VOLUME 85 - ISSUE 2

Purpose: To evaluate the concentration of tear lysozyme in individuals with Sjogren´s syndrome, meibomian gland dysfunction, and non-dry-eye disease.
Methods: Ninety subjects were recruited for this study, including 30 with Sjogren´s syndrome, 30 with meibomian gland dysfunction, and 30 with non-dry-eye disease. All subjects were referred to participate in the study based on a “dry eye” investigation. They underwent a complete ocular surface ophthalmic examination encompassing ocular surface disease index, biomicroscopy, tear break-up time, Schirmer test type I, conjunctival vital staining with fluorescein and lissamine green, tear lysozyme concentration, and impression cytology.
Results: Clinical tests yielded the following results: ocular surface disease index Sjogren´s syndrome: 64.5 ± 22.6 meibomian gland dysfunction: 43.5 ± 21.4, non-dry-eye disease: 6.7 ± 4.3 (p=0.02 between groups); Schirmer I test (mm/5 min): Sjogren´s syndrome: 4.95 ± 2.25, meibomian gland dysfunction: 13.28 ± 1.53, non-dry-eye disease 13.70 ± 1.39 (p<0.01 Sjogren´s syndrome vs. non-dry-eye disease and p<0.01 meibomian gland dysfunction vs. non-dry-eye disease); tear break-up time (seconds): Sjogren´s syndrome: 3.97 ± 1.47, meibomian gland dysfunction: 3.95 ± 0.86, non-dry-eye disease: 7.25 ± 1.90 (p<0.01 Sjogren´s syndrome vs. non-dry-eye disease and p<0.01 meibomian gland dysfunction vs. non-dry-eye disease); Lissamine green score: Sjogren´s syndrome-dry-eye: 6.18 ± 2.14, meibomian gland dysfunction-dry-eye: 5.27 ± 1.27, non-dry-eye disease: 1.52 ± 0.97 (p<0.01 Sjogren´s syndrome vs. non-dry-eye disease and p<0.01 meibomian gland dysfunction vs. non-dry-eye disease); impression cytology score: Sjogren´s syndrome: 1.88 ± 0.92, meibomian gland dysfunction: 1.67 ± 0.56, non-dry-eye: 0.45 ± 0.44 (p<0.01 Sjogren´s syndrome vs. non-dry-eye disease and p<0.01 meibomian gland dysfunction vs. non-dry-eye disease) and; tear lysozyme concentration (µg/mL): Sjogren´s syndrome: 751.25 ± 244.73, meibomian gland dysfunction: 1423.67 ± 182.75, non-dry-eye disease: 1409.90 ± 188.21 (p<0.01 Sjogren´s syndrome vs. non-dry-eye disease and p<0.01 Sjogren´s syndrome vs. meibomian gland dysfunction).
Conclusion: The concentration of lysozyme in the tears was lower in Sjögren’s syndrome patients than in meibomian gland dysfunction and non-dry-eye disease groups. Hence, the lacrimal lysozyme could be considered as a simple, non-invasive, and economical biomarker to differentiate between Sjögren’s syndrome dry eye disease and meibomian gland dysfunction dry eye disease.

Keywords: Lysozyme; Sjogren’s syndrome; Meibomian gland dysfunction; Non-dry-eye

Purpose: The aim of this study was to determine if the initial tumor size correlates with the time to regression after topical interferon alfa-2b (1 million IU/mL) therapy in the treatment of ocular surface squamous neoplasia.
Methods: A retrospective study was performed in 15 patients clinically diagnosed as having ocular surface squamous neoplasia and treated with topical interferon alfa-2b (1 million IU/mL, four times a day). All the cases of ocular surface squamous neoplasia included in the study had corneo-limbal involvement. The initial extension of the ocular surface squamous neoplasia was measured in square millimeters using the program ImageJ (LOCI, University of Wisconsin, Madison, USA) on images taken from the eyes of each patient immediately before the beginning of the treatment. The time until tumor resolution was measured for each case.
Results: Complete tumor resolution was achieved in all the cases, with a mean initial tumor extension of 26.71 mm² (standard deviation ± 17.21 mm²) and a mean time until resolution of 77 days (standard deviation ± 32 days). An increased tumor volume after 15 days of treatment was observed in 2 patients, which completely resolved. No significant correlation was found between the time to resolution and the initial tumor extension measured in square millimeters (Spearman test, p=0.347).
Conclusions: Our study suggests that the duration of topical interferon alfa-2b treatment required does not depend on the initial tumor size of the ocular surface squamous neoplasia usually found in clinical practice.

Keywords: Conjunctival neoplasm; Corneal disease/drug therapy; Carcinoma, Squamous cell; Interferon alpha-2/therapeutic use

Purpose: To investigate the association of the single-nucleotide polymorphism rs35934224 in the TXNRD2 gene with primary open-angle glaucoma in a Brazilian population.
Methods: This was a cross-sectional study conducted to verify the association between the rs35934224 TXNRD2 (thioredoxin reductase 2) and primary open-angle glaucoma in a population from the Northeast region of Brazil. A total of 184 individuals were enrolled, including 94 with primary open-angle glaucoma (45 men and 49 women) and 94 controls (40 men and 54 women) from the Recife Eye Institute.
Results: The mean age was 68.85 years for the patients with glaucoma and 68.55 years for the controls. Genomic DNA was isolated using commercially available kits, and single-nucleotide polymorphism was detected with real-time polymerase chain reaction using TaqMan probes. The studied population was in Hardy-Weinberg equilibrium. The CT genotype was associated with protection against primary open-angle glaucoma (p=0.022).
Conclusion: Our data suggest an association between TXNRD2 gene polymorphism (rs35934224) with primary open-angle glaucoma in an admixed Brazilian population. This is the first study to investigate this single-nucleotide polymorphism in Latin American individuals with primary open-angle glaucoma.

Keywords: Polymorphism, Thioredoxin reductase; Glaucoma, open-angle

Purpose: To analyze the macular ganglion cell-inner plexiform and retinal nerve fiber layer thicknesses after vitrectomy with the inverted flap technique for idiopathic macular holes.
Methods: A prospective study was conducted on 28 eyes treated with surgery for idiopathic macular holes. The inverted internal limiting membrane flap technique assisted with Brilliant Blue staining (0.05%) was performed. Ophthalmologic examinations and quantitative analysis of the macular ganglion cell complex thickness were performed at baseline,1 and 3 months after surgery.
Results: The preoperative mean thicknesses of the ganglion cell-inner plexiform layer and ganglion cell-inner plexiform layer + retinal nerve fiber layer were 88.9 and 124.8 µm, respectively. The mean ganglion cell-inner plexiform layer thicknesses at 1 and 3 months after surgery were reduced to 72.8 and 65.2 µm, respectively (p<0.001 and p<0.001, respectively). The mean postoperative ganglion cell-inner plexiform layer + retinal nerve fiber layer thickness was also reduced at 1 and 3 months (108.8 and 99.3 µm, respectively; p<0.001 and p<0.001, respectively). No significant difference was found between the preoperative and postoperative best-corrected visual acuities at 1 and 3 months (p<0.73 and p<0.14, respectively).
Conclusion: The macular ganglion cell-inner plexiform layer and ganglion cell-inner plexiform layer + retinal nerve fiber layer thicknesses were significantly reduced after vitrectomy with the inverted flap technique assisted with Brilliant Blue staining (0.05%) for idiopathic macular holes.

Keywords: Retinal ganglion cells; Nerve fiber layer; Retina; Vitrectomy

Purpose: To investigate whether meibomian gland dysfunction is the cause of dry eye in facial nerve palsy and to identify the possible relationship between the grades and durations of facial nerve palsy and meibomian gland dysfunction.
Methods: This prospective observational study included 63 patients with unilateral facial nerve palsy. Facial nerve function and severity were assessed using the House-Brackmann grading system. Unaffected contralateral eyes were used as the control group. The following parameters were compared: tear breakup time, Schirmer 1 test score, area and density scores for corneal fluorescein staining, eyelid abnormality, meibomian gland expression, meibography scores, and areas of meibomian gland loss. A Pearson correlation analysis was performed between the grades and durations of facial nerve palsy and meibomian gland dysfunction.
Results: The eyes affected by facial nerve palsy demonstrated significantly lower tear breakup time (p<0.001) and significantly higher values for corneal fluorescein staining (p<0.001), Schirmer 1 test score (p=0.042), lid abnormality score (p<0.05), meibomian gland expression level (p=0.005), meibography scores (p<0.05), and areas of meibomian gland loss (p<0.05). The grade and duration of facial nerve palsy significantly correlated with meibomian gland dysfunction (p<0.05).
Conclusions: Meibomian gland dysfunction has a significant contribution to the development of dry eye disease after facial nerve palsy. Furthermore, a strong correlation was observed between the grades and durations of facial nerve palsy and meibomian gland dysfunction.

Keywords: Meibomian gland; Dry eye syndrome; Facial Nerve; Facial paralysis

Objective: To estimate the epidemiology of the pterygium and its correlation with dry eye symptoms and with the potential systemic and ocular predictors.
Methods: This study is a population-based, cross-sectional study in which random visits were made to the 600 households of 600 participants of age ≥40 years in Ribeirão Preto-SP (n=420) and Cassia dos Coqueiros-SP (n=180) in Brazil. The participants were subjected to a structured interview with a detailed questionnaire to collect information on demography and the potential risk factors. Next, random participants with pterygium (n=63) or not (n=110) were evaluated for the ocular surface changes.
Results: The frequency of pterygium in Ribeirão Preto was 21% (15.7% among women and 32.1% among men; p=0.0002). In Cássia dos Coqueiros, the corresponding frequency was 19.4% (17.3% among women and 25.5% among men; p=0.28). The mean age of the affected individuals was higher than that of the unaffected ones (65.6 ± 10.5 years vs. 61.2 ± 12.0 years, p=0.02). A positive correlation was noted between pterygium and any prior radiotherapy and chemotherapy (p<0.0001, for both). A higher score on corneal fluorescein and conjunctival lissamine green staining was associated with pterygium (p=0.0003 and 0.0001, respectively).
Conclusion: We noted a high frequency of pterygium in two Brazilian adult populations, mainly among the men and elderly. Ocular surface damage and a previous history of radiotherapy and/or chemotherapy were found to be associated with pterygium.

Keywords: Pterygium/epidemiology; Dry-eye syndrome; Prevalence; Risk factors

Purpose: To report alterations in the anterior segment following accelerated corneal collagen cross-linking and topo-guided customized ablation treatment with the Nidek vision excimer laser system (Nidek Co., Ltd., Gamagori, Japan) in a single procedure.
Methods: We reviewed the medical records of patients who underwent cross-linking for progressive keratoconus. We divided patients into four groups based on the treatment protocol. Eyes were evaluated regarding uncorrected distance visual acuity, corrected distance visual acuity, keratometry (maximum [K_max], equivalent keratometry readings, K_steep and K_flat parameters), corneal elevations (anterior and posterior), the anterior radius of curvature, the posterior radius of curvature, anterior chamber volume, anterior chamber depth, anterior chamber angle and the pachymeter of the thinnest locale of the cornea before the surgery and at 1, 3, 6, and 12 months after the procedure.
Results: We included 259 eyes of 227 patients with progressive keratoconus who underwent treatment. The mean respective baseline uncorrected distance visual acuity and corrected distance visual acuity were: 0.68 ± 0.45 and 0.34 ± 0.40 in Group 1; 0.82 ± 0.44 and 0.33 ± 0.23 in Group 2; 0.61 ± 0.36 and 0.21 ± 0.17 in Group 3; and 0.65 ± 0.38 and 0.23 ± 0.18 in Group 4; logMAR did not show significant difference among the groups (p=0.14 and p=0.06, respectively). Visual improvements were better in the combined surgery groups. Mean K_max in Groups 1, 2, 3, and 4 were 57.24 ± 7.51, 59.26 ± 6.94, 53.73 ± 4.60, and 54.31 ± 4.25 diopter (D), respectively. Group 1 demonstrated increased K_max for 6 months. Maximum flattening by 3.38 ± 2.35 D 1 year after surgery was observed in Group 4 (p<0.05). Decreased anterior chamber angle, anterior chamber depth, and anterior chamber volume were similar, indicating the stability of the anterior chamber.
Conclusion: Visual and anatomical improvement is better, with improved stability of the anterior segment, in combined surgery groups compared with cross-linking alone.

Keywords: Anterior; Keratoconus; Photorefractive; Phototherapeutic; Scheimpflug

Purpose: To compare postoperative pain and discomfort between mechanical and transepithelial photorefractive keratectomies.
Methods: This prospective comparative study included 190 eyes of 95 patients with hyperopia (up to +4.00 D), astigmatism (up to -5.00 D), and myopia (up to -8.00 D) who underwent mechanical photorefractive keratectomy in one eye and transepithelial photorefractive keratectomy in the contralateral eye using Wavelight Allegretto EX500 excimer laser. The patients were unaware of the side treated with each technique. The interval between operations in the same patient was 15-30 days. Both eyes had similar refraction before surgery, with a maximum of 15-µm difference in ablation. Postoperative questionnaires were administered on days 1 and 7 to assess the patients’ level of discomfort (0=no discomfort to 5=extreme discomfort) with the following symptoms: pain, burning sensation, itchiness, tearing, photophobia, eye redness, foreign body sensation, and eyelid swelling. Patients were also asked about which method they preferred.
Results: The sample consisted of 61 women (64.21%) and 34 men (35.79%). The mean (SD) patient age was 31.66 (6.69) years (range, 22-54 years). On postoperative day 1, the patients reported significantly less discomfort in terms of pain (1.9 ± 1.74 vs 2.5 ± 1.83; p=0.017), burning sensation (1.8 ± 1.56 vs 2.5 ± 1.68; p=0.004), tearing (2.3 ± 1.71 vs 3.1 ± 1.69; p=0.001), and foreign body sensation (1.9 ± 1.77 vs 2.5 ± 1.86; p=0.024) in the eye that received mechanical photorefractive keratectomy than in the eye that received transepithelial photorefractive keratectomy. No significant differences were found between the mechanical and transepithelial photorefractive keratectomies on postoperative day 7. Fifty-nine patients (62.10%) preferred mechanical photorefractive keratectomy, while 32 (33.68%) preferred transepithelial photorefractive keratectomy. Four patients (4.22%) expressed no preference.
Conclusions: Our results showed that pain scores were significantly lower in the mechanical photorefractive keratectomy-treated eyes than in the transepithelial photorefractive keratectomy-treated eyes on postoperative day 1, which may have provided greater patient comfort after surgery and led patients to prefer the mechanical photorefractive keratectomy technique.

Keywords: Pain, postoperative; Astigmatism; Myopia; Hyperopia; Photorefractive keratectomy; Laser, excimer/therapeutic use

PURPOSE: The primary purpose of this study was to assess vascular retinal findings temporally related to COVID-19 vaccination. With greater information regarding all possible future adverse events, we hope to understand the real dimension and relevance of what was presented.
METHODS: Eleven patients with visual complaints after COVID-19 vaccination were enrolled. Data on the following were included: age, sex, vaccine, time of symptom onset, systemic findings, medical history, best-corrected visual acuity, and ocular findings by slit-lamp biomicroscopy as well as multimodal retinal imaging (color fundus, red-free photography, spectral-domain optical coherence tomography, optical coherence tomography angiography, and fluorescein-angiography). Inclusion criteria were the presence of ophthalmologic signs within 30 days after the first or second dose of any COVID-19 vaccine.
RESULTS: Of 11 patients, five had arterial occlusion (45.4%), four had venous occlusion (36.4%), and two (18.2%) had nonspecific vascular alterations suggestive of retinal ischemia such as cotton-wool spots. The mean age was 57 (SD = 16; range: 27-84) years. The mean time of symptoms onset was 10 (SD = 5.4; range: 3-16) days. Nine patients were female (81.8%). Systemic risk factors were observed in 36.4% of patients. Two patients had both neurological and visual symptoms, with arterial occlusion. Overall, 36.4% patients had COVID-19 in the previous year. Seven patients (63.6%) received ChAdOx1 nCoV-19 (AZD1222) vaccine.
CONCLUSIONS: Our data suggest that retinal events temporally related to COVID-19 vaccination are possible but are very rare. The relationship of these events with post-COVID-19 vaccination warrants further attention to derive a meaningful conclusion.

Keywords: COVID-19; Coronavirus infection; Vaccine; Arterial occlusion; Venous occlusion; Susac syndrome

Purpose: To measure retina/choroid complex perfusion with magnetic resonance imaging in eyes with acute primary angle-closure (APAC).
Methods: Three sequences of magnetic resonance imaging, two anatomical and one perfusional using gadolinium, were acquired in patients who were diagnosed with acute primary angle-closure. Regions of interest were drawn on the perfusional sequence and overlaid to the anatomical sequence. The relative blood volume measured during the first 2 s was considered as the baseline value and the change during the subsequent 28 s was analyzed.
Results: Five eyes of 5 patients with acute primary angle-closure were included (3 with unilateral and 2 with bilateral acute primary angle-closure). Three contralateral eyes and 2 eyes of 2 healthy patients, paired for age and sex, were included in the control group. Acute primary angle-closure patients included 4 (80%) women, with an average age of 65.8 ± 12.37 y, mean intraocular pressure of 56.2 ± 14.67 mmHg, mean arterial pressure of 113.4 ± 8.17 mmHg, and average ocular perfusion pressure of 57.2 ± 13.46 mmHg. In the control group, the mean intraocular pressure was 15.6 ± 2.61 mmHg (p=0.0625), the mean arterial pressure was 107.4 ± 6.57 mmHg (p=1.00), and the average ocular perfusion pressure was 91.8 ± 6.72 mmHg (p=0.0625). The relative blood volume of the retina/choroid complex was -0.127 ± 0.048 in acute primary angle-closure patients and -0.213 ± 0.116 in the controls (p=0.3125).
Conclusion: The magnetic resonance imaging sequence with gadolinium did not show a change in the retina/choroid complex perfusion in the eyes of patients with acute primary angle-closure.

Keywords: Angle-closure glaucoma; Magnetic resonance imaging; Gadolinium; Retina; Perfusion

Sebaceous tumors of the conjunctiva and caruncle are rare conditions, accounting for 1% of caruncle lesions and even lower among conjunctival lesions. Almost 50% of cases are associated with Muir-Torre syndrome, a rare autosomal-dominant condition characterized by at least one sebaceous skin tumor and one visceral malignancy. We report 3 cases of sebaceous adenoma with different presentations that were submitted to excisional biopsy and immunohistochemical study. Diagnosis of these tumors should increase the level of suspicion and lead to clinical investigation to rule out neoplasms, particularly because in up to 41% of cases, these can be the first sign of the disease.

Keywords: Sebaceous gland neoplasm; Adenocarcinoma; Conjunctival neoplasms; Muir-Torre syndrome; Immunohistochemistry; Biopsy; Human; Case report

Surgical management of large tumors involving the conjunctival fornix can be challenging, as exposure and clear margins may be difficult to achieve. In this case series, we report our initial experience with the open book technique in 4 patients. Through a canthotomy and cantholysis, this surgical approach provides a wide surgical field and facilitates fornix reconstruction post large tumor excision. In our series, one patient had a lateral canthus dehiscence.

Keywords: Fornix, brain; Lacrimal apparatus; Conjunctival neoplasm

Neurological manifestations of novel coronavirus disease 3019 (COVID-19) remain unclear. We report the case of a 44-year-old febrile man who presented with double vision and headache 2 d after initial symptoms of fatigue, generalized muscle weakness, and loss of appetite. He was subsequently diagnosed with COVID-19 and transient abducens nerve paresis. He did not present with any respiratory symptoms or additional specific neurological findings. We recommend that with the rising number of cases across the world, physicians develop a greater index of suspicion for COVID-19 in patients with cranial neuropathies, even in those with mild disease without typical respiratory symptoms.

Keywords: Diplopia; Severe Acute Respiratory Syndrome; Ophthalmoplegia; Coronavirus infection; Abducens nerve disease; SARS-CoV-2; Pandemic; Humans; Case report

A 38-year-old woman presented with photopsias and progressive but painless loss of vision in her right eye. Of note, she had received the first dose of inactivated COVID-19 vaccine (Sinovac/China National Pharmaceutical Group) 2 weeks prior to the onset of symptoms. Ophthalmic evaluation revealed a wreath-like foveal pattern and multiple gray-white dots throughout the posterior pole associated with discrete vitreous inflammatory reaction. Multimodal imaging analysis confirmed a diagnosis of multiple evanescent white dot syndrome. The patient underwent treatment with corticosteroids and, over the following weeks, her visual acuity improved to standard pattern.

Keywords: White dot syndrome/diagnosis; COVID-19; Coronavirus infection; Vaccine; Vaccination; Adrenal cortex hormones

The purpose of this article was to report a case of intraconal lacrimal gland tissue and to review the literature on lacrimal gland choristoma. The magnetic resonance imaging findings of a biopsy-proven orbital case are also presented. A PubMed database search was performed using the key terms heterotopic, ectopic, aberrant, choristoma, and lacrimal gland to identify all the previously documented studies on lacrimal gland choristoma, in English, Spanish, and French. We classified the lacrimal gland choristoma cases classified according to the location of the lesions, clinical appearance, management, and outcome. The search targeting the period between 1887 and 2019 returned 79 articles, which were reviewed. We found a total of 113 cases of choristomas with normal lacrimal gland tissue. Only two of them were not associated with the eye or its adnexa while the remaining 111 lesions were found either on the ocular surface (n=46) or in the orbit (n=34). Intraocular choristomas were found in 18 patients, and the rest of the lesions were noted either on the eyelids (n=10) or in the lacrimal drainage system (n=3). Orbital and intraocular choristomas are the most harmful lesions as orbital choristomas are frequently associated with permanent diplopia while intraocular lacrimal gland choristomas have a poor visual prognosis and are a common cause of enucleation of the eye. In one of the reported cases, a corneal lacrimal gland choristoma had been experimentally induced by activating the FGF10 signaling pathway. Lacrimal gland choristomas are not uncommon. This peculiar type of lesion has been experimentally induced and may appear in a variety of locations associated with the globe and its adnexa.

Keywords: Lacrimal gland; Choristoma; Prognosis