycerol and cornea culture media at a ratio of 1:1. Seven eyes from 7 patients were divided into Group 1: neurotrophic ulcers secondary to herpes simplex virus keratitis (2 cases), after corneal transplantation (1 case), and post palpebral radiation (1 case); and Group 2: scleral thinning after pterygium surgery with (2 cases) or without (1 case) beta-therapy. All cases underwent amniotic membrane transplantation to restore thickness and promote epithelialization. RESULTS: Mean follow-up time was 12 months (range, 11-15 months). One case of neurotrophic ulcer secondary to radiotherapy was unsuccessful. A successful outcome was observed in the other 6 cases. Regarding visual acuity, 1 case improved and the other 6 cases remained unchanged. The mean epithelialization time was 26.6 ± 5.8 days for group 1 and 10.6 ± 4.0 days for group 2. CONCLUSIONS: The use of amniotic membrane represents a useful alternative to ocular surface reconstruction in corneal and scleral thinning. More cases and a longer follow up are necessary to better evaluate this procedure.

Keywords: Amnion; Fetal tissue transplantation; Tissue preservation; Homologous transplantation; Cornea; Cornea; Conjunctiva; Sclera; Corneal epithelium; Follow-up

PURPOSE: To determine the principal etiological diagnoses in low vision patients and to analyze their rehabilitational management. The studies were performed according to age, visual accuracy and the needs of each group. METHODS: The transversal study observed 229 low vision patients for two years and 27 (11.8%) patients were excluded because their vision was better than 20/60. The analysis was carried out according to the following factors: age, sex, reason for seeking help at a subnormal vision centre, diagnosis, visual accuracy for both short- and longsightedness with and without visual aids, types of visual aid prescribed for short- or longsightedness, and whether adaptation of existing visual aids or visual stimulation were recommended. RESULTS: The most prevalent diagnosis in children and young adults was congenital bilateral cataract. For patients aged between 20 and 59 years, the most prevalent diagnosis was retinitis pigmentosa; for those aged sixty years or more the most prevalent diagnosis was glaucoma and macular degeneration related to age. CONCLUSION: For the group of seven to 39 years-old, the most common type of longsighted visual aid was telelupa 2.5' monocular. For the group aged sixty and above, the most common type of shortsighted aids were spherical lenses. Of the 117 patients for whom optical aids for short distances were prescribed , 71.0% achieved vision of up to 1.25M and of the 59 patients for whom optical aids for long distance were prescribed, 56.0% achieved up to 20/60 vision.

Keywords: Low vision; Low vision; Low vision; Retinitis pigmentosa; Glaucoma; Sensory aids

The authors report an unusual case of fibrous histiocytoma of the lacrimal sac. The patient presented with clinical features of chronic dacryocystitis. Dacryocystogram disclosed a high level obstruction. Surgical management was fundamental to the diagnosis and control of the disease.

Keywords: Histiocytoma, fibrous; Lacrimal apparatus

The purpose of this paper is to report a case of central retinal vein thrombosis associated with isolated heterozygous protein C deficiency. Acute occlusion of the central retinal vein presents as one of the most dramatic pictures in ophthalmology. It is often a result of both local and systemic causes. A rare systemic cause is heterozygous protein C deficiency, and it usually occurs in combination with other thrombophilic conditions. This case highlights that isolated heterozygous protein C deficiency may be the cause of central retinal vein thrombosis and underscores the importance of its screening in young patients with this ophthalmologic disease.

Keywords: Retinal vein thrombosis; Protein C deficiency; Case report

The purpose of this paper is to warn the ophthalmologist that he/she may be facing a case of chorioretinitis sclopetaria when a patient presents with trauma due to shotgun reaching the orbit. Three cases, two female and one male, with ages between 15 and 25 years, assisted at the emergency room of the "Hospital das Clínicas" of the University of São Paulo, are described.

Keywords: Chorioretinitis; Eye foreign bodies; Choroid; Penetrating eye injuries; Orbit; Gunshot wounds; Retina; Rupture; Case report

In this paper, the authors present different aspects of the phacoemulsification learning process by the new surgeon. They also discuss the professor's and student's role in the "Surgical Classroom", suggesting some principles to improve tutoring of the surgical learning, reducing complications and providing more safety for the patient.

Keywords: Phacoemulsification; Cataract extraction; Postoperative complications; Learning; Clinical competence; Ophthalmology; Interprofessional relations; Education based on competence

Refractive surgery is facing an important period of its evolution. Day by day we are getting used to terms such as: "wave front", "customized ablation", "supervision", "aberrations", etc. What will be the future of all these technologies? It is important to understand that all these terms are based on some unquestionable facts. In this manuscript the following subjects were considered: 1. Improvement of visual performance when correcting optical aberrations, 2. The change in the concept of physiologic optics, 3. The relationship between refraction and refractive map 4. Visual benefit, 5. Chromatic and spherical aberrations

Keywords: Refractive errors; Ocular refraction; Ocular adaptation; Vision; Retina; Visual acuity; Optics