VOLUME 89 - ISSUE 4

PURPOSE: The purpose of this study is to look into the relationship between tear film osmolarity, tear crystallization, and corneal esthesiometry findings in Sjögren's syndrome patients.
METHODS: This cross-sectional observational study included 43 eyes from patients with a confirmed diagnosis of Sjögren's syndrome. Tear osmolarity was measured with an iPen osmometer, tear crystallization was graded using Roland's classification, and corneal sensitivity was evaluated with a Cochet–Bonnet aesthesiometer. Ocular symptoms were assessed using the Ocular Surface Disease Index questionnaire. Patients who had undergone keratoplasty or worn contact lenses within 4 hours of testing were excluded.
RESULTS: The cohort's mean tear osmolarity was 292.5±15.0 mOsm/L (median: 293 mOsm/L, IQR: 17.5). There was no significant difference between patients with primary Sjögren's syndrome (mean: 289.4 mOsm/L) and those with secondary Sjögren's syndrome (mean: 294.5 mOsm/L; p=0.413). Tear crystallization patterns were more severe in patients with primary Sjögren's syndrome (mean: 3.25, median: 3.5, IQR: 1.25) than in those with secondary Sjögren's syndrome (mean: 3.19, median: 3.0, IQR: 1.0), though the difference was not statistically significant (p=0.87). Corneal sensitivity was reduced by 3.5±1.7 mm (median: 4.0 mm, IQR: 2.13). Tear crystallization has a significant negative correlation with corneal sensitivity (r=−0.313, p=0.041), suggesting that poorer tear quality leads to decreased corneal sensitivity.
CONCLUSION: Tear crystallization patterns and corneal sensitivity were found to be significantly correlated in Sjögren's syndrome patients. The findings also indicate that systemic medication use may affect tear film quality.

Keywords: Sjogren's syndrome, Tear crystallization, Dry eye disease, Cornea, Tears, Osmolarity

PURPOSE: To evaluate the impact of the COVID-19 pandemic and characterize the serological profile of discarded corneal donations in the coverage area of the Banco de Olhos de Londrina, through reverse transcription-polymerase chain reaction testing for COVID-19 and serological screening of cornea donors excluded because of positive test results.
METHODS: This observational retrospective study included 776 cornea donors who’s serological and reverse transcription-polymerase chain reaction test results were processed at the Hospital of Universidade Estadual de Londrina between May 2020 and 2022. The number of corneal donations and tissue utilization rates throughout the years of operation of the Banco de Olhos de Londrina were also analyzed.
RESULTS: The mean donor age was 53.14 years; 332 donors (43%) were female, and 444 (57%) were male. Positive results were identified in 15.76% of donors for hepatitis B core antibody antibodies, 0.65% for hepatitis B surface antigen, 1.03% for hepatitis C antibodies, and 0.52% for human immunodeficiency virus and human T-lymphotropic vírus. Positive reverse transcription-polymerase chain reaction results for SARS-CoV-2 were observed in 2.7% of cases. Older adults were 2.6 times more likely to test positive for SARS-CoV-2 (95% CI, 1.06-6.34) and 3.0 times more likely to test positive for hepatitis B core antibody (95% CI, 1.95-4.41) than younger individuals. A 75.2% reduction in corneal donations was observed in 2020 compared with 2019, accompanied by a 5% increase in tissue utilization, possibly associated with the effectiveness of donor screening during the pandemic.
CONCLUSION: The COVID-19 pandemic had a profound impact on the number of corneal transplants worldwide, in Brazil, and at the Banco de Olhos de Londrina because of the substantial decline in donations during this period. Hepatitis B was the leading cause of corneal tissue discard due to positive serology in both this study and previous reports, highlighting the importance of prevention programs and improved vaccination coverage. Strict legislation, comprehensive serological screening, and appropriate processing of donated tissue remain essential to eliminate potential sources of infection and ensure transplantation safety.

Keywords: Cornea; Corneal transplantation; COVID-19; Eye banks; Serology

PURPOSE: To compare the efficacy and safety of trabeculectomy with mitomycin C, performed with versus without adjunctive Ologen collagen matrix in a multicenter real-world setting.
METHODS: This multicenter retrospective comparative study included 277 patients (365 eyes) who underwent trabeculectomy with mitomycin C, with or without Ologen, between 2017 and 2022 across five Brazilian centers. Extracted data comprised demographic characteristics, glaucoma subtype, intraocular pressure, number of glaucoma medications, postoperative interventions, complications, and additional surgical procedures. Surgical success was defined using two criteria: (1) intraocular pressure ≤21mmHg with ≥20% reduction from baseline and (2) final intraocular pressure between 6 and 21mmHg. Outcomes were categorized as complete (without medications) or qualified (with medications).
RESULTS: Both groups achieved substantial reductions in intraocular pressure and medication burden at 12 months, with high rates of complete and qualified success under both definitions. The Ologen group required fewer suture lysis procedures (49.0% vs. 60.8%; p=0.025), suggesting a modulatory effect on early postoperative fibrosis. Rates of other postoperative interventions, complications, and additional glaucoma surgeries were comparable between groups. Kaplan–Meier analysis demonstrated no significant difference in cumulative success over time.
CONCLUSION: Trabeculectomy with mitomycin C is effective and safe regardless of adjunctive Ologen use. Although Ologen did not confer superior long-term efficacy, its association with reduced suture lysis suggests a potential role in modulating early wound healing.

Keywords: Trabeculectomy, Intraocular pressure, Mitomycin C; Wound healing; Sutures

PURPOSE: To compare the impact of pro re nata and treat-and-extend regimens on quality of life in patients with neovascular age-related macular degeneration.
METHODS: This cross-sectional study included 81 patients with neovascular age-related macular degeneration who completed the National Eye Institute Visual Function Questionnaire-25.
RESULTS: No statistically significant differences were observed between pro re nata and treat-and-extend regimens across quality-of-life domains measured by National Eye Institute Visual Function Questionnaire-25.
CONCLUSIONS: Pro re nata and treat-and-extend regimens demonstrated comparable effects on quality of life in patients with neovascular age-related macular degeneration. Further studies are warranted to determine optimal standardized treatment strategies.

Keywords: Macular degeneration/diagnosis; Fluorescein angiography/methods; Tomography, optical coherence/methods; Macular degeneration/drug therapy; Drug administration schedule; Angiogenesis inhibitors/therapeutic use; Intravitreal Injections; Surveys and question

PURPOSE: To assess the performance of a contemporary large language model (ChatGPT-5) against ophthalmology residents on a standardized set of glaucoma multiple-choice questions.
METHODS: We conducted a cross-sectional comparative study with 189 text-only glaucoma multiple-choice questions from the Cybersight question bank. ChatGPT-5 was tested under standardized conditions, with each item placed in a new chat and limited to letter-only outputs. Six ophthalmology residents from a Brazilian training program (two Postgraduate Year 1, two Postgraduate Year 2, and two Postgraduate Year 3) answered the same questions under supervision. Accuracy was calculated using the official key. McNemar’s exact test was used to compare items between ChatGPT-5 and residents, and matched odds ratios and 95% confidence intervals (95% CIs) were calculated using the Haldane–Anscombe correction.
RESULTS: ChatGPT-5 received 164 of 189 correct responses (86.8%; 95% CI, 81.2–90.9). Residents’ overall accuracy was 62.9% (713/1,134; 95% CI, 60.0–65.6). The top-performing resident earned 76.7%. ChatGPT-5 outperformed all residents in head-to-head comparisons, with odds ratios ranging from 1.84 (95% CI, 1.10–3.08) to 13.15 (95% CI, 5.93–29.20), all p≤0.023. ChatGPT-5 correctly answered 17/189 items (9.0%), but fewer than half of residents were correct (“large language model-only wins”), whereas residents were more successful on items that ChatGPT-5 overlooked.
CONCLUSIONS: ChatGPT-5 outperformed ophthalmology residents on text-based glaucoma multiple-choice questions, indicating its potential as a subspecialty education and assessment tool. Generalizability is limited by the single question bank, text-only items, a small resident cohort, and the evaluation of one large language model version at a single time point. Before incorporating these findings into clinical decision-making, larger, multimodal, and longitudinal studies are required.

Keywords: Glaucoma; Artificial intelligence; Large language models; Education, medical; Medical staff, hospital

PURPOSE: To compare clinical outcomes associated with different intraoperative mitomycin C exposure times during photorefractive keratectomy for myopia and astigmatism correction.
METHODS: This prospective, comparative, contralateral-eye study included 41 patients (82 eyes), comprising 28 eyes with ablation <60µm and 13 eyes with ablation >60µm, who underwent photorefractive keratectomy with varying mitomycin C application times based on ablation depth. In eyes with ablation <60µm, mitomycin C was applied for 15 s in one eye and 30 s in the fellow eye. In eyes with ablation >60µm, mitomycin C was applied for 30 s in one eye and 60 s in the fellow eye. Outcomes included visual acuity, postoperative pain (visual analog scale), subjective tearing, corneal haze, and refractive results at 3 months.
RESULTS: No statistically significant differences were observed between mitomycin C application times within either group for postoperative pain, tearing, visual acuity, refractive outcomes (spherical, cylindrical, and spherical equivalent), or haze prevalence (p>0.05 for all comparisons). Visual acuity improved in all groups, and no eyes lost ≥2 lines of corrected distance visual acuity.
CONCLUSIONS: Shorter mitomycin C exposure times (15 or 30 s) appear to be as effective and safe as longer durations (30 or 60 s) for haze prevention after photorefractive keratectomy without compromising refractive outcomes or increasing postoperative discomfort at 3-month follow-up.

Keywords: Mitomicin/therapeutic use; Photorefractive keratectomy; Lasers, excimer; Intraoperative period; Miopia/surgery; Astigmatismo/surgery; Corneal opacity; Postoperative pain; Comparative study

PURPOSE: This study aimed to evaluate early postoperative changes in retinal microvasculature in patients undergoing cardiopulmonary bypass surgery by comparing preoperative and postoperative measurements of superficial capillary plexus and, deep capillary plexus vessel density, foveal avascular zone area using optical coherence tomography angiography (OCT-A).
METHODS: This prospective longitudinal study included 38 patients, undergoing cardiopulmonary bypass surgery. Each patient served as their own control optical coherence tomography angiography imaging was performed at four time points: 3 days preoperatively and at postoperative week 1, week 2, and month 1. Vessel densities in the superficial capillary plexus and deep capillary plexuses and the foveal avascular zone area were measured and analyzed. Depending on data distribution repeated measures analysis of variance or the Friedman test was used for statistical analysis.
RESULTS: Data from all 38 patients were included in the analysis. A significant increase in overall superficial capillary plexus vessel density was observed following cardiopulmonary bypass surgery (p=0.008). In contrast, deep capillary plexus vessel density did not differ significantly between the preoperative and postoperative assessments. The foveal avascular zone area showed a significant increase at postoperative week 2 compared with baseline (p=0.016).
CONCLUSION: Cardiopulmonary bypass surgery may induce early retinal microvascular alterations, particularly in the superficial capillary plexus and foveal avascular zone. Optical coherence tomography angiography is a noninvasive and reproducible imaging modality that enables precise assessment of subtle retinal vascular changes after major cardiovascular surgery. These findings may contribute to postoperative monitoring and risk assessment in patients undergoing cardiopulmonary bypass.

Keywords: Cardiopulmonary bypass surgery; Extracorporeal circulation; Macular vessel density of the retina; Retina/blood supply; Foveal avascular zone; Optical coherence tomography angiography; Retinal microvasculature

PURPOSE: To analyze the results of the 15-gene expression profile/preferentially expressed antigen in melanoma (15-GEPP) prognostic classifier and associated survival outcomes in a series of Brazilian patients with posterior uveal melanoma.
METHODS: Patients born and raised in Brazil who were diagnosed with posterior uveal melanoma and underwent fine-needle aspiration biopsy for 15-GEPP prognostic testing using the DecisionDx-Uveal melanoma and DecisionDx-PRAME assays between September 2020 and 2023 were included. All patients were diagnosed and treated by the senior author.
RESULTS: Of 236 patients diagnosed with posterior uveal melanoma during the study period, 11 (4.6%) met the inclusion criteria, including six males and five females. Based on 15-GEPP results, seven patients (63.6%) were classified as Class 1 and 4 (36.4%) as Class 2. Preferentially expressed antigen in melanoma (PRAME) expression was negative in six patients (54.6%) and positive in five patients (45.4%). During a mean follow-up of 36.4 ± 17.6 months, five patients developed metastasis: two with Class 2/PRAME-positive tumors, one with Class 2/PRAME-negative tumors, one with Class 1/PRAME-positive tumors, and one with Class 1/PRAME-negative tumors. Three of these patients died. The mean survival after the diagnosis of metastasis was 21.2 months (median: 17.0 months).
CONCLUSIONS: The proportions of Class 1 versus Class 2 tumors and PRAME-negative versus PRAME-positive tumors as well as the prognostic performance of these biomarkers appear similar in Brazilian patients with posterior uveal melanoma compared with large published cohorts from North America. Further studies with larger Brazilian cohorts are needed to validate these findings.

Keywords: Uveal melanoma; Fine-needle biopsy; Prognosis; Biomarkers; Neoplasms; Transcriptome; Survival; Brazil

PURPOSE: The purpose of this study was to assess the clinical factors associated with dacryocystitis and the need for surgical intervention in infants with congenital dacryocystocele.
METHODS: This retrospective study included 26 infants diagnosed with congenital dacryocystocele and divided them into two groups: complicated-congenital dacryocystocele (with dacryocystitis or preseptal cellulitis) and uncomplicated-congenital dacryocystocele (without infection). Demographic and perinatal characteristics such as age at diagnosis, gender, birth weight, gestational age, delivery method, and laterality were compared between the groups. For an uncomplicated-congenital dacryocystocele, treatment included conservative management and intravenous antibiotics, followed by probing with intraoperative nasal endoscopy and endonasal marsupialization for a complicated-congenital dacryocystocele.
RESULTS: Of the 26 infants, 14 (53.8%) had complicated-congenital dacryocystocele, while 12 (46.2%) had uncomplicated-congenital dacryocystocele. There were no significant differences between the groups in terms of demographic or perinatal characteristics (p>0.05). Surgical intervention was necessary for all complicated-congenital dacryocystocele cases (100%) and two uncomplicated-congenital dacryocystocele cases (16.7%; p<0.001). During a 6-month median follow-up period, all patients demonstrated complete clinical recovery with no intraoperative complications.
CONCLUSION: In conclusion, approximately half of infants with congenital dacryocystocele developed infection-related complications. While perinatal factors were similar across groups, infectious presentation was linked to the need for surgical intervention. These findings suggest that early detection, prompt conservative management, and close follow-up can help reduce the risk of dacryocystitis and the need for surgery.

Keywords: Dacryocystocele; Dacryocystitis; Lacrimal duct obstruction; Marsupialization; Postoperative complication; Gestational age

PURPOSE: To evaluate changes in scotopic pupil diameter before and after cataract surgery performed by phacoemulsification with intraocular lens implantation.
METHODS: This prospective longitudinal observational study included patients who underwent cataract surgery. Scotopic pupil diameter was measured preoperatively and 30-40 days postoperatively using an automated keratometer after a standardized dark-adaptation period under controlled ambient illumination. Each eye was considered an independent unit of observation. Because some participants contributed both eyes, intraindividual correlation was accounted for using a linear mixed-effects model with random patient intercepts. Time of assessment (preoperative versus postoperative), age, sex, and eye laterality were included as fixed effects.
RESULTS: A total of 354 eyes from 251 patients were analyzed. The mean patient age was 69.3±7.2 yr. Mean scotopic pupil diameter decreased from 5.3±0.9mm preoperatively to 4.8±0.8mm postoperatively, representing a mean reduction of 0.5mm (9.4%). In the linear mixed-effects model, cataract surgery was associated with a significant reduction in pupil diameter, with an adjusted mean difference of 0.45mm (95% confidence interval [95% CI], 0.39-0.51; p<0.001). Age (p=0.061), sex (p=0.920), and eye laterality (p=0.152) were not significantly associated with the magnitude of pupil diameter change.
CONCLUSION: Phacoemulsification with intraocular lens implantation was associated with a significant reduction in scotopic pupil diameter, independent of age, sex, and eye laterality. This finding should be considered during preoperative planning, particularly when selecting intraocular lenses whose optical performance depends on postoperative pupil size.

Keywords: Cataract; Pupil; Phacoemulsification; Lens implantation, intraocular; Lenses, intraocular; Pseudophakia

This systematic review and meta-analysis aimed to compare the effectiveness and safety profiles of anti-vascular endothelial growth factor therapy with dexamethasone vs anti-vascular endothelial growth factor alone in patients with persistent diabetic macular edema. It was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Our data were prospectively registered on the International Prospective Register of Systematic Reviews (CRD42023482385). We searched the PubMed, Embase, Cochrane, and Web of Science databases for studies that compared treatment with anti-vascular endothelial growth factor and dexamethasone to anti-vascular endothelial growth factor alone in patients with persistent diabetic macular edema. The primary outcomes were changes in best corrected visual acuity, changes in central macular thickness, and the incidence of serious adverse events. Four studies were included, totaling 315 eyes. Of these 154 (48.88%) received anti-vascular endothelial growth factor alone, while 161 (51.12%) underwent combined therapy. Overall, combined therapy was associated with better central macular thickness (mean difference −68.21; p<0.001), although this did not translate into a significant difference in best-corrected visual acuity at 1 month follow-up (mean difference 1.29; p=0.55). There were significantly more intraocular pressure-related events (odds ratio 10.84; p=0.02) and cataract-related events (odds ratio 41.24; p<0.001) in the combined group than the anti-vascular endothelial growth factor alone group. Our results suggest that combined therapy improves macular morphology in persistent diabetic macular edema without increasing the risk of serious adverse events. However, its effects on final visual acuity outcomes were no better than those resulting from anti-vascular endothelial growth factor therapy alone.

Keywords: Diabetic macular edema; Macular edema; Central macular thickness Dexamethasone; Ozurdex; Anti-VEGF; Bevacizumab; Ranibizumab

Amblyopia is a leading, yet largely preventable, cause of visual impairment and is now recognized as a binocular neurodevelopmental disorder characterized by interocular suppression and widespread functional deficits. This narrative review synthesizes contemporary evidence on the epidemiology, pathophysiology, diagnosis, and management of amblyopia, with a focus on clinically applicable guidance. Conventional treatments—including optimal refractive correction, occlusion therapy, and pharmacologic penalization with atropine—remain highly effective when appropriately prescribed, titrated, and monitored for adherence, even among selected older children. Emerging binocular approaches, such as dichoptic digital therapies, perceptual learning, and short-term monocular deprivation, aim to restore binocular balance. Although these strategies may yield improvements in stereopsis and contrast sensitivity, their effects are generally modest and task-specific. Overall, current evidence supports the integration of traditional and novel approaches into etiology-specific, measurement-driven care pathways. Future research should prioritize functional outcomes, long-term durability, and real-world effectiveness.

Keywords: Amblyopia/diagnosis; Amblyopia/physiopathology; Amblyopia/epidemiology; Binocular vision; Vision disorders; Review