VOLUME 74 - ISSUE 4

PURPOSE: To observe the frequency of occurrence of eyelid basal cell carcinoma in the centralwest region of São Paulo State and to describe the demographic profile of the basal cell carcinoma carriers. METHODS: Transversal study, using a random sampling, carried out in 12 cities in the centralwest region of São Paulo State evolving 11,167 individuals. Patients were evaluated in a Mobile Unit, with complete ophthalmologic evaluation. The diagnosis of eyelid basal cell carcinoma was done through clinical examination and biomicroscopy of the lesion if desirable. The basal cell carcinoma carriers diagnosed were referred to Oculoplastic Clinic of Faculdade de Medicina de Botucatu for treatment. Data were submitted to analysis of frequency of occurrence. RESULTS: Five cases of eyelid basal cell carcinoma were identified in the sample, corresponding to a frequency of occurrence of 0.045%. Four patients were female, most with age equal or greater than 70 year-old and all the cases had white skin color. Only three individuals conveyed attended the service for excision of the lesion and diagnostic confirmation. CONCLUSION: The eyelid basal cell carcinoma affects 0.045% of the inhabitants of the centralwest region of São Paulo State, affecting mainly the 70 year-old female range.

Keywords: Carcinoma, basal cell; Carcinoma, basal cell; Eyelid neoplasms; Cross-sectional studies

PURPOSE: To evaluate by impression cytology (IC) the corneal surface of live limbal tissue donor eyes for autograft or allograft limbal stem cell transplantation (LSCT). METHODS: Twenty limbal donors were enrolled (17 for autograft LSCT and 3 for allograft). Impression cytology was performed before transplantation of superior and inferior limbal grafts and after the third postoperative month. RESULTS: Impression cytology analysis showed sheets of corneal epithelial cells and goblet cell absence beyond the edge of the keratectomy sites in all patients, suggesting that conjunctival invasion towards the center did not occur in any eye. Partial conjunctivalization within 2 to 3 clock hours, confirmed by the presence of goblet cells, was limited to the keratectomy site in 10% of the cases. CONCLUSION: A clear central corneal surface was demonstrated in all eyes following surgery leading to the conclusion that limbal donation was a safe procedure in this group of patients. A small percentage of eyes can have donor sites re-epithelized with conjunctival cells at the periphery of the cornea.

Keywords: Stem cells; Cytological techniques; Limbus corneae; Goblet cells; Epithelial cells; Living donors; Transplantation, autologous

PURPOSE: The outcomes of the treatment of retinopathy of prematurity (ROP) seem to be better in inborn patients than in those patients who were referred for ROP treatment. This study aims to investigate the timing of treatment and the outcomes in inborn patients and in patients referred for treatment to the Hospital de Clínicas de Porto Alegre, Brazil. METHODS: An institutional prospective cohort study was conducted from 2002 to 2010 and included in group 1 all inborn preterm neonates treated for retinopathy of prematurity and in group 2 all babies referred for treatment to the same institution. All of the included patients presented birth weight (BW) <1,500 g and/or gestational age (GA) <32 weeks. Main outcomes were postconceptional age at the treatment and one year follow-up outcomes in both groups. The considered variables were: BW, GA, stage and location of retinopathy of prematurity at treatment. RESULTS: Group 1 comprised 24 inborn patients. Mean BW and GA at birth were 918 ± 232 g and 28.2 ± 2.1 weeks, respectively, and median post-conceptional postconceptional age at treatment was 37 weeks. Group 2 comprised 14 infants transferred for treatment. Mean BW and GA at birth were 885 ± 188 g and 28.2 ± 2.4 weeks, respectively, and median postconceptional age at treatment was 39 weeks. Mean BW and GA were similar in both groups (P=0.654 and P=0.949, respectively), but the difference among the postconceptional age was significant (P=0.029). CONCLUSIONS: Inborn patients were treated for retinopathy of prematurity during the 37th week of postconceptional age while transferred patients were treated, usually, after the 39th week postconceptional age. The worst outcomes observed among referred patients could be partially explained by the delayed time for treatment.

Keywords: Infant, very low birth weight; Retinopathy of prematurity; Gestational age; Hospitals, public; Risk factors; Survival rates

PURPOSE: This study aimed to know the most common ocular findings in children with congenital toxoplasmosis. METHODS: This is a retrospective study carried out from a historical cohort, with a quantitative approach. We evaluated children referred to a pediatric infectious disease service and included only those with confirmed diagnosis of congenital toxoplasmosis. The ophthalmologic evaluation included regular fundus examination under pupil dilation. RESULTS: Of 58 children presumably exposed to risk of the disease during the pregnancy, 20 had ocular lesions during the first year of life (34 eyes). Of these, 12 were asymptomatic at birth. Strabismus was noted in 14 children (70%). In one child there was ptosis, and another had decrease in the palpebral fissure (microphthalmia). Retinochoroiditis was the most common complication, present in all 20 children. Seven children (35%) showed unilateral changes and 13 children showed bilateral changes (65%), with emphasis on the location in the posterior pole and macula. CONCLUSION: Retinochoroiditis and strabismus were outstanding as important sequelae of congenital toxoplasmosis.

Keywords: Toxoplasmosis, congenital; Retinochoroiditis; Child; Eye infections, parasitic; Signs and symptoms

PURPOSE: Uveitis is a major visual impairment disease affecting parts or the entire uveal tract and occasionally the sclera, the cornea or the optic nerve. The disease is a major cause of ocular morbidity and blindness in immunocompetent and immunocompromised patients. In this work we analyzed the sensitivity and specificity of real-time PCR to detect the etiological agent from blood, plasma, vitreous and aqueous humor and compared with the diagnostic hypothesis. METHODS: Twenty-seven patients (13 male) were studied and Real-time PCR method was used for the detection of herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), varicella zoster virus (VZV), cytomegalovirus (CMV), Mycobacterium tuberculosis (TB) and Toxoplasma gondii (Toxo) in the aqueous humor as well as in the vitreous, blood and plasma. RESULTS: Our results showed the presence of Toxo, CMV, VZV or HSV-2 in 19.2% of aqueous humor samples, and in 30% of vitreous humor samples. In plasma and blood samples, only CMV was detected (11.1% and 3.7%, respectively). CONCLUSION: Real-time PCR was able to detect and to confirm diagnostic hypothesis in uveitis. Our data also confirms that vitreous humor is the best source for molecular diagnosis of infectious uveitis but indicates aqueous humor samples that are easier to obtain may also be appropriate to be tested by Real-time PCR.

Keywords: Polymerase chain reaction; Uveitis; Uveitis; Uveitis; Eye infections, viral; Aqueous humor; Vitreous body

PURPOSE: The Functional Vision Assessment (AVIF-2 to 6 years)'s capacity to differentiate visual ability levels in children with low vision was analyzed. The AVIF-2 to 6 years was created at the Infantile Low Vision Sector from São Geraldo Hospital, Brazil. METHODS: After a debate among professionals from different areas regarding the appropriateness of the test items, AVIF-2 to 6 years was applied to 40 children aged from 2 to 6 years; twenty children with low vision (Group 1) and twenty without it (Group 2) were assessed. Group 1 was recruited from the Infantile Low Vision Sector from São Geraldo Hospital. Group 2 comprised children from two different public day care centers and children were matched by age, gender and social level with group 1. Seven domains were studied: visual fixation, visual following, visual field confrontation, eye-hand coordination and surrounding locomotion, contrast vision and color vision discrimination. Group 1 children were submitted to a complete ophthalmologic exam and group 2 to ophthalmologic screening. Children with low vision and neurologic disease were excluded. Comparative analyzes were performed for both groups and for distinct subgroups classified by age (24 to 35 months, 36 to 59 months and 60 to 78 months) and by visual acuity subgroups (<1.0 logMAR and >1.0 logMAR). RESULTS: The scores at total AVIF-2 to 6 years and its domains were statistically significant (p<0.05), except for the contrast vision and color vision discrimination domains. The total AVIF- 2 to 6 years median was lower for group 1 at the three interval ages. CONCLUSION: AVIF- 2 to 6 years can discriminate different levels of functional vision of low vision children, however the authors emphasize that although the results are encouraging, further studies shall be done until the test is ready for clinical use.

Keywords: Low vision; Childhood development; Preschool; Validation studies

Permanent exotropia (XT) occurs in 1 to 2% of the pediatric population. Its management involves careful assessment of patient, treatment of amblyopia, refractive errors and surgery. The aim of the surgery is to straighten the eyes in the primary gaze position, giving a better cosmetic outcome. The factors reported to affect surgical outcome after exotropia surgery vary widely in reports and success rates for strabismus surgery have been reported to range from 60% to 80%. There are few reports to determine the relation between amblyopia and surgical outcome in exotropic patients. PURPOSE: To compare the surgical outcome of permanent exotropia surgery in amblyopic and non-amblyopic patients. METHODS: This is a retrospective study of 37 clinical records from amblyopic patients (Group A) and non-amblyopic patients (Group B) who underwent recess-resect in one eye for XT. Postoperative deviation was analyzed in one month (immediate) and insixmonths (final) in both groups and in between. Age: group A 24.7 ± 14.2 years, group B 22.6 ± 18.6 years; Preoperative deviation: group A 29.1 ± 7.2Δ, group B 28.4 ± 6.8Δ. RESULTS: The success rate in the imediate postoperative period was 60% (Group A) and 100% (Group B) (p<0.05); 50% (Group A) and 82.3% (Group B) (p=0.082) in the final postoperative period. There was a statistical difference in the imediate postoperative deviation, but the final deviation and the variation of the deviation were similar in both groups. CONCLUSION: There is a better outcome in patients of group B and no diference in the surgical outcome between these amblyopic and non-amblyopic patients in the final postoperative period.

Keywords: Exotropia; Amblyopia

PURPOSE: To determine the health-seeking behavior of the families of children presenting with congenital and developmental cataract attending "Instituto Brasileiro de Oftalmologia" (IBOL), Rio de Janeiro, Brazil. METHODS: Caregivers of consecutive eligible children were interviewed using a pretested questionnaire and medical records were reviewed to collect information about their health-seeking behavior and socioeconomic status in June and July of 2008. RESULTS: Data from 70 children were gathered, from which 42 (60.0%) had bilateral disease. Fifty-eight (82.9%) cases were considered congenital and 12 (17.1%) developmental. Presentation delay was observed in 33 (47.1%) children. Having insurance (adjusted OR 0.17; 95% CI 0.04 - 0.82) and being the only child (adjusted OR 0.16; 95% CI 0.04 - 0.69) decreased likelihood of late presentation. CONCLUSIONS: Delayed detection and presentation for treatment of non-traumatic pediatric cataract are still significant problems in the state of Rio de Janeiro. Early recognition as well as prompt referral and appropriate treatment have to be improved, especially at the public sector.

Keywords: Cataract; Cataract; Child; Health services

PURPOSE: To evaluate the prevalence of retinopathy of prematurity (ROP) in newborns, classify the cases, describe the risk factors for disease and treatment. METHODS: A retrospective observational cross-sectional study including newborns with gestational age < 32 weeks and/or weight < 1,500 g admitted to the neonatal intensive care unit of the Hospital de Clínicas, Universidade Federal de Uberlândia (HC-UFU) during the period of July 2005 to June 2007. RESULTS: We analyzed 148 patients. In 66 (44.6%) ROP was detected; 82 (55.4%) showed no disease. The statistically significant risk factors were: birth weight (p=0.0001), gestational age (p=0.0001), mechanical ventilation (p=0.0001), blood transfusion (p=0.0001), and postconceptional age (PCA) (p=0.0001). Of the 66 premature infants with ROP, 77% were treated medically (follow-up with indirect ophthalmoscopy) and 23% required surgical treatment or photocoagulation. CONCLUSION: Based on the data above, the prevalence observed in this study was high. The development of ROP was inversely proportional to the weight and gestational age at birth.

Keywords: Retinopathy of prematurity; Infant, newborn; Blindness; Oxygen inhalation therapy; Photocoagulation

PURPOSE: External dacryocystorhinostomy is routinely performed through a cutaneous vertical incision placed on the lateral aspect of the nose. The lower eyelid crease approach has been seldom reported. The purpose of this study is to report the cosmetic and functional results of the lid crease approach for external dacryocystorhinostomy in a series of patients. METHODS: Prospective, interventional case series. Twenty-five consecutive patients (17 women) ranging in age from 3 to 85 years (mean ± SD= 44.84 ± 23.67) were included in the study. All patients but one underwent unilateral external dacryocystorhinostomy with a 10 to 15 mm horizontal incision placed on a subciliary relaxed eyelid tension line. The inner canthus was photographed with a Nikon D70S digital camera with a macrolens and resolution of 3008 x 2000 pixels at 1, 3 and 6 months after surgery. The resulting scar was judged from the photographs by 3 observers (ophthalmologist, plastic and head and neck surgeons) according to a four level scale (1= unapparent, 2= minimally visible, 3= moderately visible, 4= very visible). RESULTS: The surgery was easily performed in all patients with a 90.48% success. Three of the elderly patients (ages 61, 79 and 85 yr) developed mild lacrimal punctum ectropion, which resolved with conservative treatment. One patient had a hypometric blink which spontaneously recovered within one month. The mean score for scar visibility was 2.19 (1st mo), 1.65 (3th mo) and 1.44 (6th mo). CONCLUSIONS: The eyelid crease approach is an excellent option for external dacryocystorhinostomy. It leaves an unapparent scar since the first month after surgery, even in younger patients. The functional results are excellent and comparable to other techniques. Care should be taken in elderly patients with lower eyelid laxity in order to prevent lacrimal punctum ectropion.

Keywords: Dacryocystorhinostomy; Eyelids; Cicatrix; Lacrimal apparatus; Humans

Familial amyloidosis of the Finnish type (FAF) is an autosomal dominant form of systemic amyloidosis showing marked geographic clustering in Finland. The disease is caused by a point mutation, 654G-A, in the gelsolin gene. The Danish-subtype of FAF has been previously described in three families, the patients present clinical findings similar to FAF, and the mutation 654G-T in the gelsolin gene. Three members from two generations of the same family, with familial amyloidosis, were screened for mutations in the GSN gene. Genomic DNA was extracted from peripheral blood lymphocytes and the polymerase chain reaction (PCR) was carried out under standard conditions, using appropriate primers. Sequence analysis showed the presence of a G to T transition at nucleotide 654 of the gelsolin gene. This is the first report of gelsolin-related familial amyloidosis in a Brazilian family, and the result is particularly significant as this pedigree presents an unusual mutation, described previously in three families, with no known Finnish ancestors (Danish type).

Keywords: Amyloidosis; Gelsolin; Corneal dystrophies, hereditary; Cornea; Humans; Female; Male; Adult; Case reports

In the recent years, anti-angiogenic medications have successfully treated other diseases associated with choroidal neovascularization. The anti-angiogenic therapy alone or combined with LASER and/or steroids has been effective in controlling ocular neovascularization, not only restricted to the treatment of typical membranes due to macular degeneration in the wet form. The discovery and subsequent use of these drugs has revolutionized medicine and ophthalmology. This report illustrates an example of successful treatment in a challenging pathology where it was found important visual and anatomical response after the use of ranibizumab.

Keywords: Fovea centralis; Lutein; Retinal pigments; Tomography, optical coherence; Macula lutea; Macular degeneration; Fluorescein angiography; Choroidal neovascularization; Antibodies, monoclonal; Intravitreal injections

We report the case of a seven year-old male patient, born at term without any perinatal complications, referred to the Retina/Vitreous Service for diagnostic elucidation. He had a history of progressive visual acuity loss on his left eye that started four years ago. On examination, he had decreased corneal diameter and corectopia of the right eye (OD), without any noteworthy findings on the biomicroscopy of the left eye (OS). The fundus of the OD revealed total retinal detachment, and the OS initially showed peripheral retinal vascular abnormalities and retinal exudation, associated with retinal vitreous traction on the temporal sector. The CT and MRI of the brain/orbits showed no abnormalities, except for findings suggestive of an old retinal detachment on the OD, confirmed by ultrasonography, which also showed microphthalmia of the OD. The diagnosis of familial exudative vitreoretinopathy, a rare disease of autosomal dominant inheritance and related to consanguineous marriages, that can initially simulate Coats disease, was proposed. The patient was treated with diode laser photocoagulation in the temporal periphery of the OS, with improvement in the areas of vitreoretinal traction.

Keywords: Vitreoretinopathy, proliferative; Eye diseases, hereditary; Retinal detachment; Child; Case report

A case of a perfluoro-n-octane leakage into the orbital cavity after corneoscleral suture, scleral buckling and pars plana vitrectomy in an eye with perforating injury after trauma is reported for the first time. A previously healthy 39-year-old man was sent for ophthalmic evaluation one day after suffering a penetrating ocular trauma in his right eye while hammering a nail. On the initial evaluation, the patient presented sudden reduction of visual acuity on his right eye with a perforating corneoscleral injury, intraocular foreign body and retinal detachment. The patient was submitted to corneoscleral suture, pars plana vitrectomy with perfluoro-n-octane administration to flatten the retina and scleral buckling, when it was found transfixation of the globe by the intraocular foreign body. Postoperatively, computed tomography scans of the orbit were ordered due to proptosis, which showed the presence of hyperdense images, suggesting leakage of perfluoro-n-octane into the orbital cavity. Thus, in cases of perforating eye injury, one should be suspicious about the possibility of intraocular foreign body, as well as possible occurrence of transfixation of the globe when scheduling the surgery.

Keywords: Eye injuries, penetrating; Eye foreign bodies; Vitrectomy; Fluorocarbons; Humans; Male; Adult; Case report

PURPOSE: To conduct a systematic review with meta-analysis on the efficacy of trabeculectomy (TREC) followed by beta irradiation (BRT/TREC) compared to TREC alone for glaucoma in terms of intraocular pressure (IOP) control and adverse effects of treatment in different ethnic groups. METHODS: A meta-analysis of randomized controlled trials (RCT) was performed comparing adjunct BRT treatment for glaucoma with standard TREC after 12 months. The MEDLINE, EMBASE, LILACS, and Cochrane Library databases, Trial registers, bibliographic databases and recent studies of relevant journals were searched. Two reviewers independently reviewed relevant reports and the references from these reports were searched for additional trials, using guidelines set by QUOROM statement criteria. RESULTS: Of a total of 1,350 citations, eight studies (five cohorts, three randomized) were identified and only 3 RCT were included in this meta-analysis. Higher IOP reductions were verified in the BRT arm compared to the control arm (mean difference=1.68 mmHg, 95% CI= 0.61-2.68, P=0.002). Uncontrolled postoperative IOP (>21 mmHg) was less frequent when BRT was used (BRT/ TREC arm) compared to the control arm (38/218=17.4% versus 9/239=3.8%; OR=6.7; 95% CI 3.2-14.3, P<0.0001). Although better IOP control was observed in all patients treated with adjuvant BRT, only Black patients displayed a significant difference (P=0.005). There were no significant differences between the BRT and control arms regarding loss of visual acuity, postoperative complications and necessity of cataract surgery. CONCLUSION: Adjunct BRT increases the success rate of TREC, with better results in non Caucasian patients, and does not influence the occurrence of postoperative complications.

Keywords: Glaucoma; Glaucoma; Glaucoma; Trabeculectomy; Eye; Beta particles; Meta-analysis

Interferons alpha and beta have been used worldwide for a few decades, altering the natural history of several severe diseases including hepatitis C, cancer and immune-mediated conditions such as multiple sclerosis. The adverse events profile of interferons is well established, but only isolated reports of ophthalmological complications of interferon therapy have been published. The objective of this study was to carry out a literature systematic review on the subject, bringing to light the need for careful ophthalmological monitoring of patients undergoing interferon treatment. Nearly 500 cases of ophthalmological complications related to interferon have been reported. The most frequent findings were soft exudates, hemorrhages and retina ischemia.

Keywords: Eye; Retina; Interferon alpha; Interferon beta