VOLUME 68 - ISSUE 5

PURPOSE: To study, on Goldmann perimetry, a group of patients with complete temporal hemianopia on Humphrey perimetry (24-2 full threshold test) and to evaluate the percentage of eyes in which computerized perimetry failed to identify a temporal visual field remnants. METHODS: Nineteen patients with visual field defect by chiasmal compression were prospectively studied with manual and automated perimetry. Twenty-five eyes with complete temporal hemianopia on Humphrey Field Analyzer, 24-2 threshold test were selected and studied with Goldmann perimeter, in order to evaluate the presence of a temporal visual field remnants. According to the result of Goldmann perimetry the eyes were divided into two groups: group 1, with complete temporal hemianopia; group 2, with residual temporal visual field remnants in the periphery. The mean number of mean deviation in the 2 groups was calculated and compared using Student's t test. RESULTS: Automated perimetry failed to identify a temporal residual visual field in 17 of 25 eyes studied (68%). Mean values of the mean deviation in groups 1 and 2 were respectively -15.43 and -15.93. Statistical analysis did not indicate a significant difference between them. CONCLUSIONS: Computerized automated Humphrey perimetry using 24-2 threshold test fails to identify temporal visual field remnants in a great percentage of patients with severe chiasmal compression. Analysis of the mean deviation is not helpful in identifying such cases. Patients evaluated on automated perimetry and presenting with a complete temporal hemianopia should be checked for temporal visual field remnants.

Keywords: Perimetry; Visual fields; Optic chiasm; Vision disorders; Pituitary Neoplasms; Diagnostic techniques; ophthalmological

PURPOSE: To carry out a case-control clinical study in patients with vernal keratoconjunctivitis, aiming at information about the anterior corneal curvature and visual performance using a quantitative corneal descriptor analyzer (Holladay Diagnostic Summary). METHODS: We examined 342 eyes of 171 patients divided into 2 groups. Group 1 with 142 eyes of 71 patients with a clinical diagnosis of vernal keratoconjunctivitis (cases) and Group 2 with 200 eyes of 100 patients (controls) from the Department of Ophthalmology/"Santa Casa" of São Paulo. Patients were submitted to a complete examination and corneal topography with a quantitative corneal surface contour descriptor (Holladay Diagnostic Summary). Clinical and topographic criteria were established to diagnose keratoconus in both groups. RESULTS: The frequency of patients with a clinical diagnosis of keratoconus associated with vernal keratoconjunctivitis in Group 1 was 9.85% (7 patients). According to topographic criteria, the frequency in Group 1 was 22.53% (16 patients). In Group 2, no patient presented biomicroscopic, refratometric or topographic characteristics of keratoconus. All studied topographic variables, including corneal asphericity, presented statistical significance (p<0.05) between the two groups. CONCLUSION: Results of this study suggested high frequency of patients with keratoconus associated with vernal keratoconjunctivitis. Visual performance is compromised by aberrations and changes in corneal asphericity and other topographic variables.

Keywords: Conjunctivitis; allergic; Conjunctivitis; allergic; Keratoconjunctivitis; Keratoconus; Corneal topography; Cornea

PURPOSE: To measure the duration of the operation, the strength of tissue adhesion, and to perform a clinical and histopathological study of ocular reinsertion of superior rectus muscles of rabbits with four different tissue adhesives, as an alternative to the use of polyglactin suture in strabismus surgeries. METHODS: One hundred New Zealand rabbits were used for two experiments: I-A and I-B, with fifty rabbits for each experiment. These groups were further divided into five groups of ten rabbits (twenty eyes), which were subjected to the removal of the superior rectus muscle of both eyes, either with suture (control) or tissue adhesive: polyglactin 910, 6-0 suture and tissue adhesives made of fibrin, cyanoacrylate, albumin-glutaraldehyde and gelatine-resorcinol-formaldehyde-glutaraldehyde. The rabbits in experiment I-A were subjected to dynamometry for ten minutes following repositioning of the muscle. The rabbits in experiment I-B were subjected to clinical evaluation and to histopathologic evaluation. RESULTS: Better performance of the tissue adhesives in relation to the time taken to carry out the surgery was observed. None of the adhesives met the parameters used for strength, that is, in some cases the reinserted muscle did not resist to the application of forces up to 100 gf. The clinical and histopathologic evaluations showed that only the fibrin adhesive presented a better performance than the polyglactin suture while the other results were worse than those of the controls (suture). CONCLUSION: It was observed that the adhesives studied are not suitable for strabismus surgeries.

Keywords: Tissue adhesives; Oculomotor muscles; Strabismus; Fibrin tissue adhesive; Polyglactin 910; Sutures; Rabbits

PURPOSE: To analyse the economic viability of a mobile eye clinic of a tertiary referral Ophthalmology Service. METHODS: The amount of money spent with the purchase and construction of the unit in 2000, and the expenses with its maintenance and operation in 2001 were considered, comparing these expenses with the income obtained from appointments, supplementary tests and eye surgeries through the "Sistema Único de Saúde" (a health care service provided by the government), in 2001. In order to make an economic analysis, an interest rate of 10% per year and a period of depreciation of 10 years were stipulated. RESULTS: The total amount spent to buy and set up a mobile unit of "Hospital Oftamológico de Sorocaba" was R$ 184,140,00. The amount spent with its maintenance and operation during 2001 was R$ 28,000.00. The unit was used on average during 2 days each week in 2001 and 6492 appointments were made in this period, generating an income of R$ 32,460.00. The appointments generated complementary tests and eye surgeries making up R$ 51,540.00. Therefore, the total amount received directly with the appointments, complementary tests and eye surgeries during 2001 was R$ 84,000.00 paid by the "Sistema Único de Saúde", according to values established beforehand. Using these values it is possible to make an economic analysis of this enterprise and this was done with and without money savings for depreciation, taking into account the income and the expenses. CONCLUSION: Besides attending poor communities that are located in distant neighborhoods, a mobile eye clinic can be a source of income for ophthalmologic services.

Keywords: Mobile health Units; Referral and consultation; Vision disorders; Vision disorders; Cost-benefit analysis; Costs and cost analysis; Health services; Delivery of health care

PURPOSE: To evaluate tear film quality by rose bengal staining and its stability by breakup time, relating with palpebral fissure height and exophthalmos in patients with Graves' ophthalmopathy. METHODS: We studied 54 eyes of 27 patients with Graves' ophthalmopathy, either in the inflammatory or in the chronic phase of the disease. The evaluation consisted of tear film qualitative analysis by rose bengal staining using the van Bijsterveld grading scale, tear film stability analysis by breakup time, measurement of palpebral fissure height and exophthalmometry. Qui square test was used to perform statistical analysis. RESULTS: Among 27 studied patients, 77.8% were females and 22.2% males. Mean age was 44.26 years (SD 12.67). Mean disease time was 5.85 years (SD 4.47) and mean ophthalmopathy time was 5.81 years (SD 5.37). Among 54 studied eyes, 37% had positive test by van Bijsterveld's grading scale, 33.3% tear film breakup time lower than 5 seconds, 57.4% palpebral fissure height greater than 11 mm and 55.6% exophthalmometry greater than 19 mm. When relating tear film breakup time lower than 5 seconds with palpebral fissure height greater than 11 mm we found an odds ratio of 11.2 (p=0.0008). The remaining relationships did not show statistical significance. CONCLUSIONS: Dry eye diagnosed by rose bengal staining and tear film breakup time occurs frequently in Graves' ophthalmopathy. Palpebral fissure height correlates with tear film breakup time in Graves' ophthalmopathy. Its increase may lead to tear film instability.

Keywords: Graves' disease; Rose bengal; Keratitis; Exophthalmos; Tears; Staining and labeling

PURPOSE: To evaluate eyelid margin alterations in ectropion carriers. METHODS: An observational study was done involving 53 eyelid ectropion patients and 25 individuals with dermochalasis (control group). Eyelash position and margin inflammation were observed using digital images. The data were submitted to statistical analysis. RESULTS: Patients with ectropion showed a decreased number of eyelashes, loose convexity, trichiasis and distichiasis as compared with the control group. CONCLUSION: Patients with eyelid ectropion have eyelid margin alterations probably due to the chronic inflammatory process in this region.

Keywords: Ectropion; Eyelid diseases; Eyelids; Eyelashes; Blepharitis; Meibomian glands

PURPOSE: To evaluate both the efficacy and reliability of the cytologic method in the diagnosis of conjunctival lesions and compare it with the histologic examination. METHODS: A prospective study on 31 conjunctival lesions was performed. Samples were obtained with a Kimura spatula. The lesions were, then, surgically removed and sent for histologic examination. The Papanicolaou technique was used for the cytologic examination. RESULTS: The cytologic method showed high specificity (100%) and sensitivity (92.9%). The positive predictive value was 100% and the negative was 94.4%. CONCLUSIONS: The simple cytologic method is effective and reliable for the diagnosis of tumoral lesions of the conjunctiva.

Keywords: Conjunctival neoplasms; Conjunctival neoplasms; Conjunctiva; Conjunctiva; Cytological techniques; Reproducibility of results; Comparative study

PURPOSE: To determine the success rate of probing for congenital nasolacrimal duct obstruction and the factors related to probe failure. METHOD: A retrospective observational study was conducted, involving 80 children with congenital nasolacrimal obstruction who underwent nasolacrimal probing. The subjects were evaluated according to sex, age and probing outcome. The data were evaluated according to the descriptive method, Goodman test and Mann-Whitney test adopting a significance of 5%. RESULTS: The possibility of cure was the same in both sexes. The mean age at cure was 19.95±11.44 months and on failure was 23.67±15.21 months. The analysis showed no significant change in cure rate when over 6 months old. Nasal alterations such as rinitis, mucosal or turbinate bone hypertrophy, septum deviation and sinusitis were associated with probe failure. CONCLUSION: The cure rate does not vary significantly at intervals of increasing ages even it over 12 months old. Nasal alterations might be included in the causes of failure.

Keywords: Lacrimal duct obstruction; Nasolacrimal duct; Dacryocystorhinostomy; Time factors; Treatment failure; Retrospective studies

PURPOSE: To evaluate rabbit adipocytes of the orbital fat tissue after enucleation and evisceration. METHODS: Twenty-tree specimens from 23 rabbits aged 42 days which had undergone socket surgery (evisceration and enucleation) were evaluated. The animals were sacrificed on the 30th, 90th and 180th postoperative day. The orbital fat tissue was prepared for light microscope evaluation (magnification: 200x) and analyzed by IpWin 32 software program. The number of cells in each field and the area of each adipocyte were used to calculate the cell median area. The data were compared between the groups (enucleation and evisceration) and submitted to statistical analysis by a non-parametrical test. RESULTS: There were no statistical differences when considering the mean area of adipocytes between enucleation or evisceration or time of sacrifice. CONCLUSION: The volume decrease in the anophthalmic cavity is not related to orbital fat atrophy. The genesis of orbital volume reduction might result from the spacial distribution and interrelationships of the orbital soft tissue rather than changes in volume of adipocytes.

Keywords: Adipose tissue; Eye enucleation; Eye evisceration; Orbit; Prosthesis design; Rabbits

PURPOSE: The indications for penetrating keratoplasty (PK) vary in different regions of Brazil. Keratoconus is the main indication in the state of São Paulo. However, in the state of Amazonas the main indication is ulcerative conditions. The purpose of this study was to evaluate the indications for PK in two reference centers of ophthalmology in the state of Pernambuco. The possible frequency differences in PK indications were also analyzed regarding other Brazilian states and other countries. METHODS: A retrospective analysis of the records of 814 patients who underwent PK at the "Fundação Altino Ventura", and "Hospital de Olhos de Pernambuco" from January 1998 to December 2002 was performed. RESULTS: The leading indications for PK were ulcerative conditions (21.3%), bullous keratopathy (19.9%), keratoconus (18.6%) and corneal scarring (17.8%). In 2001 the frequency of the PK indications was altered by the high frequency of regraft. This happened because of a programmed recall of these patients by the Pernambuco Transplantation Center. CONCLUSIONS: There were no significant differences between the frequencies of the leading indications during the period of study. On the other hand, the frequencies of those indications were different from those of other centers. It should be stressed that Pernambuco and Amazonas states show greater frequencies of ulcerative conditions, not similar to other centers. This fact is associated with poverty in these states.

Keywords: Keratoplasty; Keratoplasty, penetrating; Corneal ulcer; Corneal diseases

PURPOSE: To identify patients' needs and expectations in a cataract clinic connected with a university public hospital - Cataract Institute - Department of Ophthalmology - Paulista School of Medicine (UNIFESP). METHOD: A descriptive transverse study was carried out with the patients enrolled in the clinic, distributed in two groups: those who were operated on and those who were not. Patients were approached in two stages: 1) conduct the study in four focus groups to identify the patients' most valued attributes (qualitative study); 2) a questionnaire was designed based on the main attributes and was submitted to a sample of patients (quantitative study). RESULTS: The patients' main expectations are related to: 1) the treatment results; 2) more comfortable waiting facilities; 3) be treated with respect by all the caregivers; and 4) the technological devices used in their treatments. The highest rates of satisfaction were the information material, physician care, and medical devices; the lowest rates of satisfaction were telephone service, physical environment, queue arrangements, and making contact. CONCLUSIONS: The evaluation of the services as well as the institution's public image is positive. The main reasons for choosing the clinic are related to economic and financial aspects and the majority of the patients would use the services again and would also recommend the clinic to other people.

Keywords: Cataract; Organizational analysis; Sociometric analysis; Sociometric techniques; Hospitals; public

PURPOSE: To evaluate the result of the surgical correction of esotropic patients with eccentric fixation and to compare it with operated on esotropic patients who did not have this sensorial disorder. METHODS: A retrospective study of the result of the surgical correction of essential esotropia in 19 patients with eccentric fixation of the "Santa Casa de São Paulo". As group controls, 17 esotropic patients with strabismic amblyopia and central fixation and 16 esotropic patients without amblyopia who had been operated on. The statistical test was application of variance for proportions (ANOVA). RESULTS: In the 3 studied groups undercorrection prevailed, 12 (63,2%) cases in group I, 13(76,5%) cases in group II and 13 (81,3%) patients in group III. The surgical success occurred in 7 (36,8%) patients of the group with eccentric fixation, of whom 4 cases were overcorrected and 3 of orthotropia. In group II, of the 7 cases of surgical success, 3 (17,6%) had orthotropia and 1 (5,9%) case presented with overcorrection. In group III, we had 5 (31,3%) cases of surgical success, 1 (6,3%) of them with orthotropia. Among the 36 amblyopic patients, 5 (13,9%) presented overcorrection. The standard error of the average of the surgical correction was 4,6 in the group of patients with eccentric setting. ANOVA test for the average of the surgical correction was p=0,349. Considering the good result (a deviation smaller than 10delta), the statistical analysis revealed a p=0,847. CONCLUSION: The eccentric setting did not represent a determinant factor in the surgical result (good versus bad) of the horizontal surgical alignment.

Keywords: Esotropia; Fixation; ocular; Amblyopia; Strabismus; Adaptation; ocular; Analysis of variance

PURPOSE: To evaluate the prevalence of diseases of the eye in a population aged 80 years and above in the city of Veranopolis, Rio Grande do Sul, Brazil. METHODS: 187 elderly people were submitted to ophthalmologic tests including external inspection, ocular motility examination, visual acuity determination for near and far distance, applanation tonometry, biomicroscopy, cyclopegia, direct fundus examination and static skiascopy. RESULTS: The most prevalent disease was presbyopia in 173 (92,5%) patients, cataract in 160 (85,6%), age-related ectropion in 130 (69,5%), hypermetropia in 130 (69,5%) and age-related macular degeneration (ARMD) in 59 (31,5%) patients. 85 (45,4%) patients presented marked low vision whose main causes were cataract in 46 (54,1%) and refractive error in 16 (18,9%) of the studied population. The most prevalent complaint was due to presence of age-related ectropion. CONCLUSIONS: Common diseases as cataract and retractive error are still a challenge to ophthalmologists because these diseases remain main causes of visual deficit in old age resulting in life quality losses.

Keywords: Cataract; Blindness; Macular degeneration; Presbyopia; Ectropion; Aged

PURPOSE: To evaluate the effectiveness of amniotic membrane transplantation associated with conjunctival autograft in primary pterygium treatment. METHODS: We have analyzed, prospectively, 26 patients (14 women and 12 men), from 20 to 60 years old, examined at the Evangelic Hospital Ophthalmology Outpatient Clinic. They were submitted to primary pterygium treatment with pterygium excision surgery, amniotic membrane transplantation and conjunctival autograft, from April to November, 2001. The evaluated aspects were: degree of pterygium, postoperative complications and recurrence. RESULTS: Four cases (15,38%) showed complications, none of them considered serious, conjunctival graft contraction in 2 cases being the most frequent. After a follow-up of 6 months, 24 patients (92,3%) had a successful result and 2 patients (7,69%) had corneal or conjunctival recurrence. Among the patients with complications 50% presented pterygium recurrence (P<0,05). CONCLUSION: It is a safe surgical procedure with a low degree of recurrence rate. Complications are associated with a greater chance of relapse. This procedure is also an option in cases where there is not sufficient conjunctiva to cover all excised area.

Keywords: Pterygium; Conjunctiva; Biological dressings; Amnion; Postoperative complications; Transplantation; autologous; Recurrence

PURPOSE: To evaluate the frequency, location and pattern of visual field defects as measured by SITA strategy in primary open angle glaucoma (POAG). METHODS: Six thousand and two-hundred charts were reviewed. One hundred and fifty two patients who fulfilled the inclusion criteria whe included. They were stratified according to severity into early, moderate and severe. The following visual field defects were defined: nasal step, paracentral escotomata, arcuate defect, Seidel escotomata, temporal defect, general reduction of sensitivity, anular scotomata and central island. Each examination was divided into sectors corresponding to optic disc regions. Student's t test was used to compare differences in frequency. RESULTS: In the early glaucoma group, the nasal superior step was the most frequent visual field defect, followed by paracentral scotoma and inferior nasal step. General reduction of sensitivity was noted in 7.8%. Defects were more common in the superior hemifield (p<0.05). CONCLUSION: The superior nasal step and paracentral scotoma were the most comum visual field defects in early primary open angle glaucoma as evaluated by SITA strategy, and the superior hemifield comprises most of the defects. General reduction of sensitivity was an early and rare visual field defect.

Keywords: Glaucoma; Perimetry; Sensory thresholds; Visual fields; Sensitivity and specificity

PURPOSE: To evaluate microscopically the signs of inflammatory reaction due to the fixation of an orbitary implant (magnet, covered by gold). METHODS: An experimental study was performed in 54 adult female rabbits, divided into 3 groups of eighteen with 3 subgroups of 6; an evaluation at 1, 3 and 6 postoperative weeks was performed. An implant (magnet, covered by gold) was fixed in the inferior orbital rim using biologic glue, screw or unabsorbable suture (Mersilene 5.0®). The opposite orbits (without implants) represented the control group. RESULTS: Microscopic signs of inflammatory reaction due to orbitary fixation of the implant were observed with the use of the three methods (biologic glue, screw or unabsorbable suture) (Mersilene 5.0®), until six weeks of the postoperatory period. CONCLUSIONS: Histopathological signs of inflammatory reaction to the implant and to its orbital fixation were observed up to the sixth week, with cyanoacrylate, screw, or unabsorbable suture (Mersilene 5.0®), with prevalence of the chronic inflammatory process and cicatricial fibrosis, without statistically significant difference in most of the cases.

Keywords: Orbital implants; Magnetics; Gold; Nystagmus pathologic; Rabbits; Comparative study

Mitochondrial myopathy is a genetic disorder characterized by chronic progressive external ophthalmoplegia and upper eyelid, ptosis which occurs before 30 to 40 years of life. The authors reviewed the literature and reported two cases of reading diplopia in female patients.

Keywords: Mitochondrial myopathies; Ophthalmoplegia; chronic progressive external; Diplopia; Case reports

The objective is to evaluate the effects of phototherapeutic keratectomy (PTK) in bullous keratopathy patients. Phototherapeutic keratectomy was performed in a pseudophakic patient with corneal decompensation after lens extraction, with the excimer laser Nidek EC 5000 after manual corneal epithelial debridement. There was no pain after fifteen days the laser applicattion and during the eight months of follow-up. Visual acuity was unchanged. The phototherapeutic keratectomy excimer laser must be considered one more alternative for pain treatment in bullous keratopathy of pseudophakic patients.

Keywords: Keratoplasty; penetrating; Pseudophakia; Corneal diseases; Keratectomy; photorefractive; excimer laser; Case reports

The use of intraocular lenses was a great advance in visual recovery after cataract surgery. Although usually with good biocompatibility, some alterations in the intraocular lens material may occur after implantation. Polymethylmethacrylate was the first intraocular lens material to be used on a large scale and assumed to be inert and well-tolerated. We present a rare case of late opacification of a polymethylmethacrylate lens, discussing important aspects of its management such as the indication for intraocular lens exchange.

Keywords: Cataract extraction; Lenses; intra-ocular; Lens implantation; intraocular; Polymethylmethacrylate; Device removal; Postoperative complications; Case reports

Abnormal head position is a compensatory condition which improves patients' vision. It can be caused by ophthalmological problems such as oculomotor imbalances (strabismus, nystagmus) and high astigmatisms. However, it results in esthetic impairment, orthopedic trouble and facial asymmetries. We describe a case of a girl, JL, 8 years, with abnormal head position tilted to the left since the last glasses were prescribed. The correction used by the patient was: right eye = +2.00 sph à -5.5 cyl 180° and left eye = +2.25 sph à -5.75 cyl 180°. In tilted position, the correct visual acuity was: right eye 6/12 and left eye 6/9. No deviations were noted by the cover test and the remaining ophthalmological examination was completely normal. Retinoscopy under cycloplegia and subjective test showed right eye = +3.50 sph à -6.00 cyl 10° and left eye = +3.50 sph à -6.00 cyl 170°, with visual acuity 6/6 in both eyes. With adequate prescription, the head position was normalized. Wrong cylindrical positions for correction of high astigmatisms may cause abnormal head position. Retinoscopy under cycloplegia and subjective test are essential for precise diagnoses and prescriptions.

Keywords: Head; Posture; Astigmatism; Strabismus; Reflex; vestibulo-ocular; Nystagmus; pathologic; Oculomotor muscles; Refractometry; Case reports

The authors present a case of choroidal osteoma diagnosed in a 62-year-old male patient. A well-defined and slightly elevated lesion located in the posterior pole of the right eye associated with internal vasculature and choroidal neovascularization at its superior and inferior temporal edge were suspicious of the tumor. Confirmation of diagnosis was obtained with A and B ecography and computed tomography. Optical coherence tomography showed high reflectivity through its thickness as well as elevation of the RPE-choriocapillaris complex at the choroidal neovascularization site. Although the literature and the present case show several different tomographical findings, optical coherence tomography can help establishing the diagnosis of choroidal osteoma.

Keywords: Choroidal osteoma; Optical coherence tomography; Ecography; Choroidal neovascularization; Case reports

Blepharoplasty is one of the most commonly performed surgeries for rejuvenation of the periorbital region. We present a case of unilateral permanent visual loss following a bilateral lower lid cosmetic blepharoplasty with fat removal. The etiology of retrobulbar hemorrhage following blepharoplasty, treatment, and recommendations to reduce the chance of this rare but serious complication are discussed.

Keywords: Blindness; Blepharoplasty; Retrobulbar hemorrhage; Postoperative care; Adipose tissue; Surgery; Surgery; Case reports

The authors describe a young female patient with intracranial hypertension associated with ocular manifestations, during treatment with tetracycline. This is a rare adverse effect described in the medication warnings, and in a few reported cases in the scientific literature.

Keywords: Otitis; Tetracycline; Tetracycline; Intracranial hypertension; Pseudotumor cerebri; Eye manifestations; Vision disorders; Papilledema; Case reports

The consent form is a document recommended for international declarations, resolutions and specific laws currently used in research on health. The practice or the accomplishment of the informed consent in the exercise of the medicine and the research in human beings is pertains to the last decades and characterizes the perfectioning of biomedical ethics, constitutes a legal and ethical requirement in clinical research involving human beings. The main challenge of the consent process is to guarantee the adequate understanding of the individual, however the social, cultural and intellectual aspects as well as the relationship between physician and patient, sometimes, can affect this process. The purpose of this paper is to present important criteria in the consent process that need to be highlighted in accordance with specific tenets and resolutions, such as Resolution 196/96 of the National Council of Health.

Keywords: Biomedical research; Consent forms; Informed consent; Bioethics; Clinical Trials