VOLUME 84 - ISSUE 1

PURPOSE: The aim of the study is to evaluate the retinal and choroidal microvascular changes via optical coherence tomography angiography in patients who received hydroxychloroquine.
METHODS: In total, 28 eyes of 28 patients (24 females, and 4 males) receiving treatment with hydroxychloroquine were assessed in this cross-sectional cohort study (hydroxychloroquine group). The high-and low-risk groups consisted of patients receiving hydroxychloroquine for ≥5 years (14 eyes of 28 patients) and <5 years (14 eyes of 28 patients), respectively. A total of 28 age- and gender-matched volunteers were enrolled as the control group. The macular flow area (superficial, deep, and choriocapillaris), superficial and deep vessel density, foveal avascular zone area, central foveal thickness, and subfoveal choroidal thickness parameters were measured by optical coherence tomography angiography.
RESULTS: The mean age of the 28 patients who received hydroxychloroquine and the 28 age-matched controls was 45.5 ± 11.1 years (range: 29-70 years) and 44.5 ± 13.9 years (range: 28-70 years), respectively. In patients who received hydroxychloroquine, the values for the superficial, deep, and choriocapillaris macular flow areas were 13.578 ± 0.30, 13.196 ± 0.31, and 17.617 ± 0.42, respectively. In controls, these values were 16.407 ± 0.95, 13.857 ± 0.31, and 18.975 ± 0.76, respectively (p<0.05 for all). The superficial, deep, and choriocapillaris flow areas were significantly smaller in patients who received hydroxychloroquine than those in controls (p<0.05 for all). Superficial and deep vessel densities were significantly reduced in patients who received hydroxychloroquine in all regions (i.e., foveal, parafoveal, temporal, superior, nasal, and inferior) (p<0.05 for all). Moreover, significant difference was observed between the groups in the foveal avascular zone area (superficial and deep), central foveal thickness, and subfoveal choroidal thickness (p<0.05 for all).
CONCLUSIONS: Retinochoroidal microvascular flow and vessel density of the macular area were significantly decreased in patients who received hydroxychloroquine. Hydroxychloroquine may damage the retinochoroidal microvascular architecture. Optical coherence tomography angiography may contribute to the early detection of hydroxychloroquine-induced retinal toxicity.

Keywords: Retina/drug effects; Choroid/drug effects; Optical coherence tomography; Hydroxychloroquine; Fluorescein angiography/methods

PURPOSE: To determine the effect of upper blepharoplasty on corneal topography and intraocular lens power calculation using Galilei and IOLMaster.
METHODS: Thirty patients submitted to upper blepharoplasty from May 2014 to March 2017 at the Hospital Oftalmológico de Sorocaba (São Paulo, Brazil) were included in this observational case series. All patients underwent imaging sessions with Galilei and IOLMaster preoperatively (baseline) and at 1 and 6 months postoperatively. Primary outcome measures using both devices included flattest, average, and steepest corneal curvature, corneal astigmatism, and blepharoplasty-induced corneal astigmatism. Determination of axial length and lens power calculation were performed using only IOLMaster (Holladay formula). Paired t-test and vectorial analysis were used for statistical analysis.
RESULTS: Sixty eyes from 30 patients were prospectively included. Vectorial analysis showed that 6 months after surgery, blepharoplasty induced on average 0.39 D and 0.31 D of corneal astigmatism, as measured with Galilei and IOLMaster, respectively. IOLMaster measurements showed that average corneal curvature (44.56 vs 44.64 D, p=0.01), steepest corneal curvature (45.17 vs 45.31, p=0.01) and corneal astigmatism (1.22 vs 1.34, p=0.03) were higher 6 months after surgery. IOLMaster measurements also showed that intraocular lens power was significantly smaller 6 months after surgery (22.07 vs 21.93, p=0.004). All other parameters showed no change for comparisons between baseline and 6 months (p>0.05 for all comparisons).
CONCLUSION: Upper eyelid blepharoplasty influenced intraocular lens calculation using the IOLMaster. However, the influence was not clinically significant. No topographic changes were found using Galilei.

Keywords: Blepharoplasty; Intraocular lens; Keratometry; Corneal topography; Biometry

PURPOSE: To compare the severity and laterality of keratoconus according to allergic rhinitis, scratching and sleeping habits, and manual dexterity.
METHODS: Objective assessments regarding allergic rhinitis, eye itching, and sleeping position among patients with keratoconus (diagnosed based on corneal tomography) were conducted. Diagnostic criteria and classification were based on the Amsler-Krumeich classification.
RESULTS: Ocular pruritus was reported by 29 of 34 participants (85.29%). Eighteen participants (62.07%) reported equal scratching of both eyes, six (20.69%) more on the right eye, and five (17.24%) more on the left eye. Comparison of the main sleeping position and the eye with more severe presentation of the disease using Fisher’s exact test revealed some correlations (0.567 and 0.568 in the right and left eye, respectively). However, these correlations were not statistically significant.
CONCLUSIONS: The association between higher keratometry values and sleeping position appears to be more significant than that reported between keratometry and itching, or manual dexterity.

Keywords: Keratoconus; Hypersensitivity; Sleep/physiology; Rhinitis, allergic; Cornea; Tomography

PURPOSE: The aim of this study was to present our own experience with the use of thermography as a complementary method for the initial diagnosis and differentiation of intraocular tumors, as well as for the evaluation of the efficacy of treatment of intraocular melanomas.
METHODS: The study group comprised 37 patients with intraocular tumors, including 9 with uveal melanoma, 8 with uveal melanoma after I¹²⁵ brachytherapy, 12 with a focal metastasis to the uvea, and 8 with retinal capillary hemangioblastoma. A FLIR T640 camera was used to capture images in the central point of the cornea, eye area, and orbital cavity area.
RESULTS: Eyes with uveal melanoma had higher temperature compared with the fellow normal eye of the patient in the range of all measured parameters in the regions of interest. In the group of patients with melanoma after unsuccessful brachytherapy, higher temperature was observed at the central point of the cornea. In patients with tumor regression, all measured parameters were lower in the affected eye. We observed lower temperatures in the range of all tested parameters and areas in eyes with choroidal metastases. Eyes with diagnosed intraocular hemangioblastoma were characterized by higher parameters for the regions of interest versus eyes without this pathology.
CONCLUSIONS: A thermographic examination of the eye can be used as an additional first-line diagnostic tool for the differentiation of intraocular tumors. Thermography can be a helpful tool in monitoring the treatment outcome in patients with intraocular melanoma.

Keywords: Thermography; Uveal neoplasm; Melanoma; Neoplasm metastasis; Eye neoplasm/secondary; Hemangioblastoma

Purpose: Our goal was to analyze the prevalence of depression and anxiety among patients with glaucoma and to identify risk factors related to these disorders.
Methods: A cross-sectional study was carried out between August 2016 and August 2017 at the Hospital das Clínicas of Universidade Estadual de Campinas and at the Hospital Oftalmológico de Brasília to evaluate the prevalence of depressive and anxiety disorders among patients diagnosed with glaucoma. All patients underwent a complete ophthalmologic examination with standard automated perimetry to confirm the diagnosis of glaucoma. All participants were asked to complete the Hospital Anxiety and Depression Scale questionnaire.
Results: One hundred and twenty-nine patients were included in the study. Seventy-four were men (57.36%) and 55 (42.64%) were women. The mean age of the patients was 70.14 ± 15.8 years. Ninety participants were white (69.77%) and 38 (29.46%) were black. The study demonstrated a prevalence of depression and/or anxiety at 10.08%. Logistic regression revealed that women were at higher risk for anxiety and/or depression (OR: 5.25, p=0.015) and patients with a larger number of co-morbidities also were at higher risk for anxiety and/or depressive disorders (OR: 2.82, p=0.038).
Conclusion: A significant proportion of patients with glaucoma present with depression and/or anxiety. Females and patients with co-morbidities are at greater risk for these disorders.

Keywords: Glaucoma; Depression/epidemiology; Anxiety/epidemiology; Cross-sectional studies

Purpose: We aimed to evaluate the use of automated quantitative static and dynamic pupillometry in screening patients with type 2 diabetes mellitus and different stages of diabetic retinopathy.
Method: 155 patients with type 2 diabetes mellitus (diabetes mellitus group) were included in this study and another 145 age- and sex-matched healthy individuals to serve as the control group. The diabetes mellitus group was divided into three subgroups: diabetes mellitus without diabetic retinopathy (No-diabetic retinopathy), nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy. Static and dynamic pupillometry were performed using a rotating Scheimpflug camera with a topography-based system.
Results: In terms of pupil diameter in both static and dynamic pupillometry (p<0.05), statistically significant differences were observed between the diabetes mellitus and control groups and also between the subgroups No-diabetic retinopathy, nonproliferative diabetic retinopathy, and proliferative diabetic retinopathy subgroups. But it was noted that No-diabetic retinopathy and nonproliferative diabetic retinopathy groups have showed similarities in the findings derived from static pupillometry under mesopic and photopic conditions. The two groups also appeared similar at all points during the dynamic pupillometry (p>0.05). However, it could be concluded that the proliferative diabetic retinopathy group was significantly different from the rest of the subgroups, No-diabetic retinopathy and nonproliferative diabetic retinopathy groups, in terms of all the static pupillometry measurements (p<0.05). The average speed of dilation was also significantly different between the diabetes mellitus and control groups and among the diabetes mellitus subgroups (p<0.001). While weak to moderate significant correlations were found between all pupil diameters in static and dynamic pupillometry with the duration of diabetes mellitus (p<0.05 for all), the HbA1c values showed no statistically significant correlations with any of the investigated static and dynamic pupil diameters (p>0.05 for all).
Conclusion: This study revealed that the measurements derived from automated pupillometry are altered in patients with type 2 diabetes mellitus. The presence of nonproliferative diabetic retinopathy does not have a negative effect on pupillometry findings, but with proliferative diabetic retinopathy, significant alterations were observed. These results suggest that using automated quantitative pupillometry may be useful in verifying the severity of diabetic retinopathy.

Keywords: Diabetic retinopathy; Diabetes mellitus; Diagnostic techniques, ophthalmological; Pupil; Reflex, pupillary

Purpose: To determine whether codeine plus acetaminophen after photorefractive keratectomy (PRK) have beneficial effects on sleep quality, activity levels, and food intake, beyond their effect of pain relief.
Methods: We enrolled 40 patients (80 eyes) in this randomized, double-blind, paired-eye, placebo-controlled, add-on trial. Each eye was treated 2 weeks apart, and the patients were randomly allocated to receive either the placebo or the intervention (30 mg codeine and 500 mg acetaminophen) (4 times a day for 4 days). Outcomes were sleep quality, daily activity level, and food intake within 24-72 h post-photorefractive keratectomy, as measured by the McGill Pain Questionnaire.
Results: Sleep quality and daily activity level were inversely associated with pain scores within the first 48 h post-photorefractive keratectomy. During the intervention, patients were significantly more likely to score their sleep quality as good at 24 h (relative risk=2.5; 95% confidence interval 1.48-4.21, p<0.001) and 48 h compared to during placebo (relative risk=1.37; 95% confidence interval: 1.03-1.84, p=0.023). The probability of reporting good daily activity level at 24 and 72 hours post-photorefractive keratectomy was three times higher when patients received the intervention compared to the placebo (relative risk=3.0; 95% confidence interval: 1.49-6.15, p=0.006 and relative risk=1.31; 95% confidence interval: 1.02-1.67, p=0.021, respectively). No difference was observed in food intake.
Conclusion: The oral combination of codeine and acetaminophen significantly improves sleep quality and daily activity level within the first 24-72 h post-photorefractive keratectomy compared to a placebo.

Keywords: Codeine; Photorefractive keratectomy; McGill Pain Questionnaire; Pain; Acetaminophen; Sleep; Activities of daily living

Purpose: The goal of this study was to determine the impact of a mobile eye health unit on access to eye care and to generate a profile of the population requiring ophthalmic care by age, nature of their ophthalmic diseases, and optimal management.
Methods: The study was conducted in 14 cities in the southwest region of São Paulo, Brazil. Subjects included individuals who participate in the Brazilian Unified Health System who were in need of eye care. There were no restrictions on age, gender or socioeconomic status. Data was transferred to an Excel table for statistical analyses.
Results: We evaluated 6,878 participants in this survey with mean age of 44 years (range 4 months to 96 years); 65.5% were female. Among the diagnoses, 78.6% presented with refractive errors, 9.6% presented with cataracts and 8.3% presented with pterygium. New corrective lenses were prescribed for 60.9% of the participants; 10% retained their existing lenses, ~28% required counseling only and18.1% of the participants were referred to a tertiary facility for specialized exams and/or surgical procedures. Of the participants who required outside referrals, 36.4% required oculoplastic/external eye surgery and 31.8% required cataract surgery.
Conclusion: The vast majority of patients presenting to a mobile eye health unit required prescriptions for corrective lenses. The rate of detection of ocular disorders was relatively high and the mobile unit provided effective treatment of refractive errors and referrals for specialized ophthalmic examinations and procedures. A mobile eye health unit can be an effective alternative method for improving access to basic eye care, for promoting eye health education and preventing blindness.

Keywords: Mobile health units; Eye health; Vision disorders; Refractive errors; Eyeglasses; Blindness/prevention & control

PURPOSE: The United States of America has the highest gun ownership rate of all high-income nations, and firearms have been identified as a leading cause of ocular trauma and visual impairment. The purpose of this study was to characterize firearm-associated ocular injury and identify at-risk groups.
METHODS: Patients admitted with firearm-associated ocular injury were identified from the National Trauma Data Bank (2008-2014) using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and E-codes for external causes. Statistical analysis was performed using the SPSS 24 software. Significance was set at p<0.05.
RESULTS: Of the 235,254 patients, 8,715 (3.7%) admitted with firearm-associated trauma had ocular injuries. Mean (standard deviation) age was 33.8 (16.9) years. Most were males (85.7%), White (46.6%), and from the South (42.9%). Black patients comprised 35% of cases. Common injuries were orbital fractures (38.6%) and open globe injuries (34.7%). Frequent locations of injury were at home (43.8%) and on the street (21.4%). Black patients had the highest risk of experiencing assault (odds ratio [OR]: 9.0; 95% confidence interval [CI]: 8.02-10.11; p<0.001) and street location of injury (OR: 3.05; 95% CI: 2.74-3.39; p<0.001), while White patients had the highest risk of self-inflicted injury (OR: 10.53; 95% CI: 9.39-11.81; p<0.001) and home location of injury (OR: 3.64; 95% CI: 3.33-3.98; p<0.001). There was a steadily increasing risk of self-inflicted injuries with age peaking in those >80 years (OR: 12.01; 95% CI: 7.49-19.23; p<0.001). Mean (standard deviation) Glasgow Coma Scale and injury severity scores were 10 (5.5) and 18.6 (13.0), respectively. Most injuries (53.1%) were classified as severe or very severe injury, 64.6% had traumatic brain injury, and mortality occurred in 16% of cases.
CONCLUSION: Most firearm-associated ocular injuries occurred in young, male, White, and Southern patients. Blacks were disproportionally affected. Most firearm-associated ocular injuries were sight-threatening and associated with traumatic brain injury. The majority survived, with potential long-term disabilities. The demographic differences identified in this study may represent potential targets for prevention.

Keywords: Eye injuries; Firearms; Database; demographic disparity

Purpose: Diabetic retinopathy is currently considered a chronic inflammatory disease involving NOD-like receptor family pyrin domain containing 3 inflammasome activation and retinal microglial pyroptosis. In this study, we aimed to investigate whether NOD-like receptor family pyrin domain containing 3 inflammasome signaling induces pyroptotic death of retinal microglia under high-glucose conditions.
Methods: Retinal microglia were stimulated by high glucose levels for 24 h. Cell viability, lactate dehydrogenase release, and caspase-1 activity were detected in vitro. The expression of pro-inflammatory cytokine (interleukin-1β, activated microglia marker ionized calcium-binding adapter molecule-1), NOD-like receptor family pyrin domain containing 3, cleaved caspase-1, and cleaved gasdermin D were examined. Subsequently, retinal microglia were pretreated with the inhibitors of NOD-like receptor family pyrin domain containing 3 inflammasome signaling prior to stimulation with high glucose, and their molecular and functional changes were evaluated.
Results: High-glucose (25, 50, or 100 mM) stimulation decreased cell viability, but enhanced lactate dehydrogenase release and caspase-1 activity in a dose-dependent manner. Moreover, high glucose upregulated the protein expression of interleukin-1β, ionized calcium-binding adapter molecule-1, NOD-like receptor family pyrin domain containing 3, cleaved caspase-1, and cleaved gasdermin D. However, pretreatment with the inhibitors of NOD-like receptor family pyrin domain containing 3 inflammasome signaling inhibited high glucose (25 mM)-induced cytotoxicity, NOD-like receptor family pyrin domain containing 3 inflammasome activation, and pyroptosis of retinal microglia.
Conclusions: NOD-like receptor family pyrin domain containing 3 inflammasome signaling may modulate retinal microglia-related inflammation and pyroptosis under high-glucose conditions.

Keywords: Diabetic retinopathy; Microglia; NLRP3 inflammasome; Pyroptosis; Gasdermin D

A 45-year-old female patient presented with a complaint of right eye redness and pain for 7 days. She was under investigation for urinary abnormalities and reported a previous history of recurrent oral ulcers and ocular hyperemia in both eyes. Best-corrected visual acuity was 20/30 and 20/20 in the right and left eyes, respectively. Slit-lamp biomicroscopy of the ocular surface of the right eye revealed nasal scleral hyperemia that persisted after instillation of topical phenylephrine 10%, reinforcing the diagnosis of anterior scleritis. Renal biopsy showed immunoglobulin A immune complexes and confirmed the suspected diagnosis of Berger’s disease. Maintenance immunosuppressive therapy with azathioprine following a 6-month induction of remission with cyclophosphamide was necessary after pulse therapy with methylprednisolone. Scleritis is usually related to systemic autoimmune diseases, such as rheumatoid arthritis, and polyangiitis. Herein, we describe a rare case of unilateral anterior scleritis associated with Berger’s disease.

Keywords: Glomerulonephritis; Immunoglobulin A; Scleritis; Azathioprine; Cyclophosphamide; Case report

This report is of three cases of sicca syndrome, initially suspected to be Sjögren’s syndrome, which was ruled out by clinical and laboratory investigations. The patients were a 24-year-old woman, a 32-year-old man, and a 77-year-old woman with chronic symptoms of sicca syndrome, including dry eye syndrome. The first case was associated with the use of isotretinoin, a retinoic acid. The second was associated with the use of anabolic androgenic steroids, and the third was related to a prolactin- secreting pituitary adenoma. All cases manifested sicca, including dry eye syndrome, after those events, and the manifestations persisted. Magnetic resonance imaging revealed bilateral atrophy of the lacrimal gland. The medical history, ocular examinations, laboratory exams, and magnetic resonance images confirmed dry eye syndrome; however, the exams were all negative for Sjögren’s syndrome. The lacrimal gland was absent on magnetic resonance imaging in all three cases. The clinical history revealed that the signs and symptoms appeared after chronic exposure to retinoic acid, anabolic androgenic steroids, and a prolactin-secreting pituitary adenoma, respectively. Chronic isotretinoin, anabolic androgenic steroids, and prolactin-secreting pituitary adenoma or, in this last case, its inhibitory treatment, can cause lacrimal gland atrophy, sicca syndrome, and dry eye syndrome, and a differential diagnosis of Sjögren’s syndrome. Further studies on doses, time, and other susceptibilities to the long-lasting adverse effects of retinoic acid, anabolic androgenic steroids, and the repercussions of prolactin-secreting pituitary adenoma are necessary to confirm and expand upon these associations.

Keywords: Testosterone congeners; Isotretinoin; Dry eye syndrome; Lacrimal glands; Magnetic resonance imaging; Pituitary neoplasms; Adenoma; Prolactin; Sjögren’s syndrome

Septic cavernous sinus thrombosis is a rare but often debilitating and potentially fatal disease. We describe a case of bilateral orbital cellulitis with rapidly progressing cavernous sinus thrombosis and left sigmoidal sinus thrombosis in an immunocompetent 20-year-old military man who had undergone intensive physical training. The patient presented with rapid painful swollen left eye for 2 days. The examination results were gross proptosis with total ophthalmoplegia. He was treated with intravenous antibiotics and corticosteroid. At 1 week, visual acuity improved to 20/20 OU, with a normal intraocular pressure. There was a significant improvement in proptosis. The ocular motility of the right eye was fully restored, with slight residual ophthalmoplegia in the left eye. There was no residual illness or recurrence of illness at 3 months’ follow-up.

Keywords: Cavernous sinus thrombosis; Exercise; Physical training; Orbital cellulitis, Immunocompetence

This is a rare case report of acute, paracentral corneal melting and perforation occurring 1 week after an uneventful cataract surgery, with discussions on possible pathogenetic mechanisms. Relevant literature was also reviewed. Herein, a case of an 86-year-old woman with acute, paracentral, and sterile corneal melting and perforation in her left eye at 1 week after an uncomplicated cataract extraction is described. This occurs at the base of ocular surface disorders due to previous radiation of her lower eyelid and cheeks for the treatment of cancer and previously undiagnosed rheumatoid arthritis. She underwent surgical treatment using Gundersen’s conjunctival flap for the existing perforation due to low visual expectancies and reluctance to undergo corneal keratoplasty due to the risk of corneal graft rejection. The risk of coming across an acute corneal melting after an uncomplicated cataract surgery in the eyes with ocular surface disorders should always be considered.

Keywords: Corneal perforation; Radiation; Rheumatoid arthritis; Cataract extraction

PURPOSE: Lacrimal probing is the treatment of choice for congenital nasolacrimal duct obstruction that does not have a spontaneous resolution; however, there is no consensus about the best time for probing and if it is superior to other therapies. The present study aimed to evaluate the effectiveness of lacrimal probing compared with other treatments/no intervention to treat congenital nasolacrimal duct obstruction.
METHODS: A systematic review of literature in PubMed, EMBASE, CENTRAL, clinicaltrials.gov, and LILACS databases up to December 2019 was performed. Randomized clinical trials that enrolled children diagnosed with congenital nasolacrimal duct obstruction and undergoing lacrimal probing were considered. Data extraction and a risk of bias assessment were conducted independently and in duplicate. The overall quality of evidence for each outcome was conducted using the Grading of Recommendations, Assessment, Development, and Evaluation classification system.
RESULTS: Four randomized clinical trials involving 423 participants were eligible. No statistically significant differences were observed in resolution rates between early probing and observation/late probing (two studies; risk ratio 1.00 [95% confidence interval 0.76-1.33]; p=0.99; low certainty evidence). One study reported better resolution rates with bicanalicular silicone stent intubation compared with late probing in the complex congenital nasolacrimal duct obstruction cases subgroup (risk ratio 0.56 [95% confidence interval 0.34-0.92]; p=0.02; moderate certainty evidence).
CONCLUSIONS: Low certainty evidence suggests that early probing has the same success rate as late probing. Evidence of moderate certainty suggests that late probing has a lower success rate than bicanalicular silastic intubation in patients with complex congenital nasolacrimal duct obstructione.

Keywords: Lacrimal duct obstruction/congenital; Lacrimal duct obstruction/therapy; Infant