VOLUME 75 - ISSUE 6

PURPOSE: Crotoxin is the main neurotoxin of South American rattlesnake Crotalus durissus terrificus. The neurotoxic action is characterized by a presynaptic blockade. The purpose of this research is to assess the ability of crotoxin to induce temporary paralysis of extraocular and facial muscles in humans. METHODS: Doses of crotoxin used ranged from 2 to 5 units (U), each unit corresponding to one LD50. We first applied 2U of crotoxin in one of the extraocular muscles of 3 amaurotic individuals to be submitted to ocular evisceration. In the second stage, we applied crotoxin in 12 extraocular muscles of 9 patients with strabismic amblyopia. In the last stage, crotoxin was used in the treatment of blepharospasm in another 3 patients. RESULTS: No patient showed any systemic side effect or change in vision or any eye structure problem after the procedure. The only local side effects observed were slight conjunctival hyperemia, which recovered spontaneously. In 2 patients there was no change in ocular deviation after 2U crotoxin application. Limitation of the muscle action was observed in 8 of the 12 applications. The change in ocular deviation after application of 2U of crotoxin (9 injections) was in average 15.7 prism diopters (PD). When the dose was 4U (2 applications) the change was in average 37.5 PD and a single application of 5U produced a change of 16 PD in ocular deviation. This effect lasted from 1 to 3 months. Two of the 3 patients with blepharospasm had the hemifacial spasm improved with crotoxin, which returned after 2 months. CONCLUSIONS: This study provides data suggesting that crotoxin may be a useful new therapeutic option for the treatment of strabismus and blepharospasm. We expect that with further studies crotoxin could be an option for many other medical areas.

Keywords: Crotoxin; Crotoxin; Strabismus; Oculomotor muscles; Blepharospasm

INTRODUCTION: Corneal dystrophy is defined as bilateral and symmetric primary corneal disease, without previous associated ocular inflammation. Corneal dystrophies are classified according to the involved corneal layer in superficial, stromal, and posterior dystrophy. Incidence of each dystrophy varies according to the geographic region studied. PURPOSE: To evaluate the prevalence of stromal corneal dystrophies among corneal buttons specimens obtained by penetrating keratoplasty (PK) in an ocular pathology laboratory and to correlate the diagnosis with patient age and gender. METHODS: Corneal button cases of penetrating keratoplasty from January-1996 to May-2009 were retrieved from the archives of The Henry C. Witelson Ophthalmic Pathology Laboratory and Registry, Montreal, Canada. The cases with histopathological diagnosis of stromal corneal dystrophies were stained with special stains (Peroxid acid Schiff, Masson trichrome, Congo red analyzed under polarized light, and alcian blue) for classification and correlated with epidemiological information (age at time of PK and gender) from patients' file. RESULTS: 1,300 corneal buttons cases with clinical diagnose of corneal dystrophy were retrieved. Stromal corneal dystrophy was found in 40 (3.1%) cases. Lattice corneal dystrophy was the most prevalent with 26 cases (65%). Nineteen were female (73.07%) and the PK was performed at average age of 59.3 years old. Combined corneal dystrophy was found in 8 (20%) cases, 5 (62.5%) of them were female and the average age of the penetrating keratoplasty was 54.8 years old. Granular corneal dystrophy was represented by 5 (12.5%) cases, and 2 (40%) of them were female. Penetrating keratoplasty was performed at average age of 39.5 years old in granular corneal dystrophy cases. Macular corneal dystrophy was present in only 1 (2.5%) case, in a 36 years old female. CONCLUSION: Systematic histopathological approach and evaluation, including special stains in all stromal corneal dystrophies is critical to establish the correct diagnosis.

Keywords: Corneal dystrophies; hereditary; Corneal dystrophies; hereditary; Keratoplasty; penetrating; Corneal stroma

PURPOSE: To determine the most common approach to repair the anophthalmic socket in Brazil, and to compare the data with the trends in other countries. METHODS: Exploratory study using electronic questionnaire sent by Internet to ophthalmologists members of the Brazilian Orbit and Oculoplastic Society (SBCPO). The received answers were analyzed by adhesion analysis, using Chi-square test. RESULTS: We received 75 answered questionnaires. Fifty-three per cent of the respondents frequently treat anophthalmic socket and use the 18 mm diameter polymethylmethacrylate sphere in the majority of the surgeries, mainly covered by sclera (92%). Only seven interviewees had used integrated implants with pegging procedure. Eighty-two per cent of the ophthalmologists use the dermolipid graft to reconstruct the anophthalmic socket. They also follow the patients bi-annually. CONCLUSIONS: The treatment of anophthalmic socket in Brazil generally involve polymethylmethacrylate sphere with 18 mm diameter. Pegging procedure is uncommon between us.

Keywords: Anophthalmos; Eye artificial; Orbit; Eye evisceration; Brazil

PURPOSE: To compare the interval between death and enucleation (ΔT-O-E), between enucleation and preservation (ΔT-E-P) and the quality of the cornea before and after the implantation of new technique and sanitary rules. METHODS: A retrospective study that evaluated the records of cornea donors in Sao Paulo's Santa Casa Eye Tissue Bank 2 years before and 2 years after the implementation new sanitary rules. RESULTS: An increase was observed in the absolute number of 205 to 374 donors following the adopted changes. There was no statistically significant difference in Δt-O-E and ΔT-E-P before and after the implemented changes. Of the total of 1,105 donor corneas, 388 donor corneas were observed before the changes and 717 donor corneas after the implemented changes. We observed a statistically significant increase in grading of donor cornea quality from 1.76 ± 0.90 to 1.94 ± 0.88 after the implementation of new standards of resolution. CONCLUSION: After the changes required by Resolution 347, there was a large increase in the number of donated, taken and preserved corneas. The BTO has not diminished the ΔT O-E and ΔT E-P. Cornea quality presented itself lower after the new rules.

Keywords: Corneal transplantation; Eye banks; Organ preservation; Tissue and organ harvesting; Quality control

PURPOSE: The purpose of this study was to analyze prospectively fifty patients submitted to lower eyelid blepharoplasty at the Federal University of São Paulo, between April 2005 and May 2007. METHODS: Fifty patients were assigned to interventions into two surgical groups by using random allocation. The Surgical Group1 (control group) was composed of 25 patients who were submitted to conservatively standard fat-resection lower eyelid blepharoplasty, and routine lateral canthal support. The Surgical Group 2 (experimental group) was represented by 25 patients submitted to lower eyelid blepharoplasty with periorbital fat mobilization and arcus marginalis redrape, and routine lateral canthal support. The self-esteem of all patients was compared with those in 25 age-matched volunteers from the general population. The parameters of the Rosenberg Self-Esteem Scale were determined preoperatively and at 6-month interval postoperatively. Standardized photographs obtained before and after surgery were evaluated by three independent observers. RESULTS: The median follow-up was 395 days (range 364 to 547 days). The mean age was 48.8 years, the population's gender was predominantly female (96%). Analysis of preoperative and postoperative photographs showed that 96% patients achieved significant improvement. Self-esteem scores improved from baseline preoperative mean levels of 5.1 (Standard Deviation = 4.1) to a mean level of 3.6 (Standard Deviation = 3.5) at 6 months post-surgery (p=0.001). No patients had orbital hematoma, blepharitis, lagophthalmos or ectropion. CONCLUSIONS: The authors concluded that both procedures are safe and effective with low complication rates, and marked improvement in self-esteem was observed in patients at 6-month follow-up.

Keywords: Eyelids; Blepharoplasty; Self concept; Esthetics; Patient satisfaction; Questionnaires

PURPOSE: To assess the number of ophthalmologists in Brazil, their regional distribution, ophthalmologist/habitant ratio, and the relation between ophthalmologist and State Gross Domestic Product (GDP) per capita to aid public health policies. METHODS: An ecologic study was conducted. Data were obtained from the "Census 2011 Brazilian Ophthalmology Council", from "Demographic Census of Brazilian Institute of Geography and Statistics (IBGE) 2010 and from "Brazilian Regional Accounts, 2005-2009"- Ministry of Planning, Budget and Management - IBGE. RESULTS: The number of ophthalmologists in Brazil is 15,719. Considering the performance in more than one municipality, the number of ophthalmologists in service is 17,992, that is, one ophthalmologist for 10,601; the ophthalmologist/site ratio vary among the States from a minimum of 1/51,437 (Amapá) to a maximum of 1/4,279 (Distrito Federal). There is a correlation among State GDP per capita and the number of ophthalmologists/habitant: the higher the GDP per capita, the larger is the number of ophthalmologists acting in the State (p<0.0001). CONCLUSION: According to this study, there is no lack of Ophthalmologists in the country, but a distribution imbalance which leads to professional shortage in particular places. A higher concentration of ophthalmologists/inhabitants was noticed in States which the economic growth is higher, expressed by the GDP per capita.

Keywords: Health manpower; Ophthalmologists; Human resources administration; Physician distribution; Gross domestic product; Census; Brazil

PURPOSE: To evaluate the nasolacrimal duct reconstitution with radio frequency for restoration of lacrimal flow in cases of nasolacrimal duct obstruction. METHODS: The procedure was carried out in 16 eyes of 16 patients (13 women and 3 men) by the same surgeon, with monopolar high-frequency device at 450 kHz and 150 W, with local anesthesia under sedation. Inclusion criteria were lower lacrimal system obstruction (confirmed by dacryocystogram) and age over 18 years old. Exclusion criteria were previous trauma, acute dacryocystitis, cutaneous fistula, mucocele, previous lacrimal surgery and cardiac pacemaker. RESULTS: Patients were followed for at least 120 days, patients were clinically evaluated at outpatient clinics for the presence of secretion, epiphora, reflux at compression of the lacrimal sac, placement of silicone tube and Milder test. At the 90-day postoperative visit, 13 patients had positive irrigation (81.25%) with clearance of lacrimal duct and 3 cases (18.75%) presented irrigation failure. CONCLUSION: Nasolacrimal duct reconstitution with radio frequency was effective in treating nasolacrimal duct obstruction.

Keywords: Dacryocystorhinostomy; Lacrimal duct obstruction; Nasolacrimal duct; High frequency

PURPOSE: Optical coherence tomography (OCT) is valuable for macula evaluation. However, as this technique relies on light energy it cannot be performed in the presence of opaque media. In such cases, the ultrasound (US) may predict some macular features. The aim of this study was to characterize images obtained by ultrasound with 10 and 20-MHz transducers comparing to OCT, as well as to analyze the relationship between the vitreous and retina in eyes with macular hole (MH). METHODS: 29 eyes of 22 patients with biomicroscopic evidence of MH at different stages were included. All patients were evaluated using ultrasonography with 10 and 20-MHz transducers and OCT. RESULTS: OCT identified signs of MH in 25 of 29 eyes. The remaining 4 cases not identified by US were pseudoholes caused by epiretinal membranes. In MH stages I (2 eyes) and II (1 eye), both transducers were not useful to analyze the macular thickening, but suggestive findings as macular irregularity, operculum or partial posterior vitreous detachment (PVD) were highlighted. In stages III (14 eyes) and IV (5 eyes), both transducers identified the double hump irregularity and thickening. US could measure the macular thickness and other suggestive findings for MH: operculum, vitreomacular traction and partial or complete PVD. In cases of pseudoholes, US identified irregularities macular contour and a discrete depression. CONCLUSION: 10-MHz US was useful for an overall assessment of the vitreous body as well as its relationship to the retina. The 20-MHz transducer allowed valuable information on the vitreomacular interface and macular contour. OCT provides superior quality for fine morphological study of macular area, except in cases of opaque media. In these cases, and even if OCT is not available, the combined US study is able to provide a valid evaluation of the macular area improving therapeutic approach.

Keywords: Retinal perforations; Tomography, optical coherence; Transducers; Vitreous detachment

PURPOSE: to evaluate the position of the upper eyelid margin and eye surface status in cicatricial trachoma without trichiasis (TS). METHODS: Slit-lamp biomicroscopy was employed to evaluate the location of the upper lid mucocutaneous transition of 156 eyes of 78 patients with trichiasis and of 130 eyes of 65 control subjects. For each eye the position of the upper lid mucocutaneous junction was graded with respect to the line of meibomian gland orifices into 3 categories: a) anterior, b) at the line, and c) posterior to the line. Ocular surface dye staining with lissamine green was performed in all eyes. All participants answered a questionnaire with queries on the presence and intensity of dry eye symptoms. RESULTS: In the eyes with trichiasis the location of the mucocutaneous transition was posterior to the meibomian gland line in 55 (35.3%), at the line in 77 (49.4%) and anterior to the line in only 24 (15.4%). In the control group these figures were: 5 (3.8%); 42 (42%) and 83 (63.8%). Lissamine staining and dry eye symptoms were also associated with trichiasis. CONCLUSION: Different degrees of upper lid entropion are already present in cicatricial trachoma even in the absence of trichiasis. Trichiasis is associated with lissamine green staining and dry eye symptoms. Conjunctivalization of the upper lid margin may play a role in the development of trachomatous dry eye.

Keywords: Trachoma; Cicatrix; Dry eye syndromes; Entropion; Eyelids; Lissamine green dyes; Questionnaires

PURPOSE: To assess S. aureus in vitro viability after the exposure to ultraviolet light A (UVA) and riboflavin (B2). METHODS: Samples of S. aureus in 96 well plates (in triplicate) were exposed to riboflavin (B2) and ultraviolet light A (365 nm wavelength) at a power density of 3 mW/cm², 8 mm spot diameter, for 30 minutes. Control groups were prepared as well in triplicate: blank control, ultraviolet light A only, riboflavin only and dead bacteria Control. The bacterial viability was measured using fluorescent microscopy. In order to investigate the occurrence of "viable but non-culturable" microorganisms after treatment, the cell viability was also investigated by plate culture procedure onto a broth medium. Statistical analysis was performed using the triplicate values from each experimental condition. RESULTS: No difference was observed among the treatment group and the control samples (p=1). CONCLUSION: The combination of riboflavin 0.1% and ultraviolet light A at 365 nm did not exhibit antimicrobial activity against oxacillin susceptible S. aureus.

Keywords: Keratitis; Riboflavin; Corneal ulcer; Staphylococcus aureus; Ultraviolet rays; Cross-linking reagents

A 51-year-old woman with age-related cataract had an uneventful phacoemulsification and a Tecnis ZM900 multifocal intraocular lens (IOL) implantation in both eyes. During IOL implantation in the left eye, the optic was unintentionally reversed in the bag and left that way. The refraction surprise was not significant and six months postoperatively the corrected distance visual acuity in both eyes was 20/20 and neither complained of visual discomfort. In conclusion, we found that a reversed-optic Tecnis multifocal IOL in the present case resulted in good final visual acuity without significant differences in aberrations compared to the other eye, and a conservative management can be taken as a safe option.

Keywords: Lens implantation, intraocular; Visual acuity; Case report

A 33-year-old woman complained of unilateral eyelid edema and blurred vision. Initial ophthalmic examination disclosed anterior chamber reaction with keratic precipitates on the cornea, without posterior abnormalities. Anterior uveitis was treated. Despite that, patient showed rapidly progressive unilateral vision loss with optic nerve swelling. Systemic workup was inconclusive, as well as cranial magnetic resonance imaging and cerebrospinal fluid examination. Based on the hypothesis of optic neuritis, intravenous methylprednisolone pulse was performed with no success. During the following days, the patient presented pericardial effusion and cardiac tamponade, progressing to death. Necropsy was performed and diagnosis of extranodal natural killers/T-cell lymphoma, nasal type with ocular involvement was confirmed by immunohistochemistry.

Keywords: Eye neoplasms; Lymphoma T-Cell; Nose neoplasms; Vision disorders; Uveitis; Optic neuritis; Killer cells; natural; Immunohistochemistry; Humans; Male; Adult; Case report

We report a case of recurrent iris synechiae one year after Nd:YAG laser goniopuncture for deep sclerectomy enhancement in the only functional eye of a patient with end-stage glaucoma. The possible pathophysiology of this uncommon complication and laser treatment aspects are discussed.

Keywords: Glaucoma; Laser therapy; Filtering, surgery; Iris diseasesl; Sclerostomy; Intraocular pressure; Case report; Humans; Female; Middle aged

To report a case of a patient with Valsalva retinopathy that developed sub-internal limiting membrane hemorrhage, underwent pars plana vitrectomy and had visual acuity improvement after that. A 35-year-old healthy patient presented with sudden and painless vision loss of her right eye, after coughing. During the ophthalmologic evaluation, she had a pre-macular hemorrhage and no other abnormalities. Initially, we chose for expectant management, but the hemorrhage did not clear totally. Thus, pars plana vitrectomy associated with internal limiting membrane peeling was indicated, with considerable improvement of her visual acuity, without perioperative complications or significant findings in the optical coherence tomography, autofluorescence and multifocal electroretinogram. In this case, sub-internal limiting membrane hemorrhage treatment with vitreoretinal surgery was relatively useful, with visual acuity improvement and resolution of sub-internal limiting membrane hemorrhage.

Keywords: Retinal hemorrhage; Valsalva maneuver; Vitrectomy; Tomography, optical coherence; Visual acuity; Humans; Male; Adult; Case report

Endothelial keratoplasty has been adopted by corneal surgeons worldwide as an alternative to penetrating keratoplasty (PK) in the treatment of corneal endothelial disorders. Since the first surgeries in 1998, different surgical techniques have been used to replace the diseased endothelium. Compared with penetrating keratoplasty, all these techniques may provide faster and better visual rehabilitation with minimal change in refractive power of the transplanted cornea, minimal induced astigmatism, elimination of suture-induced complications and late wound dehiscence, and a reduced demand for postoperative care. Translational research involving cell-based therapy is the next step in work on endothelial keratoplasty. The present review updates information on comparisons among different techniques and predicts the direction of future treatment.

Keywords: Endothelium, corneal; Corneal transplantation; Descemet stripping endothelial keratoplasty; Keratoplasty, penetrating; Translational medical research; Cell transplantation