VOLUME 73 - ISSUE 5

PURPOSE: To verify in two groups of patients: monocular (group 1) and binocular vision (group 2) to be submitted to cataract surgery at an University Hospital, opinions, expectances and emotional reactions related to the ocular problem, to the quality of vision and to cataract surgery. METHODS: A transversal comparative and consecutive study was performed using a structured questionnaire applied by patients interview. The questionnaire was elaborated from a previous exploratory study; visual acuity and cause of the visual loss were evaluated. RESULTS: The sample was constituted by 96 persons of group 1 (50.0% male; 50.0% female, ages ranging from 41 to 91 years; average 69.3 years ± 10.4 years) and 110 persons of group 2 (40.9% male; 59.1% female, ages ranging from 40 to 89 years; average 68.2 years ± 10.2 years). The majority of persons of both groups presented low educational level. There was no statistically significant difference between the groups in relation to gender (p=0.191), age (p=0.702) and educational level (p=0.245). No work activity was mentioned in 95.8% of the persons of group 1 and 83.6% of group 2 (p=0.005) and 30.4% of group 1 informed the impossibility to work due the visual impairment. Visual acuity of the eye to be operated was less than 0.05 in 40.6% (group 1) and in 33,6% (group 2), presented visual acuity ranging from 0.05 to 0.25. Almost the totality of the persons of both groups informed difficulties to perform activities of daily life and qualified as insufficient their visual acuities; 71.9% of the patients of group 1 and 71.6% of group 2 informed to know the reason of low vision; among these, 87.1% of group 1 and 83.3% of group 2 mentioned cataract as the reason of low visual acuity. CONCLUSION: It was concluded that the patients of both groups were submitted to cataract surgery with visual acuities less than the visual acuity ideally indicated; the patients with monocular vision showed visual acuities significantly less in relation to the patients with binocular vision; the majority of the patients of both groups mentioned difficulties to perform daily activities as a consequence of low vision; patients with monocular vision mentioned doubts in relation to the surgical results as compared with the patients with binocular vision; many patients of both groups did not know the cause of the visual difficulty or explained the visual difficulty by other cause than the cataract

Keywords: Cataract extraction; Vision, monocular; Vision, binocular; Visual acuity; Activities of daily living; Quality of life; Questionnaires

PURPOSE: To analyze the influence of botulinum toxin on the lacrimal function of patients with facial dystonias. METHODS: Patients with the diagnosis of hemifacial spasm or benign essential blepharospasm were evaluated and invited to answer the Ocular Surface Index Disease (OSID) questionnaire. All patients underwent Schirmer I and basal tests; break-up time (BUT) test and lacrimal clearance evaluation. On the following day, the patients were treated with botulinum toxin. The Ocular Surface Index Disease questionnaire and all the initial tests were reapplied 30 days after the treatment by the same examiner. RESULTS: Twenty-six patients were enrolled in this study, 15 (57.7%) with hemifacial spasm and 11 (42.3%) with benign essential blepharospasm. The mean age of patients with hemifacial spasm was 70.9 ± 13.3 years and the male:female ratio was 1:1.5. In the group of patients with benign essential blepharospasm, the mean age was 68.9 ± 8.4 years with a female preponderance (90.0%). After the treatment, the Ocular Surface Index Disease score, Schirmer I and basal tests score decreased in both groups. The mean of Break-up time test increased significantly in both groups. The lacrimal clearance evaluation showed a greater number of eyes that achieved a complete drainage of the tears after the treatment in both groups. CONCLUSION: The treatment with botulinum toxin improved dry eye symptoms in patients with facial dystonia. Despite of the aqueous portion of tear have decreased, blink modifications improved the tear stability and drainage.

Keywords: Blepharospasm; Hemifacial spasm; Botulinum toxin type A; Dystonic disorders; Dry eye syndromes; Drainage; Tears; Neuromuscular agents; Questionnaires

PURPOSE: To correlate visual field sensitivity (VFS) loss on standard automated perimetry (SAP) and quadrantic macular thickness on optical coherence tomography (OCT) in patients with permanent temporal hemianopia from chiasmal compression. METHODS: Forty eyes from 40 patients with chiasmal compression and 40 healthy eyes were submitted to standard automated perimetry and Stratus-OCT scanning. Raw data of the fast macular thickness scanning protocol were exported and macular thickness measurements were recorded and averaged for each quadrant and half of the central area. The correlation between visual field sensitivity loss and optical coherence tomography measurements was tested with Pearson's correlation coefficients and with linear regression analysis. RESULTS: A significant association was found between each macular thickness parameter and the corresponding central VF mean sensitivity. The strongest association was observed between superonasal macular thickness and the inferotemporal mean defect measured both in decibel (R=0.47; p=0.001) and in 1/Lambert (R=0.59; p<0.0001) units. CONCLUSION: Stratus-OCT-measured macular thickness was topographically related with visual field sensitivity loss in patients with temporal hemianopia from chiasmal compression. Such measurements could prove clinically useful in the diagnosis and follow-up of patients with chiasmal compression. ClinicalTrial.gov identifier number: NCT0039122.

Keywords: Tomography, optical coherence; Perimetry; Optic atrophy; Optic chiasm; Hemianopsia; Visual fields

PURPOSE: To assess the epidemiologic profile and level of knowledge of diabetic patients about diabetes and diabetic retinopathy (DR). METHODS: Cross-sectional study with patients seen at Retina and Vitreous sector of Hospital do Servidor Público Estadual de São Paulo. The subjetcs were assigned into two groups: diabetic patients sent for first ophthalmologic evaluation (G1) and patient already followed in the sector (G2). The patients answered a questionnaire and were submitted to ophthalmologic examination. It had been used chi-square (x²), exact of Fisher and non-parametric of Mann-Whitney tests, with level of significance of 5%. RESULTS: The total sample was composed for 357 patients (109 in G1 and 248 in G2). The majority of the patients were female, married, with incomplete basic education, age average of 63.3 years and affirmed to know what it is diabetes. However, 53.2% did not know their type of diabetes. The visual complications of diabetes are most known. Less of one third of the patients had heard of DR and 77.3% did not know if they had it. The majority of the patients had never received any explanation or lecture about diabetes or DR. Only 3.6% of the patients had participated of programs of education on diabetes. The visual acuity, in logMAR scale, was of 0.57 in OD and 0.51 in the OS. Half of the patients did not have DR. CONCLUSION: The majority of the patients have low knowledge about diabetes and its complications.

Keywords: Diabetes mellitus; Diabetic retinopathy; Health profile; Health knowledge, attitudes, practice; Epidemiology

PURPOSE: To evaluate the safety and efficacy of phacoemulsification and endoscopic cyclophotocoagulation (ECP) as a primary surgical treatment for glaucoma and cataract. METHODS: Three hundred and sixty-eight eyes from 243 patients with primary open-angle glaucoma and cataract from the Centro Brasileiro de Cirurgia de Olhos that underwent an uncomplicated surgery from October, 1998 to December, 2006 with at least 2 years of follow-up were retrospectively enrolled. The patients were excluded if presented a previous ocular history of any intraocular surgery or glaucoma laser treatment. Qualified success was defined as 5 mmHg < intraocular pressure (IOP) < 21 mmHg with or without topical antiglaucomatous drugs, and complete success as the same IOP levels without therapy at all timepoints. Additionally, the requirement of any further glaucoma surgery was defined as failure. RESULTS: The mean follow-up was 35.15 + 8.14 months. The preoperative IOP (23.07 + 5.52 mmHg) was significantly greater than in the first postoperative day (13.14 + 6.09 mmHg), and months 1 (11.03 + 2.59 mmHg), 6 (12.33 + 3.01 mmHg), 12 (12.19 + 2.19 mmHg), 24 (12.14 + 2.89 mmHg) and in the last appointment (12.29 + 2.44 mmHg) (p<0.001 in all timepoints). The number of preoperative medications (1.44 + 0.97) decreased (0.37 + 0.74) (p<0.001). Furthermore, there was a significant improvement in the logMAR visual acuity (p=0.01). Three hundred and thirty-four eyes (90.76%) achieved qualified success, and 205 (55.7%) complete success. Complications included immediate postoperative IOP spike 14.4% (53/368), postoperative fibrin exudates in anterior chamber 7.06% (26/368), cystoid macular edema 4.34% (16/368), transitory hypotony 2.17% (8/368), iris bombé 1.08% (4/368). CONCLUSION: Phacoemulsification associated with endoscopic cyclophotocoagulation is safe and effective as a primary procedure for combined glaucoma and cataract.

Keywords: Glaucoma; Endoscopy; Intraocular pressure; Cataract extraction; Evaluation of the efficacy-effectiveness of interventions; Retrospective studies

PURPOSE: To check the occurrence of post-visit, the patient's understanding and the assessments of the doctor on duty about the efficacy of the process, at the ophthalmology emergency sector. METHODS: It was conducted a transversal, analytical research among doctors on duty and patients being seen consecutively in the ophthalmology emergency sector of Hospital das Clínicas da Universidade de São Paulo. RESULTS: The sample was made of 28 doctors on duty and 561 patients, 51.3% male and 48.7% female, with a mean age of 39.8 years old. From 34.1% of the patients who were previously seen by other sectors, 8.4% looked for two services and 5.7% three or more services. In the previous visits, 56.9% of the patients mentioned that they did not receive any explanation about their diagnostic. From the patients seen at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, 95.1% mentioned that the ophthalmologists explained the diagnostic and from those 84.0% understood what was explained. Among 40.4% of the patients who received medicine prescriptions in the previous services, 85.5% mentioned that they received explanation about its use and 82.9% followed the orientation. At Hospital das Clínicas - FMUSP 95.0% of the patients understood how and why to use the medicine. At the ophthalmologists point of view, more than 90.0% of the patients understood the diagnostic and the prescribed treatment. CONCLUSION: According to this research, for most of the patients, it was provided post-visit orientation and patients' understanding about the disease and the treatments proposed.

Keywords: Emergency Service, Hospital; Eye Diseases; Referral and consultation; Physician-patient relations; Emergency medical services

PURPOSE: To evaluate the efficacy of scleral contact lenses use on the management of ocular sequelae from Stevens-Johnson syndrome patients. METHODS: In a retrospective study, patients who suffered sequelae of Stevens-Johnson syndrome and started the use of scleral contact lenses were followed. Patients were submitted to an evaluation of symptoms through a questionnaire; ophthalmologic exam (visual acuity measurement, biomicroscopy, ocular surface staining with fluorescein drops, Schirmer test). RESULTS: Ten eyes of seven patients were analyzed. Visual acuity varied from hand movements to 20/25. All patients presented some degree of corneal opacity and slight symblepharon. In patients whose adaptation to scleral contact lenses was successful (90%), they all refered improvement of symptoms and sight. As for the biomicroscopic findings it was observed an improvement of conjunctival hyperemia and keratitis and a reduction of the mucous secretion in 90% the cases. CONCLUSIONS: A successful adaptation to scleral contact lenses was feasible on most patients, with relief of symptoms and better visual acuity, probably due to regularization of the surface. Scleral contact lenses represent an important and accessible alternative to reduce the limitations inferred by the damages from Stevens-Johnson syndrome.

Keywords: Contact lenses; Sclera; Dry eye; Stevens-Johnson syndrome

PURPOSE: A survey was carried out with schoolchildren in Bauru, São Paulo State. The purpose of this study was to determine the prevalence of trachoma. METHODS: One thousand, seven hundred and forty-nine children from 6 to 14 years old were examined during the year of 2005. The schools were randomly chosen, according to the number of schoolchildren and the school region according to the local of the city (downtown, middle and periphery). The diagnosis was performed according to the World Health Organization (WHO) protocol and patients with clinical trachoma detection were submitted to laboratory confirmation by direct smear fluorescent antibodies cytology for Chlamydia trachomatis. RESULTS: Trachoma prevalence was 3.8%. Follicular trachoma was diagnosed in 3.7% of children, and intense trachoma in one child (0.06%). Children with trachoma were living mainly in the middle and peripheral region of the city, places with discontinuous water supply and absence of sewerage system in part of the residences. CONCLUSION: Trachoma prevalence in Bauru - São Paulo State - is 3.8%. The authors point out the survey results and also treated trachoma carriers. Other positive aspect of the survey was the community mobilization to prevent trachoma blindness.

Keywords: Trachoma; Trachoma; Blindness; Eye health; Fluorescent antibody technique; Azithromycin; Trachoma; Socioeconomic factors; Child, preschool; Child

Orbital injuries with a foreign body may result in severe structural and functional damage to the eye or orbital contents. Management and prognosis depend on the composition and location of the foreign body and whether there is secondary infection. Metallic objects and glass are the most frequently encountered and well-tolerated, whereas organic foreign bodies can elicit an inflammatory reaction and lead to serious complications. Despite the modern imaging methods, it is often difficult to identify and locate organic intraorbital foreign bodies. This paper presents a review of nine cases of impacted foreign bodies in the orbital region and discusses the diagnosis and treatment of this kind of injury. The following data were collected: age, gender, etiology of injury, occurrence of fracture, anatomical location of fracture, type of object, signs and symptoms, type of imaging exam used, approach, transoperative complication and occurrence of death. Foreign body injuries in the orbital region can be treated with a combination of clinical suspicion, basic knowledge and diagnostic tests and depend on the skill and experience of the surgeon, thereby decreasing the surgical risk of iatrogenic injury in relation to the inherent risk of retaining an organic intraorbital foreign body.

Keywords: Orbital fractures; Eye foreign bodies; Maxillofacial injuries; Case reports; Human; Male; Adult

PURPOSE: Toxoplasmosis is the most common cause of posterior infectious uveitis worldwide. It is often impossible to determine its congenital or acquired nature. Interleukin-2 (IL-2) in peripheral blood has been described as a possible marker for acquired toxoplasmosis. The purpose of this study is to evaluate the histopathological characteristics of ocular toxoplasmosis cases using CD25 as a marker for the expression of interleukin-2. METHODS: Ten formalin-fixed, paraffin-embedded enucleated globes from ten immunocompetent patients with clinical diagnosis of toxoplasmosis were evaluated. Four patients had the acquired form of ocular toxoplasmosis (positive IgM) while six were IgM negative and IgG positive for toxoplasmosis. Histopathological slides were reviewed for the extension of the retinal necrosis, number of toxo cysts, the granulomatous inflammatory reaction, the presence of T and B cells within the choroid and the IL-2 expression. Immunohistochemistry using monoclonal antibodies was performed to observe the expression of CD4, CD8, CD20, CD25, and CD68. RESULTS: The histopathological evaluation disclosed no differences between acquired and the other ocular toxoplasmosis cases regarding the characteristics studied. However, CD25 showed a higher expression of IL-2 on the 4 acquired cases of ocular toxoplasmosis compared to the remainders. CONCLUSIONS: To the best of our knowledge, this is the first report showing that the use of CD25 as a marker for interleukin-2 could differentiate acquired ocular toxoplasmosis.

Keywords: Toxoplasmosis, ocular; Immunohistochemistry, Toxoplasmosis, ocular; Toxoplasmosis, ocular; Interleukon-2; Antigens, CD5; Diagnosis, differential; Antigens, differentiation

PURPOSE: To evaluate the transfer of heterologous genes carrying a Green Fluorescent Protein (GFP) reporter cassette to primary corneal epithelial cells ex vivo. METHODS: Freshly enucleated rabbit corneoscleral tissue was used to obtain corneal epithelial cell suspension via enzymatic digestion. Cells were plated at a density of 5×10³ cells/cm² and allowed to grow for 5 days (to 70-80% confluency) prior to transduction. Gene transfer was monitored using fluorescence microscopy and fluorescence activated cell sorter (FACS). We evaluated the transduction efficiency (TE) over time and the dose-response effect of different lentiviral particles. One set of cells were dual sorted by fluorescence activated cell sorter for green fluorescent protein expression as well as Hoechst dye exclusion to evaluate the transduction of potentially corneal epithelial stem cells (side-population phenotypic cells). RESULTS: Green fluorescent protein expressing lentiviral vectors were able to effectively transduce rabbit primary epithelial cells cultured ex vivo. Live cell imaging post-transduction demonstrated GFP-positive cells with normal epithelial cell morphology and growth. The transduction efficiency over time was higher at the 5th post-transduction day (14.1%) and tended to stabilize after the 8th day. The number of transduced cells was dose-dependent, and at the highest lentivirus concentrations approached 7%. When double sorted by fluorescence activated cell sorter to isolate both green fluorescent protein positive and side population cells, transduced side population cells were identified. CONCLUSIONS: Lentiviral vectors can effectively transfer heterologous genes to primary corneal epithelial cells expanded ex vivo. Genes were stably expressed over time, transferred in a dose-dependence fashion, and could be transferred to mature corneal cells as well as presumable putative stem cells.

Keywords: Gene therapy; Corneal diseases; Lentivirus; Transgenes; Stem cells; Epithelium corneal; Gene expression

PURPOSE: To analyze corneal curvature and visual acuity after asymmetric intrastromal corneal rings implantation, not following the nomogram proposed by the manufacturer. METHODS: Seven eyes of seven keratoconus patients which had asymmetric corneal rings implanted in their corneal stroma were studied. RESULTS: A flattening of the average corneal keratometry was noted in all patients, as well as an increase of the postoperative corneal asymmetry. CONCLUSIONS: Asymmetric intrastromal corneal ring implant improves the postoperative visual acuity with and without correction. As a result we noticed flattening of the corneal curvature at the thicker ring implantation spot and increase of corneal asymmetry.

Keywords: Keratoconus; Corneal stroma; Visual acuity; Corneal transplantation

The patient was a 72-year-old male with a 1 year history of low visual acuity in the left eye. He was in use of 0.5% timolol maleate in both eyes due to glaucoma suspicion. Ophthalmoscopic examination of the left eye revealed a double optic disc pit. The hypotensive agent was discontinued and the intraocular pressure remained in the normal range in both eyes. The patient was submitted to an optical coherence tomography, which was correlated with the presented case.

Keywords: Ophthalmoscopy; Optic disc; Glaucoma; Tomography, optical coherence; Case reports

Our purpose is to report a case of diffuse unilateral subacute neuroretinitis (DUSN) in which an ophthalmoscopically visible worm was found and optical coherence tomography (OCT) scans allowed the precise localization of the parasite in the intraretinal layers. Our findings suggest that the parasite moves in the inner portions of the retina possibly explaining the severe degenerative neural changes that it causes.

Keywords: Retinitis; Optic neuritis/pathology; Eye infections, parasitic; Tomography, optical coherence; Visual acuity; Nerve fibers/pathology; Human; Male; Adult; Case reports

Clinicopathologic findings of a 44-year-old Caucasian male who presented with a congenital bilateral chorioretinal coloboma and later developed a large choroidal melanoma in his best seeing eye. The eye containing the malignant tumor was enucleated and the histopathologic findings confirmed the clinical diagnosis of choroidal melanoma, and in this case, an epithelioid cell type.

Keywords: Coloboma; Eye abnormalities; Melanoma; Choroide neoplasms; Case reports

To describe a patient with unilateral metastatic choroidal gastric adenocarcinoma as a first sign of systemic dissemination. A 54-year-old woman presented with a 7-month history of progressive pain and decrease in vision in her left eye. She had undergone total gastrectomy due to gastric adenocarcinoma two years previously. Examination of the left eye revealed an elevated creamy yellow choroidal tumor infiltrating the macular area and extending around the optic nerve head, suggesting metastasis. Treatment was enucleation of the affected eye. There was orbital recurrence of the tumor, leading to exenteration. Orbital and intraocular metastasis are generally associated with a bad prognosis. This patient represents a rare occurrence of metastatic gastric adenocarcinoma to the choroid, developing as a first sign of systemic recurrence.

Keywords: Stomach neoplasms; Adenocarcinoma; Choroid neoplasms; Neoplasm metastasis; Neoplasm recurrence, local; Orbit evisceration; Humans; Female; Middle aged; Case reports

Essential blepharospasm is a focal distonia characterized by involuntary, spasmodic, bilateral contractions of eyelid protractors. This is a rare disease, which diagnosis is frequently late and symptoms may progress until functional blindness. In this article, we perform a review and describe the most important features of the disease, including historical aspects, epidemiology, etiology, clinical findings, differential diagnosis and treatment.

Keywords: Blepharospasms; Blepharospasms; Blepharospasms; Blepharospasms; Eyelid diseases; Diagnosis, differential

Bone marrow has been proposed as a potential source of stem cells for regenerative medicine. In the eye, degeneration of neural cells in the retina is a hallmark of such widespread ocular diseases as age-related macular degeneration (AMD) and retinitis pigmentosa. Bone marrow is an ideal tissue for studying stem cells mainly because of its accessibility. Furthermore, there are a number of well-defined mouse models and cell surface markers that allow effective study of hematopoiesis in healthy and injured mice. Because of these characteristics and the experience of bone marrow transplantation in the treatment of hematological disease such as leukemia, bone marrow-derived stem cells have also become a major tool in regenerative medicine. Those cells may be able to restore the retina function through different mechanisms: A) cellular differentiation, B) paracrine effect, and C) retinal pigment epithelium repair. In this review, we described these possible mechanisms of recovery of retinal function with the use of cell therapy with bone marrow-derived stem cells.

Keywords: Retinitis pigmentosa; Retinal degeneration; Stem cell; Bone marrow