VOLUME 84 - ISSUE 5

Purpose: To investigate intraocular pressure peaks in phakic and pseudophakic patients with primary open-angle glaucoma.
Method: Overall, 40 patients with primary open-angle glaucoma were assessed. Of these, 20 patients were phakic and 20 pseudophakic. One eye (randomly selected) was included in the study. All patients underwent the intraocular pressure curves test, followed by the water-drinking test.
Results: A statistically significant difference was observed between the phakic and pseudophakic patients regarding the mean of the peaks in the intraocular pressure curves (p=0.045). A statistically significant intergroup difference was noted regarding the intraocular pressure peaks in the water-drinking test, with higher values observed in the phakic patients (p 0.004).
Conclusion: The intraocular pressure peaks in the water-drinking test and intraocular pressure curves were higher in the phakic group than in the pseudophakic group.

Keywords: Glaucoma, open-angle; Diagnostic techniques, ophthalmological; Drinking water; Intraocular pressure

Purpose: The purpose of this study is to translate and validate a Portuguese version of the Keratoconus Outcomes Research Questionnaire. The Keratoconus Outcomes Research Questionnaire is a psychometrically robust and valid instrument used to assess the impact of keratoconus on activity limitations and symptoms.
Methods: We performed a translation, cross-cultural adaptation, and validation of the Portuguese version of the Keratoconus Outcomes Research Questionnaire. The initial translation of the English version to the Portuguese language was performed by two independent native speaker translators, followed by an interdisciplinary panel evaluation of the translated version. The Portuguese version was then back-translated into English by two independent native speakers, followed by evaluation and comparison with the original English version by the same interdisciplinary panel. For subsequent validation, the translated questionnaire was administered at two different times to a population of 30 subjects, and the results were compared in a concordance analysis.
Results: The translation into Portuguese and back-translation were determined to be correct. Thirty participants were enrolled in the study (mean age, 29.23 ± 7.56 years). Nine questions (31%) had almost perfect agreement (questions 3, 4, 5, 8, 18, 22, 27, 28, and 29), 15 questions (51.7%) had substantial agreement (questions 1, 2, 6, 7, 9, 12, 14, 15, 16, 17, 20, 21, 23, 25, and 26), 4 questions (13.8%) had moderate agreement (questions 10, 11, 19, and 24) and 1 question (3.5%) had reasonable agreement (question 13). High-correlation coefficients were obtained when comparing results of the initial application and second application of this questionnaire to a sample of 30 individuals, which indicated excellent concordance with regard to results, repeatability, and reliability.
Conclusions: This translated and validated questionnaire can be applied to a larger population with the intent to assess quality of life in keratoconus patients in the overall Brazilian population as well as in distinct regions of the country.

Keywords: Keratoconus; Cornea, Quality of life, Questionnaire, Corneal ectasia

Purpose: The Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) is a tool for measuring the developmental status of children, including cognitive and motor functioning, in the first three years of life. This study aims to evaluate the correlation between grating visual acuity and visual functionality in healthy children using the Bayley-III.
Methods: Binocular grating visual acuity was measured using Teller Acuity Cards followed by the Bayley-III in healthy children aged 1-42 months. Visual acuity (logMAR) and Bayley-III scores for both cognitive and motor (gross and fine) skills were compared.
Results: Forty children (20 boys) aged 1.2-42.1 months were tested. Their mean visual acuity was 0.39 ± 0.27 logMAR, which was within the normal age limits for all children. There was a strong and significant negative correlation between visual acuity and age (r=-0.83, p<0.001). The mean cognitive raw data score was 49.92 ± 18.93 points, with a strong and significant positive correlation between cognitive score and age (r=0.81, p<0.001). The mean gross motor score was 41.72 ± 16.23 points, with a strong and significant positive correlation between gross motor score and age (r=0.75, p<0.001). The mean fine motor score was 39.75 ± 14.63 points, with a strong and significant positive correlation between fine motor score and age (r=0.77, p<0.001). Multiple linear regression demonstrated that older age and better visual acuity were significantly associated with higher Bayley-III scores.
Conclusions: This study found a high correlation between grating visual acuity measured using Teller Acuity Cards and cognitive and motor scores measured using the Bayley-III in healthy children, demonstrating that the Bayley-III might be a useful tool for assessing the repercussions of visual impairment on the cognitive and motor development of young children.

Keywords: Child development; Visual acuity; Cognition; Motor skill; Vision disorders; Neuropsychological tests; Child

Purpose: This study aimed to verify if patients with developmental dyslexia present deficits coherent with visual magnocellular dysfunction.
Methods: Participants with confirmed diagnosis of developmental dyslexia (n=62; age range=8-25 years; mean age=13.8 years, standard deviation=3.9; 77% male) were compared to a control group with normal development, matched for age, sex, ocular dominance, visual acuity, and text comprehension. The frequency-doubling technology perimetry was used to evaluate the peripheral visual field contrast sensitivity threshold. The Visagraph III Eye-Movement Recording System was used to evaluate ocular motor skills during text reading.
Results: The developmental dyslexia group had significantly worse contrast sensitivity in the frequency-doubling technology, with strong effect size, than the matched control group. The developmental dyslexia group had more eyes classified in the impaired range of sensitivity threshold to detect frequency-doubling illusion than the control group. Moreover, the developmental dyslexia group had poorer ocular motor skills and reading performance, revealed by a difference in ocular fixations, regressions, span recognition, reading rate, and relative efficiency between groups. A significant correlation was found between contrast sensitivity and ocular motor skills. Participants with good relative efficiency had significantly better contrast sensitivity than participants with poor relative efficiency.
Conclusions: The developmental dyslexia group presented a markedly worse performance in visual variables related to visual magnocellular function (i.e., frequency-doubling technology perimetry and ocular motor skills) compared with a matched control group. Professionals need to be aware of the importance of evaluating vision of individuals with developmental dyslexia beyond visual acuity and including in their assessments instruments to evaluate temporal processing, with contrast sensitivity threshold.

Keywords: Dyslexia; Reading; Visual perception; Vision disorders; Oculomotor muscles; Eye movements

Purpose: To analyze the presence of microorganisms in fluorescein eyedrops used in a reference eye center in Recife-PE.
Methods: This real-life and masked study evaluated fluorescein eyedrops used at the Altino Ventura Foundation in May 2019. Cultures were performed according to exposure times; I) three eyedrop bottles were analyzed after one day of use, II) three eyedrop bottles after 4 d of use, III) three eyedrop bottles after 8 d of use, and IV) three unopened bottles used as control. Samples were collected from the bottle’s tip, instilled drop, and residual fluid. After incubation, all colonies were analyzed and identified through biochemical tests.
Results: The contamination rate of the fluorescein eyedrop bottles in this study was 55.5% (5/9 vials). There was no contamination in the control group. The highest contamination was seen in one day exposed eyedrops, in 100% of the bottles. The bottle’s tip had a higher rate of contamination compared to the drop and residual fluid. Gram-positive bacteria were isolated in 7/27 (25.9%) samples. Growth of fungi or gram-negative bacteria was not observed.
Conclusion: The identification of gram-positive bacteria predominantly on the tip of the fluorescein eyedrop bottles suggests inadequate handling as the main cause of contamination.

Keywords: Fluorescein; Ophthalmic solution; Drug contamination; Eye infection, bacterial/microbiology; Bacteria/isolation & purification

Purpose: The aim of this study was to compare corneal structure and endothelial morphological changes after uneventful phacoemulsification cataract surgery between type 2 diabetic and nondiabetic patients and to determine the preoperative and intraoperative factors that may predict greater endothelial cell density loss.
Methods: Forty-five diabetic patients (45 eyes) and 43 controls (43 eyes) with age-related cataract were enrolled in this prospective observational study. Corneal (thickness and volume) and anterior segment parameters were measured by Scheimpflug tomography; endothelial cell density and morphology (coefficient of variation of cell size, hexagonal cells) were recorded using noncontact specular microscopy. Patients were evaluated preoperatively and at one and six months after surgery. Univariate and multivariate linear regression analyses were performed to evaluate the relationship between demographic, clinical, ocular, and intraoperative parameters and postoperative endothelial cell density changes at six months.
Results: Significant postoperative endothelial cell loss occurred one month after surgery in both groups (p<0.001), which remained stable until month 6; there were no differences between patients with and without diabetes mellitus at any time point. The mean postoperative central corneal thickness at one and six months did not change significantly from the mean preoperative value in either group (p>0.05). Multivariate linear regression analysis showed that older age (p=0.042) and higher cataract grades (p=0.001) were significantly associated with greater endothelial cell density reduction at six-month follow-up.
Conclusion: This study showed that older age and denser cataracts might be associated with greater endothelial cell density reduction after cataract surgery. Other factors, such as diabetes mellitus and preoperative anterior segment parameters, did not influence postoperative changes in endothelial cell density.

Keywords: Cataract; Phacoemulsification; Diabetes mellitus, type 2; Diabetic retinopathy; Endothelium, corneal; Corneal pachymetry; Corneal endothelial cell loss

Purpose: Microcornea is a rare condition that frequently resulets in serious cosmetic concerns due to the resultant asymmetrical appearance of the eye, and its cosmetic rehabilitation is possible with the use of colored contact lenses. This paper aims to present our experiences with the use of cosmetic Etafilcon A contact lenses for microcornea.
Methods: Eight patients with unilateral microcornea without any systemic involvement were included in this study, and they underwent routine ophthalmological examination, corneal topography, and optical biometry. We applied the cosmetic Etafilcon A contact lens (1-DAY ACUVUE^® DEFINE^® with Lacreon^®) of the same edge color to the patients. The levels of satisfaction in terms of cosmesis and comfort were evaluated with the use of visual analog scales (VAS).
Results: In the patients, the corneal diameter asymmetry was acceptably adjusted, and each of the patients reported extreme satisfaction. The mean VAS score was 8.9 ± 1.0 (range: 7-10) for the cosmetic satisfaction rate and 8.4 ± 1.0 (range: 7-10) for the comfort rate. The patients obtained the best-corrected visual acuity without or with additional eye-glasses. None of the patients complained about vision issues under photopic and scotopic conditions.
Conclusion: 1-DAY ACUVUE^® DEFINE^® with Lacreon^® lens has promising satisfactory cosmetic outcomes along with visual enhancement in cases of microcornea. This is the first study to report the use of this lens for the cosmetic rehabilitation of patients with microcornea.

Keywords: Microcornea; Contact lens, hydrophilic; Cosmetic techniques

Purpose: To comparatively evaluate the subfoveal choroidal thickness and the peripapillary retinal nerve fiber layer thickness in patients with chronic heart failure relative to control subjects.
Methods: A total of 72 chronic heart failure patients and 40 healthy control subjects were enrolled in this study. The patients were categorized into 2 groups: group 1: patients with 30-50% left ventricle ejection fraction and group 2: patients with the corresponding fraction value of <30%. The subfoveal choroidal thickness and the peripapillary retinal nerve fiber layer thickness were measured by spectral domain-optical coherence tomography.
Results: The mean subfoveal choroidal thickness was 250.24 ± 68.34 µm in group 1 and 216.72 ± 71.24 µm in group 2, while it was 273.64 ± 77.68 µm in the control group. The differences among the 3 groups were statistically significant. The average peripapillary retinal nerve fiber layer thicknesses were 100.34 ± 8.24, 95.44 ± 6.67, and 102.34 ± 8.24 µm, respectively. No significant differences were noted in the peripapillary retinal nerve fiber layer thicknesses between group 1 and control group, but it was significantly lower in group 2.
Conclusion: Our study thus revealed that the subfoveal choroidal thickness was lower in patients belonging to both the chronic heart failure groups in comparison to those in the control group. However, the alteration in the peripapillary retinal nerve fiber layer thickness was noted in only patients with <30% left ventricle ejection fraction. In the clinical practice, reductions in these values are correlated with decreased left ventricle ejection fraction, which may be important for the follow-up of chorioretinal diseases and the evaluation of glaucoma risks in patients with chronic heart failures.

Keywords: Heart failure/complications; Choroid/pathology; Tomography, optical coherence; Nerve fibers; Retina

Purpose: The aim of this study was to analyze patient data and the laboratory results of corneal samples collected from patients followed at the Ophthalmology Department, Hospital São Paulo, Brazil over a 30-year period, and correlate the analize with contact lens wearing.
Methods: Corneal samples from patients diagnosed clinically with microbial keratitis between January 1987 and December 2016 were included in this study. Cultures that were positive for bacteria, fungi, and Acanthamoeba spp. were analyzed retrospectively. To ascertain if the number of patients with contact-lens-associated microbial keratitis (as a risk factor for microbial infection) changed over time, the analysis was divided into three decades: 1987-1996, 1997-2006, and 2007-2016. Information pertaining to patient gender and age, as well as type of organism isolated, were compared among these periods.
Results: The corneal samples of 10.562 patients with a clinical diagnosis of microbial keratitis were included in the study, among which 1.848 cases were related to the use of contact lenses. The results revealed that the frequency of contact-lens-associated microbial keratitis increased over the last two decades. Overall, females had contact-lens-associated microbial keratitis more frequently (59.5%). Patients aged 19-40 years also had contact-lens-associated microbial keratitis more frequently in all study periods. Staphylococcus spp. and Pseudomonas spp. were the most frequent Gram-positive and Gram-negative bacteria, respectively, in the microbial keratitis groups. Among the fungal cases of microbial keratitis, filamentous fungi were the most frequent fungi over the entire study period, with Fusarium spp. being the most frequent fungi in the group with microbial keratitis not associated with contact lens wearing (p<0.001). Samples positive for Acanthamoeba spp. and Pseudomonas spp. were significantly correlated with contact-lens-associated microbial keratitis (p<0.001).
Conclusions: Females and young adults aged 19-40 years exhibited the highest frequency of contact-lens-associated microbial keratitis in our study. Staphylococcus spp. and Fusarium spp. were the predominant bacteria and fungi, respectively, isolated from corneal samples. Pseudomonas spp. and Acanthamoeba spp. were significantly correlated with contact-lens-associated microbial keratitis in this study.

Keywords: Contact lenses/adverse effects; Eye infections, bacterial/ microbiology; Acanthamoeba keratitis; Corneal ulcer

PURPOSE: This study aimed to optimize the effective doses of mitomycin C, 5-fluorouracil, and their combination on cultivated basal cell carcinoma.
METHODAS: Cultivated basal cell carcinoma and fibroblastic cells were treated with different concentrations of mitomycin C, 5-fluorouracil, and their combination. Cell viability, cell cycle, apoptosis, and expression levels of TP53, CDKN1A, and CDK6 were investigated. The most effective drug with its optimum dosage was administered via multiple intralesional injections to a 65-year-old woman with advanced periorbital nodulo-ulcerative BCC.
RESULTS: The concentrations of 0.00312 and 0.312 mg/mL were considered optimum for mitomycin C and 5-fluorouracil, respectively. The mean viabilities of basal cell carcinoma treated with mitomycin C alone and its combination with 5-fluorouracil were significantly less than those of the controls (p=0.002 and p=0.04, respectively). The cell cycle of all the treated basal cell carcinoma groups was arrested in the S phase. The apoptotic rates (p=0.002) of mitomycin C treated basal cell carcinoma were higher than those of the other treated cells, and their TP53 was significantly upregulated (p=0.0001). Moreover, CDKN1A was upregulated, whereas CDK6 was downregulated in basal cell carcinoma treated with either 5-fluorouracil (p=0.0001 and p=0.01, respectively) or the combination of 5-fluorouracil and mitomycin C (p=0.007 and p=0.001, respectively). Basal cell carcinoma lesions were significantly alleviated following mitomycin C injections in the reported patient.
CONCLUSION: Our in vitro results revealed that the effective doses of mitomycin C and 5-fluorouracil on cultivated basal cell carcinoma were optimized. Mitomycin C was more effective in inducing the apoptosis of basal cell carcinoma than 5-fluorouracil and their combination. The intralesional injections of the optimum dose of mitomycin C could be proposed for the nonsurgical treatment of advanced eyelid basal cell carcinoma.

Keywords: Basal Cell Carcinoma; Mitomycin C; 5-Fluorouracil; TP53; CDKN1A; CDK6

Pyogenic granuloma is a common benign, vascular lesion of the skin and mucosa. Our case was a 34-year-old woman at 28 weeks of gestation. She presented with a complaint of a growing and occasionally bleeding mass on the left lower eyelid conjunctiva for approximately 3 months. On examination, a red, pedunculated fragile lesion on the medial lower eyelid conjunctiva was observed. Ophthalmologic examination revealed that visual acuity was 20/20 in both eyes. Anterior and posterior segment examination was normal bilaterally. The lesion was excised completely under local anesthesia and sent for pathological examination. Histopathological examination revealed multiple vascular structures with small-diameters in the fibrous stroma. Vessels showed strong CD31 expression in immunohistochemical staining. Kaposi sarcoma was excluded due to negative HHV-8 staining. These findings were diagnostic of pyogenic granuloma. The frequency of pyogenic granuloma increases during pregnancy and surgical excision is important in diagnosis and treatment of these patients. This is the first reported case of conjunctival pyogenic granuloma during pregnancy.

Keywords: Granuloma, pyogenic; Conjunctival Diseases; Pregnancy complications; Case reports

Patent foramen ovale might cause cryptogenic strokes, including retinal artery occlusion. Herein, we describe a previously healthy young man who presented with central retinal artery occlusion in the setting of patent foramen ovale and explore the need for transesophageal echocardiogram for its diagnosis. Cardiovascular workup and neuroimaging were unremarkable. Transthoracic echocardiogram bubble study revealed a right to left atrial shunt and subsequent transesophageal echocardiogram disclosed patent foramen ovale. This congenital cardiac anomaly was the likely conduit for a thrombo-embolic central retinal artery occlusion. We identified seven patients with patent foramen ovale associated with central retinal artery occlusion in the literature. Transthoracic echocardiogram was diagnostic in only one patient (14.3%), whereas transesophageal echocardiogram was required to reveal patent foramen ovale in the remaining six (85.7%). Our case and the previous reports support the link between central retinal artery occlusion and patent foramen ovale. Therefore, providers should consider the more sensitive transesophageal echocardiogram during the initial evaluation of young patients without immediately identifiable causes of retinal artery occlusion.

Keywords: Retinal artery occlusion; Foramen ovale, patent; Transesophageal; Echocardiography; Case reports

Frosted branch angiitis is a rare and severe form of retinal vasculitis. It may be idiopathic or arise secondary to a systemic disease. We have reported here an unusually severe case of frosted branch angiitis in a previously healthy 13-year old girl who presented with significantly reduced vision in both eyes. In this case, frosted branch angiitis was one of the presentations of systemic lupus erythematosus. The characteristic patterns of frosted branch angiitis were observed on fundoscopy in both eyes. An extensive etiological study was conducted, whereby the diagnosis of systemic lupus erythematosus was confirmed. Only a few such cases have been reported so far in the literature.

Keywords: Lupus erythematosus, systemic/complications; Retinal vasculitis/etiology; Retinal vasculitis/drug therapy; Immunosuppressive agents/therapeutic use; Case reports

Isolated superior oblique myositis is a rare variant of idiopathic orbital myositis. We are reporting for the first time the case of a 19-year-old woman who had isolated superior oblique myositis with sinusitis that mimics a subperiosteal abscess. Despite the typical history of upper respiratory tract infection and laboratory test results and initial radiological findings suggestive of orbital cellulitis secondary to sinusitis, the initial response to systemic steroid with subsequent imaging changes and the relapse after cessation of steroid therapy helped us reach the diagnosis.

Keywords: Myositis/diagnostic imaging; Sinusitis; Orbital disease; Oculomotor muscle; Human; Case report

The degree to which viral infection and the host’s immune reaction to viral particles participate in the inflammatory process across various forms of herpetic keratitis has remained controversial. This fact has created conflicts regarding the classification of and therapeutic planning for such morbidities. This review aims to stimulate reflection on the classifications’ adequacy, nomenclatures, and therapeutic approaches related to these entities.

Keywords: Keratitis, herpetic/complications; Herpes simplex/ microbiology; Anti-bacterial agents/therapeutic use