VOLUME 87 - ISSUE 2

Purpose: The purpose of this study was to evaluate the intraretinal layer thickness in the macular region and its correlation with the duration of uveitis and visual acuity in patients with Behçet uveitis.
Methods: In this cross-sectional study, we included 93 eyes of 57 patients with Behçet uveitis and 100 eyes of 50 healthy individuals admitted to a tertiary center from January to September 2017. We performed macular measurements in all subjects via spectral domain-optical coherence tomography (SD-OCT) and divided the retina into layers using automated segmentation software on the SD-OCT device. We then compared layer thicknesses between the patient and control groups and evaluated the correlation between OCT parameters and the duration of uveitis and visual acuity in the patient group.
Results: Our records show a mean age of 37.9 ± 10.8 (18-64) years and 37.7 ± 12.2 (21-61) years in the patient and control groups (p=0.821), respectively. Meanwhile, data reveal a mean duration of uveitis of 6.9 ± 4.7 (1-20) years. We found a reduction in the total outer layer thickness in the patient group (p<0.001). However, we did not find a statistically significant difference in the inner retinal layers except in the inner nuclear layer. The duration of uveitis negatively correlated with the outer retinal layer’s thickness (correlation coefficient = -0.250). On the other hand, visual acuity positively correlated with the central macular, the total inner layer, and the outer retinal layer thicknesses (correlation coefficients: 0.194, 0.154, and 0.364, respectively). However, the inner nuclear layer negatively correlated with visual acuity.
Conclusions: Using retinal segmentation via SD-OCT for follow-ups can help estimate visual loss in patients with Behçet uveitis, which can cause significant changes in intraretinal layers in the macular region.

Keywords: Behçet disease; Behçet uveitis; Intraretinal layers; Optical coherence tomography; Retinal segmentation

Purpose: This study aimed to evaluate the long-term safety and efficacy of neodymium-doped yttrium aluminum garnet (Nd:YAG) vitreolysis for symptomatic vitreous floaters as it remains a controversial procedure due to insufficient robust evidence in the literature for the maintenance of the results and absence of adverse effects.
Methods: This is an observational extension to the previously presented prospective, randomized, double-blind clinical trial. Eight of thirteen subjects who underwent vitreolysis with YAG laser returned for a late reevaluation, 18 months after the procedure, to evaluate the efficacy and safety of the procedure.
Results: All patients maintained the improvement in symptomatology noted after the procedure, with 25% showing complete improvement and a similar proportion (37.5%) reporting significant or partial improvement. Objective improvement in opacity was similar to that found at 6 months follow-up. The NEI-VFQ 25 quality of life questionnaire showed no statistically significant difference in responses between the 6^th and 18^th month. No adverse effects were noted on clinical examination or reported by patients.
Conclusion: Vitreolysis efficacy observed at 6 months of follow-up was maintained until the eighteenth month, with all patients reporting improvement from the pre-procedure state. No late adverse effects were noted. A larger randomized clinical trial is needed to confirm the safety of the procedure.

Keywords: Laser therapy; Lasers, solid-state; Vitrectomy; Vitreous body; Vitreoretinal surgery; Visual acuity; Eye diseases; Quality of life; Surveys and questionnaires

Purpose: To assess the effects of the preoperative application of artificial tears combined with recombinant bovine basic fibroblast growth factor on the ocular surface function and inflammatory factor levels after operation in cataract patients complicated with dry eyes.
Methods: A total of 118 cataract patients (118 eyes) complicated with dry eyes treated from February 2019 to February2020 were assigned to control and observation groups (n=59 eyes/group) using a random number table. One week before the operation, the control group was administered 0.1% sodium hyaluronate eye drops (artificial tears), based on which the observation group received Beifushu eye drops (recombinant bovine basic fibroblast growth factor), both 6 times daily for 1 week. A comparison was made between the scores of clinical symptoms and the indices of ocular surface function, inflammatory factors in tears, and oxidative stress indices before and after the operation. The ocular surface function was evaluated by an ocular surface disease index questionnaire, tear film breakup-time assay, Schirmer’s I test, and corneal fluorescein stain test. The inflammatory factors in tears were measured.
Results: No significant differences were noted in the general data and clinical symptom score, ocular surface disease index, tear film breakup-time, Schirmer’s I test score, fluorescein stain score, interleukin-6, tumor necrosis factor-alpha, malondialdehyde, superoxide dismutase, lipid peroxide, and total antioxidant capacity before treatment between the 2 groups (p>0.05). After treatment, the clinical symptom score, ocular surface disease index, fluorescein stain score, tumor necrosis factor-alpha, interleukin-6, malondialdehyde and lipid peroxide declined significantly, and tear film breakup-time, Schirmer’s I test score, superoxide dismutase, and total antioxidant capacity increased in both the groups. The improvements in the clinical symptom score as well as in the indices of ocular surface function, inflammatory factors, and oxidative stress were more prominent in the observation group than in the control group (p<0.05).
Conclusions: Artificial tears combined with recombinant bovine basic fibroblast growth factor before operation. significantly improved the ocular surface function, reduced inflammatory factors in tears, and alleviated dry eye symptoms after operation in cataract patients.

Keywords: Artificial tear; Basic fibroblast growth factor; Ocular surface; Cataract; Dry eyes

PURPOSE: To translate and validate a questionnaire that evaluates the theoretical knowledge regarding fundus examination.
METHODS: A 60-item multiple-choice English questionnaire that investigates various aspects of knowledge regarding fundus examination was translated into Portuguese. The process involved translation, back-translation, and evaluation by an expert committee. The resulting questionnaire was applied to final-year medical students and ophthalmology residents. Each included subject answered the questionnaire twice, with an interval of one week between each application. Internal consistency, test-retest reliability, inter-rater reliability, and percentage agreement were calculated.
RESULTS: Thirty participants were included (25 medical students and 5 ophthalmology residents). The pass-fail cutoff was calculated at 46, the theoretical false positives were 8.7% and the theoretical false negatives were 2.8%. The observed false positive and false negative rates were 0%. Among the 60 items, test-retest reliability was strong in 17 items, which one had a negative correlation, moderate in 14 items, which one had a negative correlation, and weak in 29 items; inter-rater reliability of 34 items was under 0.4, 17 items were between 0.4 and 0.6, and 8 items were above 0.6. One item had a negative kappa. Among the percent agreement, 10 items were between 40%-60% agreement, 50 were above 60% agreement, and 18 were above 80%. Cronbach’s alpha was calculated as 0.674.
CONCLUSIONS: The translated questionnaire provided a standard instrument for future research and interventions to improve medical education in ophthalmology.

Keywords: Questionnaire and surveys; Translating; Fundus oculi

PURPOSE: Diabetes mellitus is a leading cause of impaired vision. The objective of this study was to evaluate the feasibility of use of portable retinograph and remote analysis of images along with a virtual questionnaire for screening for diabetic retinopathy in basic health units in the city of Ribeirão Preto/SP during the Covid-19 pandemic.
METHODS: Standard Covid-19 protocol was followed during the screening. Blood pressure and capillary blood glucose were measured. Demographic and social data were collected through a standardized online questionnaire via smartphone. After pupillary dilation, fundal images were obtained with portable retinographs by trained ophthalmology residents. Two standardized 45° images were acquired: one posterior segment and another nasal to the optic nerve. Diabetic retinopathy was classified according to the Early Treatment Diabetic Retinopathy Study.
RESULTS: A total of 350 patients (64% female; 45% aged 55-70 years; 55% Caucasian) were evaluated. For 40.5% of patients, the campaign was the first opportunity for retinal evaluation; 47.56% had diabetes mellitus for >10 years. On repeat analysis of images stored in a cloud-based repository by retinal specialist, a 7.8% difference was observed in the Early Treatment Diabetic Retinopathy Study diabetic retinopathy classification, compared to the screening findings. Mild diabetic retinopathy was observed in 12.23%, moderate diabetic retinopathy in 6.31%, and proliferative diabetic retinopathy in 2.58% patients. Macular edema was present in 4.58% patients. Diabetic retinopathy was not detected in 72.78% patients.
CONCLUSION: Use of portable retinographs together with telemedicine can provide efficient alternative to traditional methods for screening and diagnosis of diabetic retinopathy.

Keywords: Diabetic retinopathy/diagnosis; Covid-19; Retina/ diagnostic imaging; Ophthalmology/instrumentation; Ophthalmoscopes; Point-of-care systems; Telemedicine/methods.

PURPOSE: Trimethylamine N-oxide serum levels have been associated with type 2 diabetes mellitus and its complications. The current study aimed to find out if plasma trimethylamine N-oxide level may be a novel marker in the diagnosis of diabetic retinopathy and if it can be used in the differential diagnosis of diabetic and nondiabetic retinopathy.
METHODS: The study included 30 patients with diabetic retinopathy, 30 patients with nondiabetic retinopathy, 30 patients with type 2 diabetes mellitus without retinopathy, and 30 healthy control participants. Biochemical parameters, serum IL-6, TNF-α, and trimethylamine N-oxide levels were measured in all participants.
RESULTS: Trimethylamine N-oxide level was significantly higher in diabetic retinopathy than in the other groups (p<0.001). There was no significant difference in trimethylamine N-oxide levels between nondiabetic retinopathy and control or type 2 diabetes mellitus Groups. There was a significant positive correlation between trimethylamine N-oxide level and elevated FPG, BMI, HOMA-IR score, BUN, IL-6, and TNF-α levels.
CONCLUSION: The current study showed that the trimethylamine N-oxide level is elevated in diabetic retinopathy. These findings suggest that serum trimethylamine N-oxide level might be a novel marker for diabetic retinopathy, and it might be used in the differential diagnosis of diabetic and nondiabetic retinopathy.

Keywords: Biomarkers; Diabetic retinopathy; Differential diagnosis; Oxides; Type 2 diabetes mellitus; Trimethylamine-N-oxide; Trimethyloxamine

PURPOSE: This study aimed to evaluate the mechanisms of injury and types of orbital fractures and their relation to concurrent commotio retinae.
METHODS: This retrospective study evaluated the records of patients with orbital fractures whose diagnoses had been confirmed by computer tomography between July 2017 and September 2019. Patient demographics, the circumstances of injury, ophthalmic examination results, and radiological findings were tabulated. Statistical analysis of the data used two-tailed student’s t-tests, chi-squared tests, and odds ratio calculations. Statistical significance was set at p<0.05.
RESULTS: Of the 204 patients with orbital fractures included in this study, 154 (75.5%) were male. The mean age was 42.1 years. Orbital fractures involving one orbital wall (58.8%) were more common than those affecting multiple walls (41.2%). The majority of fractures affected the inferior wall (60.3%), with the medial walls being the next most frequently affected (19.6%). The most common cause of injury was assault (59.3%), and the second most common was falls (24%). Commotio retinae was observed in 20.1% of orbital fracture cases and was most associated with injuries caused by assault (OR=5.22, p<0.001) and least associated with those caused by falls (OR=0.06, p<0.001). Eye movement restrictions were more common in central than peripheral commotio (OR=3.79, p=0.015) and with medial wall fractures than fractures to other orbital walls (OR=7.16, p<0.001). The odds of commotio were not found to be higher in patients with multi-walled orbital fractures than in those with single-walled fractures (p=0.967).
CONCLUSIONS: In the study population, assault was the most common cause of orbital fractures and resulted in commotio retinae than other causes. Ophthalmologists should be aware of the likelihood of commotio retinae in patients with orbital fractures resulting from assault, regardless of the extent of the patient’s injuries.

Keywords: Orbital fractures; Eye movements; Retina; Commotio and injuries

PURPOSE: In this prospective study, we compared ocular clinical variables in patients with acne vulgaris with those of healthy controls. These variables included tear film break-up time, meibomian gland dropout rate, and anterior chamber parameters.
METHODS: Our sample comprised 73 eyes from 73 patients with acne vulgaris and 67 eyes from 67 healthy controls. All participants underwent a non-invasive first tear film break-up time test and the average tear film break-up time was evaluated. Meibography was used to identify any meibomian gland dropout. The parameters of the cornea and anterior chamber were measured using Scheimpflug topography imaging. Finally, the ocular surface disease index questionnaire was administered to score each participant on their subjective experience of ocular complaints.
RESULTS: The noninvasive first tear film break-up time values of the acne vulgaris Group and the control Group were 4.7 ± 2.8 and 6.4 ± 3.5 sec, respectively. There was a significant difference between the groups (p=0.016). The number of eyes with tear break-up at any time during the measurement period was also significantly higher in the acne Group (p=0.018). In the acne vulgaris Group, the mean meibomian gland dropout rates were 33.21 ± 15.5% in the upper lids and 45.4 ± 14.5% in the lower lids. In the control group, these rates were 15.7 ± 6.9% and 21 ± 9.7% respectively. Dropout was significantly higher in the acne group for both the upper and lower lids (p=0.000).
CONCLUSION: We found impaired tear stability in patients with acne vulgaris and a high rate of meibomian gland dropout. These glands play a key role in tear stability and their dropout is likely to result in evaporative dry eye. Measurement of the variables in this study allows objective diagnosis of this condition using a non-invasive, dye-free methodology, with minimum contact.

Keywords: Acne vulgaris; Meibomian glands; Anterior chamber; Noninvasive break-up time test; Tear film

Purpose: This study aimed to screen the ocular surface of children with attention deficit hyperactivity disorder and identify the adverse effects of methylphenidate related to dry eye disease.
Methods: This cross-sectional study included children with attention deficit hyperactivity disorder and healthy children (all aged 5-18 years). They were randomized into Group A (without methylphenidate treatment), Group B (with methylphenidate treatment), and Group C (healthy children). Tear film break-up time, Ocular Surface Disease Index questionnaire, tear meniscus height, tear meniscus area, and Schirmer test results were evaluated. Furthermore, symptom severity in attention deficit hyperactivity disorder was assessed by Turgay DSM-IV-based Child and Adolescent Behavioral Disorders Screening and Rating Scale and Conners Parent Rating Scale-48.
Results: Groups A, B, and C consisted of 34, 40, and 60 individuals (n=34, 40, and 60 eyes; age=11.44 ± 2.79, 11.70 ± 2.83, and 11.96 ± 3.63 years, median age=12, 12, and 11.5 years), respectively. Tear film break-up time, Ocular Surface Disease Index, tear meniscus height, tear meniscus area, and Schirmer test results were not significantly different between Groups A and C (p=0.964, 0.336, 0.445, 0.439, and 0.759, respectively). However, Group B showed a significant decrease in tear film break-up time (10.50 ± 3.39 vs. 12.52 ± 2.46 s; p=0.005), tear meniscus height (307.40 ± 5.53 vs. 310.82 ± 7.30 µm; p=0.025), tear meniscus area (0.024 ± 0.0037 vs. 0.026 ± 0.0046 mm²; p=0.010) and Schirmer test (12.75 ± 3.96 vs. 15.41 ± 3.75 mm; p=0.004) results compared with Group A.
Conclusion: Compared with healthy children, children with attention deficit hyperactivity disorder showed ocular surface parameters suggestive of dry eye disease despite taking methylphenidate. Thus, they require close ophthalmologic follow-up to prevent sight-threatening dry eye complications.

Keywords: Attention deficit disorder with hyperactivity; Methylphenidate/adverse effects; Anterior eye segment; Optical coherence tomography; Dry eye syndromes.

PURPOSES: To determine the best protocol in obtaining the higher yield of conditioned culture medium to be used for the bone marrow mesenchymal stem cell differentiation into corneal epithelial cells, five techniques for the primary culture of human corneal epithelial cells were evaluated.
METHODS: The studied culture techniques of corneal epithelial cells were: explants in culture flasks with and without hydrophilic surface treatment, on amniotic membrane, with enzymatic digestion, and by corneal scraping. The conditioned culture medium collected from these cultures was used to differentiate human bone marrow mesenchymal stem cells into corneal epithelial cells, which were characterized using flow cytometry with pan-cytokeratin and the corneal-specific markers, cytokeratin 3 and cytokeratin 12.
RESULTS: The culture technique using flasks with hydrophilic surface treatment resulted in the highest yield of conditioned culture medium. Flasks without surface treatment resulted to a very low success rate. Enzymatic digestion and corneal scraping showed contamination with corneal fibroblasts. The culture on amniotic membranes only allowed the collection of culture medium during the 1st cell confluence. The effectiveness of cell differentiation was confirmed by cytometry analysis using the collected conditioned culture medium, as demonstrated by the expressions of cytokeratin 3 (95.3%), cytokeratin 12 (93.4%), and pan-cytokeratin (95.3%).
CONCLUSION: The culture of corneal epithelial cell explants in flasks with hydrophilic surface treatment is the best technique for collecting a higher yield of conditioned culture medium to be used to differentiate mesenchymal stem cells.

Keywords: Cell culture; Mesenchymal stem cells; Cell differentiation; Epithelial cells; Cornea; Conditioned culture medium; Culture techniques

PURPOSE: This study aimed to evaluate the efficacy and clinical outcomes of a one-way fluid-air exchange procedure for the treatment of postvitrectomy diabetic vitreous hemorrhage in patients with proliferative diabetic retinopathy.
METHODS: This retrospective study included 233 patients with proliferative diabetic retinopathy, who underwent vitrectomy. A one-way fluid-air exchange procedure was performed in 24 eyes of 24 (10.30%) patients with persistent vitreous cavity rebleeding after the operation. Preprocedural and postprocedural best-corrected visual acuity values were achieved. Complications occurring during and after the procedure were analyzed.
RESULTS: Significant visual improvement was observed 1 month after the one-way fluid-air exchange procedure (2.62 ± 0.60 LogMAR at baseline vs. 0.85 ± 0.94 LogMAR at postprocedure, p<0.0001). Moreover, 19 (79.17%) eyes needed the procedure once, and 5 (20.83%) eyed had the procedure more than twice. In 3 (12.50%) eyes, reoperation was eventually required because of persistent rebleeding despite several fluid-air exchanges. No complication was observed during the follow-up.
CONCLUSIONS: The one-way fluid-air exchange procedure can be an excellent alternative to re-vitrectomy for patients with proliferative diabetic retinopathy suffering from postvitrectomy diabetic vitreous hemorrhage by removing the hemorrhagic contents directly and achieving fast recovery of visual function without apparent complications.

Keywords: Diabetic retinopathy; Vitrectomy; Vitreous body; Vitreous hemorrhage; Hemostatic techniques

PURPOSE: Wet bio-amniotic membrane plugging combined with transplantation is a novel option that combined amniotic membrane plugging with amniotic membrane transplantation for the treatment of small corneal perforations. This study aimed to evaluate the efficacy of wet bio-amniotic membrane plugging in the treatment of small corneal perforations and compared it with that of the penetrating keratoplasty procedure.
METHODS: Forty patients (41 eyes) with small corneal perforations <3 mm in diameter treated at our hospital between July 2018 and January 2021 were retrospectively included. Among them, 21 eyes were treated with wet bio-amniotic membrane plugging (wet bio-amniotic membrane plugging group), and 20 eyes were treated with penetrating keratoplasty procedure (penetrating keratoplasty procedure group). The best-corrected visual acuity, anterior chamber formation, corneal thickness, primary disease control, postoperative complications, and graft survival rate were assessed.
RESULTS: No significant difference in baseline characteristics was found between the wet bio-amniotic membrane plugging and penetrating keratoplasty procedure groups (p>0.05). The postoperative control rates of primary diseases in the wet bio-amniotic membrane plugging and penetrating keratoplasty procedure groups were 95.2% and 90.0%, respectively (p=0.481). Visual acuity was improved 6 months after the operation in the wet bio-amniotic membrane plugging group and was improved at postoperative 1 month in the penetrating keratoplasty procedure group. The formation time of the anterior chamber in the wet bio-amniotic membrane plugging group was significantly shorter than that in the penetrating keratoplasty procedure group (p=0.023). The corneal thickness of the two groups significantly increased 12 months after the operation; however, the degree of thickening in the penetrating keratoplasty procedure group was higher than that in the wet bio-amniotic membrane plugging group (p<0.001). During the follow-up, postoperative complications were not different between the two groups (p>0.999).
CONCLUSION: The results suggest that wet bio-amniotic membrane plugging is effective and safe in the treatment of small corneal perforations. Thus, it can be used as an emergency treatment alternative to penetrating keratoplasty procedure for small corneal perforations.

Keywords: Amnion; Transplantation; Amniotic membrane; Keratoplasty, penetrating; Corneal perforation; Wet bio-amniotic membrane plugging; Wet bio-amniotic membrane transplantation

PURPOSE: To compare the injection of small amounts of undiluted C₃F₈ with the traditional gas injection in vitrectomy for macular hole treatment.
METHODS: This clinical trial included 26 individuals divided into two groups. Group 1 received an intravitreal injection of 0.9-1.0 mL of 100% C₃F₈, and Group 2 received 15-20 mL of 20% C₃F₈.
RESULTS: The median intraocular gas duration was 31 days in Group 1 and 34 in Group 2. The median letter gains in corrected distance visual acuity for the 26^th postoperative week were 20 letters in Group 1 and 12.5 in Group 2. The median intraocular pressure was normal in both groups. Primary anatomical success was 11/13 in both groups.
CONCLUSIONS: The use of C₃F₈ gas in a small undiluted volume is an alternative that slightly reduces the duration of the gas without negatively affecting the anatomical and visual response.

Keywords: Retinal perforations/surgery; Vitrectomy; Sulfur hexafluoride/administration & dosage; Fluorocarbons/administration & dosage; Gases; Tomography, optical coherence

PURPOSE: This study aimed to analyze the association between magnetic resonance imaging apparent diffusion coefficient map value and histopathological differentiation in patients who underwent eye enucleation due to retinoblastomas.
METHODS: An observational chart review study of patients with retinoblastoma that had histopathology of the lesion and orbit magnetic resonance imaging with apparent diffusion coefficient analysis at Hospital de Clínicas de Porto Alegre between November 2013 and November 2016 was performed. The histopathology was reviewed after enucleation. To analyze the difference in apparent diffusion coefficient values between the two major histopathological prognostic groups, Student's t-test was used for the two groups. All statistical analyses were performed using SPSS version 19.0 for Microsoft Windows (SPSS, Inc., Chicago, IL, USA). Our institutional review board approved this retrospective study without obtaining informed consent.
RESULTS: Thirteen children were evaluated, and only eight underwent eye enucleation and were included in the analysis. The others were treated with photocoagulation, embolization, radiotherapy, and chemotherapy and were excluded due to the lack of histopathological results. When compared with histopathology, magnetic resonance imaging demonstrated 100% accuracy in retinoblastoma diagnosis. Optic nerve invasion detection on magnetic resonance imaging showed a 66.6% sensitivity and 80.0% specificity. Positive and negative predictive values were 66.6% and 80.0%, respectively, with an accuracy of 75%. In addition, the mean apparent diffusion coefficient of the eight eyes was 0.615 × 10³ mm²/s. The mean apparent diffusion coefficient value of poorly or undifferentiated retinoblastoma and differentiated tumors were 0.520 × 10³ mm²/s and 0.774 × 10³ mm²/s, respectively.
CONCLUSION: This study revealed that magnetic resonance imaging is useful in the diagnosis of retinoblastoma and detection of optic nerve infiltration, with a sensitivity of 66.6% and specificity of 80%. Our results also showed lower apparent diffusion coefficient values in poorly differentiated retinoblastomas with a mean of 0.520 × 10³ mm²/s, whereas in well and moderately differentiated, the mean was 0.774 × 10³ mm²/s.

Keywords: Retinoblastoma; Prognosis; Retinal neoplasms; Orbit; Diffusion magnetic resonance imaging

PURPOSE: To determine the absorbance coefficient of the thin porcine cornea to ultraviolet-A radiation (365 nm) submitted for crosslinking.
METHODS: This in vitro, benchtop experiment using cadaver tissue study analyzed 12 porcine corneal lamellas, which were obtained using a microkeratome after mechanical de-epithelization and separated into three thickness groups: 180, 300, and 360 µm. The corneal thickness values were measured by anterior-segment optical coherence tomography. All lamellas had ultraviolet-A (365 nm) absorbance measured with a 96-well plate spectrophotometer using an ultraviolet transparent microplate before riboflavin instillation and pre- and post-crosslinking according to the Dresden protocol.
RESULTS: The ultraviolet absorbance profiles of the 180, 300, and 360 µm groups were obtained as a-coefficients of 12.85, 76.55, and 120.27, respectively. A theoretical formula was calculated though a statistical analysis that demonstrated the correlation between stromal lamellar thickness and ultraviolet absorbance.
CONCLUSIONS: Corneal thickness and ultraviolet-A spectral absorbance of corneal lamellas showed linear correlation. These findings can potentially contribute to the optimization of ultraviolet-A application during crosslinking, making the treatment of corneas with thickness <400 µm safe and personalized energy delivery for each corneal thickness.

Keywords: Ultraviolet light; Spectrophotometry; Crosslinking; Keratoconus; Corneal thickness

PURPOSE: As superotemporal implantation of the Ahmed glaucoma valve is not always feasible in cases of refractory glaucoma, this study examined the characteristics and surgical outcomes of cases in which the valve was implanted in a nonsuperotemporal quadrant using a modified long scleral tunnel technique.
METHODS: This retrospective case-control study included 37 eyes with nonsuperotemporal quadrant-Ahmed glaucoma valve implantation in Group 1 and 69 eyes with superotemporal Ahmed glaucoma valve implantation in Group 2. The demographic characteristics of these groups, surgical outcomes, including complications, further surgical interventions, and surgical success rates were compared. Surgical success was defined as an intraocular pressure not exceeding 21 mmHg, accompanied by a minimum reduction of 20% in intraocular pressure from the baseline without any additional intraocular pressure-lowering procedures, and the absence of light perception loss or phthisis bulbi.
RESULTS: Group 1 had significantly higher numbers of eyes with secondary glaucoma and preoperative surgical procedures than Group 2 (p<0.05). Both groups had mean preoperative intraocular pressure values, and mean intraocular pressure values at the last visit of 34.2 and 27.9 months, 35.5 ± 1.5 and 35.8 ± 1.2 mmHg, and 14.5 ± 5 and 14.9 mmHg, respectively. Although both groups had 70.2% and 75.8% as their five-year cumulative probability of success, respectively, the rates of complications, revisional surgery, and additional surgical procedures did not differ significantly (p>0.05).
CONCLUSION: The modified long scleral tunnel technique for Ahmed glaucoma valve implantation in nonsuperotemporal quadrants achieves intraocular pressure control and complication rates comparable to superotemporal implantation.

Keywords: Glaucoma/surgery; Sclera/surgery; Glaucoma drainage implant; Intraocular pressure; Tenon capsule

PURPOSE: To evaluate the clinical results of cryopreserved amniotic membrane transplantation as a treatment option for refractory neurotrophic corneal ulcers.
METHODS: This prospective study included 11 eyes of 11 patients who underwent amniotic membrane transplantation for the treatment of refractory neurotrophic corneal ulcers at Hospital de Clínicas da Universidade Federal do Paraná, in the city of Curitiba, from May 2015 to July 2021. Patients underwent different surgical techniques in which the amniotic membrane was applied with the epithelium facing upward to promote corneal re-epithelialization.
RESULTS: The median age of the patients was 60 years (range, 34-82 years), and 64% were men. The predominant etiology of corneal ulcers was herpes zoster (45% of cases). Approximately one-third of the patients (27%) were chronically using hypotensive eye drops, and more than half (54%) had previously undergone penetrating corneal transplantation. At the time of amniotic membrane transplantation, 18% of the eyes had corneal melting, 9% had corneal perforation, and the others had corneal ulceration without other associated complications (73%). The time between clinical diagnosis and surgical treatment ranged from 9 days to 2 years. The corrected visual acuity was worse than 20/400 in 90% of the patients preoperatively, with improvement in 36% after 3 months of the procedure, worsening in 18% and remaining stable in 36%. Of the patients, 81% complained of preoperative pain, and 66% of them reported total symptom relief after the surgical procedure. In one month, 54.6% of the patients presented a closure of epithelial defect, and half of the total group evolved with corneal thinning. The failure rate was 45.5% of the cases.
CONCLUSION: Cryopreserved amniotic membrane transplantation can be considered a good alternative for treating refractory neurotrophic corneal ulcers, as it resulted in significant improvement in pain (66%) and complete epithelial closure (60%) in many patients at 1 month postoperatively. Notably, the high failure rate highlights the need for further studies to identify patient- and ulcer-related factors that may influence the outcomes of this procedure.

Keywords: Amnion/transplantation; Corneal ulcer; Anterior eye segment; Keratitis

PURPOSE: We aimed to study reported cases of nasopharyngeal carcinoma presenting with ophthalmic manifestations with and without a prior diagnosis of nasopharyngeal carcinoma.
METHODS: We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A literature search was conducted using the MEDLINE database in PubMed and Google Scholar. We included patients with a previous diagnosis of nasopharyngeal carcinoma in Group I and those without a prior diagnosis of nasopharyngeal carcinoma in Group II. Data included demographics, clinical presentation, history of nasopharyngeal carcinoma, treatment, histopathological description, World Health Organization classification, and outcome.
RESULTS: Fifty-eight patients (26 in Group I and 32 in Group II) were included. The male-to-female ratio was 3:1. The mean age of the patients (53.3 ± 11.7 years and 54.8 ± 16.2 years, respectively) and gender did not differ significantly between the two groups. The most common ocular presentations were diplopia and proptosis in the first group (each in 34.6%), whereas visual disturbance was most common in the second group (46.9%). Treatment options and World Health Organization grading were comparable. The outcome in 38 patients (after a comparable follow-up period) was significantly better in group II (p=0.003). There was no statistically significant difference in the outcome of 23 patients in correlation with World Health Organization grades II versus III irrespective of group (p=0.094).
CONCLUSIONS: The demographics of patients with nasopharyngeal carcinoma presenting with ophthalmic manifestations were similar between the two study groups, with a wide age range and male predominance. Patients presenting initially to ophthalmologists with no history of nasopharyngeal carcinoma have a more favorable outcome. World Health Organization grading may have less value as a prognostic indicator.

Keywords: Nasopharyngeal carcinoma; Carcinoma; Eye manifestations; Exophthalmos; Diplopia; Systematic review

PURPOSE: To investigate the clinical benefits of the co-application of bevacizumab and tissue plasminogen activator as adjuncts in the surgical treatment of proliferative diabetic retinopathy.
METHODS: Patients who underwent vitrectomy for proliferative diabetic retinopathy complications were preoperatively given intravitreal injection with either bevacizumab and tissue plasminogen activator (Group 1) or bevacizumab alone (Group 2). Primary outcomes were surgery time and number of intraoperative iatrogenic retinal breaks. Secondary outcomes included changes in the best-corrected visual acuity and postoperative complications at 3 months postoperatively.
RESULTS: The mean surgery time in Group 1 (52.95 ± 5.90 min) was significantly shorter than that in Group 2 (79.61 ± 12.63 min) (p<0.001). The mean number of iatrogenic retinal breaks was 0.50 ± 0.59 (0-2) in Group 1 and 2.00 ± 0.83 (0-3) in Group 2 (p<0.001). The best-corrected visual acuity significantly improved in both groups (p<0.001). One eye in each group developed retinal detachment.
CONCLUSION: Preoperative co-application of bevacizumab and tissue plasminogen activator as adjuncts in the surgical treatment of proliferative diabetic retinopathy shortens the surgery time and reduces the number of intraoperative iatrogenic retinal breaks.

Keywords: Diabetic retinopathy; Bevacizumab; Plasminogen activators; Vitrectomy; Operative time

To assess Meibomian gland dysfunction using meibography in patients with xeroderma pigmentosum and correlate with ocular surface changes. This cross-sectional study evaluated patients with xeroderma pigmentosum. All patients underwent a comprehensive and standardized interview. The best-corrected visual acuity of each eye was determined. Detailed ophthalmic examination was conducted, including biomicroscopy examination of the ocular surface, Schirmer test type I, and meibography, and fundus examination was also performed when possible. Meibomian gland dysfunction was assessed by non-contact meibography using Oculus Keratograph^® 5M (OCULUS Inc., Arlington, WA, USA). Saliva samples were collected using the Oragene DNA Self-collection kit (DNA Genotek Inc., Ottawa, Canada), and DNA was extracted as recommended by the manufacturer. Factors associated with abnormal meiboscores were assessed using generalized estimating equation models. A total of 42 participants were enrolled, and 27 patients underwent meibography. The meiboscore was abnormal in the upper eyelid in 8 (29.6%) patients and in the lower eyelid in 17 (62.9%). The likelihood of having abnormal meiboscores in the lower eyelid was 16.3 times greater than that in the upper eyelid.In the final multivariate model, age (p=0.001), mutation profile (p=0.006), and presence of ocular surface malignant tumor (OSMT) (p=0.014) remained significant for abnormal meiboscores. For a 1-year increase in age, the likelihood of abnormal meiboscores increased by 12%. Eyes with OSMT were 58.8 times more likely to have abnormal meiboscores than eyes without ocular surface malignant tumor.In the final model, age, xeroderma pigmentosum profile, previous cancer, and clinical alterations on the eyelid correlated with a meiboscore of ≥2.Meibomian gland dysfunction was common in patients with xeroderma pigmentosum, mainly in the lower eyelid. The severity of Meibomian gland dysfunction increases with age and is associated with severe eyelid changes.

Keywords: Meibomian glands/pathology; Meibomian glands/ diagnostic imaging; Photography; Xeroderma pigmentosum; Eyelid diseases/diagnostic imaging; Dry eye syndromes; DNA repair; Humans; Case report

A 59-year-old man presented with a unilateral blurring of vision in his left eye. His left eye’s visual acuity was hand movements level. He underwent phacoemulsification surgery, and an intrastromal posterior chamber intraocular lens was implanted. The intrastromal intraocular lens was extracted and a new intraocular lens was implanted. Usinge the Snellen chart, the final best-corrected visual acuity was 20/40. With this case report, we wish to emphasize that a single stepwise clear corneal incision merged with wound-assisted intraocular lens injections can result in intraocular lens misdirection into the corneal stroma. As a result, while performing a misdirected intraocular lens removal, we recommend that the wound be carefully constructed.

Keywords: Lens implantation, intraocular; Lenses, intraocular; Phacoemulsification; Wound healing; Cataract; Visual acuity

A 42-year-old female patient had vision loss and chronic epiphora in her left eye. Her best-corrected visual acuity was 10/10 in the right eye and 0.3/10 in the left eye. The anterior segment examination results were normal. In fundus examination, choroidal folds were detected. Optical coherence tomography showed elevation on the macula and choroidal folds. Ultrasonography revealed a T-sign. Magnetic resonance imaging revealed an ethmoidal mucocele that compresses the orbital tissues. Surgical treatment was performed in the otorhinolaryngology department. Postoperatively, choroidal folds recovered, and the best-corrected visual acuity improved, but subretinal fluid accumulated. During the follow-up period without any treatment, subretinal fluid totally disappeared.

Keywords: Maculopathy; Tomography, optical coherence; Choroid diseases, Mucocele

Keratoconus is a progressive disorder that manifests as a cone-like steepening of the central or paracentral inferior cornea and irregular stromal thinning. There is a gradual decrease in visual acuity due to corneal asymmetry, irregular astigmatism, and increased optical aberrations, consequently impacting the quality of life. Several procedures have been developed in an attempt to slow or reverse the progression. The Bader procedure, which includes a pattern of incisions around the circumference of the cornea and at the base of the protruding cone, is one such surgery. These incisions penetrate 70-90% of the cornea’s depth. Its goal is to flatten the topography and reduce corneal asymmetry and irregular astigmatism. Though prior research found these to be highly promising, we report a patient who was given contact lenses to restore and maintain his vision while his corneal ectasia and thinning progressed over the following decade.

Keywords: Keratoconus; Astigmatism; Cornea; Corneal topography; Ophthalmologic surgical procedures; Contact lenses; Dilatation, pathologic; Acuidade visual; Quality of life

Antiphospholipid syndrome is an acquired autoimmune disease characterized by hypercoagulability associated with recurrent venous and arterial thromboembolism in the presence of antiphospholipid antibodies. Herein, we report a case of rapid sequential retinal vein and artery occlusion as the first manifestation of a primary antiphospholipid syndrome triggered by an acute Mycoplasma infection in a previously healthy 11-year-old patient. On day 1, ophthalmoscopy revealed a central retinal vein occlusion. The patient developed temporal branch retinal artery occlusion the next day. On day 3, a central retinal artery occlusion was observed. Serum lupus anticoagulant, immunoglobulin (Ig) G anticardiolipin, IgG anti-β2-glycoprotein 1 antibody, and Mycoplasma pneumoniae IgM antibody levels were increased. Thus, retinal vascular occlusions can be the first manifestation of primary antiphospholipid syndrome. Although it may not improve visual prognosis, prompt diagnosis and treatment are essential to avoid further significant morbidity.

Keywords: Antiphospholipid syndrome/complications; Retinal vein occlusion; Retinal artery occlusion; Mycoplasma infection; Humans; Case report.

A 71-year-old woman presented a non-arteritic anterior ischemic optic neuropathy in an optic nerve with previously registered superonasal peripapillary myelinated nerve fibers. Her past medical history was significant for controlled systemic hypertension, hyperlipidemia, and diabetes mellitus. The physiologic cup was absent in both optic discs. Non-arteritic anterior ischemic optic neuropathy mainly affected the temporal and inferior sectors of the peripapillary retinal nerve fiber layer, as could be demonstrated by retinal nerve fiber layer optical coherence tomography and optic disc optical coherence tomography angiography. Unlike other published reports, just a slight regression of the myelinated nerve fibers was observed after 1 year of follow-up. This occurred because ischemia mainly affected the temporal and inferior peripapillary sectors, whereas myelinated nerve fibers were superonasal to the optic disc.

Keywords: Optic neuropathy, ischemic; Nerve fibers, myelinated; Optic nerve diseases; Tomography, optical coherence; Retinal neovascularization; Visual acuity; Humans; Case report.

Follicular thyroid cancers account for 15%-20% of all thyroid tumors. Choroidal metastases secondary to follicular thyroid cancer rarely occur. Herein, we report the case of an 85-year-old woman who presented choroidal metastasis from a follicular thyroid carcinoma in the right eye 7 years after total thyroidectomy and underwent enucleation. To confirm the diagnosis and primary tumor site, histopathological, and immunohistochemical examinations were performed. One year later, she presented metastasis in the contralateral eye. Few similar cases have been described in the literature.

Keywords: Choroid neoplasms/secondary; Neoplasm metastasis; Adenocarcinoma, follicular; Thyroid neoplasms

The creation of a scleral flap during trabeculectomy can be complicated by a buttonhole, partial amputation at the limbus, and extensive thinning. In some cases, the procedure must be aborted to prevent more serious postoperative complications. This report describes a technique of converting complicated trabeculectomy into ab externo cyclodialysis. A 41-year-old patient with congenital glaucoma presented with a perforated scleral wall with the choroidal tissue exposed during the dissection of the partial-thickness scleral flap. By using a Barraquer cyclodialysis spatula through the scleral perforation, the choroid was separated from the sclera up to the scleral spur over 30º into the anterior chamber. The sclera and conjunctiva/Tenon were sutured with 10-0 nylon single sutures. Two months later, the intraocular pressure was reduced to 16 mmHg with no hypotensive topical medications. This case illustrates an alternative approach to managing a flap-related perioperative complication in trabeculectomy, which yielded good early results.

Keywords: Glaucoma/surgery; Trabeculectomy; Ophthalmologic surgical procedures /adverse effects; Cyclodialisys; Postoperative complications

Hepatitis C virus infection may be implicated in 12.7% of ocular adnexal marginal zone lymphomas. We present the first case of an orbital-systemic mucosa-associated lymphoid tissue lymphoma that responded to hepatitis C virus medical treatment. A 62-year-old male with a right-sided orbital mass was diagnosed with stage IIA orbital marginal zone lymphoma in addition to hepatitis C virus infection based on clinical, imaging, laboratory, and histological examinations. The systemic and orbital responses were achieved 1 year after undergoing hepatitis C virus treatment with glecaprevir/pibrentasvir. The association between the hepatitis C virus infection and orbital-systemic mucosa-associated lymphoid tissue lymphoma is relevant. Accordingly, patients with orbital mucosa-associated lymphoid tissue lymphoma should be assessed for hepatitis C virus seroreactivity for therapeutic and prognostic purposes.

Keywords: Orbital disease; Orbital neoplasms; Lymphoma, B-cell marginal zone; Hepacivirus; Hepatitis C; Humans; Case reports

Due to the development of complications and the biocompatibility and scarcity of transplant donor tissues, artificial corneas, which can be used for the rehabilitation of optical functions, have been developed. The current study aimed to analyze the visual rehabilitation effects of the Boston type I keratoprosthesis, Boston type II keratoprosthesis, Aurolab keratoprosthesis, osteo-odonto-keratoprosthesis, and tibial bone keratoprosthesis. Results showed that the Boston type I keratoprosthesis was the most effective for visual rehabilitation in patients with moist ocular surfaces. The Aurolab keratoprosthesis had a lower efficacy for visual rehabilitation. Nevertheless, it is still a viable option for individuals in economically restricted countries. In patients with dry eyes, the Boston type II keratoprosthesis was associated with the best visual rehabilitation. However, the final visual acuity of patients who received osteo-odonto-keratoprosthesis and tibial bone keratoprosthesis implantation was not evaluated as the necessary information was not available.

Keywords: Corneal transplantation; Visual prosthesis; Cornea; Rehabilitation; Visual acuity

Vascular anomalies comprise a wide spectrum of clinical manifestations related to disturbances in the blood or lymph vessels. They correspond to mainly tumors (especially hemangiomas), characterized by high mitotic activity and proliferation of the vascular endothelium, and malformations, endowed with normal mitotic activity and no hypercellularity or changes in the rate of cell turnover. However, the classifications of these lesions go beyond this dichotomy and consist various systems adapted for and by different clinical subgroups. Thus, the classifications have not reached a consensus and have historically caused confusion regarding the nomenclatures and definitions. Cavernous venous malformations of the orbit, previously called cavernous hemangiomas, are the most common benign vascular orbital lesions in adults. Herein, we have compiled and discussed the various evidences, including clinical, radiological, morphological, and molecular evidence that indicate the non-neoplastic nature of these lesions.

Keywords: Orbital neoplasms; Vascular malformations; Vascular system injuries; Cavernous hemangioma; Cavernous venous malformations; Biomakers, tumor; Endothelium, vascular; Cell proliferation