VOLUME 85 - ISSUE 5

Purpose: To evaluate the vision quality by measuring the objective light scatter index and objective optical quality parameters (Strehl Ratio and Modulation Transfer Function) in patients with emmetropia and ametropia.
Methods: This prospective, cross-sectional study included 408 eyes. The ametropic group comprised of eyes with best-corrected visual acuity of 0.0 logMAR or better and present at least a refractive error of ≥0.25 D. Patients underwent slit lamp examination, visual acuity, refraction, and vision quality using the HD Analyzer.
Results: The mean objective light scatter indices were 0.62 ± 0.63, 0.77 ± 0.70, 0.74 ± 0.30, 0.93 ± 0.55, and 0.85 ± 0.61, and mean Strehl Ratio and Modulation Transfer Function scores were 38.17 ± 10.4, 37.37 ± 10.06, 29.84 ± 9.71, 33.2 ± 12.11, and 33.13 ± 10.09 in emmetropes, myopia, hyperopia, spherical equivalent of ≥0, and spherical equivalent of <0, respectively. Differences in all variables were significant between emmetropic and corrected hyperopic and between spherical equivalent of ≥0, and spherical equivalent of <0 eyes (p<0.05).
Conclusion: In spectacle-corrected conditions (with trial frames), emmetropic and simple myopic eyes had significantly better vision quality compared to hyperopic and astigmatic eyes. The clinical significance of these results should be investigated in further studies.

Keywords: Refractive error; Emmetropia; Optical device; Diagnostic technique, ophthalmological/instrumentation; Refraction, ocular; Visual acuity

Purpose: To investigate the antiproliferative effect of carboplatin-loaded surface-modified poly(lactide-co-glycolide) on retinoblastoma cells.
Methods: Carboplatin-loaded poly(lactide-co-glycolide) with or without sodium alginate surface modification was prepared using sodium alginate-poly(lactide-co-glycolide) and poly(lactide-co-glycolide). The zeta potential and carboplatin release behavior were investigated. The cellular uptake of the released drug was observed in the retinoblastoma cell line Y79. The inhibitory effect of carboplatin-loaded nanoparticles against the Y79 cell line was evaluated using methyl thiazolyl tetrazolium assay and western blot. Native carboplatin and void nanoparticles without carboplatin loading were used as controls.
Results: The zeta potential was -(26.1 ± 3.1) mV for carboplatin-loaded poly(lactide-co-glycolide) and-(43.1 ± 8.1) mV for carboplatin-loaded sodium alginate-poly(lactide-co-glycolide). The burst release percentages of carboplatin-loaded poly(lactide-co-glycolide) and sodium alginate-poly(lactide-co-glycolide) were (40.0% ± 8.2%) and (18.9% ± 4.3%) at 24 hours, respectively. A significant difference was identified regarding drug release between carboplatin-loaded sodium alginate-poly(lactide-co-glycolide) and carboplatin-loaded poly(lactide-co-glycolide). Fluorescence detection revealed that intense uptake of carboplatin into the cytoplasm of the Y79 cell line that was exposed to carboplatin-loaded sodium alginate-poly(lactide-co-glycolide). Carboplatin-loaded poly(lactide-co-glycolide) or sodium alginate-poly(lactide-co-glycolide) exposure inhibited proliferating cell nuclear antigen expression in Y79 cells on day 3. Extension of exposure to day 5 revealed that the sodium alginate-poly(lactide-co-glycolide) surface modification was superior to that of poly(lactide-co-glycolide) in terms of proliferating cell nuclear antigen inhibition. The cell viability test using methyl thiazolyl tetrazolium revealed a similar inhibitory effect. Furthermore, the carboplatin-loaded nanoparticles of lower concentration inhibited cell viability more strongly than native carboplatin of higher concentration in methyl thiazolyl tetrazolium assay.
Conclusions: Carboplatin-loaded sodium alginate-poly(lactide-co-glycolide) inhibited retinoblastoma cell proliferation with superior effect as compared with poly(lactide-co-glycolide) and native carboplatin. Sodium alginate surface modification offers a potential strategy for the sustained carboplatin release system.

Keywords: Carboplatin; Alginate; Retinoblastoma; Nanoparticle

Purpose: Ocular disorders are among the most frequent manifestations of psoriatic arthritis. The incidence, type, and severity of these disorders may be influenced by genetics, local environmental factors, and access to ophthalmic treatment. Here we describe the ocular manifestations of psoriatic arthritis among denizens of the Amazon region of Para, Brazil, treated by the rheumatology service of Universidade do Estado do Pará.
Methods: This cross-sectional study examined 23 psoriatic arthritis patients (median age 47.78 years, no sex predominance) diagnosed according to Caspar’s criteria. Disease activity was evaluated according to the Clinical Disease Activity Index for Psoriatic Arthritis. Ophthalmological examinations performed included visual acuity with distance correction, biomicroscopy, applanation tonometry, fundoscopy, Schirmer test I, tear breakup time, fluorescein staining, and lissamine green staining. Patients also completed The Ocular Surface Disease Index questionnaire.
Results: The most common ophthalmic disorders were dry eye (60.9%), cataracts (56.5%), blepharitis (47.8%), keratitis (43.5%), meibomitis (30.4%), pterygium (26, 1%), and pinguecula (13%). More than half of all patients demonstrated recent onset (>5 years), the peripheral disease type, and severe symptoms according to Clinical Disease Activity Index for Psoriatic Arthritis.
Conclusion: The ocular manifestations of psoriatic arthritis are varied and mainly affect the ocular surface. Regular ophthalmological follow-up is recommended for patients in the early stage with high disease activity.

Keywords: Psoriatic arthritis; Eye manifestation; Keratoconjunctivitis sicca; Dry eye syndrome; Blepharitis

Purpose: To report the distribution of referral reasons for children from a pediatric glaucoma outpatient clinic in a tertiary eye care service.
Methods: The medical records of patients aged <18 years who were referred to a pediatric glaucoma center in the city of São Paulo, Brazil, between 2012 and 2018 were retrospectively reviewed. The data collected included the referral reasons, age, hospital of origin, and who detected the ocular alteration. For defining the diagnosis, the Childhood Glaucoma Research Network classification was used.
Results: Five hundred sixty-three eyes of 328 patients were included in the study. Glaucoma diagnosis was confirmed in 162 children (49%). In 83 patients (25%), the glaucoma diagnosis was ruled out, and 83 (25%) continued outpatient follow-up for suspected glaucoma. The main referral reasons were a cup-to-disc ratio >0.5 or an asymmetry ≥0.2 (24%), intraocular pressure >21 mmHg (21%), and corneal opacity (15%). In the neonatal period, the referral reasons were corneal opacity, buphthalmos, tearing, and photophobia. After the neonatal period, besides these external changes, other signs were also reasons for referral, such as cup-to-disc ratio >0.5 or asymmetry ≥0.2, intraocular pressure >21 mmHg, and myopic shift. The referrals were made by health professionals in 69% and parental concern in 30% of the cases. In 97% of the primary congenital glaucoma cases, the parents were the first to identify the change and to seek for health care.
Conclusions: The referral reasons of the children to a tertiary glaucoma clinic were differed between the age groups and diagnoses. We suggest that awareness with these findings is important to avoid and postpone diagnosis, identify their impacts on prognosis, and avoid spending important resources for the management of diseases with inaccurate referrals.

Keywords: Glaucoma/congenital; Glaucoma/physiopathology; Corneal opacity; Child; Visual acuity; Referral and consultation; Eye health services

Purpose: This study aimed to compare the anatomical and visual outcomes of idiopathic epiretinal membrane peeling surgery, with and without foveal herniation.
Methods: This retrospective, comparative, two-center study included age- and sex-matched patients exhibiting an idiopathic epiretinal membrane with and without foveal herniation (epiretinal membrane + foveal herniation group and epiretinal-membrane-only group, respectively). The baseline best-corrected visual acuity and central foveal thickness were compared within the groups through months 1, 3, 6, and 12 of follow-up postoperatively. Then, changes in these two parameters at all follow-up points were compared between the groups.
Results: We enrolled 16 patients per study group. The baseline best-corrected visual acuity and central foveal thickness were not significantly different between the two groups (p>0.05). Compared with the baseline, both the best-corrected visual acuity and central foveal thickness improved significantly in both groups in all follow-ups (p<0.05), except for the best-corrected visual acuity of the epiretinal-membrane-only group after month 1 (p<0.05). The mean best-corrected visual acuity improvement after month 1 and the mean central foveal thickness reduction after months 1, 3, and 6 were significantly better in the foveal herniation + epiretinal membrane group than in the epiretinal-membrane-only group (p<0.05). However, the best-corrected visual acuity and central foveal thickness changes were not significantly different between the groups at the final visit (p>0.05).
Conclusions: Although epiretinal membrane + foveal herniation demonstrated prompt anatomical and functional improvement, foveal herniation occurrence did not affect the final surgical outcomes in patients with idiopathic epiretinal membrane.

Keywords: Epiretinal membrane; Tomography, optical coherence; Fovea centralis; Vitrectomy; Visual acuity

Purpose: To examine the effect of subepithelial corneal infiltrates on corneal biomechanical properties after epidemic keratoconjunctivitis compared to that in healthy controls.
Methods: The cross-sectional study included consecutive patients with bilateral subepithelial corneal infiltrates after epidemic keratoconjunctivitis and healthy controls. Best corrected visual acuity corneal subepithelial infiltrate scoring Fantes grading scale, and central corneal thickness were measured. Corneal hysteresis corneal resistance factor Goldmann correlated intraocular pressure and corneal compensated intraocular pressure were assessed using an ocular response analyzer.
Results: This study included 66 eyes of 33 patients with subepithelial corneal infiltrates following epidemic keratoconjunctivitis and randomly selected 37 eyes of 37 healthy volunteers. The mean Fantes and CSIS scores were 1.8 ± 0.8 and 2.9 ± 1.3, respectively, in the first involved eyes and 1.3 ± 1.1 and 1.9 ± 1.7, respectively, in the fellow eyes (p=0.009 and p=0.002, respectively). The first (526.1 ± 28.1 µm; p=0.005) and second involved eyes (523.4 ± 38.1 µm; p=0.044) had significantly thinner corneas compared to that in healthy controls (557.0 ± 38.1 µm). While best-corrected visual acuity showed a positive correlation with corneal resistance factor (r=0.363, p=0.045) and corneal hysteresis (r=0.414, p=0.021), corneal subepithelial infiltrate scoring showed a negative correlation with Goldmann correlated intraocular pressure (r=-0.479, p=0.006) and corneal compensated intraocular pressure (r=-0.413, p=0.021).
Conclusion: Eyes with subepithelial corneal infiltrates had significantly thinner corneas compared to that in healthy controls. A positive correlation of the corneal resistance factor and corneal hysteresis with best-corrected visual acuity and a negative correlation of the Goldmann correlated intraocular pressure and corneal compensated intraocular pressure with corneal subepithelial infiltrate scoring should be taken into account when measuring intraocular pressure values in patients with subepithelial corneal infiltrates.

Keywords: Keratoconjunctivitis; Intraocular pressure; Epithelium, corneal; Adrenal cortex hormones; Cyclosporine; Tonometry, ocular

Purpose: To evaluate the effect of pupil dilation on intraocular pressure in preterm and term newborns.
Methods: This prospective study involved 55 eyes of 28 preterm infants and 38 eyes of 20 term infants. The infants were divided into two groups according to their gestational ages at birth as follows: preterm group, <37 weeks and term group, ≥37 weeks. Pupil dilation was attained with tropicamide 0.5% and phenylephrine 2.5%. Intraocular pressure measurements were performed with Icare PRO (Icare Finland Oy, Helsinki, Finland) before and after pupil dilation. A paired t test was used to compare the measurements before and after pupil dilation.
Results: The mean intraocular pressure change was -1.04 ± 3.03 mmHg (6.20/-11.40 mmHg) in the preterm group and -0.39 ± 2.81 mmHg (4.60/-9.70 mmHg) in the term group. A statistically significant difference in intraocular pressure was observed only in the preterm group after pupil dilation (p=0.01).
Conclusion: An unexpected alteration in intraocular pressure in newborns may occur after pupil dilation, especially in preterm infants.

Keywords: Infant; Infant, newborn; Infant, premature; Intraocular pressure; Pupil; Phenylephrine; Tropicamide; Dilatation

Purpose: The objective of this study was to investigate the usefulness of four different algorithms to correct noncontact intraocular pressure measurement errors in keratoconus patients and normal individuals.
Methods: Noncorrected intraocular pressure and corrected intraocular pressures were measured in one eye of 34 patients with keratoconus and 34 age- and gender-matched healthy controls using Corvis Scheimpflug Technology. The correlation of noncorrected intraocular pressure and corrected intraocular pressures with age, axial length, corneal shape, thickness, and biomechanics was calculated. Corrected intraocular pressures were compared with noncorrected intraocular pressure using paired t test and Bland-Altman plots (95% limits of agreement).
Results: The noncorrected intraocular pressure correlated with corneal thickness and biomechanical parameters in both groups (all p≤0.047), and front and back mean keratometry in the keratoconus group (r=-0.39, p=0.02, and r=0.39, p=0.02, respectively). After adjustment with different intraocular pressure correction algorithms, biomechanically corrected intraocular pressure showed a minimal correlation with corneal features and a nonsignificant difference with noncorrected intraocular pressure in the healthy group (-0.1 ± 1.1 mmHg, p=0.58; 95% limits of agreement: -2.3 to 2.1 mmHg).
Conclusions: Measuring intraocular pressure using noncontact tonometry and its corrected forms with a corneal thickness-based simple linear formula in patients with keratoconus is associated with many errors. Using more complex formulas that take into consideration more corneal stiffness parameters in addition to corneal thickness, such as biomechanically corrected intraocular pressure formula, may be more reliable and beneficial in this group of patients.

Keywords: Intraocular pressure; Noncontact tonometry; Cornea; Corneal pachymetry; Keratoconus

Purpose: To assess choroidal changes using enhanced depth imaging optical coherence tomography in coronavirus disease (COVID-19).
Methods: Thirty-two patients with moderate COVID-19 and 34 healthy subjects were included in the study. Choroidal thickness was measured at 3 points as follows: at the subfovea, 1500 mm nasal to the fovea, and 1500 mm temporal to the fovea. The total choroidal area, luminal area, stromal area, and choroidal vascular index were measured with Image-J. All the measurements were performed during the disease and at 4 months after remission.
Results: In the patient group, the subfoveal, nasal, and temporal choroidal thicknesses were decreased as compared with those in the controls, but without statistically significant differences (p=0.534, p=0.437, and p=0.077, respectively). The mean total choroidal, stromal, and luminal areas and choroidal vascular index were statistically significantly decreased in the patient group (p<0.001, p=0.001, p=0.001, and p=0.003; respectively). At 4 months after remission, the choroidal structural parameters and choroidal vascular index revealed statistically significant increases as compared with the baseline measurements in the patients with COVID-19 (all p<0.001 and p=0.047, respectively).
Conclusion: The choroidal vascular and stromal parameters showed significant transient decreases during the disease course of COVID-19.

Keywords: Choroid; COVID-19; Coronavirus infections; tomography, optical coherence

Purpose: To evaluate the epidemiological and clinical profiles of corneal transplants performed in a reference eye center in Recife, state of Pernambuco, Northeastern Brazil.
Methods: This cross-sectional study collected epidemiological and clinical data from the medical records of patients who underwent keratoplasty at the Altino Ventura Foundation between January and December 2017.
Results: A total of 356 procedures were performed in 327 patients, of whom 165 (50.5%) were female. The mean age at surgery was 50.9 ± 22.6 years (range, 10-89 years). Most patients (n=152 [46.5%]) were from the capital and metropolitan areas. The mean waiting time for keratoplasty was 52.4 ± 58.9 days (range, 0-460 days). The main indications for keratoplasty were infectious keratitis (n=88 [24.7%]), keratoconus (n=80 [22.5%]), and previous transplant failure (n=75 [21.1%]). Penetrating keratoplasty was the most common surgical technique performed (n=213 [59.9%]) and more frequently performed in men (n=132 [76.7%]), whereas posterior lamellar transplant (n=143 [41.1%]) was more frequently performed in women (p<0.001).
Conclusion: Infectious keratitis was the main indication for keratoplasty, which was similarly performed in economically active adults of both sexes. Penetrating keratoplasty was more frequently performed in men and lamellar transplants in women.

Keywords: Corneal disease/epidemiology; Corneal transplantation; Keratoplasty, penetrating; Brazil/epidemiology

The most frequently reported ophthalmic manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is conjunctivitis. We have described a case of Purtscher-like retinopathy in a patient with severe coronavirus disease 2019 (COVID-19)-associated coagulopathy. A young woman with multiple comorbidities was admitted for COVID-19-related acute respiratory distress syndrome. Her course was complicated by fungemia. Ophthalmic examination revealed bilateral posterior pole, intraretinal lesions and fluconazole was added for presumed fungal retinitis. At 1-week follow-up, widespread peripapillary cotton-wool spots and hemorrhages suggestive of Purtscher-like retinopathy were observed. The levels of D-dimers, fibrinogen, and C-reactive protein were markedly elevated prior to our consultation, indicating preceding prothrombotic and pro-inflammatory states. Subsequent venous duplex revealed deep venous thrombosis in the right subclavian and internal jugular veins. Von Willebrand factor indices were markedly elevated, suggesting severe COVID-19-associated coagulopathy. Purtscher-like retinopathy, a rare occlusive microangiopathy has been described in various pro-inflammatory and prothrombotic conditions. To the best of our knowledge, this is the first report of Purtscher-like retinopathy in COVID-19-associated coagulopathy.

Keywords: Retinal disease; Coronavirus infection; Severe acute respiratory syndrome; Case report.

We report the case of a previously healthy 48-year-old man who developed an isolated abducens nerve palsy 18 days after presenting with coronavirus disease (COVID-19) confirmed by reverse transcriptase polymerase chain reaction. His main complaint at arrival was double vision. Ocular examination revealed a sixth cranial nerve palsy in the left eye. The incomitant esotropia at arrival was 30 prism diopters. Abduction was markedly limited, while adduction was normal in the left eye. The patient underwent complete clinical, neurological, and neuroimaging investigations, including cerebrospinal fluid sample analysis to rule out infectious causes. A conservative approach with orthoptic therapy and Fresnel prism was opted. Eight months after the onset of COVID-19, regression of the strabismus was observed, and the patient reported complete recovery of the diplopia. This case suggests that isolated abducens nerve palsy caused by severe acute respiratory syndrome coronavirus 2 infection may improve with a conservative approach.

Keywords: Coronavirus infections; Abducens nerve diseases; Strabismus; SARS virus; Ocular motility disorders; Humans; Case reports

Aberrant regeneration in third nerve palsies, linking medial rectus contraction to the levator palpebrae muscle, is a great opportunity for surgical planning to address both the ptosis and horizontal deviation in a single procedure. We report a case of severe ptosis associated with exotropia that was successfully corrected with a single horizontal strabismus surgery owing to aberrant regeneration and discuss the basis underlying the surgical planning.

Keywords: Oculomotor nerve diseases/surgery; Strabismus; Blepharoptosis; Eye movement/physiology; Ophthalmologic surgical procedure; Nerve regeneration; Human; Case report

We report the case of a 68-year-old man who presented to our outpatient clinic for routine examination. Fifteen months before, he had undergone combined cataract and idiopathic full-thickness macular hole surgery in his right eye at another institution. In the present evaluation, the best-corrected visual acuity in his right eye was counting fingers. Fundus examination evidenced an idiopathic full-thickness macular hole in that eye, which was confirmed on spectral domain optical coherence tomography. A new surgery was offered, but the patient declined. Twenty-one months after his first consultation with us (36 months after the surgery), spectral domain optical coherence tomography revealed spontaneous closure of the idiopathic full-thickness macular hole, with a gap at the foveal ellipsoid zone. At the final visit, 22 months after the closure of the idiopathic full-thickness macular hole, the patient’s best-corrected visual acuity was 20/25, and the gap at the ellipsoid zone had decreased.

Keywords: Retinal perforations/surgery; Vitreoretinal surgery; Treatment failure; Time factors; Remission, spontaneous; Humans; Case reports

Transthyretin familial amyloidosis is the most common form of inherited systemic amyloidosis worldwide. The condition develops secondary to more than 100 different point mutations in the transthyretin gene (18q12.1). The mutations lead to abnormal amyloid deposits, mainly in the heart and peripheral nerves. Leptomeningeal and mainly ocular involvement is common. Although there are several different types of treatment available, ocular involvement, which occurs also in liver transplant recipients, remains a major challenge, progressing even in liver transplant recipients. Patients with ocular involvement require efficient ophthalmological follow-up to prevent vision loss. In this review, different forms of ocular involvement characterizing the subtypes of transthyretin mutations were described, and the effects of different treatments were summarized. Further research is necessary to fully elucidate these issues.

Keywords: Cataract; Amyloidosis, familial; Glaucoma; Neuropathy; Transthyretin