VOLUME 81 - ISSUE 5

Purpose: This study evaluated changes in choroidal and macular thickness in healthy volunteers and chronic smokers.
Methods: Thirty-three eyes of 33 chronic smokers (study group) and 33 eyes of 33 healthy controls who had never smoked were prospectively evaluated. Comprehensive ophthalmic assessment included slit lamp biomicroscopy, stereoscopic fundus examination, and intraocular pressure measurement. Spectral domain optical coherence tomography was used to measure choroidal and macular thickness 1 month before smoking cessation (smoking period) and after 3 months of smoking cessation (nonsmoking period).
Results: The mean age of the participants was 41.88 ± 6.52 years (range, 26-52), and the average smoking duration was 8.6 ± 2.5 years (range, 5-16). The thickness of the paracentral choroid (nasal: 1,500 µm, p=0.001 and temporal: 1,500 µm, p=0.001) had significantly decreased after 3 months of smoking cessation. The thicknesses of the subfoveal choroid in the smoking and nonsmoking periods were not significantly different (p=0.194). The mean central macular thickness was 267.21 ± 18.42 µm in the smoking period and 268.42 ± 18.28 µm in the nonsmoking period (p=0.022).
Conclusions: Smoking was associated with statistically significant changes in paracentral choroidal and central macular thickness in healthy volunteers. Pathological studies should be performed to evaluate the effects of smoking on posterior ocular structures.

Keywords: Choroid/anatomy & histology; Macula lutea/anatomy & histology; Smoking cessation; Tomography, optical coherence

Purpose: To evaluate the outcomes of dermis-fat graft procedure for orbital volume replacement in anophthalmic socket.
Methods: A retrospective chart review was performed studying all dermis-fat graft surgeries done at King Khlaed Eye Specialist Hospital in the last 10-year period. Sixty-two anophthalmic socket carriers underwent dermis-fat graft during the study period. Data were collected on characteristics of the patients, postoperative complications, cosmesis, and functional results such as the ability to hold an external prosthesis.
Results: Mean age of the patients included in the study was 34.2 ± 9.7 years. There were 38.7% of patients with grade 3 anophthalmic socket, 64.5% of patients had an acquired anophthalmic socket, and dermis-fat graft was performed as a secondary procedure in 61.3% of patients. Postoperative complications included lagophthalmos (22.6%), graft necrosis (17.7%), pyogenic granuloma (12.9%), decreased graft size (12.9%), malpositioned lids (3.2%), and volume deficiency (3.2%). The prosthesis was held in place in 49 patients (79%) preoperatively and in 55 patients (88.7%) postoperatively.
Conclusion: Dermis-fat graft is an excellent option for congenital or acquired as well as primary or secondary anophthalmic sockets, with or without contraction. The outcomes are favorable, and complications are rare.

Keywords: Anophthalmos/surgery; Orbit; Dermis; Adipose tissue/transplantation; Retrospective study

Purpose: The aim of this study was to analyze the bacterial and fungal microbiota found in contact lens cases among two groups of patients to correlate the data on the habits of contact lens users and to evaluate whether there is a difference in the culture results between users of ridged and nonridged contact lens cases.
Methods: Two groups (35 patients per group) were included, consisting of hospital workers and those who had not visited a hospital in the past 30 days, and a questionnaire regarding epidemiological data and habits related to contact lens and lens case use was administered. In addition, 140 samples collected from the right and left compartments of each lens case by swabbing the bottom of the wells were tested using bacterioscopy as well as fungal and bacterial cultures via computerized identification of the species.
Results: No fungal growth was identified in any of the 70 contact lens cases; however, bacteria were found in 39 cases, and there was no statistical difference between the groups. Most bacteria (>85%) were gram-negative bacilli. Contamination inone compartment of the contact lens case elevated the risk of contamination of the other side (>80%). Moreover, contamination was statistically higher in the ridged cases than in nonridged cases (p=0.0149).
Conclusion: The types of bacteria contaminating the cases are generally not seen in eye diseases associated with contact lens use, suggesting that other decisive variables are involved in eye infection from a contaminated lens or case. Fungal contamination of contact lens cases appears to be an exception. Ridged cases are commonly used by contact lens wearers and present a potential risk to eye health. In addition, the results of bacterial tests between hospital workers and those who did not visit a hospital were not significantly different.

Keywords: Contact lenses; Keratitis; Hospital; Microbiota

Purposes: To develop an efficient and xeno-free standard eye-derived induced pluripotent stem cell reprogramming protocol for use during induced pluripotent stem cell-based cell therapies in treating retinal degenerative diseases and to compare the relative effectiveness of both animal- an non-animal-derived culture systems in the generation of induced pluripotent stem cells.
Methods: Primary cultured human pterygium fibroblasts and human Tenon’s capsule fibroblasts were induced to induced pluripotent stem cells using a non-integrated virus under two xeno-free systems; as part of this study, a traditional non-xeno-free reprogramming system was also assessed. Induced pluripotent stem cell clones were selected and counted by live staining. Reprogramming efficiencies were evaluated between the fibroblasts and among different culture systems. In a series of experiments, such as PCR and immunofluorescence staining, the induced pluripotent stem cells were characterized.
Results: Human pterygium fibroblast- and human Tenon’s capsule fibroblast-derived induced pluripotent stem cells were successfully established using different reprogramming systems, under which they exhibited properties of induced pluripotent stem cells. Reprogramming efficiencies of induced pluripotent stem cells using the cell therapy system, the traditional system, and the E6/E8 system were 0.014%, 0.028%, and 0.001%, respectively, and those of human pterygium fibroblast- and human Tenon’s capsule fibroblast-derived induced pluripotent stem cells-using the aforementioned systems-were 0.018% and 0.017%, respectively.
Conclusions: Sendai virus facilitates induced pluripotent stem cell reprogramming of ocular fibroblasts-both human pterygium and human Tenon’s capsule fibroblasts being safe and efficient for induced pluripotent stem cell reprogramming. Although the reprogramming efficiencies of ocular-derived induced pluripotent stem cells under xeno-free conditions were not superior to those observed using the traditional reprogramming system, the cell therapy system reprogramming system is a good option when induced pluripotent stem cells are to be induced under xeno-free conditions.

Keywords: Induced pluripotent stem cells; Sendai virus; Fibroblasts, cellular reprogramming techniques

Purposes: To investigate the intra-laboratory reproducibility of clinical features and to evaluate corneal optical anisotropies in a rabbit model of limbal stem cell deficiency.
Methods: Limbal injury was induced in the right eye of 23 adult New Zealand White rabbits using a highly aggressive protocol that combined 360 degrees limbal peritomy, keratolimbectomy, alkaline chemical burn, and mechanical removal of the epithelium. Clinical evaluation of the injured eyes was performed for 28 days and included corneal impression cytology. Corneas with a severe clinical outcome set typical of limbal stem cell deficiency were then collected, subjected to a histopathological examination, and examined for optical anisotropies. Corneas from healthy rabbit eyes were used as controls. Differences in optical path due to stromal collagen birefringence, as well as linear dichroism related to the expression and spatial orientation of glycosaminoglycan chains from proteoglycans, were measured from cross-sections under a quantitative polarized light microscope.
Results: One eye showed signs of hypopyon and was excluded. Signs of ocular inflammation were observed in all eyes studied (n=22). Corneal impression cytology did not detect goblet cells. Twelve of the 22 corneas presented a clinical outcome set typical of limbal stem cell deficiency, which is characterized by the presence of epithelial defects, inflammatory cells, moderate-to-severe opacity, and neovascularization. Microscopic studies under polarized light revealed that relative to controls, limbal stem cell deficiency caused a 24.4% increase in corneal optical path differences. Further, corneas with limbal stem cell deficiency were less dichroic than controls.
Conclusions: These results suggest that rabbit models of limbal stem cell deficiency must be rigorously screened for use in preclinical studies to ensure experimental homogeneity because protocols used to create limbal stem cell deficiency could be not associated with good intra-laboratory reproducibility of clinical features. Limbal stem cell deficiency, as induced herein, altered the optical anisotropic properties of the corneal stroma. Such alterations are indicative of changes in collagen packing and the spatial orientation of glycosaminoglycan chains from proteoglycans. Knowledge of these changes is important to potentiate strategies aimed at restoring the morphofunctional integrity of the corneal stroma affected by limbal stem cell deficiency.

Keywords: Birefringence; Corneal stroma; Anisotropy; Stem cells; Limbus corneae; Glycosaminoglycans

Purpose: The aim of this study was to compare the corneal cell viability and thickness of LASIK flaps created by 3 femtosecond lasers in eye-bank human corneas. Methods: Forty-five eye-bank human sclerocorneal buttons (15 corneas in each group) were examined after the creation of 120 µm-thick laser-assisted keratomileusis (LASIK) flaps with 150kHz iFS IntraLase^TM (IL), Z6 Femto LDV^TM (LDV), or 200kHz Wavelight^TM FS200 (FS200). The thickness of the flaps was measured using anterior segment optical coherence tomography (AS-OCT; Visante^TM). Cell viability was blindly evaluated with immunohistochemistry for keratocyte apoptosis using anti-caspase 3 antibodies. Results: The standard deviation from the intended flap thickness was less than 10 µm in all the groups. There was a statistically significant difference in corneas treated with LDV and IL with regard to the flap thickness horizontally at +3.00 mm (p=0.0124), -0.5 mm (p=0.0082), and -1.00 mm (p=0.0425) from the corneal vertex and +0.5 mm from the flap edge (p=0.0240), and those treated with LDV and FS200 with regard to the flap thickness horizontally at -0.5 mm from the corneal vertex (p=0.0082). The mean keratocyte apoptosis numbers were 13.09 ± 1.10, 15.59 ± 3.28, and 17.72 ± 1.49 in corneas treated with IL, FS200, and LDV, respectively (p<0.001). Conclusion: All 3 assessed femtosecond lasers provided predictable LASIK flap thickness. The mean stromal keratocyte apoptosis number was low in all groups.

Keywords: Keratomileusis, laser in situ; Femtosecond; Tomography, optical coherence, Anti-caspase 3; Cornea; Eye-bank

Purpose: To study visual acuity, refractive errors, eccentric fixation, and reading performance in patients with toxoplasmic macular retinochoroiditis.
Methods: Twenty-three participants with bilateral toxoplasmic macular retinochoroiditis and 4 with toxoplasmic macular retinochoroiditis in their unique eye were evaluated. Participants reported their eye dominance, confirmed by the Portus and Miles test. Best corrected visual acuity, spherical equivalent refraction, magnification need, and reading speed were measured. Microperimetry (MAIA, Centervue - Padova, Italy) recorded the preferred retinal locus and fixation stability by means of the bivariate contour ellipse area. Fourteen eyes from 14 normally sighted subjects served as controls.
Results: Mean ± SD best corrected visual acuity was better in the dominant eye than in the nondominant eye: 0.9 ± 0.2 (logMAR 0.5 to 1.4) vs. 1.2 ± 0.3 (logMAR 0.6 to 1.7) (p<0.0001, paired t-test). Spherical equivalent myopia of -4.00 or higher was present in 42% of the eyes. Microperimetry was performed in 42 eyes. Eccentric fixation was observed in all examined eyes. In 14 eyes (33%), the preferred retinal locus was placed (in the retina) superior temporal to the macular lesion, in 10 (24%) superior nasal, in 6 (14%) inferior temporal, and in 12 (28%) inferior nasal. There was no significant difference in the distribution of the preferred retinal locus position between dominant and nondominant eyes (p=0.85, Pearson test). There was no correlation between reading speed and the distance between the preferred retinal locus and the estimated original foveal position (r=-0.09; p=0.73), the bivariate contour ellipse area (r=-0.19; p=0.44), or best corrected visual acuity (r=0.024; p=0.92).
Conclusions: Myopia is more prevalent in patients with toxoplasmic macular retinochoroiditis. Reading speed is not dependent on preferred retinal locus position, stability, or visual acuity. Nevertheless, documentation of fixation provides new data on the impact of visual impairment in these patients and may be useful for rehabilitation efforts.

Keywords: Choroiditis; Chorioretinitis; Myopia; Toxoplasmosis, ocular; Reading

Purpose: We aimed to evaluate the safety of single intravitreal injection of each of two concentrations of 0.1 ml of sunitinib (1 and 10 mg/ml), 0.1 ml of a drug-free dispersion containing solid lipid nanoparticles, and 0.1 ml of a drug-free dispersion containing polymeric nanocapsules for analyzing the possible toxic effects using electrophysiology and histology in albino rabbit retina.
Methods: We conducted an experimental controlled study of 20 eyes of albino rabbits. Intravitreal injections of each specific agent were applied to one eye per rabbit in each 5-rabbit group, while the contralateral eyes received no treatment and were used as controls.
Results: We noted no electroretinographic changes in the sunitinib (1 and 10 mg/ml) or in solid lipid nanoparticles groups. However, we observed significant abnormalities in ocular morphology and in the electroretinogram in the nanocapsules group. At the histological level, only the nanocapsules group demonstrated abnormal changes, including severe edema and cytoplasmic vacuole formation.
Conclusions: While nanocapsules intravitreal injections indicated retinal toxic effects, sunitinib and solid lipid nanoparticles intravitreal injections were not toxic to the retina. Our results suggest that a sunitinib preparation with solid lipid nanoparticles for controlled release may offer a significant therapeutic approach for vasoproliferative ocular disease.

Keywords: Pathological neovascularization; Angiogenesis inhibitors; Nanotechnology; Nanoparticles; Intravitreal injections; Rabbits

Purposes: The purpose of this study was to evaluate the magnitude and determinants of bilateral blindness and visual impairment (VI) in the southwest region of São Paulo State, Brazil.
Methods: This cross-sectional study conducted during 2013 and 2014 targeted people of all ages in 10 districts in the southwest region of São Paulo State, Brazil. Ophthalmologists in a mobile unit measured visual acuity and examined eyes. Visual acuity was categorized according to the World Health Organization sex-adjusted rates with 95% confidence intervals (CI) were calculated. Number of blindness and visually impaired was projected for the entire study area.
Results: We examined 2,306 participants. The age- and sex-adjusted frequency of bilateral blindness was 0.26% (95% CI: 0.1-0.4). Females (0.35%) and patients ≥50 years old (0.58%) had higher rate of blindness compared with males and younger individuals. The rate of severe VI was 9.1% (95% CI: 8.8-10.6) and was higher among males (11.6%) and those ≥50 years (12.3%). There could be 880 people with bilateral SVI in the study area. Bilateral severe VI was attributed to cataracts in 63% and was attributed to refractive error in 18%.
Conclusion: Visual impairment and blindness in the study population was low and mainly due to cataract and refractive errors. Initiatives should be addressed by health care services to further reduce avoidable blindness in the region.

Keywords: Visual impairment; Blindness; Cataract; Refractive errors; Brazil

Purpose: To compare the efficacy of 0.03% topical tacrolimus in combination with oral omega (ω) 3 with different ratios of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and antioxidants as adjuvant in the treatment of keratoconjunctivitis sicca (KCS) in dogs.
Methods: Forty-five dogs with KCS were evaluated monthly for 6 months. Evaluations included performance of the Schirmer tear, fluorescein, and lissamine green tests. Tear film break-up time (TBUT) was assessed. Conjunctival cytology was evaluated at the beginning, middle, and end of the study. Conjunctiva was biopsied at the beginning and end of the study. Dogs were randomly assigned to one of the three groups (n=15): Group T (topical tacrolimus 0.03%), Group TO (topical tacrolimus + ω-1.5 EPA: 1 DHA), or Group TOA (topical tacrolimus + ω-1 EPA:4.5 DHA + antioxidants).
Results: There was a significant improvement in clinical signs in all groups. TBUT increased throughout treatment in all groups; this effect was most pronounced in Group TO. Cytological analysis performed at the end of the study period, showed decreased levels of lymphocytes, neutrophils, and metaplastic and squamous cells in Groups T, TO, and TOA. Histological analysis performed at the end of the study period showed decreased levels of lymphocytes and neutrophils and increased levels of goblet cells. These effects were most pronounced in Group TO.
Conclusion: Oral treatment with ω-3 containing a higher proportion of EPA than DHA increased the effectiveness of topical tacrolimus 0.03% in the treatment of keratoconjunctivitis sicca in dogs.

Keywords: Keratoconjunctivitis sicca; Tacrolimus; Eicosapentaenoic acid; Docosahexaenoic acids; Antioxidants; Animal; Dogs

We report the trans-operative approach and short-term outcome for a patient who suffered a traumatic avulsion of the cilioretinal artery branch during the surgical management of a cilioretinal arterial branch occlusion with intraocular embolectomy. The patient underwent a pars plana vitrectomy with in situ embolectomy. The blocked artery was incised using 25 Ga vertical scissors, and embolus manipulation was performed using microsurgical forceps. During embolus extraction, the occluded cilioretinal artery and its branch were inadvertently avulsed and torn with subsequent intense bleeding. Laser and endodiathermy were used for acute hemostasis. The maneuvers created an unintended retinochoroidal anastomosis. Visual-field improvement was noted three months after the surgery. In the event of a complicated surgical embolectomy with the avulsion of the artery, the formation of a retinochoroidal anastomosis and reperfusion of the occluded artery may occur along with the improvement of the visual field in some cases.

Keywords: Retinal artery occlusion; Ciliary arteries; Embolectomy; Vitrectomy; Postoperative complications; Case reports

A patient with bilateral aniridia and progressive congenital cataract was treated at the age of 7 years through phacoaspiration with femtosecond laser capsulotomy, in-the-bag intraocular lens implantation, and pars plana vitrectomy (combined with posterior capsulotomy). The diameter of the planned anterior capsulotomy was 4.7 mm; however, due to elevated tension in the young capsular bag, the capsulotomy diameter increased (to around 6 mm) shortly after release of the tension by the laser. In addition, the patient had a very flat and small cornea, causing the formation of air bubbles in the curved laser interface. This was addressed by filling the gap by using a viscoelastic. A very similar situation was observed in both eyes. Use of the femtosecond laser facilitated a successful outcome in a complex congenital cataract case with a safe capsulotomy that ensured in-the-bag intraocular lens placement.

Keywords: Aniridia; Cataract/congenital; Capsulorhexis; Phacoemulsification; Lens implantation, intraocular; Laser therapy; Case reports

A 89-year-old Black female with a 6-year history of advanced open-angle glaucoma was referred to the Glaucoma Service of the Ophthalmology Department - Federal University of São Paulo (UNIFESP). Best-corrected visual acuity was 20/400 in the right eye and 20/60 in the left eye. Pseudoexfoliation material was observed at the iris border, angle, and the anterior lens surface. Anterior biomicroscopy revealed exfoliation material forming an evident peripheral zone and a central disc separated by a clear intermediate zone on the anterior lens surface OU. Gonioscopy showed an open-angle Sampaolesis’s line and whitish material deposits OU. Fundus examination revealed a cup-to-disc ratio of 1.0 OU with peripapillary atrophy. Genetic analysis for single nucleotide polymorphisms of the lysyl oxidase-like 1 gene linked to exfoliation syndrome identified two such single nucleotide polymorphisms, rs1048661 and rs216524.

Keywords: Exfoliation syndrome; African continental ancestry group; Exfoliation syndrome; Lysyl oxidase-like 1 gene; Brazil

We report on a case of two sisters, daughters of consanguineous parents, presenting with a similar condition of low visual acuity associated with retinal dystrophy in both eyes associated with alopecia and bone alterations or syndactyly.

Keywords: Ectodermal dysplasia/genetics; Syndactyly; Alopecia; Retina/abnormalities; Retinal dystrophy; Hand deformities, congenital/genetics; Syndrome

Nature has always provided an unlimited source of biologically-active compounds. Since the beginning of mankind, humans have sought resources in fauna and flora to treat eye diseases. However, it was only after the Industrial Revolution that extracts of plants and substances of animal origin could be used safely, as has been determined by controlled interventional studies. Two major challenges faced by ocular pharmacology are the following: developing drugs that are able to reduce blindness due to glaucoma; and controlling the pain associated with eye surgery. The search for a drug that effectively lowers intraocular pressure and controls the progression of glaucoma has led to the development of various ocular hypotensive agents, such as physostigmine from the Physostigma venenosum plant. The anesthetic properties of cocaine, extracted from Erythroxylon coca, finally enabled surgical procedures in the eye. Several new natural compounds have been investigated in an attempt to identify substances with the potential to provide additional benefits to eye tissue and vision. Emerging evidence of anti-inflammatory, wound-healing, antimicrobial, antioxidant, antitumor, and antiangiogenic properties attributed to plant extracts and animal tissues has encouraged more investment in research in this area. Despite technological advances in synthesizing drugs, the pharmaceutical industry still seeks new active compounds from natural sources as well as from revisiting already-established naturally derived compounds. Although a large number of naturally-occurring compounds is known, this review article focuses on the bioactive substances with scientifically-proven benefits for ocular tissues.

Keywords: Nature; Plants, medicinal; Molecules; History of medicine; Pharmacology; Eye diseases; Pharmaceutical industry