publicação oficial do conselho brasileiro de oftalmologia ... · Cristian Luco (Chile) Emílio...

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78 06publicação oficial do conselho brasileiro de oftalmologia

noVembro/deZembro 2015

issn 0004-2749versão impressa

indexada nas bases de dados

medline | embase | isi | scielO

Conjunctival tumors in children

Adjustable versus non-adjustable suture for horizontal strabismus

Upper lid crease approach in trachomatous cicatricial entropion

Toxoplasma gondii DNA detection by real-time PCR

Rebound versus Goldmann tonometry in school children

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Frequency of publication: Bimonthly Arq Bras Oftalmol. São Paulo, v. 78, issue 6, pages 337-398, Nov/Dec. 2015

Continuous publication since 1938

Publisher: Ipsis Gráfica e Editora S.A. Divulgation: Brazilian Council of OphthalmologyCirculation: 8.500 copies

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Contents

OffiCiAl PuBliCAtiON Of thE BrAziliAN COuNCil Of OPhthAlmOlOgy (CBO) iSSN 0004-2749(Printed version)


Frequency of publication: Bimonthly Arq Bras Oftalmol. São Paulo, v. 78, issue 6, pages 337-398, Nov/Dec. 2015

PUBLICAÇÃO OFICIAL DOCONSELHO BRASILEIRO

DE OFTALMOLOGIA

EditorialV Could you imagine that much of images? Você poderia imaginar essa quantidade de imagens? Eduardo Melani Rocha, Luiz Fernando Resende da Silva Nominato, Valdair Francisco Muglia, Denny Marcos Garcia

Original Articles337 Conjunctival tumors in children: histopathologic diagnosis in 165 cases Tumores conjuntival em crianças: diagnóstico histopatológico em 165 casos Martin A. Zimmermann-Paiz, Juan Carlos García de la Riva

340 Comparison of intravitreal ranibizumab and bevacizumab treatment for retinopathy of prematurity Comparação de ranibizumab e bevacizumab intravítreos no tratamento da retinopatia da prematuridade Muhammet Kazim Erol, Deniz Turgut Coban, Esin Sogutlu Sari, Ahmet Burak Bilgin, Berna Dogan, Ozdemir Ozdemir, Zuhal Ozen Tunay

344 optic coherence tomography measurement of choroidal and retinal thicknesses after uncomplicated yag laser capsulotomy Medidas das espessuras de coroide e retina após capsulotomia por YAG laser não complicada İsa Yuvacı, Emine Pangal, Yudum Yüce, Sümeyra Yuvacı, Nurettin Bayram, Döndü Melek Ulusoy, Ali Akal, Orhan Altunel

348 Characteristics of the cornea in patients with pseudoexfoliation syndrome Características da córnea em pacientes com síndrome de pseudoexfoliação Refik Oltulu, Gunhal Satirtav, Emine Tinkir Kayitmazbatir, Gulfidan Bitirgen, Ahmet Ozkagnici, Adnan Karaibrahimoglu

352 Adjustable versus non-adjustable suture techniques for concomitant horizontal strabismus: a comparative study Estudo comparativo das técnicas de sutura ajustável e não ajustável para o estrabismo comitante horizontal Galton C. Vasconcelos, Henderson C. de Almeida

356 Detection of Toxoplasma gondii DNA in peripheral blood and aqueous humor of patients with Toxoplasmic active focal necrotizing retinochoroiditis using real-time PCr

Detecção de DNA do Toxoplasma gondii no sangue periférico e humor aquoso por PCR em tempo real Fabio Felipe dos Santos, Heloisa Nascimento, Cristina Muccioli, Deise Fialho da Costa, Luiz Vicente Rizzo, Alessandra Gonçalves Commodaro, Rubens Belfort Jr.

359 rebound tonometry versus goldmann tonometry in school children: feasibility and agreement of intraocular pressure measurements

Tonometria de rebote versus tonometria de Goldmann em crianças em idade escolar: viabilidade e concordância entre as medidas da pressão intraocular Bruno Leonardo Barranco Esporcatte, Flávio Siqueira Santos Lopes, Camila Fonseca Netto, Vespasiano Rebouças-Santos, Diego Torres Dias, Fábio Iglesias Marujo,

Christiane Rolim-de-Moura

363 Analysis of corneal esthesia in patients undergoing photorefractive keratectomy Análise da estesia corneal em pacientes submetidos à ceratectomia fotorrefrativa Elmar Torres Neto, Lucas Marcel Amaral Silva, Giovana Arlene Fioravanti Lui, Rachel Lopes Rodrigues Gomes, Adamo Lui-Netto

367 upper lid crease approach for margin rotation in trachomatous cicatricial entropion without external sutures Abordagem via sulco palpebral superior para a rotação marginal no entrópio cicatricial tracomatoso sem o emprego de suturas externas Antonio Augusto Velasco e Cruz, Patricia M. S. Akaishi, Mohammed Al-Dufaileej, Alicia Galindo-Ferreiro

371 Effects of morphine on the expression of cytokines and inflammatory mediators in a rabbit model of endotoxin-induced experimental uveitis

Efeitos da morfina na expressão de citocinas e de mediadores inflamatórios em coelhos com uveítes experimental induzida por endotoxina Kethye P. Ortencio, Roberta Renzo, Alexandre A. F. B. Sobrinho, Karina Kamachi Kobashigawa, Roberta M. Crivelaro, Germana A. Silva, Marcela Aldrovani,

Alexandre Pinto Ribeiro, Tiago W. P. Mineo, José Luiz Laus

Case Reports376 Bilateral isolated lens coloboma associated with bicuspid aortic valve Coloboma de cristalino bilateral isolado associado à valva aórtica bicúspide Mustafa Dogan, Onur Polat, Onder Akcı, Guliz Fatma Yavas, Umit Ubeyt Inan

379 Molten metal-related ocular thermal burn: report on two cases Queimadura térmica ocular por metal derretido: relato de dois casos Ceyhun Arici, Guzin Iskeleli, Eray Atalay, Mehmet Serhat Mangan, Belgin Kilic

382 Acute lymphoblastic leukemia presenting with bilateral serous macular detachment Leucemia linfoblástica aguda com descolamento macular seroso bilateral Luisa Vieira, Nuno Aguiar Silva, Marco Dutra Medeiros, Rita Flores, Vitor Maduro,

385 Pachychoroid neovasculopathy in a male patient: a case report Espessamento de coroide com neovascularização em paciente do sexo masculino: relato de um caso Miguel Hage Amaro, Rubens Belfort Matos Junior

Review Articles388 rho kinase inhibitors for glaucoma treatment - review Inibidores da Rho-Quinase para o tratamento do glaucoma - Revisão Renato Antunes Schiave Germano, Simone Finzi, Pratap Challa, Remo Susanna Junior

Letters to the Editor392 A review of “cataract surgery teaching” Um comentário sobre o “ensino de cirurgia de catarata” Newton Kara-Junior

393 Production of an intraocular device using 3D printing: an innovative technology for ophthalmology Primeiro dispositivo intraocular utilizando impressão 3D: uma tecnologia inovadora para oftalmologia Sérgio Canabrava, Alberto Diniz-Filho, Paulo Schor, David F. Fagundes, Amanda Lopes, Wagner D. Batista

395 Instructions to Authors

V

Editorial

http://dx.doi.org/10.5935/0004-2749.20150088

Could you imagine that much of images?Você poderia imaginar essa quantidade de imagens?

Eduardo MElani rocha1, luiz FErnando rEsEndE da silva noMinato1, valdair Francisco Muglia2, dEnny Marcos garcia1

An individual’s life or his/her entire medical history, from conception to death, may be documented as ultrasound images, radiographies, tomographies, photos, movies of surgical procedures, and measurable data converted into graphics illustrating descriptive and comparative statistics. Could anyone have predicted this 20 years ago?

This is possible and not only limited to ophthalmology. Most, if not all, medical areas are capturing, analyzing, and saving patient data from early development to senescence, and the information supporting this technology is growing day by day. New medical studies, addressing the issue of medical image technology in different areas, are being published. Recently launched medical journals are entirely dedicated to the science of medical image analysis. Moreover, major clinical medical journals have specific sections dedicated to diagnostic imaging(1). What is the impact of this image revolution on modern medicine that is strongly affecting developments within ophthalmology?

Before a solution regarding portability and safe storage of all this information is available, there are three major concerns for daily practice in ophthalmology. To adapt to and survive in the image data avalanche, ophthalmologists are sometimes forced to make decisions on topics hardly covered by their skills and regular training, including security of digital data, decisions on treatment based on new and unique parameters, and communication of prognosis based on database comparisons and metadata analyses. Medical schools and residency programs will be required to prepare and teach trainees on how to wisely deal with these challenges.

Being one of the pioneers in the use and storage of diagnostic images, ophthalmology has a particular responsibility in this scenario, and over the past few years, it has been a leading medical specialty with regard to introducing equipment and generating image and/or digital analytical graphics to support diagnosis and disease outcomes (Table 1).

The first published human fundus photography was developed in 1886 by Jackman and Webster. At first, these images were quite blurry. However, improvements in instrumentation and technology enabled the use of fundus photography for clinical purposes in 1926 with the release of the first commercially available fundus camera by Carl Zeiss Company(2). These retina images represented a major contribution in the management of diabetic retinopathy, infections, and neoplasias, among other diseases. Before that, and until recently, direct microscopy and color pencils were used in eye clinics worldwide to draw and illustrate vascular changes, peri-metric fields, ocular surface changes, and other findings. These manual resources were standardized by reputed experts in ophthalmology, and although useful, they were very dependent on the skills, time, and patience of the observer/painter(3).

Following fundus photography, the first member of the family and grandfather of the actual image eye center, generations of machines started to emerge in hospital departments and budgets, including ocular ultrasound modes A and B, corneal topography, and more recently, automatic visual field, multifocal electrore-tinography, GDX, and optical coherence tomography (OCT) (Table 1).

The clinical relevance of this image revolution can be summarized in few words: digital images and exa-mination data in conjunction with automated comparison with databases encouraging the decision to treat. Protocols and guidelines are ultimately based on a unique parameter or its variation over a period of time, so as to support medical decisions. This is applicable to corneal endothelial cell counting, visual field mean deviation, macular retinal, and corneal thickness or curvature, just to mention a few(4-5).

To prepare the clinic for a new season, pioneering ophthalmologists must be familiar with some specific terms and new technologies. It is necessary to plan ahead the future steps in terms of technology acquisition and to be ready for changes and expansion, without starting over after every new release. Here is some advice for ophthalmologists interested in the field (Table 2).

Submitted for publication: July 8, 2015 Accepted for publication: July 17, 20151 Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade

de Medicina, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.2 Centro de Ciências da Imagem e Física Médica, Departamento de Clínica Médica, Faculdade de

Medicina, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.

Funding: No specific financial support was available for this study.

Disclosure of potential conflicts of interest: None of the authors have any potential conflicts of interest to disclose.

Corresponding author: Eduardo Melani Rocha. Departamento de Oftalmologia, Otorrinolaringolo-gia e Cirurgia de Cabeça e Pescoço, Faculdade de Medicina, Universidade de São Paulo (USP). Av. Bandeirantes, 3.900 - Ribeirão Preto - SP - 14049-900 - Brazil - E-mail: [email protected]

Could you imagine that much of images?

VI

Health records need to be electronically stored and easily shareable in a secure manner. The following obsta-cles must be overcome to achieve this goal. The first is accessibility; to know where they are and how to access patient data. This requires the ability to store data in standard formats. Currently, the standard of reference for medical images is the Digital Imaging and Communications in Medicine (DICOM) format, which was created by the National Electrical Manufacturers Association, a North American organization, to improve distribution and viewing of medical images initially acquired using ultrasound, computed tomography, and magnetic reso-nance scanners. Nowadays, the DICOM format has gained wide acceptance in almost every medical field that uses images, including cardiology, gastroenterology, and ophthalmology. The major advantage of the DICOM format is that every file (image) not only has all information pertinent to any given particular examination but also maintains relevant patient data that is included in the header of scanners/devices, such as name, date of birth, and the institution’s ID.

The second obstacle is to develop a stable and expansible database. Another important issue is privacy that ensures only authorized practitioners can access and extract information from stored records. For increased security, a method for verification of authenticity is required, along with integrity and authorship, which can be provided using a public key infrastructure encryption. Last, but not the least, remote accessibility maintaining pri-vacy remains a challenging task because when one moves from the intranet to Internet, theoretically anyone can access such information. The use of a virtual private network is required to encrypt and protect data transmission.

It is possible to predict that in the future we may need to ask or recall less with regard to medical facts of individual patients because most, if not all, facts will be documented by images and digital files. Clinical histories will be stored in the patient’s medical cloud, which will be accessible to the doctor in a display terminal, in the presence of or in remote contact with the patient to clarify and attend to specific requests. One can also assume that most routine tests and appointments will be automatically scheduled to keep individual files updated and to promote individual health in the best possible way.

Table 1. Data on digital equipment used in diagnostic ophthalmology, year of invention, and introduction in the clinical practice

Equipment Inventors Invention Clinical use* Objective CompanyFundus photography WT Jackman & JD Webster 1886 1926 Observation of the fundus Carl Zeiss

Fluorescein angiography HR Novotny & DL Alvis 1961 Observation of the retinal vasculature

Ultrasound mode A and B(6,7) Mundt & Hughes 1956 1958 Ultrasonic ocular diagnosis

Specular microscopy(8) Maurice 1974 1979 Observation of corneal endothelium Konan Medical

Corneal topography(9) Klyce 1984 1987 Observation of anterior corneal curvature Computed Anatomy Inc

Automated visual field F Frankhauser 1972 1976 Visual field evaluation Interzeag AG

Electroretinography J Dewar 1877 1941 Electric activity of retinal cells

Scanning laser polarimetry (GDX) EA Essok & MJ Sinai 1992 Assessment of the thickness of the retinal nerve fiber layer

Laser Diagnostic Technologies Inc.

OCT(10) J Fujimoto 1991 1996 Histological analysis of the retina in vivo Humphrey Systems

Orbscan(9) E. Sarver and C. Broadus 1994 1995 Observation of the posterior corneal curvature

Orbteck Inc.

* Year the technology began to be used in clinical practice.

Table 2. Tips for eye clinics interested in an efficient digital image storage and display system

Item Issue Solution

1 How to capture and store the information from the equipment Digital Imaging and Communications in Medicine (DICOM)

2 How to store accumulating digital data Cloud/picture archiving and communication system (PACS)/ Health Insurance Portability and Accountability Act (HIPAA)

3 How to protect patient privacy Data encryption

4 How to remotely transfer the information to the clinical file Standard protocols accessing “cloud” by mobile apps.

5 How to share patient information XML tags

REFERENCES 1. Browse figures & Multimedia. New Engl J Med [Internet]. [cited 2015 Jul 18]. Available

from: http://www.nejm.org/multimedia/images-in-clinical-medicine 2. Saine PJ. Landmarks in the historical development of fluorescein angiography. J

Ophthalmic Photogr. 1993;15(1):17-23. 3. Waring GO, Laibson PR. A systematic method of drawing corneal pathologic condi-

tions. Arch Ophthalmol. 1977;95(9):1540-2. 4. Folgar FA, Jaffe GJ, Ying GS, Maguire MG, Toth CA; Comparison of Age-Related Macular

Degeneration Treatments Trials Research Group. Comparison of optical coherence tomography assessments in the comparison of age-related macular degeneration treatments trials. Ophthalmology. 2014;121(10):1956-65. Collaborators: 893.

5. Wittig-Silva C, Chanb E, Islam FM, Wu T, Whiting M, Snibson GR. A randomized, con-

trolled trial of corneal collagen cross-linking in progressive keratoconus: three-year results. Ophthalmology. 2014;121(4):812-21.

6. Mundt GH Jr, Hughes WF Jr. Ultrasonics in ocular diagnosis. Am J Ophthalmol. 1956; 421(3):488-98.

7. Baum G, Greenwood I. The application of ultrasonic locating techniques to ophthal-mology. II. Ultrasonic slit-lamp in the ultrasonic visualization of soft tissues. Arch Oph thalmol.1958;60(2):263-79.

8. Maurice, D. A scanning slit optical microscope. Invest Ophthalmol. 1974;13(12):1033-7. 9. Gutmark R, Guyton DL. Origins of the keratometer and its evolving role in ophthalmo-

logy. Surv Ophthalmol. 2010;55(5):481-97. 10. Huang D, Swanson EA, Lin CP, Schuman JS, Stinson WG, Chang W, et al. Optical co-

herence tomography. Science. 1991;254(5035):1178-81.

Original Article

337Arq Bras Oftalmol. 2015;78(6):337-9http://dx.doi.org/10.5935/0004-2749.20150089

INTRODUCTIONThe conjunctiva is derived from the surface ectoderm of the optic

vesicle and neuro ectoderm. It comprises epithelium (stratified squa-mous and columnar) and stroma (fibrovascular connective tissue)(1,2). Conjunctival tumors (Figures 1 and 2) can arise from any of the com-ponent cells; therefore, their presentation varies as either benign or malignant. Few series of studies on pediatric patients have been published, and the epidemiological characteristics vary with age(3-6). Cunha et al. reported the histopathology of 282 consecutive, clini-cally diagnosed epibulbar tumors excised from children. The most common tumors were melanocytic (23%), choristomatous (22%), and benign epithelial (10%) tumors(3). In another case series, Elsas et al. reported 302 cases of epibulbar tumors in children, comprising 33% choristomas, 29% conjunctival nevi, 11% epithelial inclusion cysts, 7% papillomas, 6% pyogenic granulomas, and 5% granulomas(4). Beby et

ABSTRACTPurpose: Conjunctival tissue tumors have a varied presentation, and few series studies on pediatric patients have been published. The objective of this paper is to report the histopathologic diagnoses (spanning over 1988-2013) of conjunctival tumors in children younger than 14 years. Methods: We conducted a retrospective, descriptive, and observational study by reviewing the database of all children in whom a conjunctival tumor was sur-gically removed at Hospital de Ojos y Oídos “Dr. Rodolfo Robles V.,” Benemérito Comité Pro Ciegos y Sordos de Guatemala. The data pertaining to gender, age, and histopathologic diagnosis of all cases was collected. The same ocular pathologist made all diagnoses. Results: One hundred sixty-five cases were found, with a mean age of 7.88 years, being 91 (55.15%) male subjects. Melanocytic lesions were the most common tumors found (30.91% of cases), with only one case (0.60%) being malignant.Conclusions: Melanocytic lesions were the most common tumors found, and of all the cases, only one was malignant; this was in a patient with xeroderma pigmentosum. These findings are consistent with those reported in other studies regarding the frequencies of the histopathology of conjunctival tumors in the pediatric population.

Keywords: Conjunctival neoplasms/diagnosis; Conjunctival neoplasms/patho-logy; Child

RESUMOObjetivo: Tumores do tecido conjuntival tem uma apresentação variada. Poucas séries de pacientes pediátricos foram publicadas. O objetivo deste trabalho é apre-sentar os diagnósticos histopatológicos de tumores conjuntivais em crianças com menos de 14 anos de idade, obtidas durante um período de 25 anos.Métodos: Estudo retrospectivo, descritivo e observacional foi realizado. Nós revisamos o banco de dados de todas as crianças em quem um tumor conjuntival foi removido cirurgicamente no Hospital de Ojos y oidos “Dr. Rodolfo Robles V.,” Benemérito Comité Pro Ciegos y Sordos de Guatemala. Sexo, idade e diagnóstico histopatológico de todos os casos foram compilados. O mesmo patologista ocular fez todos os diagnósticos. Resultados: Cento e sessenta e cinco casos foram encontrados, com média de 7,88 anos, sendo 91 (55,15%) do sexo masculino. Lesões melanocíticas foram as mais fre-quentes (30,91% dos casos). Apenas um caso (0,60%) era maligno. Conclusões: Lesões melanocíticas foram as mais frequentes. Do total, apenas uma lesão era maligna, o que correspondeu a um paciente com xeroderma pigmentoso. Estes resultados são consistentes com o relatado em outros estudos quanto à frequência de diagnóstico histopatológico de tumores da conjuntiva na população pediátrica.

Descritores: Neoplasias da túnica conjuntiva/diagnóstico; Neoplasias da túnica con -juntiva/patologia; Criança

al. described the clinicopathological characteristics of 42 conjuncti-val tumors that were surgically removed from children; 83% of the cases in this series were pigmented conjunctival nevi(5). Further, in a clinical series of 262 pediatric patients, Shields et al. reported mela-nocytic tumors in 67% of the cases(6).

The aim of this paper is to report the frequency and histopatho-logic diagnosis of conjunctival tumors that were surgically removed from children under 14 years of age from 1988 to 2013 at an eye care center from a developing country.

METHODSWe conducted a retrospective, descriptive, and observational study

by reviewing the database of all pediatric patients under 14 years of age with a conjunctival tumor that was surgically removed from

Conjunctival tumors in children: histopathologic diagnosis in 165 casesTumores conjuntival em crianças: diagnóstico histopatológico em 165 casos

Martin a. ziMMErMann-Paiz1, Juan carlos garcía dE la riva2

Submitted for publication: January 2, 2015 Accepted for publication: August 23, 20151 Unidad de Oftalmología pediátrica, Estrabismo y Neuro-Oftalmología, “Dra. Ana María Illescas

Putzeys,” Hospital de Ojos y Oídos “Dr. Rodolfo Robles V.” Instituto de Ciencias de la Visión, Benemérito Comité Pro Ciegos y Sordos de Guatemala, Guatemala.

2 Unidad de patología ocular, Hospital de Ojos y Oídos “Dr. Rodolfo Robles V.” Instituto de Ciencias de la Visión, Benemérito Comité Pro Ciegos y Sordos de Guatemala.


Disclosure of potential conflicts of interest: None.

Corresponding author: Dr. Martin A. Zimmermann-Paiz. Diagonal 21, 19-19 anillo periférico Zona 11 - Guatemala, Guatemala C.A. - E-mail: [email protected]

Conjunctival tumors in children: histopathologic diagnosis in 165 cases

338 Arq Bras Oftalmol. 2015;78(6):337-9

1988 to 2013 at Hospital de Ojos y Oídos “Dr. Rodolfo Robles V.,” Be nemérito Comité Pro Ciegos y Sordos de Guatemala. The data per-taining to gender, age, and histopathological diagnosis of all cases was obtained. All diagnoses were made by the same ocular patho-logist and were classified based on the tissues of origin. The data were analyzed using the EPI-INFO® program (database and statistics software for public health professionals; 2014; Centers for Disease Control and Prevention, Atlanta, GA, USA), which was used to obtain descriptive statistics for this study population.

RESULTSA total of 165 cases, 91 (55.15%) male and 74 (44.85%) female, were

found. The age ranged from 7 months to 13 years, with a mean age of 7.88 years. The tumors were classified based on their tissue of ori-gin, and included melanocytic, choristomatous, vascular, epithelial, lymphoid, and others. Table 1 summarizes the frequencies observed, depending on the type and histological diagnosis of the lesions. Melanocytic lesions were the most common (30.91% of the total cases), of which 47 (92.15%) were classified as benign, 4 (7.85%) as borderline, and none as malignant; the most frequent histological diagnosis was conjunctival nevi (41.18%). The most frequent histolo-gical diagnoses for the remainder of the tumor types were dermoid tumors (38.89%) in the choristoma group, pyogenic granulomas (77.78%) in the vascular group, and papillomas in the epithelial group (80.00%). Among the epithelial lesions, 26 (86.66%) were classified as benign, 3 (10.00%) as borderline, and 1 (3.33%) as malignant (in a patient with xeroderma pigmentosum). This lesion was the only

malignancy found in the 165 cases (0.60%). Moreover, 12.12% of the lesions did not fit into any of the categories, and were thus grouped as miscellaneous lesions.

DISCUSSIONThe importance of determining the histopathological diagnosis

and behavior of conjunctival tumors in children is primarily to esta-blish the aggressiveness of the surgical approach. Indications for the removal of these lesions in children may be as varied as the suspicion of malignancy, purely functional disorders, or cosmesis, which is the most common. Our study shows that the histopathological diagnoses of patients from a referral hospital, which may have resulted in biased data, because tumor incidences may differ from those seen in clinical practice in the general population. In this series, melanocytic lesions were the most common (30.91%), which is consistent with other repor-ted series of patients in both children (23-83%)(3-6) and adults (53%)(7) Conjunctival nevi are the most common melanocytic tumors and are usually occur before 20 years of age. The intensity of the pigment increases in 5% of these tumors, 7% grow in size with increasing age, and less than 1% become malignant.(6). Management is usually expectant (measurement of the lesion and taking photographs for future comparisons), and if major changes are documented, surgical removal of the lesion must be considered(2,6). Choristomatous lesions were the second most common. These consist of tissue that is not normally located in the area affected by the lesion(1,2,6). These lesions are usually treated conservatively(2,6). In vascular lesions, the most common histopathological diagnosis is pyogenic granuloma, a fibro-

A B C

Figure 1. A) Pigmented lesion (nevi). B) Choristoma (epibulbar dermoid). C) Vascular lesion (pyogenic granuloma).

Figure 2. A) Pigmented lesion: conjunctival biopsy showing nevoid tissue with cystic degeneration in a prepubescent boy (40×). B) Choristoma: conjunctival tumor showing mature sebaceous tissue with hair shafts and glandular channels (40×). C) Vascular lesion: granulation tissue with chronic inflammatory cells, fibroblasts, and endothelial cells of budding capillaries. The typical arborizing pattern is not seen in this specimen (40×).

A B C

Zimmermann-Paiz MA, de la Riva JCG

339Arq Bras Oftalmol. 2015;78(6):337-9

Table 1. Frequencies of conjunctival tissue tumors found in 165 children in terms of the type and histological diagnosis of the lesion

Histopathological diagnosis N (%) % of total cases

Melanocytic

Conjunctival nevus 21 (41.18) 12.72

Single nevus 14 (27.45) 08.48

Compound nevus 13 (25.49) 07.88Conjunctival nevus with atypia 02 (3.92) 01.21Benign acquired melanosis 01 (1.96) 00.60Total 51 (100.00) 30.91

ChoristomasDermoid tumor 14 (38.89) 08.48Epidermoid cyst 12 (33.33) 07.27Dermolipoma 09 (25.00) 05.45Ectopic striated muscle 01 (02.78) 00.60Total 36 (100.00) 21.82

VascularPyogenic granuloma 21 (77.78) 12.72Capillary hemangioma 05 (18.52) 03.03Cavernous hemangioma 01 (03.70) 00.60Total 27 (100.00) 16.36

EpithelialPapilloma 20 (80.00) 12.12Inclusion cyst 05 (20.00) 03.03Acanthosis 03 (12.00) 03.03Squamous carcinoma 01 (04.00) 00.60Pseudoepitheliomatous hyperplasia 01 (04.00) 00.60

Total 30 (100.00) 18.18Lymphoid

Atypical lymphoid hyperplasia 1 (100.00) 00.60Total 1 (100.00) 00.61

OtherElastotic degeneration 5 (20.00) 03.03Vernal conjunctivitis 2 (08.00) 01.21nonspecific inflammatory reaction 2 (08.00) 01.21Granulation tissue (part of wound repair processes)

2 (08.00) 01.21

Foreign body 1 (4.00) 00.60Subconjunctival epidermization 1 (4.00) 00.60Granuloma (indeterminate) 1 (4.00) 00.60Foreign body granuloma 1 (4.00) 00.60Parasitic cyst 1 (4.00) 00.60Valve remaining fibrosis 1 (4.00) 00.60Insufficient sample 2 (8.00) 01.21Total 20 (100.00) 12.12

vascular proliferation in response to a previous insult(2,6). In many cases, they are secondary to inflammatory processes, either postsurgical or from trauma. These usually respond well to steroid therapy; however, in some cases, surgical removal of the lesion is necessary because of the size and functional problems incurred.

The most common epithelial lesions are papillomas. These benign tumors are generally associated with papillomavirus infection(1,2,6) and are small in children and may present as multiple lesions. As these cases are usually symptomatic, we recommend surgical removal of the lesion; however, it should be noted that spontaneous remission occurs for some of these lesions.

The main difference between conjunctival tissue tumors in pe -diatric and adult populations is that the incidence of malignant le sions in the former was less than 1% in the present study (one case in a patient diagnosed with xeroderma pigmentosum), which is cons-istent with the literature(2-8). Patients with immunosuppression, such as those having recently undergone a transplant or having an HIV in-fection or disorders of DNA repair, such as xeroderma pigmentosum, should be carefully followed up because malignant epithelial lesions are more frequently found in these patients(6).

CONCLUSIONSMelanocytic lesions were the most frequently found conjunctival

tissue tumors in the 165 pediatric patients (30.91% of the total cases) in the present study. Of all cases, only one (0.60%) was a malignant lesion, in a patient with xeroderma pigmentosum. These findings are consistent with those reported in other studies regarding the frequency of histopathological diagnoses of conjunctival tumors in the pediatric population.

REFERENCES 1. Taylor D, Hoyt CS. Pediatric ophthalmology and strabismus. 3rd ed. Edinburg: Elsevier

Saunders; 2005. 2. Shields Cl, Shields JA. Tumors of the conjunctiva and cornea. Surv Ophthalmol. 2004;

49(1):3-24. 3. Cunha RP, Cunha MC, Shields JA. Epibulbar tumors in children: a survey of 282 biopsies.

J Pediatr Ophthalmol Strabismus. 1987;24(5):249-54. 4. Elsas FJ, Green WR. Epibulbar tumors in childhood. Am J Ophthalmol. 1975;79(6):1001-7. 5. Beby F, Kodjikian L, Roche O, Bouvier R, Donate D, Guerillon F, et al. Conjunctival

Tumors in children. A histopathologic study of 42 cases. J Fr Ophthalmol. 2005;28(8): 817-23.

6. Shields CL, Shields JA. Conjunctival tumors in children. Curr Opin Ophthalmol. 2007; 18(5):351-60.

7. Shields CL, Demirci H, Karatza E, Shields JA. Clinical survey of 1643 melanocytic and nonmelanocytic conjunctival tumors. Ophthalmology. 2004;111(9):1747-54.

8. Reddy SC, Sarma CS, Ramana Rao VV, Banerjea S. Tumor and cysts of conjunctiva - A study of 175 cases. Indian J Ophthalmol. 1983;31(5):658-60.

Original Article

340 Arq Bras Oftalmol. 2015;78(6):340-3 http://dx.doi.org/10.5935/0004-2749.20150090

Comparison of intravitreal ranibizumab and bevacizumab treatment for retinopathy of prematurityComparação de ranibizumab e bevacizumab intravítreos no tratamento da retinopatia da prematuridade

MuhaMMEt KaziM Erol1, dEniz turgut coban1, Esin sogutlu sari2, ahMEt buraK bilgin3, bErna dogan1, ozdEMir ozdEMir4, zuhal ozEn tunay4

Submitted for publication: November 25, 2014 Accepted for publication: October 20, 20151 Antalya Training and Research Hospital, Department of Ophthalmology, Antalya, Turkey.2 Balikesir University, Medical School, Department of Ophthalmology, Balikesir, Turkey.3 Akdeniz University, Medical School, Department of Ophthalmology, Antalya, Turkey.4 Zekai Tahir Burak Hospital, Department of Ophthalmology, Ankara, Turkey.


Disclosure of potential conflicts of interest: None of the authors have any potential conflict of interest to disclose.

Corresponding author: Muhammet Kazim Erol. Antalya Training and Research Hospital. Eye Clinic, Antalya, Turkey - E-mail: [email protected]

ABSTRACTPurpose: To compare the efficacy of intravitreal ranibizumab and bevacizumab treatment for type 1 retinopathy of prematurity (ROP). Methods: 36 eyes of 20 patients with type 1 ROP who received anti-vascular en-dothelial growth factor (anti-VEGF) intravitreal injections between August 2011 and February 2013 were retrospectively evaluated. Fifteen eyes of 8 patients received 0.25 mg ranibizumab (group 1), and 21 eyes of 12 patients received 0.625 mg be vacizumab (group 2). Eyes were examined by indirect ophthalmoscopy on the first day, third day, first week, and first month and as required after injections. Laser photocoagulation was performed in cases with progression of ROP. Results: The mean gestation time was 26.2 ± 2.7 weeks in group 1 patients and 27.1 ± 2.5 weeks in group 2 patients. No statistical difference in the time of gestation was observed between the two groups. The mean follow-up period was 20 ± 4.5 months. Laser photocoagulation was performed in 6 of 15 eyes from group 1 and 2 of 21 eyes from group 2. No eyes developed retinal detachment during the follow-up period. Conclusion: Ranibizumab and bevacizumab showed an efficacy in the treat-ment of type 1 ROP. The incidence of disease relapse was higher in eyes which received ranibizumab. Further randomized, controlled clinical trials are required to compare the efficacy of ranibizumab and bevacizumab.

Keywords: Retinopathy of prematurity; Vascular endothelial growth factor A; An tibodies, monoclonal; Angiogenesis inhibitors; Intravitreal injections

RESUMOObjetivo: Comparar a eficácia de ranibizumab e bevacizumab intravítreos no tratamento da retinopatia da prematuridade (ROP) tipo 1.

Método: Foram avaliados retrospectivamente 36 olhos de 20 pacientes com retinopatia da prematuridade tipo 1 que receberam injeções intravítreas anti fator de crescimento endotelial vascular (anti VEGF) entre agosto de 2011 e fevereiro 2013. Quinze olhos de 8 pacientes receberam 0,25 mg ranibizumab (grupo 1) e 21 olhos de 12 pacientes receberam 0,625 mg bevacizumab (grupo 2). Os olhos foram examinados por oftalmoscopia indireta no primeiro dia, terceiro dia, primeira semana, e primeiro mês e conforme necessário após a injeção. Fotocoagulação com laser foi realizada quando foi detectada progressão da re tinopatia da prematuridade.

Resultados: Média do tempo de gestação para os pacientes do grupo 1 foi de 26,2 ± 2,7 semanas, enquanto para o grupo 2 foi de 27,1 ± 2,5 semanas. Não houve diferença estatística em relação ao tempo de gestação entre os grupos. A média de acompanhamento foi de 20 ± 4,5 meses. Fotocoagulação a laser foi realizada a 6 dos 15 olhos do grupo 1 e 2 dos 21 olhos do grupo 2. Nenhum dos olhos desenvolveu descolamento de retina no período de acompanhamento.

Conclusão: O ranibizumab e bevacizumab são eficazes no tratamento da retino-patia da prematuridade tipo 1. Incidência de progressão foi maior nos olhos que receberam ranibizumab. Ensaios clínicos controlados futuros são necessários para comparar esses dois medicamentos.

Descritores: Retinopatia da prematuridade; Fator de crescimento do endotélio vascu lar; Anticorpos monoclonais; Inibidores da angiogênese; Injeções intravítreas

IntroductIonRetinopathy of prematurity (ROP) is a potentially blinding disor-

der in preterm infants characterized by the presence of immature blood vessels. ROP is one of the most important causes of blindness in developing countries(1). The reported incidence of ROP is 16%-48% in babies with a birth weight of less than 1000 g and 27%-35% in babies with a birth weight under 1500 g(2). ROP is a two-staged disease. In the first stage, all vessel formation ceases because of hyperoxia, with vasoproliferation occurring in the latter stage(3).

The Early Treatment for Retinopathy of Prematurity (ETROP) study demonstrated that earlier treatment in carefully selected cases results in an overall improved visual outcome and posited novel guidance for ROP treatment. According to ETROP, all cases of type 1 disease,

zone I ROP with plus disease, zone I stage III ROP, and zone II stage 2-3 with plus disease should be treated(4).

A previous study reported significantly increased vitreal vascu-lar endothelial growth factor (VEGF) levels in ROP patients. In the same study, an excess production of VEGF was shown to play an im-portant role in ROP pathogenesis(5). In the Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity (BEAT-ROP) study, bevacizumab treatment was found to be more effective than laser photocoagulation for ROP treatment, particularly in patients with zone 1 and 2 posterior disease(6). Moreover, other anti-VEGF the rapies, macugen and ranibizumab, demonstrated efficacy in the treatment of ROP when used alone or in combination with laser photocoagulation(7-9).

Erol MK, et al.


The present study aimed to compare the efficacy and reliabili-ty of two anti-VEGF agents, ranibizumab and bevacizumab, in the treatment of ROP.

MethodsThe medical charts of 422 patients screened for ROP between Au-

gust 2011 and February 2013 in Antalya Training and Research Hos-pital were retrospectively evaluated. Twenty patients who received anti-VEGF treatment as first-line monotherapy were included in the present study. The study was conducted according to the Declaration of Helsinki, and informed consent was obtained from the parents of all patients. The study was approved by local ethic committee of Zekai Tahir Burak Hospital, Ankara, Turkey. Cases of type 1 disease, zone I ROP with plus disease, zone I stage III ROP, and zone II stage 2-3 with plus disease were classified according to ETROP(10).

We provided detailed information to the parents of patients re garding single-dose ranibizumab and single-dose bevacizumab separately. Intravitreal injections were performed according to parent decisions. Parents with higher socioeconomic status elected to use ranibizumab because it was specifically developed for the treatment of eye disease. Parents with a lower socioeconomic status chose be-vacizumab because it is cheaper.

Group 1 included patients in whom ranibizumab was used as the first-line therapy and group 2 included patients who received bevacizu-mab. Gestational weeks, birth weight, intubation period, maximum oxy-gen saturation, systemic disorders, and ROP relapse during the follow-up period were compared between the two groups. Post menstrual age (PMA) on initial treatment, relapse, and number of laser shots performed were also compared.

Intravitreal injections were performed under local anesthesia after installation of povidone iodine, eyes were draped, and lid specula were inserted. Injections were performed at 1.5 mm from the limbus with a 30-gauge needle. Fundoscopic examination was performed after all injections, controlling for central retinal artery flow, cataracts, and retinal tear formation. Netilmicin eye drops were prescribed four times per day for 10 days. The dose of ranibizumab was half the typical adult dose (0.25 mg). The bevacizumab dose was 0.625 mg. Fundoscopic examinations were performed on the first day, third day, first week, and first month and as required until vascularization was completed or laser spot scarring had occurred. All exams were perfor-med with indirect ophthalmoscopy and a 28 D lens. In cases of relapse, confluent laser photocoagulation was performed under sedation anesthesia. Relapse was defined as increased arterial tortuosity and venous dilation, formation of retinal neovascularization, and stage III ROP. In addition, cases with membrane formation extending into the vitreous from the retina underwent laser treatment.

Statistical analyses were performed using SPSS 13 program with Mann-Whitney U test, Fisher’s exact test and two sample t-tests used to compare groups. P-values less than 0.05 were considered statisti-cally significant.

resultsIntravitreal anti-VEGF injections were administered to 36 eyes of

20 patients as first treatment. Fifteen eyes of 8 patients (4 males, 4 females) received ranibizumab injections in group 1. In group 2, 21 eyes of 12 patients (5 males, 7 females) received bevacizumab (Figu-res 1, 2). The mean gestational time was 26.2 ± 2.7 weeks in group 1 and 27.1 ± 2.5 weeks in group 2. The mean birth weight was 853 ± 120 g in group 1 and 925 ± 110 g in group 2 (Table 1). The mean post menstrual age (PMA) at the time of injection was 34.4 ± 1.8 weeks in group 1 and 35.3 ± 1.7 weeks in group 2 (Table 2). Intravitreal an ti-VEGF injection was not administered to one eye of one patient in group 1 and three fellow eyes of three patients in group 2 because no progression to type 1 ROP was observed, and ROP had re gressed in 1 week in the three fellow eyes of three patients in group 2.

Figure 1. Right and left eyes of a premature baby born at 28 weeks with a 910 g birth weight.

Figure 2. One year after IV bevacizumab injection in the same patient shown in figure 1.

Table 1. Patient demographics and risk factors

Ranibizumab (group 1)

Bevacizumab (group 2)

P-value8 infants 12 infants

Zone 1 ROP 10 eyes 0.41

Zone 2 ROP 5 eyes 9 eyes 0.72

Male gender 4 5 0.53

Gestational time (weeks) 26.2 ± 2.7 27.1 ± 2.5 0.83

Birth weight (kg) 853 ± 120 925 ± 110 0.97

Sepsis (n) 4 7 0.65

Intraventricular hemorrhage (n) 3 5 0.50

Necrotizing enterocolitis (n) 5 5 0.65

Intubation (n) 7 9 0.46

APROP 1 1 NA

APROP= aggressive posterior ROP; NA= not applied.

Table 2. Mean gestational age at the time of injection

Ranibizumab (group 1)

Bevacizumab (group 2)

P-value8 infants 12 infants

Eyes that received laser photocoagulation

6/15 2/21 0.015

Mean follow-up time (weeks) 20.2 ± 4.7 19.8 ± 3.6 0.970

Age at initial injection (weeks) 34.4 ± 1.0 35.3 ± 1.7 0.830

No statistical difference in risk factors, such as sepsis, intraventi-cular hemorrhage, intubation period, bronchopulmonary dysplasia, and necrotizing enterocolitis, were observed between the groups (P>0.05; Table1).

Comparison of intravitreal ranibizumab and bevacizumab treatment for retinopathy of prematurity


Plus disease (arterial tortuosity and venous dilation), formation of retinal neovascularization, and ROP stage regression was observed on the 3rd day following intravitreal injection in group 2 patients and on the 7th day in group 1 patients, except for one patient who recei-ved confluent laser photocoagulation during the first week.

Relapse following regression of plus disease was observed in 4 eyes of 2 patients from group 1 and 2 eyes of 1 patient from group 2 (Figure 3). Relapse was observed on the 8th week in 2 patients from group 1 and 14th week in 1 patient of group 2. One session of con-fluent laser photocoagulation was performed in both groups with relapse (Figure 4). The average age at the time of laser treatment was 41 ± 3 weeks in group 1 and 50 weeks in group 2.

The mean follow-up duration was 20 ± 4.5 months (range, 12-27). No eyes developed retinal detachment during the follow-up period. Local complications secondary to treatment, such as retinal hemor-rhage, tear, cataract formation and glaucoma, were not observed in any patients. Only subconjunctival hemorrhage was observed. Ne-tilmicin eye drops were prescribed four times in a day for 10 days to all patients. This was not implemented as additional treatment. One patient from group 1 developed proteinuria and growth retardation of unknown cause.

dIscussIon

An increase in VEGF levels is one of the main mechanisms un-derlying ROP development. The aim of laser photocoagulation is to decrease VEGF levels produced by the avascular retina by abla-ting the retinal periphery. Lately, anti-VEGF drugs have been used as monotherapy agents or in addition to laser photocoagulation, with successful results obtained(7-9,11-16). The majority of studies have

reported the results of bevacizumab therapy. There are a few case series presenting results with ranibizumab(7,8). Although there are stu dies comparing the efficacy of ranibizumab and bevacizumab in patients with age-related macular degeneration, to the best of our knowledge, the present study is the first to compare their efficacy in patients with ROP(17).

In a prospective study, Mintz-Hittner et al.(18) treated 22 eyes of 11 infants with stage 3 ROP in zone I or posterior zone II with bilateral intravitreal bevacizumab injection without laser photocoagulation. One injection was found to be sufficient, and normal retinal vascu-larization proceeded in all cases. Dorta et al.(19) also performed single intravitreal bevacizumab injection for the treatment of type 1 ROP in 12 eyes of 7 premature infants and demonstrated disease regression without additional treatment. Quiroz-Mercado et al.(20) treated 18 eyes of 13 premature infants with a mean gestational age of 29 weeks and mean age at the time of the treatment of 38 weeks by single intravi-treal bevacizumab injection. They observed regression of neovascu-larization in all eyes and reattachment of the retina in one eye with stage 4a ROP without systemic or ocular complications. Castellanos et al.(7) treated 6 eyes with high-risk pre-threshold and threshold ROP disease by intravitreal ranibizumab without laser photocoagulation and demonstrated a single dose of intravitreal ranibizumab was sufficient to regress retinal neovascularization with no recurrences observed after a 3-year follow-up period.

Consistent with previous studies, the present study demonstra-ted that both ranibizumab and bevacizumab are effective in type 1 ROP treatment, with relapse rates higher with ranibizumab injections. The efficacy and reliability of these two agents in the treatment of age-related macular degeneration have previously been shown to be similar(17). Different pharmacokinetic behavior in prematures whose organ development is not complete may contribute to the difference in relapse rates observed between the two drugs. In adults, the syste-mic half-life of ranibizumab is 2 h, while the half-life of bevacizumab is up to 20 days because of the attachment of fragment crystallizable region (Fc region) to endothelial cells, thereby decreasing clearance(21). However, the systemic pharmacokinetic properties of these two drugs in children have not to be fully elucidated.

In an animal study, the efficacy of bevacizumab in fellow eyes was apparently superior to ranibizumab in suppressing subretinal neovascularization in rats(22). The efficacy of bevacizumab may have been doubled in the nine patients who received bilateral injections, which may have contributed to the low relapse rate in the present study. The lack of progression in fellow eyes may be associated with systemic effects of the anti-VEGF drugs.

Still, relapse following bevacizumab therapy has been reported. Jennifer et al.(23) reported relapse in 17 eyes of 9 patients who received bevacizumab. The mean time to relapse was 14.4 weeks. One case of retinal detachment occurring 3 months after combined intravitreal ranibizumab injection and laser photocoagulation for zone 1 ROP with plus disease has been reported(24). The time to relapse in the present case in the bevacizumab group was also 14 weeks. Relapse was seen in the 8th week in the ranibizumab group. Earlier relapse may be due to the shorter half-life of ranibizumab.

The risk of systemic complications is apparently higher after in travitreal bevacizumab injections compared to ranibizumab. In the present study, a patient was diagnosed with proteinuria in the rani-bizumab group. The exact cause of proteinuria was not assessed. Proteinuria following ranibizumab injection may be incidental. Ho-wever, nephropathy has previously been reported after intravitreal injections of both bevacizumab and ranibizumab for exudative age-re lated macular degeneration(25,26). Pelle et al.(26) proposed excessive VEGF expression by podocytes in the normal kidney as the mechanism underlying proteinuria. Dysregulation of VEGF expression within the glomerulus has been associated with a wide range of renal diseases, many of which cause significant hypertension and varying amounts of proteinuria that may occur within weeks to months after adminis-tration intravitreal anti-VEGF therapy(25,26).

Figure 3. The ROP line is more evident with increases in vascular tortuosity observed, particularly in the right eye, 8 weeks after IV ranibizumab injection.

Figure 4. Fundus view of the same patient 3 months after laser photocoagulation.

Erol MK, et al.


A number of previous studies have evaluated the utility of anti- VEGF therapies in ROP; however, the optimal dosage and timing of injections remains under debate(23). Although Avery claims that rani-bizumab is a safer alternative to bevacizumab, complications may be seen following intravitreal administration(27). Harder et al.(28) obtained successful results with the use of 0.375 mg bevacizumab, which is lower than the ROP dose. The results observed with bevacizumab in the present study may be attributable to the later time the injections, although this difference was not statistically significant.

The present study was limited by the retrospective design and the number of cases recruited. Moreover, the less precise criterion used for relapse than used for primary ROP was a further weakness.

Both ranibizumab and bevacizumab therapies showed an effi-cacy in the treatment of type 1 ROP treatment. Relapse rates were apparently less following bevacizumab injections compared to ranibizumab. Further randomized prospective studies with higher numbers of cases are required to validate the results of the present study.

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16. Erol MK, Coban DT, Özdemir Ö, Tunay ZÖ, Bilgin AB, Dogan B. Spectral-domain OCT Analyses of Macular Changes After Ranibizumab Therapy for Type 1 Retinopathy of Prematurity. J Pediatr Ophthalmol Strabismus. 2015;52(3):152-8.

17. CATT Research Group; Martin DF, Maguire MG, Ying GS, Grunwald JE, Fine SL, Jaffe GJ. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med. 2011;364(2):1897-908. Comment in: JAMA. 2014 ;311(15):1491-2. N Engl J Med. 2011;364(20):1966-7. N Engl J Med. 2011;365(23):2238. N Engl J Med. 2011; 365(23):2237; author reply 2237.

18. Mintz-Hittner HA, Kuffel RR. Intravitreal injection of bevacizumab (Avastin) for treat-ment of stage 3 retinopathy of prematurity in zone I or posterior zone II. Retina. 2008; 28(6):831-8.

19. Dorta P, Kychenthal A. Treatment of type 1 retinopathy of prematurity with intravitreal bevacizumab (Avastin). Retina. 2010;30(4 Suppl):S24-31.

20. Quiroz-Mercado H, Martinez-Castellanos MA, Hernandez- Rojas ML, Salazar-Teran N, Chan RV. Antiangiogenic therapy with intravitreal bevacizumab for retinopathy of prematurity. Retina. 2008;28( 3 Suppl):S19-S25.

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22. Miki K, Miki A, Matsuoka M, Muramatsu D, Hackett SF, Campochiaro PA. Effects of intraocular ranibizumab and bevacizumab in transgenic mice expressing human vas cular endothelial growth factor. Ophthalmology. 2009;116(9):1748-54.

23. Hu J, Blair MP, Shapiro MJ, Lichtenstein SJ, Galasso JM, Kapur R. Reactivation of retinopathy of prematurity after bevacizumab injection. Arch Ophthalmol. 2012; 130(8):1001-6. Erratum in: Arch Ophthalmol. 2013;13(2):212. Comment in: JAMA Oph-thalmol. 2013;131(4):546-7. JAMA Ophthalmol. 2013;131(4):544-5.

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Original Article


INTRODUCTIONDespite changes in lens design and advances in surgical tech-

niques, the development of posterior capsular opacification (PCO) is the most common complication following cataract surgery. Al-though various methods to treat PCO have been attempted, neody-mium yttrium-aluminum-garnet (YAG) capsulotomy is yet the gold standard because it is non-invasive, can be applied rapidly under polyclinic conditions, and has a high success rate. However, some complications may occur after YAG capsulotomy(1-3).

Changes in intraocular pressure are frequently observed follo-wing YAG capsulotomy(4) and may have an impact on the choroid, which is sensitive to fluctuations inintraocular pressure (IOP). Further-more, the probability of a reaction in the retina and choroid structures induced by the inflammation that may occur in the first days of the

procedure should be considered. Moreover, retinal complications that may emerge later affect the choroid tissue. Various studies associated with anterior chamber and retinal changes in patients who have un-dergone YAG capsulotomy have been published(4-6). However, to the best of our knowledge, there are no publications regarding choroi dal change.

Therefore, we aimed to evaluate retinal and choroidal struc-tures within the time periods when such changes are frequently observed. Potential positive findings could indicate whether optic coherence tomography (OCT) can be used for follow-up. We aimed to identify whether there were any changes at the 72-h follow-up, when inflammation after the procedure is high,and at 8-12 weeks after the procedure, when cystoid macular edema (CME) develop-ment is expected.

Optic coherence tomography measurement of choroidal and retinal thicknesses after uncomplicated YAG laser capsulotomyMedidas das espessuras de coroide e retina após capsulotomia por YAG laser não complicada

İsa Yuvacı1, EMinE Pangal1, yuduM yücE1, süMEyra yuvaci1, nurEttin bayraM1, döndü MElEK ulusoy1, ali aKal2, orhan altunEl1

Submitted for publication: August 5, 2015Accepted for publication: September 12, 20151 Kayseri Training and Research Hospital Eye Clinic, Kayseri, Turkey.2 Department of Ophthalmology, Harran University School of Medicine, Sanliurfa, Turkey.



Corresponding author: İsa Yuvacı. Kayseri Training and Research Hospital Eye Clinic. Hastane Str, 38010 - Kocasinan, Kayseri - Turkey - E-mail: [email protected]

Approved by the following research ethics committee: Erciyes University Ethics Committee 2014/356.

ABSTRACT Purpose: Optic coherence tomography (OCT) evaluation of the choroid, retina, and retinal nerve fiber layer after uncomplicated yttrium-aluminum-garnet (YAG) laser capsulotomy. Methods: OCT analysis of retinal and choroidal structures was performed in 28 eyes of 28 patients following routine examinations before and 24 h, 72 h, 2 weeks, 4 weeks, and 12 weeks after YAG laser capsulotomy. Data were analyzed using the SPSS software. Results: Data collected before YAG capsulotomy and at the above mentioned follow-up visits are summarized as follows. Mean central subfoveal choroidal thickness before YAG capsulotomy was 275.85 ± 74.78 µm; it was 278.46 ± 83.46 µm, 283.39 ± 82.84 µm, 280.00 ± 77.16 µm, 278.37 ± 76.95 µm, and 278.67 ± 76.20 µm after YAG capsulotomy, respectively. Central macular thickness was 272.14 ± 25.76 µm before YAG capsulotomy; it was 266.53 ± 26.47 µm, 269.14 ± 27.20 µm, 272.17 ± 26.97 µm, 270.91 ± 26.79 µm, and 273 ± 26.63 µm after YAG capsulotomy, respectively. Mean retinal nerve fiber layer thickness before YAG was 99.89 ± 7.61 µm; it was 98.50 ± 8.62 µm, 98.14 ± 8.69 µm, 99.60 ± 8.39 µm, 99.60 ± 8.39 µm, and 99.60 ± 8.35 µm after YAG capsulotomy, respectively. No observed change was statistically significant. No significant changes were observed with regard to mean intraocular pressure. Conclusions: After YAG laser capsulotomy, no statistically significant changes were found in choroidal, retinal, and optical nerve fiber layer thicknesses, although slight thickness changes in these structures were observed, particularly during the first days.

Keywords: Choroid; Retina; Tomography, optical coherence; Posterior capsulo-tomy/methods

RESUMOObjetivo: Avaliação da coroide, retina e a camada de fibras nervosas da retina por meio de tomografia de coerência óptica (OCT ) após capsulotomia por YAG laser não complicada. Método: Vinte e oito olhos de 28 pacientes foram incluídos neste estudo. Estruturas da retina e coroide foram analisados usando ACT nos exames de rotina antes da capsulotomia posterior por YAG laser e 24 horas, 72 horas, 2 semanas, 4 semanas e 12 semanas após YAG. Os resultados foram avaliados através do programa SPSS. Resultados: Os resultados deste estudo, pré YAG e às visitas de acompanhamento acima, podem ser resumidos da seguinte forma. A espessura média de coroide subfoveal central antes do YAG foi 275,85 ± 74,78 m; após YAG foi 278,46 ± 83,46 µm, 283,39 ± 82,84 µm, 280,00 ± 77,16 µm, 278,37 ± 76,95 µm, e 278,67 ± 76,20 µm, res-pectivamente. A espessura macular central foi 272,14 ± 25,76 mm antes YAG; e 266,53 ± 26,47 µm, 269,14 ± 27,20 µm, 272,17 ± 26,97 µm, 270,91 ± 26,79 µm, e 273 ± 26,63 µm, respectivamente. Espessura média da camada de fibras nervosas da retina antes do YAG foi 99,89 ± 7,61 mm; e 98,50 ± 8,62 µm, 98,14 ± 8,69 µm, 99,60 ± 8,39 µm, de 99,60 ± 8,39 µm, 99,60 ± 8,35 µm, respectivamente. Nenhuma das alterações observadas foram estatisticamente significativas. As médias da pressão intraocular, também não mostraram alterações significativas. Conclusões: Não houve mudanças significativas foram encontradas na coroide, camada de fibras nervosas da retina espessuras e ópticos, após a capsulotomia por YAG laser, embora houvesse, especialmente nos primeiros dias, discretas alterações de espessura nas estruturas mencionadas.

Descritores: Coroide; Retina; Tomografia de coerência óptica; Capsulotomia pos-terior/métodos

Yuvacı İ, et al.


METHODSThis prospective study was performed at the Ophthalmology

Department of the Kayseri Education and Research Hospital. The study adhered to the tenets of the Declaration of Helsinki and was approved by the Local Ethics Committee of Erciyes University. All individuals received both oral and written information regarding the study, and each subject provided written and informed consent before participation in the study.

Patients were selected between December 2014 - March 2015, and the study involved 28 eyes of 28 patients suffering from PCO. The patients had to fulfill the following inclusion criteria: underwent cataract surgery with phacoemulsification and clinically observable PCO as observed by the slit lamp examination in only one eye; ca-pable of being evaluated for at least 3 months after intervention by capsulotomy; and exhibited a centered intra ocular lens (IOL) with complete overlap between the anterior capsule and IOL. Patients who had glaucoma, corneal or retinal disease, uveitis, previous laser treatments, ocular trauma, or surgery during the follow-up period were excluded.

All individuals underwent a screening process involving a com-plete ophthalmologic examination, including refraction and visual acuity, slit-lamp biomicroscopy, intraocular pressure measured using non-contact tonometry, and fundus examination. Data on retinal nerve fiber layer (RNFL) thickness, macular thickness, macular volume, and choroidal thickness were obtained using the Spectralis OCT (Hei-delberg Engineering, Heidelberg, Germany).

Image acquisition: The procedure for obtaining enhanced depth imaging (EDI)-OCT has previously been described(7). The central sub-foveal choroidal thickness (CEDI) was measured using spectral-do-main OCT (Spectralis, Wave-length: 870 nm; Heidelberg Engineering Heidelberg, Germany) with the EDI modality. CEDI was defined as the vertical distance from the hyperreflective line of Bruch’s membrane to the hyper-reflective line of the inner surface of the sclera. All subjects were imaged by the same experienced technician. Two independent clinicians measured CEDI, and the average of these measurements was used in the analysis. All scans were performed during the same time of the day, between 11:00-12:00, to minimize the possibility of CEDI changes attributable to diurnal CEDI fluctuations(8). Routine examinations and OCT measurements were repeated at 24 h, 72 h, 2 weeks, 4 weeks, and 12 weeks following the application of YAG capsulotomy.

Surgical technique

YAG laser capsulotomy was performed at least 3 months after surgery. Patients were treated with minimal energy and the mini-mal count of shots to provide sufficient capsule clarity, and a full ophthalmological examination was conducted for all patients. Pupil dilatation was provided with 1% tropicamide instillation before cap-sulotomy. Topical 0.5% proparacaine hydrochloride was used for corneal anesthesia. The biomicroscope was set to observe the pos-terior capsule after implantation of the capsulotomy lens to the eye.

Capsulotomy was performed using a Tango YAG laser system (Ellex, Adelaide, Australia). The number of laser shots and shot energy were recorded. A cross or circular technique was performed according to the surgeon’s preference to obtain a capsulotomy of approximately 4 mm. After the procedure, 5 mg/mL of prednisolone phosphate four times a day was applied to the treated eye for 2 weeks.

StatiStical analySiS

All statistical analyses were performed using SPSS for Windows version 22.0 (SPSS, Inc, Chicago, IL, USA). Continuous variables were presented as mean ± standard deviation. Pearson’s chi-square test was used to assess qualitative variables. Normal distribution was evaluated by using the Kolmogorov-Smirnov test. Homogeneity of variance was tested using Levene’s test. For parametric statistics, normallydistributed data were analyzed using the repeated measu-res ANOVA test. When a significant result was obtained, Bonferroni’s correction was used for post-hoc comparisons. A p value <0.05 was considered statistically significant.

RESULTSOverall, 28 patients (13 males and 15 females) were included in

the study. The mean age was 63.17 ± 9.67 years (age range, 42-80 years). The mean axial length (AL) was 23.23 ± 0.88 mm. The mean time passed from cataract surgery to YAG capsulotomy was 47.46 ± 16.98 months. The mean application of YAG power was 41.93 ± (14-83) mj. The mean three month spherical equivalent was measu-red as -0.55 ± 1.49 diopter (D).

As shown in table 1, while the mean IOP before YAG was 14.25 ± 2.74 mmHg, it was measured to 15.21 ± 3.22 mmHg 12 weeks after YAG capsulotomy, but this difference and the other observed differences during the follow-up measurements were not found to be statistically significant. Similarly, as demonstrated in table 1 and figure 1, CEDI was 275.85 ± 74.78 µm at baseline and 278.67 ± 76.20 µm 12 weeks after YAG capsulotomy. Changes in CEDIresults were not statistically significant (p=0.198). Similarly, as shown in table 1 and figure 2, the central macular thickness (CMT) before YAG capsulotomy was 272.14 ± 25.76 µm and 273 ± 26.63 µm 12 weeks after YAG capsulotomy. These findings were not statistically signifi-cant either (p>0.05).

Table 1 shows that the central macular volume (CMV) value was 0.2100 ± 0.01 mm3 at baseline and 0.2139 ± 0.001 mm3 12 weeks after YAG. Changes in CMV values were alsofound statistically insignificant (p=0.115). Table 1 demonstrates a total macular volume (TMV) value of 8.53 ± 0.33mm3 before YAG capsulotomy and 8.54 ± 0.34 mm3 12 weeks after YAG capsulotomy; however, again the displayed changes with regard to TMV values were statistically insignificant (p=0.245).

Figure 3 and table 1 show the RNLF changes between baseli-ne (99.89 ± 7.61 μm) and 12 weeks after YAG capsulotomy (99.60 ± 8.35 μm); no statistical significance (P=0.130) was observed through the follow-up.

Table 1. Most important findings observed before and after neodymium yttrium aluminum garnet capsulotomy (YAG)

TO mmHg CMTµ CEDİµ GnRNFLµ CMV mm3 TMV mm3

B YAG 14.25 ± 2.74 272.14 ± 25.76 275.85 ± 74.78 99.89 ± 7.61 0.2100 ± 0.01 8.53 ± 0.33

A 24 h 14.32 ± 3.07 266.53 ± 26.47 278.46 ± 83.46 98.50 ± 8.62 0.2111 ± 0.01 8.52 ± 0.32

A 72 h 15.03 ± 3.21 269.14 ± 27.20 283.39 ± 82.84 98.14 ± 8.69 0.2100 ± 0.01 8.52 ± 0.33

A 2 w 14.82 ± 3.07 272.17 ± 26.97 280.00 ± 77.16 99.60 ± 8.39 0.2100 ± 0.03 8.53 ± 0.33

A 4 w 15.01 ± 3.10 270.91 ± 26.79 278.37 ± 76.95 99.60 ± 8.39 0.2136 ± 0.01 8.53 ± 0.33

A 12 w 15.21 ± 3.22 273.00 ± 26.63 278.67 ± 76.20 99.60 ± 8.35 0.2139 ± 0.01 8.54 ± 0.34

B= before; A= after; CMT= central macular thickness; CEDI= central subfoveal EDI; GnRNFL= average retinal nerve fiber layer; CMV= central macular volume; TMV= total macular volume

Optic coherence tomography measurement of choroidal and retinal thicknesses after uncomplicated YAG laser capsulotomy


Changes in the values of IOP, CMT, CMV, TMV, CEDI, and the ge-neral RNFL were found to be statistically insignificant as measured before and after YAG capsulotomy (Table 1).

DISCUSSIONYAG lasercapsulotomy is the standard treatment for PCO, which

is seen generally between 20%-50% after 5 years of the surgery(9-11). Although it is a reliable method, complications such as refraction changes, IOP changes, IOL injury, IOL dislocation, macular edema, iridocyclitis, vitritis, vitreous hemorrhage, and retinal detachment have been reported after YAG laser capsulotomy(2,3,12).

Post-YAG capsulotomy retinal complications generally tend to be revealed later and have more risks in terms of functional loss. A previous study(3) evaluated YAG-associated complications and found a ruptured anterior hyaloid rate of 7.5%, a retinal tear rate of 4.1%, a re-tinal detachment rate of 2.5% and a macular edema rate of 4.1%. CME, in particular, which is commonly observed after surgery (observed clinically at a 1%-level post-phaco) is the most delicate problem and may present as disturbed vision after YAG capsulotomy(13). It is most commonly observed between 8 and 12 weeks after YAG. IOP changes, vitreous fluctuations, degradation products, and inflammation after YAG can result in disruption of the blood retinal barrier and retinal detachment(14,15). The inflammation and damage caused by particles which were revealed besides the impact of inflammation generally made by the process can create a response in the retina. All these factors can result in increased thickness or a decrease in the thickness of posterior structures like the retina and choroid.

In one study, the authors stated that they did not detect any mea-ning ful increase in OCT measurements after laser capsulotomy for patients in whom the authors measured the thickness of the central macula with preoperative OCT(16). In our study, the measurements were repeated 24 h and 72 h after application to closely follow any potential inflammatory processes, and at the 2nd and 4th week after discontinuation of drug administration, and because of the possi-bility of disruption of the blood retinal barrier, the measurements were repeated at the 12th week in which week CME is observed most frequently. On the first day following YAG capsulotomy, an increase was observed in CMT. This rise had a tendency to recover on the 3rd day, and the values at week 2, week 4, and week 12, were similar to those observed on the first day. No statistically significant difference was observed during all these changes. Probably, a slight vasocons-triction occurred in the retinal vessels, and by that time, because no complication had developed, there was recovery.

Cystoid macular edema was not observed in any of the 28 pa-tients, and no statistically significant difference was observed in CME measurements in terms of macular thickness and macular volume. Similarly, a study(17) monitoring various parameters after YAG capsu-lotomy in 31 eyes, reported that the change in arc macular thickness was not statistically significant. Another similarity to this study was that no complications developed over the follow-up period, which had an equal length. Therefore, this demonstrates that the follow-up of complicated cases would be more significant during the process. The reason for preferring uncomplicated cases in particular is to enable normal results to be monitored. No statistically significant change in macular thickness was observed in this study during the follow-up of 3 months. Furthermore, for this period, the procedure is found reliable for uncomplicated cases. The follow-up of 3 months may be too short for these cases.

In a study on the comparison of post-YAG capsulotomy size and macular thickness, it was stated that a rise in IOP could be related to a large capsulotomy but not a change in macular thickness(6). Similarly, in a study performed by reviewing the applied force and complica-tion, the authors(4) found that CMT change was significant in cases where >80 mj was applied, but insignificant when a force <80 mj was applied. Here if we consider that the necessary dose is applied to open the capsule, this means that a higher dose results in a more rigid and thick capsule and the release of more capsular degradation products. In our study, no significant thickness or IOP change was observed. The average dose applied in our study was 40.97 (10-80) mj

CEDI= central subfoveal EDI; B= before; A= after; H= hour; W= week.Figure 1. CEDI changes over time.

CMT= central macular thickness; B= before; A= after; H= hour; W= week.Figure 2. CMT changes over time.

RNFL= retinal nerve fiber layer; B= before; A= after; H= hour; W= week.Figure 3. RNFL changes over time.

Yuvacı İ, et al.


and could be considered equivalent to that applied in the group in which <80 mj was used. In this regard, the results of our study over lapped with that study. The long-term effect of the reactions that occur in the early days after YAG capsulotomy vary depending on the distortion of the blood retinal barrier while it recovers from inflammation; it is unlikely that they could be independent there of in the process.

The choroid, being responsible for 85% of ocular perfusion, is sen-sitive to IOP changes. Increased IOP following YAG is the most com-mon complication; despite prophylactic treatment its incidence was observed as between 15%-30% in some studies(18,19). The short- and long-term results are unclear in studies(19-21) examining IOP changes after YAG capsulotomy. Whether or not the choroid is influenced as a result of pressure fluctuations after YAG capsulotomy should the-refore be subject to scrutiny. Moreover, there is a possibility that the inflammation in the first days after the procedure might bring about a change in choroidal tissues. Various changes in the choroid are also probable in retinal complications (which are seen at a later stage).

For various diseases and conditions, the thickness of the choroid, which has an important role in the nutrition of the inner layers of the retina, have been measured and published(22-26). To the best of our knowledge, no study has been performed to investigate choroidal thickness after YAG capsulotomy. Our purpose here was to reveal whether there is a subclinical change. The causes of retinal complica-tions observed post-YAG capsulotomy, particularly of CME, are com-monly revealed as capsular degradation products and a deteriorated blood retinal barrier. Considering the data of our study, no significant choroidal thickness was observed at either 24 or 72 h or at follow-up 3 months after application. Although a slight thickening was observed in the early stages of the process, this thickening had a tendency to diminish over time to the level observed on the first day. A slight rise in thickness particularly in the early days of application could suggest a mild subclinical inflammation (although not statistically significant). Investigating this in detail would necessitate studies with larger sam-ple sizes. The follow-up of changes could be more significant in cases where scanning of macular thickness was made, especially in cases where CME development occurred.

In the analysis of RNFL, a change in average thickness (similar to retinal thickness and volume) was observed with a slight decrea-se initially in measurements at 4 and 12 weeks; thickness levels reached a thickness level, which was similar to the initial results. The difference between the results were not statistically signifi-cant. No significant change in IOP was observed in any case; this circumstance may have a direct effect on the result. Because we have no further data for comparison in this regard, we believe that a comparison with future data would be helpful. If the change in IOP is held more responsible for the alteration in the RNFL level, we believe that conducting this evaluation on cases with IOP changes would be more appropriate.

In our study, after YAG capsulotomy, there was a tendency of slight macular thinning, thinning of RNFL, and thickening of the choroid, and these parameters returned to pre-YAG levels with time. Although not statistically significant, the parameters indicate that the application triggers a mild inflammation. To conclude, YAG cap-sulotomy is a safe and effective method. However, the smallest dose application and close follow-up would increase the reliability of the application.

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Original Article


INTRODUCTIONPseudoexfoliation syndrome (PEX) is an age-related disease cha-

racterized by the deposit of anomalous fibrillar extracellular material on intraocular structures in the anterior segment of the eye(1). Pseu-doexfoliation material (PEM) is detected by electron microscopy and indirect immunofluorescence in the stromal connective tissue of the conjunctiva, ciliary body, iris, lens capsule, and cornea. The presence of PEM on the anterior lens surface is the most consistent and impor-tant clinical diagnostic feature of PEX(2).

In vivo corneal confocal microscopy enables real-time, high re so-lution microscopic imaging of the cornea and has been increa singly used to evaluate the corneal changes in PEX(3,4). Previously, the only method of delineating the structural features of this disease was pa-thological examination after corneal biopsy. In vivo corneal confocal microscopy allows the examination of PEX-related corneal altera-tions. Using in vivo confocal microscopy, Zheng et al. showed that eyes with PEX, as well as their contralateral eyes, have significantly lower cell densities in the basal epithelium, anterior and posterior

stroma, and endothelium(3). They also demonstrated the deposition of hyperreflective material on the endothelium, which they presumed to be PEM, on eyes with PEX and the contralateral eyes(3).

To our knowledge, no study has compared the density of cells of corneal layers and the presence of hyperreflective endothelial de-posits in patients with PEX. The aim of this study was to measure the density of cells in different layers of the cornea and determine whether there are morphologic changes of the sub-basal corneal nerve plexus in eyes with PEX.

METHODSOne eye each of 37 patients diagnosed with PEX without glauco-

ma and of 20 healthy control subjects was studied. In the patients with PEX, the eyes with more PEM as determined by biomicroscopic examination were used in the present study The study protocols were approved by the local ethics committee and follow the tenets of the Declaration of Helsinki. All patients underwent a complete

Characteristics of the cornea in patients with pseudoexfoliation syndromeCaracterísticas da córnea em pacientes com síndrome de pseudoexfoliação

rEFiK oltulu¹, gunhal satirtav¹, EMinE tinKir KayitMazbatir¹, gulFidan bitirgEn¹, ahMEt ozKagnici¹, adnan KaraibrahiMoglu²

Submitted for publication: May 27, 2015 Accepted for publication: August 23, 20151 Ophthalmology Department, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey.2 Biostatistics Unit, Medical Education and Informatics Department, Necmettin Erbakan University

Faculty of Medicine, Konya, Turkey.



Corresponding author: Refik Oltulu. Ophthalmology Department. Necmettin Erbakan University Meram Faculty of Medicine. Meram, Konya 42080 - Turkey - E-mail: [email protected]

Approved by the following research ethics committee: Necmettin Erbakan University Meram Faculty of Medicine. Project number: 2013/96.

ABSTRACT Purpose: To quantify the morphological alterations in corneal nerve fibers and cells in patients with pseudoexfoliation syndrome (PEX) and their relationship with the presence of hyperreflective endothelial deposits observed using in vivo confocal microscopy. Methods: One eye each of 37 patients with PEX and 20 age-matched healthy control subjects was evaluated by in vivo corneal confocal microscopy. Patients with PEX were further classified into two groups: those with and without hyper-reflective endothelial deposits. We evaluated the densities of basal epithelial cells, anterior and posterior stromal keratocytes, and endothelial cells and structure of sub-basal nerve fibers. Results: The mean anterior and posterior stromal keratocyte and endothelial cell densities and corneal sub-basal nerve plexus variables were significantly lower in patients with PEX compared with those in healthy control subjects. The mean basal epithelial cell density did not significantly differ. Conclusion: Eyes with PEX presented decreased corneal sub-basal nerve plexus variables and cell densities in all corneas, except for the mean basal epithelial cell density. Further, a trend of lower corneal sub-basal nerve plexus measurements in patients with hyperreflective endothelial deposits compared with those without endothelial deposits was observed.

Keywords: Cornea/physiopathology; Cornea/innervation; Exfoliation syndrome/diagnosis; Confocal microscopy; Nerve fibers/pathology

RESUMOObjetivo: Quantificar as alterações morfológicas nas fibras nervosas e nas células da córnea em pacientes com síndrome de pseudoexfoliação (PEX) e sua relação com a presença de depósitos endoteliais hiper-refletivos, observados por meio da micros-copia confocal in vivo. Métodos: Trinta e sete olhos de 37 pacientes portadores de PEX e 20 olhos de 20 indivíduos saudáveis, pareados por idade, foram avaliados por meio da microsco -pia confocal de córnea. Os pacientes com PEX foram classificados em dois grupos: pacientes sem depósitos endoteliais hiper-refletivos e pacientes com depósitos en-doteliais hiper-refletivos. Células basais epiteliais, ceratócitos do estroma anterior e posterior, e densidades celulares endoteliais assim como a estrutura das fibras nervosas sub-basais foram avaliadas. Resultados: A média de ceratócitos do estroma anterior e posterior, as densidades celulares endoteliais, bem como as variáveis de plexo nervo sub-basal foram significa-tivamente menores nos pacientes com PEX em comparação com indivíduos saudáveis. A densidade celular epitelial basal não diferiu significativamente. Conclusões: Os olhos com PEX apresentaram diminuição das variáveis do plexo do nervo sub-basal e das densidades celulares em toda a córnea, exceto na camada basal das células epiteliais. Além disso, foi notada uma tendência para valores mais baixos nas variáveis do plexo do nervoso sub-basal em pacientes com depósitos endoteliais hiper-refletivos em comparação àqueles sem depósitos endoteliais.

Descritores: Córnea/fisiopatologia; Córnea/inervação; Síndrome de exfoliação/diag -nóstico; Microscopia confocal; Fibras nervosas/patologia

Oltulu R, et al.


ophthalmic examination, and in vivo corneal confocal microscopy was performed. The diagnosis of PEX was made by visualizing PEM on the anterior lens surface and/or pupillary margin on slit-lamp biomicroscopy following pupillary dilation. On biomicroscopic exa-mination, pigment granules were not observed on the endothelium in any patient. Based on the in vivo confocal microscopy images, one independent observer assessed the patients for hyperreflective endothelial deposits and classified the patients into two groups: patients without hyperreflective endothelial deposits (group 1, n=20) and patients with hyperreflective endothelial deposits (group 2, n=17). The subjects in the control group had no history of intraocular or refractive surgery and glaucoma, no previous or active ocular disea-se, no corneal pathology, no prior contact lens use, and no systemic disease that may have affected the cornea. Laser scanning in vivo corneal confocal microscopy was performed on all subjects using the Rostock Corneal Module/Heidelberg Retina Tomograph III (RCM/HRT III; Heidelberg Engineering GmBH, Dossenheim, Germany). The RCM uses an entirely digital image capture system. During the in vivo corneal confocal microscopy examination, proparacaine was instil-led, and a contact lens was placed on the cornea while the patient was asked to fixate on a distant target aligned to enable examination of the central cornea. Two frames per location that contained the clearest images were selected from each of the following layers: ba-sal epithelium, anterior stroma, posterior stroma, and endothelium. A standard central counting frame size of 200 × 200 µm was used for all epithelial and endothelial images, and a frame size of 300 × 300 µm was used for the stromal images. Two frames were analyzed for each corneal layer, and an average was taken. The number of cells/mm2 was calculated by the proprietary software within the RCM/ HRT III. Three-to-five high-quality images of the sub-basal nerve plexus from the center of the cornea were assessed from each sub-ject. For all sub-basal nerve plexus images, the full 400 × 400-µm fra-me was used. Automatic CCMetrics software, version 1.0 (University of Manchester, Manchester, UK) was used for the quantitative analysis of the nerve fibers. Three parameters were quantified: the corneal nerve fiber density (NFD), i.e., the total number of major nerves per square millimeter; the total length of the nerve fibers (TLNF) and branches (millimeters per square millimeter); and the nerve branch density (NBD), i.e., the number of branches emanating from the major nerve trunks per square millimeter(5). All images were analyzed by one observer (GB), who was unaware of whether the images belonged to a patient with PEX or a control subject.

Statistical analyses were performed using SPSS software version 16.0 (SPSS Inc., Chicago, IL, USA). Descriptive analyses were presented

using means and standard deviations for basal epithelial cell, anterior stromal keratocyte, posterior stromal keratocyte, and endothelial cell densities, as well as the NFD, NBD, and TLNF, and using frequencies for PEX and control groups. Statistical significance was determined by the non-parametric Kruskal-Wallis test and Mann-Whitney U test. P-values <0.05 were considered statistically significant.

RESULTSThe mean age of the subjects was 68.7 ± 4.4 years (range, 61-76

years) in group 1, 70 ± 5.4 years (range, 59-85 years) in group 2, and 67.8 ± 2.6 years (range, 64-74 years) in the control group. None of the enrolled eyes had remarkable pathology of the cornea on slit-lamp biomicroscopy. There was no statistically significant difference within the three groups in terms of age (p=0.196) and sex (p=0.52). Table 1 shows a summary of the quantitative in vivo corneal confocal micros-copy findings of the cell density measurements and nerve fiber varia-bles in patients with PEX and healthy control subjects. Figures 1 and 2 illustrate in vivo corneal confocal microscopy images of the sub-basal corneal nerve plexus and endothelial layer, respectively, in a healthy subject, a patient without hyperreflective endothelial deposits, and a patient with hyperreflective endothelial deposits.

The mean anterior stromal keratocyte, posterior stromal keratocyte, endothelial cell densities, and the corneal sub-basal nerve plex us variables (NFD, NBD, and TLNF) were significantly lower in patients with PEX compared with those in healthy control subjects (p<0.001); conversely, the mean basal epithelial cell density did not differ signi-ficantly between the two groups (p=0.173).

When groups 1 and 2 were compared, no statistically significant differences for the corneal cell density and corneal sub-basal nerve plexus variables (p>0.907 and p>0.32, respectively), were observed. Group 2 presented significantly lower TLNF (p=0.024).

When comparing the group without hyperreflective endothelial deposits (group 1) with the control group, the mean anterior stromal keratocyte, posterior stromal keratocyte, and endothelial cell densi-ties as well as the corneal sub-basal nerve plexus variables except for the NFD (p=0.310) were significantly lower in group 1 subjects. There was no statistically significant difference between the two groups for the mean basal epithelial cell density (p=0.53).

When comparing the group with hyperreflective endothelial deposits (group 2) with the control group, there were statistically sig-nificant differences for the corneal sub-basal nerve plexus variables and all of the corneal cell density variables except for the mean basal epithelial cell density (p=0.447).

Table 1. Corneal confocal microscopic variables in patients with PEX and healthy control subjects

Basal epithelium (cells/mm2)

Anterior stroma (cells/mm2)

Posterior stroma

(cells/mm2)Endothelium

(cells/mm2)Nerve fiber density

(fibers/mm2)Nerve branch density

(branches/mm2)

Total length of the nerve fibers

(mm/mm2)

Control subjects (n=20) 5913 ± 480 764 ± 139 280 ± 49 2570 ± 369 34.6 ± 08.4 73.4 ± 32.1 25.0 ± 2.7

PEX (n=37) 5722 ± 531 434 ± 131 227 ± 45 2124 ± 346 28.6 ± 09.6 37.6 ± 21.4 17.3 ± 4.2

Group 1 (n=20) 5736 ± 464 433 ± 131 229 ± 48 2067 ± 289 30.6 ± 10.4 41.3 ± 19.9 19.0 ± 4.4

Group 2 (n=17) 5705 ± 616 436 ± 134 225 ± 42 2190 ± 403 26.2 ± 08.2 33.3 ± 22.9 15.3 ± 3.0

P values

Control subjects vs. PEX 0.173 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

Control subjects vs. group 1 0.530 <0.001 <0.010 <0.001 <0.310 <0.004 <0.001

Control subjects vs. group 2 0.447 <0.001 <0.004 <0.027 <0.004 <0.001 <0.001

Group 1 vs. group 2 0.982 1 1 <0.907 <0.278 <0.759 <0.024

PPEX= pseudoexfoliation syndrome; the data are presented as the mean ± standard deviation.

Characteristics of the cornea in patients with pseudoexfoliation syndrome


DISCUSSIONIn vivo confocal microscopy offers direct, non-invasive visual ac-

cess to the cornea at the cellular level and also permits evaluation of the sub-basal nerve plexus(6). A few studies in the literature have used in vivo corneal confocal microscopy to study the corneas of patients with PEX. Martone et al. detected hyperreflective deposits and den dritic cells infiltrating the basal epithelial cell layer in one case using in vivo corneal confocal microscopy(7). They also found fibrillar subepithelial structures, and the endothelial layer showed cellular anomalies. In a prospective observational case series, Sbeity et al. used noncontact in vivo corneal confocal microscopy to detect PEM on the lens surfaces and corneal endothelium of PEX eyes and their fellow eyes(8). Moreover, Zheng et al. demonstrated a decrease in corneal sensitivity as well as all of the corneal cell density and corneal sub-basal nerve plexus variables in patients with PEX(3).

In our study, we studied the cell density in different layers of the cornea and aimed to determine whether there are morphologic diffe-rences in the sub-basal corneal nerve plexus between eyes with and without PEX. We found no significant difference in the mean basal epithelial cell density between groups 1 and 2 and between patients with PEX and healthy control subjects. This finding contradicts those of previous studies, which showed significant differences in the mean basal epithelial cell density between patients with PEX and healthy control subjects(3,4).

We further observed significantly lower anterior and posterior stro-mal keratocyte densities in patients with PEX compared with heal thy control subjects. However, these variables did not significantly differ between groups 1 and 2. Zheng et al. observed PEM deposits in the anterior stroma of PEX eyes and suggested that the PEM may so-mehow cause PEX, perhaps by inducing apoptosis of the keratocytes as well as other pathogenic factors, such as altered levels of cytokines or chemokines in the cornea(3).

Oxidative stress is generally induced through the formation of multiple reactive oxygen species, including superoxide, hydrogen pe roxide, and hydroxyl radicals, which can initiate and propagate free radicals. The net oxidative burden between the prooxidant and antio-xidant systems represents the oxidative stress that damages cellular and tissue macromolecules, such as lipids, proteins, and nucleic acids, and results in cellular and tissue dysfunction and cellular death(9). The numbers of keratocytes and other cells of the cornea may decline with age in response to cumulative oxidative insults or declining an -tio xidant protection(10). Demirdögen et al. reported that the total an tioxidant status (TAS) levels were significantly lower in patients with PEX and pseudoexfoliation glaucoma (PG) compared with that in controls, and that lack of antioxidants may play an important role in the development of PEX/PG(11). This reduced level of antioxidants may be a contributing factor in the lower keratocyte density in patients with PEX compared with that in control subjects found in

Figure 1. In vivo confocal microscopic images of the sub-basal nerve plexus. (A) Representative image from a healthy control subject with normal corneal nerve fibers. (B) Representative image from a patient without hyperreflective endothelial deposits showing lower nerve branch density (branches/mm2) and the total length of the nerve fibers (mm/mm2) compared with the control. (C) Representative image from a patient with hyper-reflective endothelial deposits showing lower nerve fiber density (fibers/mm2), nerve branch density (branches/mm2), and the total length of the nerve fibers (mm/mm2) compared with the control.

A B C

A B C

Figure 2. In vivo confocal microscopic images of the endothelial layer. A) Representative image from a healthy control subject with a normal en-dothelial layer. B) Representative image from a patient without hyperreflective endothelial deposits. C) Representative image from a patient with hyperreflective endothelial deposits (arrowheads).

Oltulu R, et al.


our study, although stromal deposits were not found in any of the patients. Additionally, the lack of any difference between groups 1 and 2 concerning the keratocyte density, together with the previou-sly reported decreased TAS levels in patients with PEX, supports the altered cytokine and chemokine level hypothesis suggested by Zheng et al.(3). Furthermore, groups 1 and 2 did not differ with regard to the cell numbers in the corneal layers, and therefore, the presence or ab-sence of PEM on the endothelium does not affect the number of cells; instead, a secondary mechanism is thought to affect the cell numbers.

Various studies have described the changes in the histopatholo-gical endothelial characteristics(3,7,12), although few used in vivo cor neal confocal microscopy to analyze the possible differences between patients with and without PEX. Zheng et al. observed not only lower endothelial cell density but also increased degrees of pleomorphism and polymegathism and a higher coefficient of variation in the cell sizes in the patients with PEX compared with those in the healthy control subjects(3). We found that the mean endothelial cell density was lower in patients with PEX compared with that in healthy control subjects. Although we observed qualitative variation in the size and shape of the endothelial cells in eyes with PEX, quantitative analysis of pleomorphism and polymegathism was not performed in the current study, which limits detailed analysis. Deposition of PEM has been described as irregular clumps deposited on the corneal endo-thelium and has been associated with a decrease in the endothelial cell count(13). However, there was no statistically significant difference in the mean endothelial cell density when comparing group 1 with group 2. This suggests that factors other than the presence of PEM may be associated with the reduction of the endothelial cell density.

Abnormalities of the sub-basal nerve plexus were another im-portant finding of the present study. We found that NFD, NBD, and TLNF were significantly lower in patients with PEX compared with those in healthy controls; additionally, we further showed that TLNF was significantly lower in group 2 compared with that in group 1. Additionally, neither NFD nor NBD differed significantly among the study subgroups, although both of them tended to be lower in group 2 compared with those in group 1. The reason for this may be that the two groups were at different stages of the PEX process; the eyes in group 1 may have been at an early stage of PEX.

There were some limitations in this study. First, the quantitative analysis of the in vivo corneal confocal microscopy images was per-formed by an observer who was unmasked regarding whether the images belonged to a patient with PEX or a control subject. Secondly, the study groups had small sample sizes. However, the sample sizes of our report are comparable with those of similar studies in the lite-rature. Another factor that could be considered as a limitation in this study is the possible effect of the presence of hyperreflective endo-thelial spots on the accuracy of measurements of the sub-basal nerve plexus variables. Further studies are needed to address whether the

etiology of the differences between the measurements of the groups was due to an actual effect of the presence of hyperreflective spots on the nerve variables or an artifact effect of these deposits that limited the accuracy of the measurements.

In conclusion, in vivo corneal confocal microscopy permits in vivo imaging of microstructural changes in the corneas of patients with PEX. Our study demonstrated that eyes with PEX have lower cell den-sities in all layers of the cornea except for the basal epithelium, as well as the corneal sub-basal nerve plexus variables, compared with those in control subjects. Further, we found trends toward lower corneal sub-basal nerve plexus measurements in patients with hyperreflec-tive endothelial deposits compared with those in subjects without hyperreflective endothelial deposits. Further studies are needed to elucidate the relationships between hyperreflective endothelial de-posits and in vivo corneal confocal microscopy findings.

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drome. Am J Ophthalmol. 2006;141(5):921-37. 2. Schlötzer-Schrehardt U, von der Mark K, Sakai LY, Naumann GO. Increased extracellu-

lar deposition of fibrillin-containing fibrils in pseudoexfoliation syndrome. Invest Oph thalmol Vis Sci. 1997;38(5):970-84.

3. Zheng X, Shiraishi A, Okuma S, Mizoue S, Goto T, Kawasaki S, et al. In vivo confocal microscopic evidence of keratopathy in patients with pseudoexfoliation syndrome. Invest Ophthalmol Vis Sci. 2011;52(3):1755-61.

4. Zheng X. New findings for an old disease: morphological studies on pseudoexfolia-tion syndrome-related keratopathy and binocular asymmetry. Cornea. 2013;32(Suppl 1): S84-90.

5. Dabbah MA, Graham J, Petropoulos IN, Tavakoli M, Malik RA. Automatic analysis of diabetic peripheral neuropathy using multi-scale quantitative morphology of nerve fibres in corneal confocal microscopy imaging. Med Image Anal. 2011;15(5):738-47.

6. Guthoff RF, Zhivov A, Stachs O. In vivo confocal microscopy, an inner vision of the cornea-a major review. Clin Exp Ophthalmol. 2009;37(1):100-17.

7. Martone G, Casprini F, Traaversi C, Lepri F, Pichierri P, Caporossi A. Pseudoexfoliation syn-drome: in vivo confocal microscopy analysis. Clin Exp Ophthalmol. 2007;35(6):582-5.

8. Sbeity Z, Palmiero PM, Tello C, Liebmann JM, Ritch R. Non-contact in vivo confocal scanning laser microscopy in exfoliation syndrome, exfoliation syndrome suspect and normal eyes. Acta Ophthalmol. 2011;89(3):241-7.

9. Tanito M, Kaidzu S, Takai Y, Ohira A. Status of systemic oxidative stresses in patients with primary open-angle glaucoma and pseudoexfoliation syndrome. PLoS One. 2012; 7(11):e49680.

10. Patel S, McLaren J, Hodge D, Bourne W. Normal human keratocyte density and corneal thickness measurement by using confocal microscopy in vivo. Invest Ophthalmol Vis Sci. 2001;42(2):333-9.

11. Demirdögen BC, Ceylan OM, Işikoğlu S, Mumcuoğlu T, Erel O. Evaluation of oxidative stress and paraoxonase phenotypes in pseudoexfoliation syndrome and pseudoexfo-liation glaucoma. Clin Lab. 2014;60(1):79-86.

12. Quiroga L, Lansingh VC, Samudio M, Peña FY, Carter MJ. Characteristics of the corneal endothelium and pseudoexfoliation syndrome in patients with senile cataract. Clin Experiment Ophthalmol. 2010;38(5):449-55.

13. Naumann GO, Schlötzer-Schrehardt U. Keratopathy in pseudoexfoliation syndrome as a cause of corneal endothelial decompensation. A clinicopathologic study. Oph-thalmology. 2000;107(6):1111-24.

Original Article


INTRODUCTION The objective of strabismus surgery is to achieve motor alignment

and sensory improvement with a minimum number of procedures(1). Long-lasting favorable results depend on good control of over- and under-corrections during the immediate postoperative period(2). Tables and algorithms for the number of muscles to be included in the surgery have been formulated based on the results obtained from large patient populations; however, standardized calculations are affected by various factors that could reduce the success of sur-gical results(3). Moreover, the ability to modify the site of the muscle insertion in the globe and possibility of refining surgical results and

controlling postoperative deviations caused Jampolsky to reintro-duce an adjustable suture technique in 1975 that was based on the ideas of O’Connor, Harms, and Bielschowsky(4-6). The indications for adjustable sutures are numerous and include several circumstances of an unforeseen nature (paralysis, restrictive strabismus, and history of prior surgery). Although the adjustable suture technique has been used for over three decades and the applicability of the method has been widely reported, randomized control trials are required(7), and its indication for horizontal concomitant deviations is controversial.

To highlight these issues, we compared the surgical results of adjus -table and non-adjustable suture techniques for concomitant hori-

Adjustable versus non-adjustable suture techniques for concomitant horizontal strabismus: a comparative studyEstudo comparativo das técnicas de sutura ajustável e não ajustável para o estrabismo comitante horizontal

galton c. vasconcElos1, hEndErson c. dE alMEida1

Submitted for publication: April 8, 2015Accepted for publication: September 12, 20151 Hospital São Geraldo, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.



Corresponding author: Galton Carvalho Vasconcelos. Rua Padre Rollim, 541 - Belo Horizonte - MG - 30130-090 - Brazil.

ABSTRACT Purpose: To compare the surgical results of adjustable and non-adjustable hori-zontal strabismus surgery for concomitant horizontal strabismus. Methods: The charts of 231 patients, who underwent horizontal strabismus sur gery, selected using probabilistic sampling, were retrospectively reviewed. Patients were divided into two groups according to the surgical technique used and strabismus type. The adjustable suture technique was used for 107 patients (Group 1), and non-adjustable or conventional surgery was performed in the remaining 124 patients (Group 2). Patients with esotropia (ET) or exotropia (XT) of <55 prism diopters (PD) at distance were included. The following exclusion criteria were applied: all intermittent or vertical deviations, anisotropias >5 PD, syndromes, restrictive or paretic strabismus, reoperations, botulinum toxin injection, and patients postoperatively followed up for <3 months. Surgical success was set to a range between orthotropia and an esodeviation of up to 10 PD for both ET and XT. Results: An amblyopia rate >50% was present in all subgroups. Significant differences between strabismus groups submitted to adjustable technique and non-adjustable on postoperative day 1 were observed (p=0.00 for ET and p=0.01 for XT) and at the last visit for the XT group with a follow-up of at least 1 year (p=0.05). Conclusion: The adjustable suture technique produced a higher success rate than non-adjustable strabismus surgery for both ET and XT groups on postoperative day 1. For XT patients, the adjustable suture technique appears to produce better surgical results than non-adjustable surgery, when the surgical goal is long-lasting maintenance of a small hypercorrection.

Keywords: Strabismus/surgery; Ophthalmologic surgical procedures/methods; Outcome assessment; Suture techniques; Oculomotor muscles/surgery

RESUMOObjetivo: Comparar os resultados cirúrgicos das técnicas com sutura ajustável e não-justável na cirurgia do estrabismo comitante horizontal. Métodos: Os prontuários de 231 pacientes, submetidos à cirurgia do estrabismo horizontal ao longo de 25 anos e selecionados por amostragem aleatorizada foram revisados retrospectivamente. Os pacientes do estudo foram divididos em dois subgrupos de acordo com a técnica cirúrgica empregada e o tipo de estrabismo. Foram selecionados 107 pacientes submetidos à técnica ajustável (Grupo 1) e 124 patientes submetidos a técnica não ajustável ou convencional (Grupo 2). Foram incluídos esotropias (ET ) ou exotropias (XT ) com menos de 55 dioptrias prismáticas (DP), medidos para longe. Críterios de exclusão rigorosos foram adotados: todos os desvios intermitentes, desvios verticais, anisotropias maiores que 5 DP, síndromes, estrabismos paréticos ou restritivos, reoperações, injeção de toxina botulínica e pacientes seguidos no pós-operatório inferior a 3 meses. O sucesso cirúrgico foi definido como faixa situada entre ortotropia e esodesvio de até 10 DP, tanto para as esotropias quanto para as exotropias. Resultados: Um índice de ambliopia maior que 50% foi encontrado em todos os subgrupos. O teste do chi- quadrado revelou diferenças estatisticamente significativas entre os grupos de estrabismo submetidos às técnicas com sutura ajustável e não ajustável, no primeiro dia pós-operatório (p=0,00 for ET and p=0,01 for XT ) e à última visita para o grupo dos XT, seguidos por pelo menos um ano (p=0,05). Conclusão: A técnica com sutura ajustável produziu maiores índices de sucesso do que a cirurgia de estrabismo não ajustável, para ambos os grupos ET e XT no primeiro dia pós-operatório. Para pacientes com XT, a técnica com sutura ajustável parece produzir melhores resultados cirúrgicos, quando objetiva a manutenção de uma pequena hipercorreção no pós-operatório tardio.

Descritores: Estrabismo/cirurgia; Procedimentos cirúrgicos oftalmológicos/métodos; Avaliação de resultados; Técnicas de sutura; Músculos oculomotores/cirurgia

Vasconcelos GC, Almeida HC


zontal strabismus immediately after surgery and at a later time point, using probabilistic sampling of a patient population.

METHODS The subjects for this historical cohort study were recruited through

the charts of patients undergoing horizontal strabismus sur gery at a strabismus unit at a university hospital in Brazil, and from the private practice of one of the authors (HCA), for a 25 year-period, beginning in 1977. One of the authors was present during all surgeries. Subjects were selected, using probabilistic sampling based on the surgical technique employed: adjustable or non-adjustable.

Initially, a pilot study was conducted with the charts of 58 patients (29 for each surgical technique) to define the number of patients necessary to achieve sufficient statistical power. A relative risk of 0.62 was found for the two techniques. A power (β) of 90% and an alpha error (α) of 5% were adopted. These parameters defined a required minimum sample of 104 patients in each group, using the StatCalc module of Epi Info. A 15% increase in the number of patients was adopted to compensate for possible losses during the study.

The charts of patients with esotropia (ET) or exotropia (XT) of up to 55 prism diopters (PD) at distance were included. Exclusion criteria included all intermittent or vertical deviations, anisotropias >5 PD, syndromes, paresis or paralysis of eye muscles, a history of vertical muscle surgery, restrictive or paretic strabismus, reoperations, botu-linum toxin injection, and patients postoperatively followed up for <3 months.

The inclusion criteria were as follows: a chart was initially selected by probabilistic sampling from the total number of charts, including 252 adjustable strabismus surgery charts (Group 1) and 1187 non-ad-justable strabismus surgery charts (Group 2). Group 1 was always the first choice. A chart was selected and included in the study if it met all of the inclusion and exclusion criteria; if not, it was rejected and a new chart was selected. Therefore, 231 patients were selected: 107 had undergone operation using an adjustable suture technique, and 124 had undergone non-adjustable surgery.

The following data were extracted from the selected charts: visual acuity, preoperative deviation, age during surgery, surgical planning, adjustment information if performed, and postoperative deviation. Visual acuity considered for each eye was the one used for optical correction. In amblyopes, the most recent visual acuity measured be-fore surgery was considered, upon failed occlusion. The most recent preoperative deviation for distance (ET/XT), obtained immediately before surgery, was recorded in PD.

Surgical planning was recorded for each patient, including the number of millimeters recessed or resected. For the adjustable surge-ries, the following parameters were assessed: the surgical planning, need for adjustment, and deviation before and after the adjustable maneuver. The adjustable suture technique and adjustment postope-ratively performed were in accordance with the technique pre viously described by Jampolsky(1,8). Adjustments were performed only on recessed muscles. Surgical success was defined as an esodeviation of up to 10 PD. For XT patients, surgical success was defined as a residual deviation ranging from orthotropia and an esodeviation of up to 10 PD. Undercorrections were not included in the success group in this study, as we have previously excluded all intermittent deviations, and reoperations with a higher risk of postoperative diplopia. Postopera-tive data on deviation were recorded at postoperative day 1, 1 and 3 months after surgery, and the last visit.

For statistical analysis, data were stratified according to the type of surgery and strabismus, and the chi-square and Fisher’s tests were used. An α error of 0.05 was specified. The comparability between subgroups ET and XT was verified based on variants, such as the presence of amblyopia, angle of deviation, preoperative follow-up, and age during surgery.

RESULTS The study involved 107 and 124 patients in the adjustable and

non-adjustable surgery groups, respectively. The adjustable surgery group comprised 84 patients with ET (78.5%) and 23 with XT (21.5%), and the non-adjustable surgery group comprised 93 cases with ET (75.0%) and 31 with XT (25.0%).

In the ET subgroup, the frequency of amblyopia was 58.3% (49 patients) in the adjustable group and 55.9% (52 patients) in the non-adjustable group; in the XT subgroup, the frequency of amblyo-pia was 60.9% (14 patients) in the adjustable group and 54.1% (17 cases) in the non-adjustable group. With regard to the distribution of ametropia, the majority of patients in both subgroups under-going either technique presented with spherical equivalents of <5 diopters (between 83% and 90%). Mean angles of deviation were similar: adjustable ET, 37° ± 11° PD; non-adjustable ET, 38° ± 10° PD; adjustable XT, 31° ± 7° PD; and non-adjustable XT 37° ± 10° PD. Mean preoperative follow-up was similar between subgroups and techni-ques: adjustable ET, 2.4 ± 3.8 years; non-adjustable ET, 2.4 ± 4.0 years; adjustable XT, 1.3 ± 2.6 years; and non-adjustable XT, 2.0 ± 3.4 years. The mean age of patients in the adjustable suture subgroups was higher than that of patients in the non-adjustable suture subgroups: 19.1 ± 7.0 years and 9.9 ± 7.4 years in the ET subgroups and 24.2 ± 7.5 years and 15.9 ± 10.4 years in the XT subgroups.

The highest rate of monocular surgery was observed in the adjustable groups: 91.7% (77 patients) for ET and 100% (23 patients) for XT; monocular surgery was performed in 77.4% (24 patients) of patients undergoing non-adjustable XT. Binocular surgery (bilateral recession) was predominant in the non-adjustable ET group, 36 pa-tients (61.3%). After initial postoperative evaluation, adjustment was required in 60% of all patients in Group 1; 64.3% of those with ET, and 56.5% of those with XT. Muscle adjustment failed in 9 patients (16.7%) from the ET group and 2 (15.4%) from the XT group. Surgical results of adjustable and conventional techniques were compared at postoperative day 1, 1 and 3 months after surgery, and the last visit. On postoperative day 1, the overall success rates for adjustable and non-adjustable sutures were 90.3% and 57.2%, respectively. The success rates for each group were as follows: on postoperative day 1 ET adjustable, 89.3%; ET non-adjustable, 61.2%; XT adjustable, 91.3%; and XT non-adjustable, 53.1%. The chi-square test revealed significant differences on postoperative day 1 (p=0.00 for ET, and p=0.01 for XT), which could not be detected at 1 and 3 months after surgery and the last visit for the ET group (p>0.05; Figures 1 and 2).

For the XT group with a follow-up of at least 1 year, there were significant differences between patients undergoing adjustable and non-adjustable strabismus surgery: surgery was successful in 9/18 patients (50.0%) from the XT adjustable subgroup and in 5/23 (21.7%) from the XT non-adjustable subgroup (p=0.05); The chi-square

Figure 1. Surgical success at day 1st, 1 month and 3 months for patients with Esotropia, according to surgical technique.

Adjustable versus non-adjustable suture techniques for concomitant horizontal strabismus: a comparative study


test failed to show any correlation (p>0.05) between the presence of am blyopia and ametropia and surgical success at the last visit. No significant differences were found for ET patients with a follow-up of at least 1 year.

The relative risk of success at the last visit (non-adjustable/adjus-table) was 0.96 for ET and 0.60 for XT. The pre-established parameter of 0.62 obtained during the pilot study correlates with the XT group results, although it indicates the need a larger sample of patients than that used for the ET group.

DISCUSSION A historical or retrospective cohort was adopted for the present

study to highlight the need of a reliable sample of patients whose selection followed strict inclusion and exclusion criteria(9). According to Weston et al.(10) and Wisnicki et al.(11), the success rate among adjus-table suture surgeries is lower in patients previously operated on to correct ET and XT. Therefore, patients who had undergone previous surgeries were excluded from the present study to avoid the possi-bility of bias. In our study, the samples were uniformly distributed according to the frequency of amblyopia, angle of deviation, and preoperative follow-up. Consistent with the distribution of horizontal deviation in the general population, the ratio of ET cases to XT cases was 3:1 in the two groups.

An amblyopia rate >50% was present in all subgroups, indicating that the majority of the patients had little or no fusion capacity, unlike the patients presented by Pratt-Johnson in 1985(12), who inclu-ded vertical deviations, paralysis, and reoperations, finding fusion abi lity in 40% of the patients. This is a potential reason for the lack of postoperative diplopia in XT patients who present with a slight overcorrection.

Deviations of up to 55 PD were included to compare between monocular and binocular two-muscle surgeries and to avoid large undercorrections and exaggerated adjustments, which could have distorted the results.

The mean age of patients undergoing operation with adjustable suture (22 years) was lower than that previously reported by Pratt-Johnson (33 years)(12). Mean age during surgery of the adjustable suture group was higher than that of the conventional group, which is consistent with previous studies and can be explained by the selection of cooperative patients(13). In our sample, 16 children (4-12 years old) underwent surgery with adjustable sutures under general anesthesia and were adjusted when necessary, without sedation. Chan et al. reported adjustable suture surgery in younger children(14). We found a higher rate of adjustments: 65.9% for ET and 56.5% for XT, compared with previous studies (around 40%)(10,12,15). The success rate for the adjustable surgery technique was 90.3%, which is similar to the rates described in the literature, which range from 67% to 90%(9,14-16).

The adjustable suture technique produced better surgical results than non-adjustable strabismus surgery for both the ET and XT groups on postoperative day one. At the last visit, the adjustable technique produced significantly better surgical results than the non-adjustable surgery for the XT subgroup. Mohan et al.(17) studied 38 patients with alternant exotropia equally allocated to adjustable and non-adjustable surgery and they found no statistically significant difference between the techniques at postoperative day 1 or at the last visit. The authors emphasized the need for a larger number of patients in each group. In 2009, Park et al.(18) could not show any significant differences between the results when comparing adjusta-ble and non-adjustable surgery in the treatment of 54 patients with sensory exotropia. In a larger group comprising 370 patients with horizontal strabismus (primary and re-operation cases), Kraft et al.(19), found that XT patients who underwent adjustable surgery had a significant 15% in success rate compared to patients undergoing non-adjustable surgery.

The predominance of monocular surgery in both the adjustable and non-adjustable XT subgroups allowed for an equal distribution of characteristics such as hypercorrection, thereby avoiding biased information, which can occur in retrospective studies. The predo-minance of binocular surgery for the non-adjustable ET group and the presence of a high frequency of amblyopia, may have interfered negatively in the comparison with the ET adjustable group, predomi-nantly representing of monocular surgery.

The results of the adjustable suture technique appear to be more effective when the recess-resection technique is employed. This te-chnique places the recessed muscle under tension, which allows it to slide backwards when released during the adjustment.

We believe, based on our findings, that if a surgeon’s goal is to obtain 5 to 10 PD hypercorrection postoperatively in XT patients, this could possibly be more easily obtained with adjustable sutures. The high amblyopia rate in our sample (>50%) could explain the need for minor hypercorrection during the immediate postoperative period for XT patients in order to minimize the risk of poor long-term surgical results in patients with no fusion ability.

Considering the lack of randomized control trials(7), we think that the present study will contribute significantly to the field, presenting a comparison of adjustable with non-adjustable sutures for horizon-tal strabismus using probabilistic sampling, rigid exclusion criteria, and homogeneous distribution of bias.

REFERENCES 1. Jampolsky A. Current techniques of adjustable strabismus surgery. Am J Ophthalmol.

1979;88(3 Pt 1):406-18. 2. Scott WE, Martin-Casals A, Jackson OB. Adjustable sutures in strabismus surgery. J Ped

Ophthalmol. 1977;14(2):71-5. 3. Siegel LM, Lozano MJ, Santiago AP. Adjustable and nonadjustable recession and

resection techniques. In: Rosenbaum A, Santiago A, editors. Clinical strabismus mana-gement: Principles and Surgical Techniques. Philadelphia: WB Saunders; 1999. p.435-47.

4. Jampolsky A. Strabismus reoperation technique. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol. 1975;79(5):704-17.

5. O’Connor R. A new shortening technique. JAMA. 1916;67:268-76. 6. Harms H. [Ein Vorlagerungsverfahren mit nachtraglicher Dosierungs Möglichkeit]. Klin

Monatsbl Augenheilkd. 1941;104:728. German. 7. Haridas A, Sundaram V. Adjustable versus non-adjustable sutures for strabismus. Co-

chrane Database Syst Rev. 2013;7:CD004240. 8. Jampolsky A. Adjustable strabismus surgical procedures. In: Helveston EM, editor.

Sym posium on Strabismus. Transactions of the New Orleans Academy of Ophthal-mology. St Louis: CV Mosby; 1978. p.321-49.

9. Gordis L. Cohort studies. In: Gordis L, editor. Epidemiology. 4th ed. Philadelphia: WB Saun-ders; 2009. p.167-76.

10. Weston B Enzenauer RW, Kraft SP, Gayowsky GR. Stability of the postoperative alignment in adjustable-suture strabismus surgery. J Ped Ophthalmol Strabismus. 1991; 28(4):206-11.

11. Wisnicki HJ, Repka MX, Guyton DL. Reoperation rate in adjustable strabismus. Arch Oph-thalmol. 1988;25(3):112-4.

12. Pratt-Johnson JA. Adjustable suture strabismus surgery: a review of 255 consecutive cases. Can J Ophthalmol. 1985;20(3):105-9.

Figure 2. Surgical success at day 1st, 1 month and 3 months for patients with Exotropia, according to surgical technique.

Vasconcelos GC, Almeida HC


13. Metz HS. Adjustable suture strabismus surgery. Ann Ophthalmol. 1979;11(10):1593-7. 14. Chan TK, Rosenbaum AL, Hall L. The efficacy of adjustable suture technique (AST) in

paediatric strabismus surgery. In: Lennerstrand G, editor. Advances in strabismology. Buren (The Netherlands): Eolus Press; 1998. p.373-6.

15. Wygnanski-Jaffe T, Wysanbeek Y, Bessler E, Spierer A. Strabismus surgery using the adjustable suture technique. J Pediatr Ophthalmol Strabismus. 1999;36(4):184-8.

16. Keech RV, Scott WE, Christensen LE. Adjustable suture strabismus surgery. J Ped Ophthal-mol Strabismus. 1987;24(2):97-102.

17. Mohan K, Ram J, Sharma A. Comparison between adjustable and non-adjustable

hang-back muscle recession for concomitant exotropia. Indian J Ophthalmol. 1998; 46(1):21-4.

18. Park YC, Chun BY, Kwon JY. Comparison of the stability of postoperative alignment in sensory exotropia: adjustable versus non-adjustable surgery. Korean J Ophthalmol. 2009;23(4):277-80.

19. Kraft SP, Mireskandari K, Cotesta M, Schofield J. A comparative study of adjustable vs. non-adjustable suture horizontal strabismus surgery in adults In: Ozkan S, editor. Upda-te on strabismology. 11th Meeting of the International Strabismological Association. Ankara: Rotatip Publisher; 2010. p.241-4.

Original Article


INTRODUCTIONToxoplasma gondii infection is the most common cause of pos-

terior uveitis worldwide and is an important cause of ocular disease in both immunocompromised and immunocompetent individuals(1), accounting for 30% to 50% of uveitis in different countries(2).

The prevalence of T. gondii infection in adults in Brazil ranges from 50% to 80% depending on the region studied(1,3-5). In Erechim, a city located in the south of Brazil, 88% of the population is seropositive for T. gondii, with 18% developing ocular toxoplasmosis(5,6).

Clinical diagnosis of ocular toxoplasmosis is usually made by ophthalmic examination. Molecular biology techniques can be suc-cessfully used to detect T. gondii DNA(7) when the clinical diagnosis is unclear. Polymerase chain reaction (PCR) can detect microorganism DNA and is a rapid method with high sensitivity and specificity that has been used to detect T. gondii DNA in different biological samples(8,9). With the recent advances in molecular biology, the use of real-time PCR makes quantitative measurement of T. gondii DNA possible in patients with ocular toxoplasmosis(10-12). Rapid recogni-

ABSTRACTPurpose: To evaluate the ability of real-time quantitative PCR (qPCR) for detecting Toxoplasma gondii DNA in the peripheral blood and aqueous humor of patients with toxoplasmic active focal necrotizing retinochoroiditis. Methods: Fifty-five patients with infectious uveitis seen from 2009 to 2013 at the Department of Ophthalmology and Visual Sciences of the Federal University of São Paulo were enrolled in this study. Forty-three patients had toxoplasmic active focal necrotizing retinochoroiditis, and the remaining 12 had non-toxoplasmic infectious uveitis and served as controls. qPCR analysis for T. gondii DNA was performed on the patients’ peripheral blood and aqueous humor samples. Results: The qPCR was positive for T. gondii DNA in 37.21% (16/43) of the aqueous humor samples and 2.33% (1/43) of the peripheral blood samples; further, 16.27% (7/43) of the patients had positive results in both their blood and aqueous humor samples. Conclusion: qPCR was able to detect T. gondii DNA in patients with toxoplasmic active focal necrotizing retinochoroiditis in the blood as well as the aqueous humor and can help with the diagnosis of the disease.

Keywords: Toxoplasmosis, ocular/diagnosis; Toxoplasma; Blood/parasitology; Cho -roiditis; Real-time polymerase techniques/methods; Aqueous humor

RESUMOObjetivo: Analisar o uso do PCR em tempo real (qPCR) na detecção do DNA do T. gondii no sangue periférico e no humor aquoso de pacientes com lesões de re ti-nocoroidite focal, ativa por toxoplasmose. Métodos: Cinquenta e cinco pacientes com uveite infecciosa foram incluídos neste estudo. Os pacientes foram atendidos entre 2009 a 2013, no Departamento de Oftalmo-logia e Ciências Visuais da Universidade Federal de São Paulo. Quarenta e três pacientes tiveram o diagnóstico de lesões de retinocoroidite focal, ativa por toxoplasmose e, os outros 12 tiveram o diagnóstico de uveíte infecciosa não toxoplásmica e, por isso foram usados como grupo controle. A técnica de qPCR foi utilizada na detecção de DNA do T. gondii em amostras de sangue periférico e humor aquoso. Resultados: O qPCR foi positivo para o DNA do T. gondii em 37,21% (16/43) das amostras de humor aquoso, 2,33% (1/43) nas amostras de sangue periférico e, 16,27% (7/43) em ambas amostras simultaneamente. Conclusão: O qPCR foi capaz de detectar o DNA do T. gondii em pacientes com lesões de retinocoroidite focal, ativa por Toxoplasmose, no sangue bem como, no humor aquoso, podendo ajudar no diagnostico.

Descritores: Toxoplasmose ocular/diagnóstico; Toxoplasma; Sangue/parasitologia; Coriodite; Reação em cadeia da polimerase em tempo real; Humor aquoso

tion of specific infections is important for adequate management of uveitis(13).

The aim of this study was to evaluate the ability of real-time quan-titative PCR (qPCR) for the detection of T. gondii DNA in peripheral blood and aqueous humor samples of patients with toxoplasmic active focal necrotizing retinochoroiditis.

METHODS

PatientS

Fifty-five patients with uveitis seen from 2009 to 2013 at the De-partment of Ophthalmology and Visual Sciences of the Federal Univer-sity of São Paulo were included in this study. From the 55 patients, 43 were diagnosed with toxoplasmic active focal necrotizing retinocho-roiditis. The remaining 12 were diagnosed with non-toxoplasmic in-fectious uveitis (toxocariasis=6, tuberculosis=3, and herpes virus=3), and served as controls.

Detection of Toxoplasma gondii DNA in peripheral blood and aqueous humor of patients with Toxoplasmic active focal necrotizing retinochoroiditis using real-time PCRDetecção de DNA do Toxoplasma gondii no sangue periférico e humor aquoso por PCR em tempo real

Fabio FEliPE dos santos1, hEloisa nasciMEnto1, cristina Muccioli1, dEisE Fialho da costa1, luiz vicEntE rizzo2, alEssandra gonçalvEs coMModaro1, rubEns bElFort Jr.1

Submitted for publication: May 4, 2015 Accepted for publication: October 1, 20151 Instituto da Visão and Departament of Ophthalmology, Escola Paulista de Medicina, Universidade

Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.2 Hospital Albert Einstein, São Paulo, SP, Brazil.

Funding: This work was supported by grants from FAPESP, CNPq-473179/2011-3, instituto da visão and CAPES.


Corresponding author: Alessandra G. Commodaro. Rua Botucatu, 822 - São Paulo, SP - 04023-062 Brasil - E-mail: [email protected]

Santos FF, et al.


The study was approved by the local ethics committee investiga-tional review board (0094/09), and informed consent was obtained from all patients.

SamPleS

The samples were collected by an ophthalmologist. Peripheral blood (5 ml) was collected in EDTA tubes. Approximately 0.1 ml of the aqueous humor was collected by anterior chamber paracentesis with a 30-gauge needle. Aqueous samples were obtained from patients who had at least two anterior chamber cells.

A total of 43 peripheral blood and 43 aqueous humor samples were collected from 43 patients with toxoplasmic necrotizing active focal retinochoroiditis and two or more inflammatory cells in the aqueous humor. Twelve non-toxoplasmic patients with active uveitis and two or more inflammatory cells in the aqueous humor (12 peri-pheral blood and 12 aqueous humor samples) were used as controls.

Dna extraction

Total DNA was extracted from the peripheral blood and aqueous humor with a commercially available DNA mini column kit (Qiagen, Hilden, Germany) according to the manufacturer’s protocol. The DNA samples were stored at -20°C until use.

real-time qPcrReal-time qPCR was performed using TaqMan 10 µl, with sense

and antisense primers at a concentration of 10 mM, 0.4 µl of probe, 6.8 µl of nuclease- and DEPC-free water (Invitrogen, Carlsbad, CA, USA), and 2 µl of DNA, with a total reaction volume of 20 µl. qPCR was performed on an ABI Prism 7500 DNA sequence detection system (Applied Biosystems, Waltham, MA, USA) and targeted the T. gondii 529-bp repetitive genomic sequence (rep529)(14,15) and the B1 gene(16). β-globin qPCR was performed in parallel for each sample as described previously(17) in order to confirm the integrity of the DNA and to verify the PCR inhibitors.

RESULTSReal-time qPCR analysis detected T. gondii DNA in 37.21% (16/43)

of the aqueous humor samples and 2.33% (1/43) of the peripheral blood samples; further, 16.27% (7/43) of the patients had positive results in both the peripheral blood and aqueous humor samples (Table 1).

Further, among the 43 patients, the qPCR analysis showed nega-tive results in both the peripheral blood and aqueous humor samples in 19 patients (data not shown).

In the control group (n=12), all samples analyzed showed nega-tive qPCR results for T. gondii (data not shown).

DISCUSSION Blindness and visual impairment caused by infectious uveitis can

be prevented at least partially by early identification of the pathogen and the subsequent administration of appropriate treatment(18). The

use of real-time PCR as a diagnostic tool for infectious uveitis has been demonstrated by many groups(11,19-21).

In this study, qPCR identified T. gondii infection in 37.21% of the aqueous humor samples, confirming the clinical hypothesis of toxoplasmic active focal necrotizing retinochoroiditis. A previous study reported that aqueous PCR analyses are useful in AIDS patients with ocular toxoplasmosis (sensitivity of 75%)(19) and demonstrated that the aqueous humor is the best source for identifying T. gondii infection. Another study also detected T. gondii DNA (38%) by PCR in aqueous humor samples(16).

PCR has been found to detect T. gondii DNA more effectively in aqueous humor (25%) than in peripheral blood (5%) samples(22). Recently, a study demonstrated that the sensitivity for blood was poor (4.1%) compared with that for ocular samples (35.9%)(23). These findings corroborate our results, which showed that the ability of PCR to detect T. gondii DNA was more sensitive in aqueous humor (37.21%) than in peripheral blood samples (2.33%). Positive results in the peripheral blood were found in only one patient (2.3%), while positive results were found in both peripheral blood and aqueous humor samples in 16.27% of the patients. This finding confirms that qPCR can identify parasites circulating in the peripheral blood of pa-tients. T. gondii has been found in the blood of acutely and chronically infected patients with ocular toxoplasmosis(24).

CONCLUSIONqPCR is a useful tool for detecting T. gondii DNA in patients with

toxoplasmic active focal necrotizing retinochoroiditis and may help in the establishment of appropriate treatment, with the exception of noninfectious uveitis or infectious uveitis caused by other pathogens.

REFERENCES 1. Cordeiro CA, Moreira PR, Dutra WO, Young L, Campos WR, Oréfice F, et al. Imunologia

da retinocoroidite toxoplásmica. Arq Bras Oftalmol. 2010;73(6):548-51. Comment in: Arq Bras Oftalmol. 2011;74(3):227.

2. de-la-Torre A, Sauer A, Pfaff AW, Bourcier T, Brunet J, Speeg-Schatz C, et al. Severe South American ocular toxoplasmosis is associated with decreased Ifn-γ/Il-17a and increased Il-6/Il-13 intraocular levels. PLoS Negl Trop Dis. 2013;7(11):e2541.

3. Garcia JL, Navarro IT, Ogawa L, de Oliveira RC, de Faria Garcia SM, Leite J. Soroepide-miologia da toxoplasmose e avaliação ocular pela Tela de Amsler, em pacientes da zona rural, atendidos na unidade de saúde do município de Jaguapitã, PR, Brasil. Rev Soc Bras de Med Trop. 1999;32(6):671-6.

4. Kompalic-Cristo A, Britto C, Fernandes O. Diagnóstico molecular da toxoplasmose: revisão. J Bras Patol Med Lab. 2005;41(4):229-35.

5. Khan A, Jordan C, Muccioli C, Vallochi AL, Rizzo LV, Belfort Jr R, et al. Genetic divergen-ce of Toxoplasma gondii strains associated with ocular toxoplasmosis. Brazil. Emerg Infect Dis. 2006;12(6):942-9.

6. Silveira C, Belfort Jr R, Muccioli C, Abreu MT, Martins MC, Victoria C, et al. A Follow-up study of Toxoplasma gondii infection in Southern Brazil. Am J Ophthalmol. 2001; 131(3):351-4.

7. Park YH, Nam HW. Clinical features and treatment of ocular toxoplasmosis. Korean J Parasitol. 2013;51(4):393-9.

8. Cantos GA, Prando MD, Siqueira MV, Teixeira RM. Toxoplasmose: ocorrência de anti-corpos antitoxoplasma gondii e diagnóstico. Rev Assoc Med Bras. 2000;46(4):335-41.

9. Bou G, Figueroa MS, Martí-Belda P, Navas E, Guerrero A. Value of PCR for detection of toxoplasma gondii in aqueous humor and blood samples from immunocompetent patients with ocular toxoplasmosis. J Clin Microbiol. 1999;37(11):3465-8.

10. Costa JG, Carneiro AC, Tavares AT, Andrade GM, Vasconcelos-Santos DV, Januário JN, et al. Real-time PCR as a prognostic tool for human congenital toxoplasmosis. J Clin Microbiol. 2013;51(8):2766-8.

11. Santos FF, Commodaro AG, Souza AV, Pinho JR, Sitnik R, Garcia C, et al. Real-time PCR in infectious uveitis as an alternative diagnosis. Arq Bras Oftalmol. 2011;74(4):258-61.

12. Novais EA, Commodaro AG, Santos F, Muccioli C, Maia A, Nascimento H, et al. Patients with diffuse uveitis and inactive toxoplasmic retinitis lesions test PCR positive for Toxoplasma gondii in their vitreous and blood. Br J Ophthalmol. 2014;98(7):937-40.

13. Aouizerate F, Cazenave J, Poirier L, Verin P, Cheyrou A, Begueret J, et al. Detection of Toxoplasma gondii in aqueous humour by the polymerase chain reaction. Br J Ophthalmol. 1993;77(2):107- 9.

14. Danise A, Cinque P, Vergani S, Candino M, Racca S, De Bona A, et al. Use of polymerase chain reaction assays of aqueous humor in the differential diagnosis of retinitis in pa-tients infected with human immunodeficiency vírus. Clin Infec Dis. 1997;24(6):1100-6.

Table 1. Real-time quantitative polymerase chain reaction (qPCR) posi-tivity of Toxoplasma gondii DNA in the peripheral blood and aqueous humor samples of patients with toxoplasmic active focal necrotizing retinochoroiditis.

Real-time PCR

Peripheral blood

Aqueous humor

Both peripheral blood and aqueous humor

No of positive/total 1/43 16/43 7/43

% 2.33 37.21 16.27

Detection of toxoplasma gondii DNA in peripheral blood and aqueous humor of patients with toxoplasmic active focal necrotizing retinochoroiditis using real-time PCR


15. Hierl T, Reischl U, Lang P, Hebart H, Stark M, Kyme P, et al. Preliminary evaluation of one conventional nested and two real time PCR assays for the detection of Toxoplasma gondii in immunocompromised patients. J Med Microbiol. 2004;53(Pt 7):629-32.

16. Fekkar A, Bodaghi B, Touafek F, Le Hoang P, Mazier D, Paris L. Comparison of immu-noblotting, calculation of the goldmann-witmer coefficient, and real-time PCR using aqueous humor samples for diagnosis of ocular toxoplasmosis. J Clin Microbiol. 2008; 46(6):1965-7.

17. Bispo PJ, de Melo GB, Hofling-Lima AL, Pignatari AC. Detection and gram discrimina-tion of bacterial pathogens from aqueous and vitreous humor using real-time PCR assays. Invest Ophthalmol Vis Sci. 2011;52(2):873-81.

18. London NJ, Rathinam SR, Cunningham ET Jr. The epidemiology of uveitis in develo-ping countries. Int Clin Ophthalmol. 2010;50(2):1-17.

19. Matos K, Muccioli C, Belfort Jr. R, Rizzo LV. Correlation between clinical diagnosis and PCR analysis of serum, aqueous, and vitreous samples in patients with inflammatory eye disease. Arq Bras Oftalmol. 2007;70(1):109-14.

20. Oahalou A, Schellekens PA, de Groot-Mijnes JD, Rothova A. Diagnostic pars plana vitrectomy and aqueous analyses in patients with uveitis of unknown cause. Retina. 2014;34(1):108-14.

21. Sugita S, Ogawa M, Shimizu N, Morio T, Ohguro N, Nakai K, et al. Use of a comprehen-sive polymerase chain reaction system for diagnosis of ocular infectious diseases. Ophthalmology. 2013;120(9):1761-8.

22. Lee SE, Hong SH, Lee SH, Jeong YI, Lim SJ, Kwon OW, et al. Detection of ocular Toxo-plasma gondii infection in chronic irregular recurrent uveitis by PCR. Korean J Parasitol. 2012;50(3):229-31.

23. Bourdin C, Busse A, Kouamou E, Touafek F, Bodaghi B, Le Hoang P, et al. PCR-based detection of Toxoplasma gondii DNA in blood and ocular samples for diagnosis of ocular toxoplasmosis. J Clin Microbiol. 2014;52(11):3987-91.

24. Silveira C, Vallochi AL, Rodrigues da Silva L, Muccioli C, Holland GN, Nussenblatt RB, et al. Toxoplasma gondii in the peripheral blood of patients with acute and chronic toxoplasmosis. Br J Opththalmol. 2011;95(3):396-400.

Original Article


INTRODUCTIONTonometry is fundamental to routine ophthalmological eva-

luation, and Goldmann applanation tonometry (GAT) is the gold standard method. Several devices, including the Perkins tonometer, Tono-Pen, Pascal tonometer (dynamic contour), and non-contact to-nometer, can provide reliable values in adults(1-4). However, in general practice, intraocular pressure (IOP) measurement can be difficult in children due to a lack of cooperation.

ABSTRACTPurpose: High intraocular pressure (IOP) is an important risk factor for a variety of pediatric ophthalmic conditions. The purpose of this study is to evaluate the feasibility, length of examination, and corneal epithelial damage induced by rebound tonometry (RBT) versus Goldmann applanation tonometry (GAT) in school children.Methods: Healthy children (n=57) participated in a randomized, transversal study with IOP measurement by GAT followed by RBT (study arm 1) or RBT followed by GAT (study arm 2). The number of attempts to acquire a reliable IOP measurement and the length of the examination were quantified. Corneal epithelial damage induced by tonometry was evaluated. Bland-Altman analysis was performed to establish the level of agreement between the two techniques. Results: The IOP was measured in all children with at least one of the devices. In both study arms, more children failed to be examined with GAT than with RBT (26% vs. 4%, and 16% vs. 6%, p<0.001, in study arm 1 and 2, respectively). The length of examination was shorter for RBT than for GAT (67.81 s ± 35.20 s vs. 126.70 s ± 56.60 s; p<0.0001); IOP measurements with RBT in both study arms were higher than those with GAT (15.20 ± 2.74 mmHg vs. 13.25 ± 2.47 mmHg, p=0.0247 and 16.76 ± 3.99 mmHg vs. 13.92 ± 2.08 mmHg, p=0.003, respectively). No difference was observed between RBT and GAT regarding the corneal epi-thelial damage caused by tonometry. Conclusion: IOP measurement is feasible in a greater number of children with RBT, and the examination was faster than that for GAT. Compared with GAT, RBT tended to overestimate the IOP. None of the methods induced marked corneal epithelial defects.

Keywords: Glaucoma/diagnosis; Tonometry, ocular; Ocular hypertension; Intraocu-lar pressure; Rebound effect; Visual acuity

RESUMOObjetivo: A pressão intraocular (PIO) elevada é um importante fator de risco presente em diversas patologias que acometem crianças. O objetivo deste estudo é avaliar a viabilidade, a duração do exame e o dano epitelial corneano induzido pela tonometria de rebote (RBT ) versus a tonometria de aplanação de Goldmann (GAT ) em crianças em idade escolar. Métodos: Crianças sem comorbidades (n=57) participaram de um estudo ran do-miza do e transversal com medidas da pressão intraocular com GAT seguido de RBT (sequência 1) ou RBT seguido de GAT (sequência 2). O número de tentativas para adqui rir uma medição confiável da pressão intraocular e a duração de exame foi quantificado. Danos epiteliais induzidos pela tonometria foram avaliados. Análise de Bland-Altman foi realizada para estabelecer a concordância entre as duas técnicas. Resultados: A pressão intraocular foi medida em todas as crianças com pelo menos com um dos dispositivos. Em ambas as sequências do estudo, mais crianças não permitiram o exame com GAT (26% vs. 4% e 16% vs. 6%, p<0,001). A duração exame com RBT foi menor (67,81 ± 35,20 s vs. 126,70 ± 56,60 s; p<0,0001). As medições de pressão intraocular com este tonômetro em ambas as sequências do estudo foram mais elevadas do que as medidas adquiridas com GAT (15,20 ± 2,74 mmHg vs 13,25 ± 2,47 mmHg, p=0,0247 e 16,76 ± 3,99 mmHg vs. 13,92 ± 2,08 mmHg; p=0,003, respec-tivamente). Não foi observada diferença quanto à lesão epitelial corneana induzida pela tonometria com RBT e GAT. Conclusão: A medição da pressão intraocular foi possível em um maior número de crianças com a tonometria de rebote, além de ser um exame mais rápido do que GAT. A pressão intraocular foi superestimada com RBT em comparação com GAT. Nenhum dos métodos induziu defeito epitelial corneano significativo.

Descritores: Glaucoma/diagnóstico; Tonometria ocular; Hipertensão ocular; Pressão intraocular; Efeito rebote; Acuidade visual

Several conditions, such as childhood glaucoma, uveitis, and ocular trauma, can present elevated ocular pressure. When a routine IOP measurement is not possible, the procedure is often conducted under general anesthesia. However, general anesthesia is associated with a number of complications. Studies have revealed increased mortality associated with IOP measurement under general anesthesia in children compared with that in adults; the procedure may also be associated with long-term adverse neurodevelopmental effects(5-7).

Rebound tonometry versus Goldmann tonometry in school children: feasibility and agreement of intraocular pressure measurementsTonometria de rebote versus tonometria de Goldmann em crianças em idade escolar: viabilidade e concordância entre as medidas da pressão intraocular

bruno lEonardo barranco EsPorcattE1, Flávio siquEira santos loPEs1, caMila FonsEca nEtto1, vEsPasiano rEbouças-santos1, diEgo torrEs dias1, Fábio iglEsias MaruJo1, christianE roliM-dE-Moura1

Submitted for publication: May 29, 2015 Accepted publication: October 1, 2015

1. Department of Ophthalmology, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.

Funding: This study was supported by coordenação de aperfeiçoamento de pessoal de nível superior (CAPES).


Corresponding author: Bruno Leonardo Barranco Esporcatte. Rua Botucatu, 821 - Vila Clementino São Paulo, SP - 04023-062 - Brazil - Email: [email protected]

Approved by the following research ethics committee: Federal University of São Paulo Ethics committee. Project number: CAAE: 15172413.4.0000.5505.

Rebound tonometry versus Goldmann tonometry in school children: feasibility and agreement of intraocular pressure measurements


The Icare™ tonometer (Icare, Helsinki, Finland) is a portable tono-meter that does not require topical anesthetics and causes minimal discomfort during examination(8). This device is based on the impact and rebound of a probe against the cornea(9). Previous studies have demonstrated a strong agreement between IOP measurements obtained by rebound tonometry (RBT) and GAT. Moreover, the va-riables that influence reliable measurement are the same for both devices(10,11).

By providing greater comfort during IOP measurement, the Icare tonometer is generally well tolerated by children. Sahin et al. eva-luated the levels of discomfort during IOP examination in school children, with 93.4% reporting no discomfort and 6.6% reporting slight discomfort(12). Flemmons et al. reported that it was possible to acquire a reliable IOP measurement on the first attempt in over 93% of the examined children(13).

The purpose of the present study was to evaluate and compare the feasibility, length of the examination, and corneal epithelial da-mage induced by tonometry with RBT versus GAT in school children. The level of agreement between the two methods and the corre-lation between IOP and the central corneal thickness (CCT) were analyzed.

METHODSThis protocol was approved by the Ethical Committee of the Fe-

deral University of São Paulo and was performed in accordance with the ethical standards laid down in the Declaration of Helsinki and the International Conference on Harmonisation Guidelines for Good Clinical Practice(14). Informed parental consent was obtained for all of the enrolled participants before the study.

Healthy children aged between 6 and 8 years were recruited through a general ophthalmological office after refractive error screening. Exclusion criteria included logMAR vision worse than 0.7, a history of ocular disease, medication use, and corneal epithelial defects. All children underwent slit-lamp examination, and those found to have corneal pathology were excluded.

The subjects were randomly selected using a sequentially num-bered, opaque sealed-envelope technique(15) to undergo IOP mea-surement by GAT followed by RBT (study arm 1) or RBT followed by GAT (study arm 2). Tonometric examination with the second device was performed 5 min following the end of the first examination. All of the IOP measurements were conducted by glaucoma specialists with pediatric care experience, and all of the tonometric evaluations and corneal status assessments were performed by three masked examiners in three different offices.

Anesthesia was not required for IOP measurement with RBT. The subjects were instructed to look straight ahead, and the instrument was positioned with the tip of the probe at a distance of 4 mm to 8 mm from the corneal apex. For RBT, when the operator activates the tonometer, six measurements are automatically performed, and the mean value is calculated. After topical administration of anes-thesia and fluorescein eye drops, GAT measurement was performed using a slit lamp. The length of time taken for each examination was quantified with a chronometer and included the time taken for administering the drops, explaining the examination procedure, and performing the measurements. The number of attempts with each tonometric method was recorded, with a maximum of three attempts allowed to measure IOP in each eye for each tonometer. Only RBT readings with a high level of reliability were used. After the third attempt, if the subject did not allow the examination to be performed, the test was considered to be unsuccessful. The right eye was measured first for both tonometers in all subjects.

Corneal epithelial damage was assessed after the first tonometric method (RBT or GAT) of IOP measurement using biomicroscopic exa-mination of the type and extent of staining. When RBT was performed first, the examiner instilled anesthetic and fluorescein drops after the

measurement to mask the second examiner for the assessment of the corneal status of the eye. The corneal surface was divided into five zones of equal area (central, nasal, superior, inferior, and temporal). The type of staining in each zone was classified as absent, micro-punctate, macropunctate, coalescent macropunctate, or patch. The extent of staining in each zone was graded 0 (absent), 1 (1%-15% of the surface), 2 (16%-30% of the surface), 3 (31%-45% of the surface), or 4 (≥46% of the surface).

The CCT was determined using a central ultrasonic pachymeter (Alcon Laboratories Inc., Fort Worth, TX, USA). Under topical anesthe-sia, the seated patient was asked to look at a distant target ahead. The pachymeter probe was aligned perpendicularly and central to the pupil; the mean of five measurements was calculated.

All statistical analyses were performed using GraphPad Prism version 6.00 for Mac (GraphPad Software, La Jolla, CA, USA). Pooling of data from the right and left eyes during statistical analysis may cause bias as they are not independent variables; therefore, to avoid such bias, only data from the right eyes were analyzed. Moreover, a Bland-Altman analysis was performed to examine the level of agreement between the two devices. The differences between the category frequencies were evaluated by chi-square tests, and paired analysis of nonparametric measures was performed using the Wil-coxon matched-pairs signed-rank test. Student’s t-tests were used to analyze data with a normal distribution. Correlations between variables were evaluated by Pearson’s correlation coefficients. The level of statistical significance was set at p<0.05.

RESULTSIn the present study, 36 (63.2%) out of 57 patients were male

and 21 (36.8%) were female. The mean age of the children was 6.76 ± 0.38 years, and the mean uncorrected visual acuity was 0.85 ± 0.11 logMAR.

To achieve a reliable measurement, more attempts were made with GAT than RBT (1.54 ± 0.69 vs. 1.13 ± 0.34, p=0.0021) in both study arms. All children permitted IOP measurements with at least one tonometer. More children did not allow the examination to be performed with GAT than with RBT in both study arms (study arm 1: 26%, n=7 vs. 4%, n=1, p<0.001; study arm 2: 16%, n=5 vs. 6%, n=2, p<0.001; chi-square test). Examination with RBT was faster than that with GAT (67.81 s ± 35.20 s vs. 126.70 s ± 56.60 s, p<0.0001).

IOP measurements quantified with RBT were statistically diffe-rent from those quantified with GAT in both study arms 1 (15.20 ± 2.74 mmHg vs. 13.25 ± 2.47 mmHg, p=0.0247) and 2 (16.76 ± 3.98 mmHg vs. 13.92 ± 2.08 mmHg; p=0.0003; Table 1). Figure 1 shows the Bland-Altman plots of IOP and the linear regression of these values. A positive correlation between the difference and the mean IOP measurements was observed in study arm 2 (r=0.6347, p=0.0007; Figure 1 B). No statistically significant difference was obser-ved in the degrees of bias in study arms 1 and 2 (1.95 ± 3.58 mmHg vs. 2.84 ± 3.37 mmHg, respectively).

Table 1. Intraocular pressure as measured by GAT and RBT

Method Mean* SD Minimum Median Maximum

Study arm 1 (n=20)

GAT 13.25 2.47 10 14 19

RBT 15.20 2.74 11 15 21

Study arm 2 (n=25)

GAT 13.92 2.08 10 14 17

RBT 16.76 3.98 09 18 24

RBT= rebound tonometry; GAT= Goldmann applanation tonometry; SD= standard deviation.*All recorded values of intraocular pressure are presented in mmHg.The difference between GAT and RBT was statistically significant (p<0.05; paired t-test) in both study arms.

Esporcatte BLB, et al.


The mean CCT was 558 ± 36 μm, and a positive correlation was found between CCT and IOP for GAT (r=0.3163, p=0.0388) and RBT (r=0.3080, p=0.0445; Figure 2).

The frequency of corneal epithelial damage induced by RBT and GAT was similar (13% vs. 11%; chi-square test), and the most common type of staining was micropunctate on less than 16% of the corneal surface (grade 1). Only one patient who underwent RBT examination presented staining of 16% to 30% of the surface (grade 2), and this was located in the inferior corneal zone.

DISCUSSIONIn clinical practice, IOP measurement is often impaired by a lack

of cooperation by school children. The present study revealed good tolerance for RBT, with only <6% of the examined children refusing the tonometry. Moreover, the examination was less time consuming, and the number of attempts required was fewer than that with GAT. RBT was better tolerated as it can be performed without adminis-tering anesthesia. Due to the reduction of discomfort, tonometric examination could be successfully performed in more children. The impact of the tonometer tip is extremely gentle in RBT, and frequently does not provoke an eye-blinking reflex(9).

Although IOP measurements with RBT were statistically signifi-cantly higher than those with GAT, this difference was not clinically relevant. Several authors have reported a good level of agreement between the two tonometers, with RBT generally overestimating IOP by around 3 mmHg(16-18). The difference between the acquired values by the two tested tonometers was higher for high mean IOP values than that for low mean IOP values. Furthermore, in accordance with previous studies, we observed positive correlations between IOP measured by both devices and CCT(19-21).

Despite a small number of children being uncooperative during IOP measurements, neither of the tonometers produced marked cor-neal epithelial defects. This may be because ophthalmologists that conducted the examinations were experienced in pediatric care.

The small number of children enrolled limited our study. As only healthy children were evaluated, these results may not be applicable to patients with childhood glaucoma or other ophthalmic diseases. Further, the corneal applanation induced by GAT may have influenced IOP measurements when RBT was performed second (study arm 1). However, only the influence of corneal thickness was evaluated in the present study.

CONCLUSIONIOP was successfully measured in all children with at least one of

the tonometers. RBT was better tolerated and was faster than GAT examination. RBT did not induce epithelial lesions, although it overes-timated IOP by around 3 mmHg. However, we do not believe this to be a clinically relevant disadvantage of RBT. In routine clinical settings, GAT remains the gold standard for the measurement of IOP; however, RBT may be a useful screening tool for non-cooperative patients, such as school children, and may allow avoidance of the use of general anesthesia for IOP measurement. High RBT measurements should be corroborated by assessment of the clinical presentation, and IOP should be measured by other tonometric methods.

REFERENCES 1. Bradfield YS, Kaminski BM, Repka MX, Melia M; Pediaric Eye Disease Investigator Group,

et al. Comparison of Tono-Pen and Goldmann applanation tonometers for measure-ment of intraocular pressure in healthy children. J AAPOS. 2012;16(3):242-8.

2. Cook JA, Botello AP, Elders A, Fathi Ali A, Azuara-Blanco A, Fraser C, McCormack K, Margaret Burr J; Surveillance of Ocular Hypertension Study Group. Systematic review of the agreement of tonometers with Goldmann applanation tonometry. Ophthal-mology. 2012;119(8):1552-7.

3. Okafor KC, Brandt JD. Measuring intraocular pressure. Curr Opin Ophthalmol. 2015; 26(2):103-9.

Figure 2. Correlations between central corneal thickness (CCT) and intraocular pressure (IOP) acquired with Goldmann applanation tonometry (GAT) and rebound tonometry (RBT). Positive correlations were observed with GAT (r=0.3163, p=0.0388) and RBT (r=0.3080, p=0.0445).

Figure 1. Bland-Altman analyses of IOP measurements between rebound tonometry (RBT) and Goldmann applanation tonometry (GAT) in study arms 1 (A) and 2 (B). The mean bias (solid line) and 95% limits of agreement (dashed lines) are shown. In study arm 1 (A), the mean bias was 1.95 ± 3.58, and the correlation between the differences and the mean values was not significant (r=0.1062, p=0.6558). In study arm 2 (B), the mean bias was 2.84 ± 3.37, and a positive correlation was observed between the differences and the mean values (r=0.6347, p=0.0007).

A

B

Rebound tonometry versus Goldmann tonometry in school children: feasibility and agreement of intraocular pressure measurements


4. Vincent SJ, Vincent RA, Shields D, Lee GA. Comparison of intraocular pressure mea-surement between rebound, non-contact and Goldmann applanation tonometry in treated glaucoma patients. Clin Experiment Ophthalmol. 2012;40(4):e163-70.

5. Chang TC, Cavuoto KM. Anesthesia considerations in pediatric glaucoma manage-ment. Curr Opin Ophthalmol. 2014;25(2):118-21.

6. DiMaggio C, Sun LS, Ing C, Li G. Pediatric anesthesia and neurodevelopmental im-pairments: a Bayesian meta-analysis. J Neurosurg Anesthesiol. 2012;24(4):376-81.

7. Gonzalez LP, Pignaton W, Kusano PS, Módolo NS, Braz JR, Braz LG. Anesthesia-related mortality in pediatric patients: a systematic review. Clinics (Sao Paulo). 2012;67(4):381-7. Comment in: Clinics (São Paulo). 2012;67(6):675-6.

8. Grigorian F, Grigorian AP, Olitsky SE. The use of the iCare tonometer reduced the need for anesthesia to measure intraocular pressure in children. J AAPOS. 2012;16(6):508-10.

9. Kontiola AI. A new induction-based impact method for measuring intraocular pressure. Acta Ophthalmol Scand. 2000;78(2):142-5.

10. Davies LN, Bartlett H, Mallen EA, Wolffsohn JS. Clinical evaluation of rebound tono-meter. Acta Ophthalmol Scand. 2006;84(2):206-9.

11. Munkwitz S, Elkarmouty A, Hoffmann EM, et al. Comparison of the iCare rebound tonometer and the Goldmann applanation tonometer over a wide IOP range. Graefes Arch Clin Exp Ophthalmol. 2008;246(6):875-9.

12. Sahin A, Basmak H, Niyaz L, Yildirim N. Reproducibility and tolerability of the ICare rebound tonometer in school children. J Glaucoma. 2007;16(2):185-8.

13. Flemmons MS, Hsiao YC, Dzau J, Asrani S, Jones S, Freedman SF. Icare rebound tono-metry in children with known and suspected glaucoma. J AAPOS. 2011;15(2):153-7.

14. International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use. ICH harmonized tripartite guideline: Guideline for Good Clinical Practice. J Postgrad Med. 2001;47(1):45-50.

15. Doig GS, Simpson F. Randomization and allocation concealment: a practical guide for researchers. J Crit Care. 2005;20(2):187-91; discussion 91-3.

16. Beasley IG, Laughton DS, Coldrick BJ, Drew TE, Sallah M, Davies LN. Does rebound to-nometry probe misalignment modify intraocular pressure measurements in human eyes? J Ophthalmol. 2013;2013:791084.

17. Rehnman JB, Martin L. Comparison of rebound and applanation tonometry in the management of patients treated for glaucoma or ocular hypertension. Ophthalmic Physiol Opt. 2008;28(4):382-6.

18. Suman S, Agrawal A, Pal VK, Pratap VB. Rebound tonometer: ideal tonometer for measurement of accurate intraocular pressure. J Glaucoma. 2014;23(9):633-7.

19. Nakamura M, Darhad U, Tatsumi Y, Fujioka M, Kusuhara A, Maeda H, et al. Agreement of rebound tonometer in measuring intraocular pressure with three types of applana-tion tonometers. Am J Ophthalmol. 2006;142(2):332-4.

20. Rao A, Kumar M, Prakash B, Varshney G. Relationship of central corneal thickness and intraocular pressure by iCare rebound tonometer. J Glaucoma. 2014;23(6):380-4.

21. Salim S, Du H, Wan J. Comparison of intraocular pressure measurements and assessment of intraobserver and interobserver reproducibility with the portable ICare rebound tonometer and Goldmann applanation tonometer in glaucoma patients. J Glaucoma. 2013;22(4):325-9.

39o Simpósio Internacional Moacyr Álvaro - SIMASP - Oftalmologia Regenerativa

25 a 27 de fevereiro de 2016Maksoud Plaza Hotel

São Paulo - SP

informações:Site: simasp.com.br/2016/

Original Article


INTRODUCTIONRefractive surgery with excimer lasers is used worldwide for the

treatment of myopia, hyperopia, astigmatism, corneal scar, and other diseases(1-3). Postoperative corneal hypoesthesia has been reported as a consequence of refractive surgery. The photorefractive keratec-tomy (PRK) technique, despite being considered a safe procedure, has been reported as associated with marked reduction in corneal sensitivity(4-8).

The cornea is one of the regions of the human body that has the highest amount of naked nerve endings and, therefore, has a high level of pain sensitivity. The sensory innervation of the cornea is essential in maintaining corneal integrity(9,10). The touch sensitivity threshold of the cornea, particularly in the center, is rather low. Loss or reduction of normal corneal sensitivity may compromise reactions to flash, delay epithelial healing, reduce tear flow, and predispose to the development of neurotrophic keratitis, sterile corneal necrosis, and infectious keratitis(11,12).

The PRK procedure consists of removing the corneal epithelial layer with its basement membrane followed by excimer laser photo-disruption of Bowman’s layer and the anterior portion of the corneal stroma resulting in impairment of nerve endings in the nerve plexus of the subepithelial and anterior stromal(13,14).

The Cochet-Bonnet esthesiometer is an established tool for de ter-mining corneal sensitivity by evaluating the corneal touch threshold (CTT). This instrument contains an adjustable nylon filament with a defined diameter, which is applied in different lengths to the cornea in five prescribed regions. The length of the nylon filament estimates the applied pressure on the corneal surface. The shorter the filament, the more pressure is applied to the cornea and vice versa. The CTT is reached as soon as a blink reflex is consistently elicited with the same pressure or length of filament. Estimation of corneal sensitivity may be necessary for the diagnosis and monitoring of eye diseases or the evaluation of corneal healing following surgery(15).

Analysis of corneal esthesia in patients undergoing photorefractive keratectomyAnálise da estesia corneal em pacientes submetidos à ceratectomia fotorrefrativa

ElMar torrEs nEto1,2, lucas MarcEl aMaral silva1, giovana arlEnE Fioravanti lui1, rachEl loPEs rodriguEs goMEs2, adaMo lui-nEtto1

ABSTRACTPurpose: To quantitatively analyze corneal esthesia in patients undergoing pho-torefractive keratectomy (PRK) surgery. Methods: Forty-five patients selected for PRK in one eye underwent corneal esthesia using a Cochet-Bonnet esthesiometer preoperatively and 30 and 90 days postoperatively. Patients with a refractive diopter error of 4 or greater received intraoperative 0.02% mitomycin C for 20 s. Results: Twenty-four (53.3%) of the 45 eyes received intraoperative 0.02% mi-tomycin. Decreased sensitivity was observed on postoperative day 30. By posto-perative day 90, corneal esthesia had normalized but remained 14.9% lower than preoperative levels. In the mitomycin group, no recovery of corneal esthesia to normal sensitivity levels was observed. The mean esthesiometer level was 39.2 mm on postoperative day 90 (P<0.001). Conclusions: The results of the present study demonstrate recovery of corneal esthesia to normal levels at 90 days postoperatively in patients who did not receive mitomycin C. In patients administered mitomycin C, a 23.59% reduction in the corneal touch threshold was observed compared with preoperative levels indicating a failure of recovery to normal levels.

Keywords: Mitomycin; Cornea; Photorefractive keratectomy; Myopia; Prospective studies

RESUMOObjetivo: Análise quantitativa da estesia corneal em pacientes submetidos à cirurgia refrativa (PRK). Métodos: Estudo prospectivo, longitudinal e intervencionista, analisando 45 olhos com estesiômetro de Cochet Bonnet no período pré-operatório, no 30o dia após a cirurgia e no 90o dia após cirurgia refrativa. Os pacientes com erro refracional maior ou igual a 4 dioptrias, foram submetidos ao uso de mitomicina 0,02%, por período de 20 segundos no intraoperatório. Resultados: Observou-se diminuição da sensibilidade corneal no 30o dia em todos os olhos, retornando a níveis próximo ao normal no 90o dia, apresentando redução média final de 14,9%. Mitomicina C foi utilizada em 24 (53,3%) dos 45 olhos examinados. No grupo que recebeu mitomicina C, não houve recuperação da estesia normal (média de 39,2 mm) (p<0,001), após 90 dias de cirurgia. Conclusão: Com base nos resultados obtidos, verificamos que ocorreu recuperação da estesia corneal próximo ao normal 90 dias após a cirurgia, porém inferior aos valores iniciais, no grupo sem o uso de mitomicina C intraoperatória. No entanto, no grupo submetido ao uso de mitomicina, não houve a recuperação da sensibilidade corneal a níveis normais, mesmo após o período de 90 dias.

Descritores: Mitomicina; Córnea; Ceratectomia fotorrefrativa; Miopia; Estudos pros-pectivos

Submitted for publication: May 7, 2015 Accepted for publication: October 20, 20151 Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil.2 Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, SP, Brasil.



Corresponding author: Elmar Torres Neto. Universidade Federal de São Paulo. Departamento de Oftalmologia, Secretaria Administrativa. Rua Botucatu, 821, 1o andar, São Paulo, SP - 04023-062 Brazil - E-mail: [email protected]

Approved by the following research ethics committee: Irmandade da Santa Casa de Misericórdia de São Paulo; protocolo 261728.

Analysis of corneal esthesia in patients undergoing photorefractive keratectomy


The present study aimed to evaluate preoperative and postope-rative corneal sensitivity following PRK surgery with and without intraoperative use of mitomycin C.

METHODSWe performed a prospective, longitudinal, interventional study.

Pa tients were enrolled between December 2013 and January 2014, with all surgeries performed on April 3, 2014. Patients were advised to discontinue the use of contact lenses 2 weeks prior to surgery.

Individuals over 21 with stable ametropia (considered stable when no variation >0.25 D in static refraction is observed within 1 year), a spherical equivalent between -1.50 and -8.00 D, and a cylindrical com-ponent of <2.00 D with normal corneal topography were enrolled in the present study. Patients unavailable for control visits or with pre-vious eye surgery, corneal thickness <500 µm, systemic diseases (i.e., collagenosis, uncontrolled diabetes, and immunodeficiency), or eye diseases that could affect surgical outcomes were excluded from the present study.

All tests were performed 1 week prior to surgery (Pre), on posto-perative day 30 (30 post), and postoperative day 90 (90 post). Corneal sensitivity was measured in the central region using a Cochet-Bonnet esthesiometer(9). The esthesiometer filament was applied perpendi-cularly to the pressing surface of the cornea obtained by bending a small portion (approximately 5%) of its length. The procedure was repeated with a gradual reduction in the length of wire in 5-mm increments. Patients reported perception of the test at every touch of the filament. To confirm patient responses, the central area of the cornea was tested three times with a minimum interval of 60 s. The greatest length of the wire that elicited a response to the stimulus was recorded in millimeters and considered the CTT of the corneal central area(15). Normal values for corneal sensitivity evaluated by Cochet-Bonnet esthesiometry are >40 mm in the central region of the cornea. All tests were conducted in the same environment in a closed room.

Pattern delineation and mechanical scarification (spatula) of the cornea was performed followed by photoablation using an EC5000®

excimer laser (Nidek Inc. Fremont, California) targeting a 6.5-mm abla-tion zone. Patients with a greater refractive error of 4 D were intrao-peratively administered 0.02% mitomycin C for 20 s with subsequent washing with balanced saline solution. A bandage contact lens was maintained for 7 days in all patients. Standard prescription eye drops included tobramycin 0.3% and dexamethasone 0.1% (Tobradex®, Alcon Laboratories, Inc. Fort Worth, TX) instilled as one drop every 4 h for 7 days and ketorolac tromethamine eye drops (Acular®, Alcon Laboratories, Inc. Fort Worth, TX) instilled every 6 h for 40 days.

Statistical analyses were initially performed in a descriptive manner by calculating a number of summary measures including mean, median, minimum and maximum values, standard deviation, absolute and relative frequencies (percentage), and individual gra-phic profiles (lines). The inferential analyses performed to confirm or

refute findings of descriptive analyses were: analysis of variance in blocks with two random factors (patient and side effect) compared with central corneal sensitivity (mm) at varying study time points (preoperatively, and 30 and 90 days postoperatively) adjusted for mitomycin use and gender. Comparisons were performed using the Tukey method (Neter et al., 1996) when necessary(16). A significance level α=5% was set for all inferential analyses. Data were entered into Excel 2010 spreadsheets for Windows for proper storage of information. Statistical analyses were performed using the statistical program, R, version 2.15.2.

RESULTSThe selected sample in the present study consisted of 45 patients

comprising 23 (52.2%) women and 22 (47.8%) men. The mean age was 31.8 ± 7.4 years, ranging from 21 to 46 years. Mitomycin C was administered to 24 eyes (53.3%).

The following CTT values for the sensitivity in the central region of the cornea were obtained: 51.1 ± 7.4 in the preoperative period; 26.7 ± 9.3 at 30 days postoperatively; and 43.2 ± 8.3 at 90 days posto-peratively. A statistically significant difference in CTT values was observed between the three study time points (P<0.001; Table 1; Figure 1). The inferential results confirmed the results of descriptive analyses, with no significant differences in quantitatively measured sensitivity observed between the three study time points (Table 2). Sensitivity values in the central region >40 mm were considered nor-mal, with 25 (55.6%) of 45 eyes found to have normal sensitivity on postoperative day 90.

Decreased sensitivity in the central region between the preope-rative values and postoperative day 30 was also evaluated. The reduction was estimated using the following expression:

The average reduction in central region sensitivity observed in the 45 eyes was 45.9%, ranging from 33.3% to 75.0% with a standard deviation of 23.2%. The corneal esthesia analysis performed preope-ratively and on postoperative day 90 revealed an average reduction of 14.9%, ranging from 6.7% to 41.7% with a standard deviation of 13.6%.

Mean sensitivity values in the group administered mitomycin C preoperatively and on postoperative day 90 groups were 51.3 ± 6.1 and 39.2 ± 6.7, respectively (P<0.001). In patients who did not receive intraoperative mitomycin, mean sensitivity values preoperatively and on postoperative day 90 were 51.0 ± 8.7 and 47.9 ± 7.7, respectively (P=0.021; Table 3).

DISCUSSIONIn the present study, we observed a reduction in corneal sensiti-

vity on postoperative day 30 and a recovery of sensitivity to normal values on postoperative day 90; however, corneal sensitivity did not

Table 1. Summary of central corneal sensitivity measurements (mm) over time

Central corneal sensitivity (mm)

N Mean Median Minimum Maximum Standard deviation P-value

Preoperative 45 51.1 50.0 30.0 60.0 7.4 <0.001a

30 days 45 26.7 25.0 15.0 50.0 9.3

90 days 45 43.2 45.0 30.0 60.0 8.3a= analysis of variance in blocks with two random factors.

Torres Neto E, et al.


Figure 1. Mean measures of sensitivity in the central region of the cornea (mm) from the eyes of patients with standard deviations according to study time point.

Table 2. Results of multiple comparisons by the Tukey method of quantitative evaluations of central cornea region sensitivity (mm) over time

Comparison P-value

Preoperative vs. 30 days postoperatively <0.001

Preoperative vs. 90 days postoperatively <0.001

30 days postoperatively vs. 90 days postoperatively <0.001

Table 3. Summary of pre and 90th postoperative central cornea sensitivity (mm) measurements according mitomycin use

Central sensitivity (mm)

N Mean Median Minimum Maximum Standard deviation P-value

Mitomycin Preoperative 24 51.3 50.0 40.0 60.0 6.1 <0.001a

90 days post 24 39.2 37.5 30.0 55.0 6.7

Without mitomycin Preoperative 21 51.0 50.0 30.0 60.0 8.7 <0.021a

90 days post 21 47.9 45.0 30.0 60.0 7.7a= analysis of variance in blocks with two random factors.

fully recover to preoperative values (P<0.001). These data are consis-tent with previous literature demonstrating reduced central corneal sensitivity in the first month following PRK. Studies conducted in rabbits, which have a similar inervacional structure to the human cornea, have demonstrated the reappearance of peripheral neurites around the sixth week following PRK(17). Likewise, Pallikaris et al. observed reco-very of central corneal sensitivity to values considered normal or near normal in the third month after PRK(18).

In the mitomycin C group of the present study, no recovery of cor neal esthesia to normal values was observed ay 90 days after the procedure, with a mean value of 39.2 (P<0.001). As mitomycin was only used in patients with ablation >4 D, the lack of sensitivity recovery

during the expected period may be attributable to the greater amount of tissue removed in these patients. However, the relationship between ablation depth and decreased corneal sensitivity following photore-fractive surgery remains unclear(19). Although Chuck et al. reported that the measurement of the decreased corneal sensitivity induced by laser-assisted in situ keratomileusis (LASIK) appears to be indepen-dent of the depth of the ablation, other studies have shown that the depth of cut or ablation in PRK affects recovery of corneal sensitivity(20). Campos et al. reported patients with a preoperative myopia of -6.50 D recovered 95.7% of central corneal sensitivity after 3 months in a series of 14 eyes that underwent PRK, while patients with severe myopia (>-9.00 D) recovered 86.2% of the original cornea sensitivity to values within normal limits(21).

Péres-Santoja et al. and Matsui et al. investigated the sensitivity of the central cornea in similar patients groups but without the adminis-tration of 0.02% mitomycin C and observed a recovery of esthesia 90 days after the procedure to preoperative values(14,19). Thus, although patients administered mitomycin C in the present study had greater amounts of tissue removed (between -4.00 and -8.00 D), this amount was relatively small compared with previous comparable studies, and corneal sensitivity would still be expected to return to normal levels in these patients.

Farahi et al. compared CTT values between PRK alone and PRK with mitomycin C over a 12-month period postoperatively. The authors observed a reduction in CTT values in both groups postope-ratively, with no statistically significant difference observed between groups(22).

Corneal sensitivity can be influenced by many variables including age, iris color, hormonal changes, type of eyelid closure, and psycho-logical state. The determination of any single factor responsible for reduced sensitivity corneal in individual patients is questionable, par-ticularly in patients undergoing refractive surgery(9).

Further studies are required to evaluate late recovery of corneal sensitivity in patients administered mitomycin C and compare outcomes with patients undergoing other refractive procedures. Recovery following LASIK typically occurs at approximately 6 months postoperatively(14,23).

CONCLUSIONThe results of the present study demonstrate corneal sensitivity

following PRK recovered to normal levels at 90 days after surgery in patients who did not receive mitomycin C; however, a 6.08% reduction in corneal sensitivity was observed at this time point compared with preoperative levels.

In patients administered mitomycin C, a 23.59% reduction in CTT compared with preoperative levels was observed who did not reco-ver to normal levels by postoperative day 90.

Analysis of corneal esthesia in patients undergoing photorefractive keratectomy


REFERENCES 1. Hersh PS, Stulting RD, Steinert RF, Waring GO, 3rd, Thompson KP, O’Connell M, et al. Results

of phase III excimer laser photorefractive keratectomy for myopia. The Summit PRK Study Group. Ophthalmology. 1997;104(10):1535-53.

2. Campos M, Hertzog L, Garbus J, Lee M, McDonnell PJ. Photorefractive keratectomy for severe postkeratoplasty astigmatism. Am J Ophthalmol. 1992;114(4):429-36.

3. Vestergaard AH, Hjortdal JO, Ivarsen A, Work K, Grauslund J, Sjolie AK. Long-term outcomes of photorefractive keratectomy for low to high myopia: 13 to 19 years of follow-up. J Refract Surg. 2013;29(5):312-9.

4. Biermann H, Grabner G, Baumgartner I, Reim M. [Corneal sensibility following epikera-tophakia]. Klin Monbl Augenheilkd. 1992;201(1):18-21. German.

5. Koenig SB, Berkowitz RA, Beuerman RW, McDonald MB. Corneal sensitivity after epikeratophakia. Ophthalmology. 1983;90(10):1213-8.

6. Kohlhaas M, Bohm A, Schmitz N, Draeger J. [Measuring corneal sensitivity with the air aesthesiometer in comparison with the Draeger electromagnetic air aesthesiometer]. Ophthalmologe. 1994;91(5):685-90. German.

7. Linna TU, Vesaluoma MH, Perez-Santonja JJ, Petroll WM, Alio JL, Tervo TM. Effect of myo-pic LASIK on corneal sensitivity and morphology of subbasal nerves. Invest Ophthalmol Vis Sci. 2000;41(2):393-7.

8. Murakami Y, Manche EE. Prospective, randomized comparison of self-reported posto-perative dry eye and visual fluctuation in LASIK and photorefractive keratectomy. Ophthalmology. 2012;119(11):2220-4.

9. Martin XY, Safran AB. Corneal hypoesthesia. Surv Ophthalmol. 1988;33(1):28-40. 10. Schimmelpfennig B. Nerve structures in human central corneal epithelium. Graefe’s

archive for clinical and experimental ophthalmology = Albrecht von Graefes Arch Clin Exp Ophthalmol. 1982;218(1):14-20.

11. Beuerman RW, Schimmelpfennig B. Sensory denervation of the rabbit cornea affects epithelial properties. Experimental neurology. 1980;69(1):196-201.

12. Credie MG, Nishiwaki-Dantas MC, Felberg S, Amorim F, Dantas PE. [Quantitative chan-

ges in tear film after refractive surgery: comparative study between PRK and LASIK]. Arq Bras Oftalmol. 2007;70(1):23-30. Portuguese.

13. Kanellopoulos AJ, Pallikaris IG, Donnenfeld ED, Detorakis S, Koufala K, Perry HD. Com-parison of corneal sensation following photorefractive keratectomy and laser in situ keratomileusis. J Cataract Refract Surg. 1997;23(1):34-8.

14. Perez-Santonja JJ, Sakla HF, Cardona C, Chipont E, Alio JL. Corneal sensitivity after photorefractive keratectomy and laser in situ keratomileusis for low myopia. Am J Oph thalmol. 1999;127(5):497-504.

15. Chao C, Stapleton F, Badarudin E, Golebiowski B. Ocular surface sensitivity repeatability with Cochet-Bonnet esthesiometer. Optom Vis Sci. 2015;92(2):183-9.

16. Neter J, Wasserman W. Applied linear statistical models. 4th ed. Chicago: Irwin; 1996. 720 p. 17. Trabucchi G, Brancato R, Verdi M, Carones F, Sala C. Corneal nerve damage and rege-

neration after excimer laser photokeratectomy in rabbit eyes. Invest ophthalmology Vis Sci. 1994;35(1):229-35.

18. Pallikaris IG, Papatzanaki ME, Stathi EZ, Frenschock O, Georgiadis A. Laser in situ ke-ra tomileusis. Lasers Surg Med. 1990;10(5):463-8.

19. Matsui H, Kumano Y, Zushi I, Yamada T, Matsui T, Nishida T. Corneal sensation after correction of myopia by photorefractive keratectomy and laser in situ keratomileusis. J Cataract Refract Surg. 2001;27(3):370-3.

20. Chuck RS, Quiros PA, Perez AC, McDonnell PJ. Corneal sensation after laser in situ keratomileusis. J Cataract Refract Surg. 2000;26(3):337-9.

21. Campos M, Hertzog L, Garbus JJ, McDonnell PJ. Corneal sensitivity after photorefrac-tive keratectomy. Am J Ophthalmol. 1992;114(1):51-4.

22. Farahi A, Hashemi H, Mehravaran S. The effects of mitomycin C on tear function after photorefractive keratectomy: a contralateral comparative study. J Refract Surg. 2013; 29(4):260-4.

23. Huang JC, Sun CC, Chang CK, Ma DH, Lin YF. Effect of hinge position on corneal sen-sation and dry eye parameters after femtosecond laser-assisted LASIK. J Refract Surg. 2012;28(9):625-31.

Original Article


INTRODUCTIONUpper eyelid cicatricial entropion (UCE) is a common cause of tri-

chiasis and results from any pathological process that causes scarring of the tarsal plate and consequent inward rotation of the lid margin. In several regions of the Middle East and Africa, trachoma is the most common cause of UCE(1). In Western countries, UCE is usually due to a variety of other causes including chronic blepharitis, previous surgeries, pemphigus, chronic use of topical glaucoma medications, and anophthalmic socket contraction(2).

ABSTRACTPurpose: To describe the use of a lid crease incision for upper eyelid margin ro-tation in cicatricial entropion combining internal traction on the anterior lamella, tarsotomy, and tarsal overlap without external sutures. Methods: Surgical description: The main steps of the procedure consisted of exposure of the entire tarsal plate up to the eyelashes followed by tarsotomy through the conjunctiva. A double-armed 6.0 polyglactin suture was then passed through the distal tarsal fragment to the marginal section of the orbicularis oculi muscle. As the sutures were tied, the distal tarsus advanced over the marginal section, and traction was exerted on the marginal strip of the orbicularis muscle. There were no bolsters or external knots. The pretarsal skin-muscle flap was closed with a 6.0 plain gut suture.Results: We used this procedure at a tertiary hospital in Saudi Arabia from 2013 to 2014. Sixty upper lids of 40 patients (23 women and 17 men) were operated on, with an age range of 44-99 years [mean ± standard deviation (SD) = 70.9 ± 13.01 years]. Bilateral surgery was performed on 21 patients. Follow-up ranged from 1 to 12 months (mean 3.0 ± 2.71 months). Forty percent of the patients (24 lids) had more than 3 months’ follow-up. The postoperative lid margin position was good in all cases. Trichiasis (two lashes) was observed in only one patient with unilateral entropion on the medial aspect of the operated lid. Conclusions: The upper lid margin can be effectively rotated through a lid crease incision with internal sutures. The technique combines the main mechanisms of the Wies and Trabut approaches and avoids the use of bolsters or external sutures, which require a second consultation to be removed. Some other lid problems, such as ptosis, retraction, or dermatochalasis, can be concomitantly addressed during the procedure. Keywords: Cicatrix; Entropion/surgery; Eyelids/surgery; Ophthalmologic surgical procedures; Suture techniques

RESUMO Objetivo: Descrever uma técnica de rotação marginal superior para a correção do entrópio cicatricial combinando incisão via sulco palpebral, tarsotomia e tração na lamela anterior sem o emprego de suturas externas. Métodos: Técnica cirúrgica. Os passos críticos da cirurgia incluem exposição completa da superfície anterior do tarso até a linha dos cílios e tarsotomia horizontal a 3 mm da margem palpebral, produzindo dois segmentos tarsais, marginal e distal. O fragmento distal é avançado sobre o marginal por meio de 3 suturas biagulhadas absorvíveis 6.0 passadas entre a margem do segmento tarsal distal e o músculo orbicular marginal. Dessa maneira, além da superposição tarsal as suturas tracionam o orbicular mar-ginal evertendo simultaneamente a margem palpebral e a linha ciliar. Nenhum fio é exteriorizado. O retalho pretarsal miocutâneo era fechado com suturas de catugt 6,0. Resultados: A técnica descrita foi utilizada em hospital terciário na Arábia Saudita, em 2013 e 2014. Sessenta pálpebras superiores de 40 pacientes (23 mulheres e 17 homens) foram operadas. A idade dos pacientes variou de 44 a 99 anos (média= 70,9 ± 13,01 anos). A cirurgia foi bilateral em 21 pacientes. O seguimento variou de 1 a 12 meses (média= 3,0 ± 2,71 meses). Em 24 pálpebras (40%) o seguimento foi superior a 3 meses. A posição da margem palpebral foi considerada boa em todos os casos. Somente 1 paciente com entrópio unilateral apresentou recidiva da triquíase (2 cílios). Conclusão: A margem palpebral de pacientes com entrópio cicatricial pode ser evertida utilizando-se incisão no sulco palpebral e suturas internas. A técnica descrita combina os princípios das cirurgias de Wies e Trabut e tem como principais vantagens incisão cosmética no sulco palpebral e o não uso de suturas externas. Adicionalmente, o acesso pelo sulco palpebral permite a correção de condições associadas, como dermatocálase, ptose ou retração palpebral.

Descritores: Cicatriz; Entrópio/cirurgia; Pálpebras/cirurgia; Procedimentos cirúrgicos oftalmológicos; Técnicas de sutura

As trachoma is an ancient blinding disease, there is a considerable amount of literature on surgical techniques for correcting trachoma-tous UCE that can be traced back to ancient Chinese medical texts(3). Most modern procedures are based on a horizontal tarsotomy across the entire tarsal plate and the use of sutures to evert the lid margin. In English literature, a majority of authors advocate different variants of the anterior approach described by Wies during the 1950s for spastic entropion of the lower eyelid(4,5) as well as that used by Ballen(6) to rotate the upper lid margin in cases of cicatricial entropion. These surgeries

Upper lid crease approach for margin rotation in trachomatous cicatricial entropion without external suturesAbordagem via sulco palpebral superior para a rotação marginal no entrópio cicatricial tracomatoso sem o emprego de suturas externas

antonio augusto vElasco E cruz1, Patricia M. s. aKaishi1, MohaMMEd al-duFailEEJ2, alicia galindo-FErrEiro2,3

Submitted for publication: April 23, 2015 Accepted for publication: October 1, 20151 Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Escola de Medicina

de Ribeirão Preto, Universidade de São Paulo (USP), São Paulo, SP, Brazil.2 King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.3 Department of Ophthalmology, Complejo Asistencial Palencia, Palencia, Spain.



Corresponding author: Antonio Augusto V. Cruz. Department of Ophthalmology, School of Medicine of Ribeirão Preto, University of São Paulo. Av Bandeirantes, 3.900, Ribeirão Preto, SP, Brazil

E-mail: [email protected]

Approved by the following research ethics committee: King Khaled Eye Specialist, Project number: RP 1374-R.

Upper lid crease approach for margin rotation in trachomatous cicatricial entropion without external sutures


were typically performed with a through-and-through incision placed 3 mm or 4 mm from the lid margin(7-11). In African French-speaking countries and many places in the Middle East, the posterior approach as described by Trabut is the preferred procedure(12).

We describe a lid crease approach with internal absorbable sutu-res for upper lid margin rotation in cases of trachomatous cicatricial entropion. This is a versatile procedure that does not require any bolsters and allows the surgeon to correct the lid margin position and simultaneously address a variety of associated conditions with a single external incision.

METHODSInstitutional Review Board approval was obtained for a chart review

of patients with trachomatous cicatricial entropion who underwent surgery at the King Khaled Eye Specialist Hospital (Riyadh, Saudi Arabia). All surgeries were performed with an anterior approach and a lid crease incision. Preoperatively, all lids had trachomatous entro-pion, trichiasis, and the typical conjunctivalization of the margin with the mucocutaneous junction overriding the meibomian gland line. Other signs of trachoma, such as Herbert’s pits and corneal pannus, were also present in all cases.

Postoperatively, the position of the lid margins was assessed with slit-lamp biomicroscopy in all patients. The degree of rotation was categorized as good only when the meibomian gland orifices were clearly visible without any traction on the anterior lamella and were not covered by the tarsal conjunctiva. Any residual trichiasis or inward displacement of the meibomian gland line was registered as unsatisfactory.

Surgical technique

The surgery (Figure 1) is performed with local anesthetic (2% lido-caine with 1:100,000 epinephrine). Initially, a 4-0 silk traction suture is

inserted through the tarsal edge of the lid margin. Next, a standard lid crease incision is used to create a pretarsal skin-muscle flap. At this point, if desired, a standard blepharoplasty skin/muscle resection can be performed. The pretarsal skin-muscle flap is raised, exposing the whole tarsal plate and dissection under the pretarsal orbicularis muscle with Westcott scissors or a Colorado needle proceeds towards the lid margin until the lash roots are visible. The eyelid is everted over a cotton-tipped applicator and held in position with the traction suture. During this maneuver, care is taken to place the applicator under and not over the skin-muscle flap. Using a No. 15 Bard-Parker scalpel blade and Westcott scissors, a curved incision paralleling the lid margin is made through the full thickness of the tarsus 3 mm pos-teriorly to the margin. Next, the lid is returned to its natural position. Three double-armed 6-0 polyglactin sutures are then passed through the central, medial, and lateral aspects of the distal cut edge of the tarsus and attached to the orbicularis muscle near the lash line. As the sutures are tied, the distal portion of the tarsus is advanced over the marginal tarsus, and the marginal orbicularis is pushed backward, rotating both lamellae of the lid margin outward (Figure 2).

Using this method, the sutures remain within the lid, and no bolsters are used. The lid crease incision is closed with a running 6.0 fast absorbable suture.

RESULTSSixty upper lids of 40 patients (23 women and 17 men) were ope-

rated on, with an age range of 44-99 years [mean ± standard deviation (SD) = 70.9 ± 13.01 years]. Bilateral surgery was performed on 21 pa-tients. Follow-up ranged from 1 to 12 months (mean 3.0 ± 2.71 months). Forty percent of the patients (24 lids) had more than 3 months of follow-up, and in this subgroup, the mean postoperative time to final follow-up was 5.6 ± 2.68 months. Trichiasis was corrected in all but one lid, which had two inward lashes medially touching the cornea

Figure 1. Top: Left - a standard lid crease incision is used to raise a pretarsal skin-muscle flap, exposing the whole tarsal flap until the lash roots are visible. Right - tarsotomy is performed with a conjunctival incision 3-4 mm from the lid margin. Bottom: left - a 6-0 Vicryl suture is passed on the orbicularis muscle close to the lash roots and through the mid portion of the distal tarsal fragment. Right - as the sutures are tied, the distal tarsal fragment is slightly advanced over the marginal tarsus and traction is exerted on the orbicularis.

Velasco e Cruz AA, et al.


despite adequate margin position, and was managed with lash elec-trolysis. Figure 3 shows a typical effect of the surgery on patients with cicatricial entropion and residual vision in the right eye.

DISCUSSIONUCE is usually seen in aged patients, who may also present with

other lid problems, such as dermatochalasis, aponeurotic ptosis, upper sulcus deformity, anterior lamella laxity, and lid retraction. In endemic trachomatous areas, the clinical picture can be quite obvious, with severe trichiasis and blepharospasm. In mild cases, the condition may be difficult to diagnose and is commonly called “rubbing lashes”(2). A typical sign is an abnormal location of the mucocutaneous junction that overlies the meibomian gland line(13-15).

The current literature on the surgical correction of UCE is heavily based on epidemiological studies reporting the outcomes of a large series of procedures that are usually not performed by ophthalmo-logists from rural communities with few medical resources(16-18). In this context, the ideal procedure is the simplest operation that can be successfully performed in the least amount of time. In African French-speaking countries, the preferred procedure is Trabut surgery, which is a posterior tarsotomy with external sutures secured by bols-ters(12). From a mechanical point of view, in this surgery, lid rotation is achieved by the advancement of the distal tarsal portion over the mar-ginal tarsus. The tarsal overlap creates a downward vector on the pos-terior edge of the marginal tarsus and rotates the lid margin upward.

The World Health Organization recommends the same anterior approach procedure described by Ballen in 1964(6,10). The mechanics involved in the margin rotation in the Ballen procedure is based on a tarsotomy, without any tarsal overlap, and traction on the anterior lamella with external sutures.

We believe that in more conventional surgical settings, an ante-rior incision placed 3 mm from the margin is not the best approach to address upper lid entropion. There are several advantages with the use of a lid crease incision. Firstly, the tarsal plate and the anterior la-mellae are not incised on the same level. This reduces the chances of ischemia of the narrow marginal lid strip that is created with a classic Ballen surgery. Secondly, the suborbicularis dissection can be easily performed until Riolan’s muscle is reached. Absorbable sutures can then be passed internally on the marginal portion of the orbicularis muscle, thus increasing the upward rotation of the lashes without the use of bolsters or subsequent suture removal. The absence of bolsters or external sutures renders a more comfortable postoperative care. Thirdly, the tarsal plate is not incised. The distal portion of the tarsus is slightly advanced over the marginal portion, thereby creating the same mechanical downward tension on the margin as described by Trabut(12).

Theoretically, this effect keeps the lid margin rotated, thus decrea-sing the chances of entropion recurrence. Although the advance-ment of the distal tarsus fragment over the marginal portion slightly shortens the posterior lamella, we did not observe any retraction, and if needed, the surgeon can address any positional anomalies of the lid recessing or advancing the levator aponeurosis at the end of the margin rotation.

An important limitation of our study is the short postoperative follow-up time. It is well known that the rate of trichiasis recurrence is quite high when non-oculoplastic surgeons perform community-based lid margin rotations(15,19). For example, trichiasis occurs in 20% to 40% of cases after a bilamellar tarsal rotation procedure (Wies/Ballen ope-ration) or a posterior lamellar tarsal rotation (Trabut surgery)(15,19). The recurrence of trichiasis appears to be multifactorial in nature; however, tarsotomies that are non-parallel to the eyelid margin are associated with poor margin rotation(20). The lid crease approach combines the advantage of complete tarsal exposure with the ability to perform the tarsotomy through the conjunctiva; thus, the surgeon is able to simultaneously visualize both the lid margin and tarsal incision at all times, allowing careful control of the location of the tarsotomy.

A discussion on the long-term effects of our margin rotation pro-cedure is not possible at this time. However, we believe that the proce-dure is stable and can also be used to correct other forms of cicatricial entropion, such as those induced by tarsal buckling after supramaxi-

Figure 2. Double mechanism of lid rotation. The distal fragment exerts a downward vector on the marginal tarsus, and the internal suture tractions the anterior lamella near the lash line.

Figure 3. Top - a patient with bilateral recurrent cicatricial entropion following sur-gery performed elsewhere. The left eye is blind and the right has a keratoprosthesis. Bottom-Immediate postoperative result of the lid margin rotation.

Upper lid crease approach for margin rotation in trachomatous cicatricial entropion without external sutures


mal levator resection. The authors have used the described lid crease approach to correct UCE in patients at the King Khaled Eye Specialist Hospital. The level of satisfaction is quite high, and we did not observe any serious complications, such as lid margin necrosis or deficient fissu-re closure. In addition to the functional outcomes, the cosmetic aspect of this procedure is superior to that of other techniques.

REFERENCES 1. Polack S, Brooker S, Kuper H, Mariotti S, Mabey D, Foster A. Mapping the global dis-

tri bution of trachoma. Bull World Health Organ. 2005;83(12):913-9. 2. Kersten RC, Kleiner FP, Kulwin DR. Tarsotomy for the treatment of cicatricial entropion

with trichiasis. Arch Ophthalmol. 1992;110(5):714-7. Comment in: Arch Ophthalmol. 1992;110(12):1685.

3. Al-Rifai KM. Trachoma through history. Int Ophthalmol. 1988;12(1):9-14. 4. Wies F. Spastic Entropion. Trans Am Acad Ophthalmol Otolaryngol. 1955;59(4):503-6. 5. Wies FA. Surgical treatment of entropion. J Int Coll Surg. 1954;21(6):758-60. 6. Ballen PH. A Simple procedure for the relief of trichiasis and entropion of the upper lid.

Arch Ophthalmol. 1964;72:239-40. 7. Merbs SL, West SK, West ES. Pattern of recurrence of trachomatous trichiasis after

surgery surgical technique as an explanation. Ophthalmology. 2005;112(4):705-9. 8. Sandford-Smith JH. Surgical correction of trachomatous cicatricial entropion. Br J

Ophthalmol. 1976;60(4):253-5. 9. Reacher MH, Muñoz B, Alghassany A, Daar, AS, Elbualy M, Taylor HR. Controlled trial

of surgery for trachomatous trichiasis of the upper lid. Arch Ophthalmol. 1992;110(5): 667-74.

10. Reacher M, Foster A, Huber J. Trichiasis surgery for trachoma. The bilamellar tarsal rotation procedure. Geneva: World Health Organization; 2001 (WHO/PBL/93.29)

11. Bleyen I, Dolman PJ. The Wies procedure for management of trichiasis or cicatricial entropion of either upper or lower eyelids. Br J Ophthalmol. 2009;93(12):1612-5.

12. Trabut G. Entropion-trichiasis en Afrique du Nord. Son opération par voie conjunctivale. Arch Ophthalmol. 1949;9:701-7.

13. Sarkies JW. Early changes in margin of upper eyelid in entropion complicating tra-choma. Br J Ophthalmol. 1965;49(10):538-41.

14. Lucena A1, Akaishi PM, Rodrigues Mde L, Cruz AA. Upper eyelid entropion and dry eye in cicatricial trachoma without trichiasis. Arq Bras Oftalmol. 2012;75(6):420-2.

15. Rajak SN, Habtamu E, Weiss HA, Kello AB, Abera Bm Zerugb Nm Gebre CE, et al. The outcome of trachomatous trichiasis surgery in Ethiopia: Risk factors for recurrence. PLoS Negl Trop Dis. 2013;7(8):e2392.

16. Gower EW, West SK, Harding JC, Cassard SD, Munoz BE, Othman MS, et al. Tracho-matous trichiasis clamp vs standard bilamellar tarsal rotation instrumentation for trichiasis surgery: results of a randomized clinical trial. JAMA Ophthalmol. 2013;131(3): 294-301.

17. Kerie A, Bejiga A. Pattern of recurrence of trachomatous trichiasis after surgery in Enemor and Ener district, Central Ethiopia. Ethiop Med J. 2010;48(4):301-8.

18. Rajak SN, Habtamu E, Weiss HA, Kello AB, Gebre T, Genet A, Bailey RL, et al. Absorbable versus silk sutures for surgical treatment of trachomatous trichiasis in Ethiopia: a randomised controlled trial. PLoS Med. 2011;8(12):e1001137.

19. West ES, Mkocha H, Munoz B, Mabey D, Foster A, Bailey R, et al. Risk Factors for post-surgical trichiasis recurrence in a trachoma-endemic area. Invest Ophthalmol Vis Sci. 2005;46(2):447-53.

20. Merbs SL, West SK, West ES. Pattern of recurrence of trachomatous trichiasis after sur-gery. Surgical technique as an explanation. Ophthalmology. 2005;112(4):705-9.

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Original Article


INTRODUCTION Uveitis is defined as inflammation of the uveal tract and has been

shown to be associated with a number intraocular diseases, inclu-ding cataract(1-3). Experimentally, uveitis can induced by intravitreal lipopolysaccharide (LPS) injection(4,5) leading to inflammatory cell in filtration at four hours after injection, with peak inflammation between 18 and 24 hours later(4). Acute inflammatory responses in uveitis are maintained by the action of molecular mediators which

ABSTRACTPurpose: To evaluate the effects of 1% morphine instillation on clinical parameters, aqueous humor turbidity, and expression levels of tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1beta), prostaglandin E2 (PGE2), and myeloperoxidase (MPO) in rabbits with endotoxin-induced experimental uveitis. Methods: Twenty four New Zealand white rabbits were divided into four groups (n=6 each): control (CG), morphine (MG), naloxone (NG), and morphine-naloxone (MNG) groups. Under dissociative anesthesia, 0.1 mL of solution containing 0.2 μg of lipopolysaccharide (LPS) endotoxin from the Salmonella typhimurium cell wall was injected in the vitreous chamber. Clinical evaluations (conjunctical hyperemia, chemosis blepharospasm, and ocular discharge) and laser flaremetry were per-formed before (baseline), and 10 and 20 hours after induction of uveitis. Rabbits were subsequently euthanized and eyes were enucleated to quantify expression levels of TNF-α, IL-1 beta, PGE2, and MPO. Results: No significant differences in clinical parameters and flare values were observed between the study groups. TNF-α and IL-1 beta levels increased sig-nificantly in the CG, MG, NG, and MNG groups compared to baseline (P<0.05). Significant differences in PGE2 levels were observed between the MG and NMG groups (P<0.05). A trend toward increased MPO activity was observed in response to uveitis induction; however, this trend did not reach statistical significance (P>0.05). Conclusions: Morphine has no effect on clinical parameters, flare, or expression levels of inflammatory mediators in a rabbit model of uveitis induced by intravi-treal injection of LPS.

Keywords: Lasers/diagnostic use; Photmetry/methods; Morphine/administration & dosage; Endotoxins/toxicity; Uveitis/chemically induced; Rabbit

RESUMO Objetivo: Estudaram-se os efeitos da instilação de morfina 1% sobre parâmetros clíni-cos, turbidez do humor aquoso e expressão de fator de necrose tumoral alfa (TNF-alfa), de interleucina-1 beta (IL-1beta), de prostaglandina E2 (PGE2) e de mieloperoxidase (MPO), em olhos de coelhos com uveíte induzida por endotoxina. Material e Métodos: Vinte e quatro coelhos da raça Nova Zelândia Branco foram distribuídos em quatro grupos (n=6, em cada): grupo controle (GC), morfina (GM), naloxona (GN) e morfina-naloxona (GMN). Sob anestesia dissociativa, injetou-se 0,1 mL de solução contendo 0,2 µg de lipossacarídeo (LPS) endotóxico da parede celular de Salmonella typhimurium na câmara vítrea. Realizou-se avaliação clínica (hiperemia conjuntival, quemose, blefaroespasmo e secreção ocular) e a flaremetria a “laser” antes (basal) e após 10 e 20 horas da indução da uveíte. No final, os coelhos foram submetidos à eutanásia e os olhos com uveíte foram enucleados para a quan-tificação dos níveis de TNF-alfa, IL-1 beta, PGE2 e MPO. Diferenças foram consideradas significativas quando p<0,05. Resultados: Os grupos da pesquisa não diferiram quanto aos parâmetros clínicos e os valores de “flare”. Observou-se elevação significativa nos níveis de TNF-alfa e de IL-1 beta, comparativamente ao basal, nos grupos GC, GM, GN e GMN (p<0,05). Valores de PGE2 variaram entre os grupos GM e GNM (p<0,05). A atividade de MPO aumentou após a indução da uveíte, porém, sem significância estatística (p>0,05). Conclusões: A morfina não atuou sobre parâmetros clínicos, “flare” e expressão dos mediadores inflamatórios estudados, quando instilada em olhos de coelhos com uveíte induzida por injeção intravítrea de LPS.

Descritores: Lasers/uso diagnóstico; Fotometria/métodos; Morfina/administração & dosagem; Endotoxinas/toxicidade; Uveítes/induzido quimicamente; Coelhos

leads to decreased active secretion of aqueous humor and increased vascular permeability(6,7).

Pro-inflammatory cytokines, such as interleukin-1 alpha (IL-1 alpha) and interleukin-1 beta (IL-1 beta), have been shown to actively recruit leukocytes to sites of inflammation(6). IL-1 alpha and IL-1 beta are predominantly secreted by activated macrophages, B lymphocytes, and endothelial cells(8). Tumor necrosis factor-alpha (TNF-α) is also synthesized by monocytes, macrophages, neutrophils, mast cells,

Effects of morphine on the expression of cytokines and inflammatory mediators in a rabbit model of endotoxin-induced experimental uveitis Efeitos da morfina na expressão de citocinas e de mediadores inflamatórios em coelhos com uveítes experimental induzida por endotoxina

KEthyE P. ortEncio1, robErta rEnzo1, alExandrE a. F. b. sobrinho1, Karina KaMachi Kobashigawa1, robErta M. crivElaro1, gErMana a. silva1, MarcEla aldrovani1, alExandrE Pinto ribEiro2, tiago w. P. MinEo3, José luiz laus1

Submitted for publication: March 23, 2015 Accepted for publication: September 14, 20151 Ophthalmology Unit, Department of Veterinary Clinical Medicine and Surgery, Faculdade de Ciências

Agrárias e Veterinárias de Jaboticabal, Universidade Estadual Paulista “Julio de Mesquita Filho” (UNESP), Jaboticabal, SP, Brazil.

2 Departament of Veterinary Clinical Medicine, Faculdade de Agronomia, Medicina Veterinária e Zootecnia, Universidade Federal de Mato Grosso (UFMG), Cuiabá, MT, Brazil.

3 Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia (UFU), Umuarama, MG, Brazil.

Funding: This study was supported by FAPESP (São Paulo Research Foundation - process number 2011/08734-8); CAPES (Coordination for the Improvement of Higher Education Personnel); CNPq (National Council for Scientific and Technological Development - process 300833/2010-5).


Corresponding author: José Luiz Laus. Faculdade de Ciências Agrárias e Veterinárias (FCAV). Uni-versidade Estadual Paulista. Departamento de Clínica e Cirurgia Veterinária. Via de Acesso Professor Paulo Donato Castellane, s/n - Jaboticabal, SP - 14884-900 - Brazil - E-mail: [email protected]

Approved by the following research ethics committee: Ethics Committee on Animal Use (CEUA), College of Agriculture and Veterinary Sciences, UNESP, Jaboticabal, SP, Brazil, under the protocol 014274/11. Bioethical care, in relation to standards of the Association for Research in Vision and Ophthalmology - ARVO were followed.

Effects of morphine on the expression of cytokines and inflammatory mediators in a rabbit model of endotoxin-induced experimental uveitis


and T lymphocytes(9). As inflammation progresses, TNF-α modulates leukocyte infiltration by promoting the synthesis of molecules invol-ved in adhesion, maturation, and maintenance of dendritic cells(9). Evidence suggests that elevated expression of TNF-α, as observed in immune-mediated uveitis, correlates with pea inflammation(10). In corroboration, a recent study reported significantly increased expres-sion of TNF-α at 18 hours after cataract surgery(11).

Prostaglandins (PGs) have also been shown to cotribute to in -traocular inflammation(12-14). Infectious disease, trauma, ocular sur-gery, and neoplasia may also cause injury to the aqueous-blood barrier, leading to increased PG synthesis(7). Ribeiro et al.(13) and Gilmour and Payton(14) reported the utility quantifying prostaglandin E2 (PGE2) levels as a measure of intraocular inflammation in dogs.

Opioids bind to specific endogenous receptors inducing anti-no ciceptive effects in the central nervous system. Studies have demonstrated that local application of opoids can elicit analgesia via the neuroimmune system due to the presence of opioid receptors in peripheral tissues(15,16). Wenk et al.(15) demonstrated attenuation of leukocyte infiltration by infusion of morphine directly into corneal ulcerations in mice. Clark et al.(17) demonstrated the efficacy of parente-ral administration of morphine reducing cutaneous expression of IL-1 beta, interleukin-6, and TNF-α, and local neutrophil infiltration. Studies have also demonstrated the expression of kappa opioid receptors in the anterior chamber of the eye(18). In humans and primates, opioids are known to suppress chemotaxis and migration of neutrophils, the-reby modulating adaptive immune responses(19). Dortch-Canes and Russell(20) reported that morphine instillation reduced the intraocular pressure in healthy rabbits but only for five minutes.

Naloxone is a non-selective opioid antagonist that may be used to reverse the action of morphine(21). Its effects, however, are limited when administered in patients that have not been pretreated with opioids. The half-life of naloxone is approximately one hour as it is rapidly metabolized by the liver(22).

The stability of the aqueous-blood barrier was evaluated by Ribei-ro et al.(16) as the local administration of opioids, particularly morphine, is frequently used for pain control in ulcerative keratitis. Studies have demonstrated that morphine inhibits the release of proinflammatory cytokines in response to skin incisions and decreases the infiltration of leukocytes in silver nitrate-induced corneal ulcers(15,17). In corneas following lamellar keratectomy, morphine reportedly increases the number of extracellular metalloproteinases without altering the expression of interleukin-10(16). Husain et al.(23) observed that intrape-ritoneal administration of morphine has protective effects on retinal ganglion cells in a rat model of experimental ocular hypertension, most likely though inhibition of TNF-α production. A previous study at our institution demonstrated, with the use of laser flaremetry, that morphine increases the total protein content of the aqueous humor when administered after paracentesis of the anterior chamber(24).

The present study aimed to evaluate the effects of morphine instillation on rabbit eyes with uveitis. Morphine is used to promote analgesia in ulcerative keratitis, and after refractive surgeries, condi-

tions that lead to the breakdown of the aqueous-blood barrier and increased expression of cytokines and other inflammatory mediators.

METHODSA total of 24 New Zealand White adult rabbits (Oryctolagus cuniculus)

with a mean weight of 3.0 kg were used in the present study. Rabbits were kept in clean and sanitized individual cages in a ventilated environment. Food and water were offered ad libitum. Only rabbits free of ocular and systemic diseases were used in the present study.

Intravitreal injections in the right eye of each rabbit were given un-der dissociative anesthesia (ketamine Agener 10% Agener Uniao, To-ronto, ON and xylazine Dopaser, Hertape Calier, Juatuba, MG) following the instillation of anesthetic eye drops (anestésico®, Allergan, Guaru-lhos, SP). Under aseptic conditions, 0.1 mL of a solution containing LPS (0.2 μg endotoxin from the Salmonella typhimurium cell wall; L6511, Sigma Chemical Co.; St. Louis, MO) was applied approximately 3.5 mm from the sclerocorneal limbus to induce uveitis. A 0.25 × 0.7 mm needle and 1 mL syringe were used as previously described(3). Oph thal-moscopy was performed to confirm the absence of iatrogenic retinal lesions(25).

Eyes were clinically evaluated for conjunctival hyperemia, chemo-sis, blepharospasm, ocular discharge, and aqueous turbidity(7). Laser flaremetry was used to quantify the turbidity of the aqueous humor (Laser Flaremeter® FC-600, Kowa, Japan) before uveitis induction and at 10 and 20 hours after inflammation induction.

Rabbits were divided into four groups (n=6 each): control (CG), morphine (MG), naloxone (NG), and morphine-naloxone (MNG) groups. Eyes with endotoxin-induced uveitis, in a total of 10 applica-tions, received one drop of 0.9% saline solution (CG), 1% morphine (MG), 1% naloxone (NG), or morphine and naloxone (MNG) immedia-tely after the induction of inflammation and at regular 2-hour intervals. Commerically available ophthalmic solutions of 1% morphine sulfate (experimental 1% morphine ophthalmic solution without preservati-ves, Cristália, Campinas, SP) and 1% naloxone (experimental 1% nalo-xone ophthalmic solution without preservatives, Cristália, Campinas, SP) were used with the pH adjusted to 6.0. In the MNG, morphine was administered first followed by naloxone 10 minutes later.

Twenty hours after uveitis induction, rabbits were euthanized (overdose of thiopental sodium, Thiopentax, Cristália, Campinas, SP) and subconjunctival enucleation of the right eye was performed. Immediately after, the iris and ciliary body were collected (Figure 1), stored in tubes, and cryogenically preserved at a temperature of -80°C until further use. Approximately four months later, stored samples were mace-rated, and TNF-α, IL-1beta, MPO, and PGE2 levels were quanti fied by enzyme-linked immunosorbent assay (ELISA) according to the manufacturer›s recommendations (Enzyme-linked Immunosorbent Assay kit, Uscn Life Science Inc., China).

Nonparametric Friedman analysis of variance with post-hoc analy-sis using the Dunn’s test was used to evaluate aqueous humor flare data, expressed as the median, maximum, and minimum. Data related

Figure 1. Protocol used following enucleation of the right eye in New Zealand white rabbits. A) scleral section to remove the corneoscleral button; B) corneoscleral button; C) separation of the iris and ciliary body by traction; and D) iris and ciliary body storage conditions.

A B C D

Ortencio KP, et al.


to cytokine levels were compared using one-way ANOVA followed by Turkey’s test. Cytokines values were expressed as means and standard errors of the mean. P values <0.05 were considered statistically signifi-cant (SigmaStart 3.0®, Systat Software Inc., San Jose, USA).

RESULTSConjunctival hyperemia, chemosis, blepharospasm, ocular dischar-

ge, and aqueous turbidity were observed two hours after LPS injection and persisted for 20 hours in all eyes with endotoxin-induced uveitis.

The median aqueous humor photon counts at 20 hours were not significantly higher than those at the baseline in MG (2.10 vs. 4.10 PC/ms), NG (3.80 vs. 4.40 PC/ms), or MNG (2.90 vs. 3.25 PC/ms) (Figure 2). In CG, there was a trend toward increased median photon counts at baseline compared to other time periods; however, this trend did not reach statistical significance. Twenty hours after the induction of uveitis, there was a trend toward a higher median photon in MG (9.20 PC/ms), followed by MNG (7.90 PC/ms), NG (5.00 PC/ms), and CG (4.25 PC/ms); however, this trend did not reach statistical significance.

In all groups, uveitis induction resulted in increased expression of TNF-α and IL-1 beta (Table 1). Significant differences in TNF-α values as compared to baseline levels (467.1 ± 54.54 pg/mL) were observed in CG (5652 ± 145.7 pg/mL), NG (4601 ± 599.7 pg/mL), MG (5442 ± 417.7 pg/mL), and MNG (4714 ± 426.9 pg/mL; P<0.001 for all). IL-1 beta levels were significantly increased in CG (950.1 ± 71.97 pg/mL), NG (1087 ± 127.9 pg/mL), MG (1137 ± 96.53 pg/mL), and MNG (994.2 ± 86.03 pg/mL) compared to baseline values (509.3 ± 49.59 pg/mL; P<0.001 for all). No significant difference in PGE2 values compared

to baseline values (569.7 ± 73.99 pg/mL) were observed in CG (632.1 ± 77.44 pg/mL), NG (663.7 ± 32.67 pg/mL), MG (694.2 ± 45.12 pg/mL), or MNG (449.4 ± 27.29 pg/mL); however, a significant difference was observed between the MG (694.2 ± 45.12 pg/mL) and MNG (449.4 ± 27.29 pg/mL; P<0.001). No significant difference in MPO levels were observed between baseline (4.780*10-4 ± 1.647*10-4 mU/mL) and treated groups (CG, 7.975*10-4 ± 2.362*10–4 mU/mL; NG, 8.826*10-4 ± 3.697*10-4 mU/mL; MG, 3.838*10-4 ± 1.615*10-4 mU/mL; MNG, 7.086*10-4 ± 1.935*10-4 mU/mL).

The results presented in figure 3 demonstrate that the observed in-creases in the expression levels of all cytokines were similar between groups, except for PGE2 values which were lower in the MNG group.

DISCUSSION LPS injection has been demonstrated to be valid as an experi-

mental model of uveitis and can be performed via intraperitoneal, subcutaneous, intracameral, and intravitreal routes(4,5). The intravitreal route(26) was chosen in the present study as numerous ocular altera-tions related to other methods have been reported in previus studies. In corroboration with previous studies(26) in rabbits, the clinical signs associated with uveitis, such as conjunctival hyperemia, chemosis, blepharospasm, and ocular discharge, were also observed in the present study.

Nussenblatt et al.(26) reported a 3-fold increase in flare values in rabbit eyes at 3 hours after LPS injection before decreasing 9 hours later. However, no significant changes in flaremetry were observed following endotoxin intravitreal injection in the present study. As albino rabbits were used, the absence of pigmentation in the uveal tract may have influenced the results of the present study.

Inflammatory mediators have been shown to act as vasoactive substances contributing to conjunctival hyperemia, injection of episcleral vessels, and engorgement of iris vessels(7) during the uvei-tis evolution process. The inflammatory process occurs as a tissue response to cell injury(28) initiated by the release of pro-inflammatory agents, particularly IL-1 and TNF-α, which stimulate the production of metabolites and cytokines and the liberation of arachidonic acid, PGs, and leukotrienes(27).

In the present study, compared to baseline values, the levels of IL-1 and TNF-α and not of MPO and PGE2 increased after the induction of uveitis; this can be attributed to evaluations being performed during the initial phase of inflammation. The results of the present study corroborate with those of previous studies that have used LPS to induce inflammation(28) and increase levels of TNF-α and IL-1beta. TNF-α, IL-1beta, IL-2, IL-6, and interferon-gamma have also been detected in eyes with idiopathic uveitis. Studies in humans and rats have reported increased expression of TNF-α in tissues adja-cent to the infiltration of inflammatory cells(29). In contrast, Pinard et al.(12) observed no significant increases in TNF-α levels in dogs with paracentesis-induced uveitis.

* Dunn test (P>0.05).Figure 2. Median (lines inside boxes), maximum, minimum, and inter-quartile ranges (25 and 75%) for aqueous humor turbidity (photon/msec) before (basal) and 10 and 20 hours after the induction of uveitis in New Zealand white rabbits divided into the following groups: 0.9% saline (CG), 1% morphine (MG), 1% naloxone (NG), and 1% morphine followed by 1% naloxone (MNG).

Table 1. Expression levels of tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1 beta), prostaglandin E2 (PGE2), and myeloperoxidase (MPO), before (Baseline) and after 20 hours of induced uveitis in New Zealand white rabbits, quantified by enzyme-linked immunosorbent assay (ELISA) in the following groups: control (CG), morphine (MG), naloxone (NG), and morphine-naloxone (MNG). Data presented as mean ± standard error of the mean

TNF-α (pg/mL) IL-1 beta (pg/mL) PGE2 (pg/mL) MPO *10-4 (mU/mL)

Baseline 467.1 ± 54.54* 509.3 ± 49.59* 569.7 ± 73.99** 4.780 ± 1.647

CG 5652 ± 145.7* 950.1 ± 71.97* 632.1 ± 77.44** 7.975 ± 2.362

NG 4601 ± 599.7* 1087 ± 127.9* 663.7 ± 32.67** 8.826 ± 3.697

MG 5442 ± 417.7* 1137 ± 96.53* 694.2 ± 45.12** 3.838 ± 1.615

MNG 4714 ± 426.9* 994.2 ± 86.03* 449.4 ± 27.29** 7.086 ± 1.935

*= statistically different from baseline; **= statistically different between groups.

Effects of morphine on the expression of cytokines and inflammatory mediators in a rabbit model of endotoxin-induced experimental uveitis


* Turkey’s test (P<0.001).Figure 3. Expression levels of tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1 beta), prostaglandin E2 (PGE2), and myeloperoxidase (MPO) before (basal) and after uveitis induction in New Zealand white rabbits divided into the following groups: 0.9% saline group (CG), 1% morphine (MG), 1% naloxone (NG), and 1% morphine plus 1% naloxone (MNG). Horizontal lines represent mean values, geometric symbols (○ □ ◊) represent data dispersion.

Bonfiglio et al.(30) reported that local instillation of varying concen-trations of morphine causes variable intraocular alterations; for example, they observed that 1% morphine instillation, as used in the present research, increased nitric oxide production and affected the anterior chamber. These same authors, as well as Russel-Randall and Dortch-meat(18), observed the presence of opioid receptors, particu-larly mu opioid receptors, in the anterior chamber of the eye.

Endogenous and exogenous opioids, such as morphine, are known to have immunosuppressive effects(22). However, there is a lack of data regarding the anti-inflammatory effects of morphine infusion in the uveal tract. In the present study, local administration of morphine was not found to ameliorate increased PGE2 expression in response to uveitis.

As a limitation of this study, in order to avoid the use of paracente-sis, levels of inflammatory mediators in the aqueous humor were not evaluated, which may have biased the results. However, expression levels of TNF-α, IL-1beta, PG2, and MPO were measured in iris and ciliary body samples. Previously, Green et al.(4) observed transient ele-vations in iris, ciliary body, and choroidal blood flow using fluorescein angiography in rabbits with endotoxin-induced experimental uveitis.

CONCLUSIONS In the present study, 1% morphine instillation had no effect on

clinical parameters or aqueous humor photon counts, as determined by laser flaremetry in rabbits with endotoxin-induced experimental uveitis. No significant differences in the expression levels of TNF-α, IL-1beta, PGE

2, or MPO were between values measured before (base-

line) and 20 hours after uveitis induction.

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41o Congresso da Associação Paranaense de Oftalmologia

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Case Report


INTRODUCTION Coloboma is an embryological eye abnormality caused by ocular

developmental defects occurring during 5th to 7th weeks of gesta-tion(1). Lens coloboma is characterized by notching of the equator of the lens and is induced by regional defective or absent development of the zonules(2).

Bicuspid aortic valve is an inheritable condition representing one of the most common cardiac anomalies. Although bicuspid aortic valve is commonly observed as an isolated finding, it may be asso-ciated with other cardiovascular anomalies such as aortic coarctation, Shone complex, Williams syndrome, patent ductus arteriosus, supra-valvular/subvalvular aortic stenosis, Turner syndrome, and coronary artery anomalies(3).

Several cases of sporadic unilateral or bilateral lens coloboma with and without systemic abnormalities have been described(4). However, as far as we know, bilateral isolated lens coloboma associated with cardiovascular anomalies has not been reported before. Here, we re port a case of bilateral isolated lens coloboma and associated bi -cuspid aortic valve.

CASE REPORTA 27-year-old female was admitted to our clinic with a complaint

of decreased vision since childhood. Uncorrected visual acuity was 1/10 for both eyes. The best-corrected visual acuity was 2/10 in the right eye with -10.00/-5.00 × 165° diopter correction and 3/10 in the left eye with -7.00/-4.00 × 10° diopter correction. Ocular movements were normal. Intraocular pressure in both eyes as measured by Gold mann applanation tonometry was 14 mmHg. Anterior segment

examination revealed a normal iris and no coloboma. After dilatation of the pupils, bilateral lens coloboma located in the inferior temporal regions was detected (Figure 1). Other ocular examinations, including fundus examination, fluorescein angiography, and optical coherence tomographic imaging revealed normal findings (Figure 2). Visual field testing using the 24-2 full-threshold strategy of the Humphrey Field Analyzer did not detect any defect. Medical and family histories were unremarkable. Because of the risk of an associated systemic disease, the patient was examined thoroughly by specialists in the departments of neurology, cardiology, internal medicine, and gene-tics. Neurology and internal medicine work-up did not reveal any abnormalities. Chromosomal analysis was normal, showing the 46 XX karyotype. In the cardiology work-up, echocardiography revealed a bicuspid aortic valve accompanied by an abnormal aorta (Figure 3). Coronary angiography or computerized tomographic angiography for imaging of other possible cardiac anomalies was not performed.

DISCUSSIONThe eye develops from three embryological layers, including the

neural ectoderm, neural crest, and the surface ectoderm. During the 4th week of embryogenesis, the optic vesicle derived from the neural ectoderm invaginates and fuses through the lower nasal margin, leading to the formation of the optic cup. Any defects in the closure of fissures at this developmental stage leads to the occurrence of coloboma(1).

The etiopathogenesis of coloboma is heterogeneous. Although most frequently inherited as an autosomal dominant trait, autosomal recessive, X-linked, or sporadic cases can be observed. Furthermore,

Bilateral isolated lens coloboma associated with bicuspid aortic valveColoboma de cristalino bilateral isolado associado à valva aórtica bicúspide

MustaFa dogan1, onur Polat1, ondEr aKci2, guliz FatMa yavas1, uMit ubEyt inan1

Submitted for publication: September 25, 2014 Accepted for publication: January 21, 20151 Department of Ophthalmology, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar, Turkey. 2 Department of Cardiology, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar, Turkey.

Funding: No specific financial support was obtained for this study.


Corresponding author: Dr. Mustafa DOĞAN. Cumhuriyet Mahellesi. Müsevvit Ömer Sokak. No: 4 Emirgan Konagı. Daire: 13 03200 - Afyonkarahisar - Turkey - Email: [email protected]

ABSTRACTA 27-year-old woman presented with a history of long-standing poor vision in both eyes. Ophthalmologic examination after pupillary dilatation revealed bilateral lens coloboma situated in the inferotemporal quadrant. No associated ocular abnorma-lities were seen, except amblyopia. A bicuspid aortic valve was observed during echocardiography during systemic evaluation. Lens coloboma usually occurs unilaterally; however, bilateral lens coloboma which is isolated or associated with other ocular malformations is also encountered. This is the first description of bilateral isolated lenticular coloboma associated with bicuspid aortic valve. Although the association between bicuspid aortic valve and lens coloboma may be an incidental finding, they may be components of an unknown syndrome.

Keywords: Coloboma; Aortic valve; Lens; Crystalline; Visual acuity; Humans

RESUMOUma mulher de 27 anos apresentou-se com uma história de longa data de deficiência visual em ambos os olhos. O exame oftalmológico após dilatação pupilar revelou coloboma de cristalino bilateral localizado no quadrante temporal inferior. Nenhuma outra alteração ocular associadas foi observada, exceto ambliopia. A valva aórtica bicúspide foi diagnosticada no exame de ecocardiograma durante a avaliação sis-têmica. Coloboma cristaliniano ocorre geralmente de forma unilateral, no entanto já foi descrito bilateralmente, associado a outras malformações oculares ou isolado. Esta é a primeira descrição de coloboma cristaliniano isolado bilateral associado à valva aórtica bicúspide. Embora a associação de valva aórtica bicúspide e colobo-ma cristaliniano no nosso caso pode ter sido um achado incidental, eles podem ser componentes de uma síndrome desconhecida.

Descritores: Coloboma; Valva aórtica; Cristalino; Acuidade visual; Humanos

Dogan M, et al.


the iris, lens, choroid, retina, optic nerve, and/or ciliary body may be involved(5). Lens coloboma is extremely rare, and its existence is still questionable. In the present case, no other ocular structures were affected, and the lack of zonules was observed on the infero-temporal side. Lens coloboma is most frequently inherited as an autosomal dominant trait. The frequency of the location of the lesion compatible with optic vesicle coloboma suggests a developmental defect in the ciliary region of the optic vesicle which forms zonules. Zonular fibers may be absent or may be attached to the notch of the coloboma. Weakening of zonular fibers may be attributed to toxic, inflammatory, and genetic factors(1,2).

Lens coloboma may be an isolated ocular finding; however, asso-ciation with other ocular abnormalities such as retinal detachment,

optic disc coloboma, or hypoplasia may be observed(6,7). In our case, apart from a refractive error, we did not detect any other ocular abnor malities.

While lens coloboma may not be accompanied by systemic findings, some systemic disorders such as Marfan syndrome and Alport-like glo-merulonephritis may be observed(8,9). Bavbek et al.(2) reported five ca-ses of lens coloboma without any systemic disorders, three of which had bilateral lens coloboma. In addition, two cases with bilateral lens coloboma had no other ocular anomalies. Aggarwal et al.(4) reported craniofacial dysmorphism in one of two cases with isolated bilateral lens coloboma. As far as we know, isolated bilateral lens coloboma in the absence of other ocular anomalies have been reported only rarely, and the association with bicuspid aortic valve has not been previously reported, to the best of our knowledge.

The mechanisms underlying the development of bicuspid aortic valve are not clearly known. Other than being a simple anomaly of the fusion of the two valvular leaflets, it is suggested to be a disorder cau-sed by complex developmental events. Because of association with other neural crest anomalies, it has been suggested that abnormal behavior of neural crest cells may lead to the formation of a bicuspid aortic valve. In addition, mutation in the notch1 gene, which encodes a class I transmembrane protein, functioning as a ligand-activated transcription factor and playing multiple roles in embryogenesis and self-renewing tissues of the adult organism, has been suggested to induce the bicuspid aortic valve; furthermore, abnormal fibrillin-1 and fibrillin microfibrillar proteins and deficient endothelial nitric oxide synthase have also been held responsible. The fibrillin-1 gene encodes a member of the fibrillin family. The encoded protein, Fi-brillin-1, is a large, extracellular matrix glycoprotein that serves as a structural component of 10-12 nm calcium-binding microfibrils. These microfibrils provide force-bearing structural support in elastic and non-elastic connective tissue throughout the body. Mutations in this gene are associated with the Marfan syndrome, isolated ectopia

Figure 3. Bicuspid aortic valve as detected by echocardiography.

Figure 1. Lens coloboma, right eye (left), left eye (right).

Figure 2. Normal fundus, right eye (left), left eye (right).

Bilateral isolated lens coloboma associated with bicuspid aortic valve


lentis, autosomal dominant Weill-Marchesani syndrome, and Shprint-zen-Goldberg craniosynostosis syndrome. Ocular findings such as hy pertelorism, ptosis, strabismus, blue sclera, and cataract have been previously reported in bicuspid aortic valve cases, and bicuspid aortic valve in this case may be a minor expression of Marfan syndrome; however, as far as we know, our case is the first to be associated with bilateral lens coloboma(10).

In conclusion, lens coloboma may present bilaterally as an isola ted ocular finding, apart from being associated with other ocular anoma-lies. Both coloboma and bicuspid aortic valve may be observed in asso-ciation with other congenital syndromes. Bicuspid aortic valve and lens coloboma presented in our case may be components of an unknown syndrome, which needs to be corroborated by additional studies.

REFERENCES 1. Onwochei BC, Simon JW, Bateman JB, Couture KC, Mir E. Ocular colobomata. Surv

Ophthalmol. 2000;45(3):175-94.

2. Bavbek T, Ogut MS, Kazakoglu H. Congenital lens coloboma and associated patho-logies. Doc Ophthalmol. 1993;83(4):313-22.

3. Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll Cardiol. 2010;55(25): 2789-800. Comment in: J Am Coll Cardiol. 2011;57(4):518; author reply 519; J Am Coll Cardiol. 2011;57(4):518-9; author reply 519.

4. Aggarwal A, El-Bash AR, Inker S, Musarella MA. Symmetrical bilateral lens colobomas in two brothers. J Pediatr Ophthalmol Strabismus. 2004;41(5):302-4.

5. Stoll C, Alembik Y, Dott B, Roth MP. Epidemiology of congenital eye malformations in 131,760 consecutive births. Ophthalmic Paediatr Genet. 1992;13(3):179-86.

6. Hovland KR, Schepens CL, Freeman HM. Developmental giant retinal tears associated with lens coloboma. Arch Ophthalmol. 1968;80(3):325-31.

7. Fard AK, Traboulsi EI. Coloboma of the lens, optic nerve hypoplasia and orbital heman-gioma-A possible developmental field defect. Ophthalmic Genet. 1998;19(4):209-12.

8. Mehrotra AS, Solanki N, Sabharwal KK. Bilateral coloboma of lens in Marfan’s syndrome. Indian J Ophthalmol. 1985;33(3):201-2.

9. Amari F, Segawa K, Ando F. Lens coloboma and Alport-like glomerulonephritis. Eur J Ophthalmol. 1994;4(3):181-3.

10. Fedak PW, Verma S, David TE, Leask RL, Weisel RD, Butany J. Clinical and pathophysio-logical implications of a bicuspid aortic valve. Circulation. 2002;106(8):900-4. Comment in: Circulation. 2003;107(16):e105; author reply e105.

Case Report


INTRODUCTIONThermal and chemical ocular burns are a medical emergency that

require prompt initiation of treatment, and the usual procedures of obtaining full medical history and performing a detailed ophthalmic examination are delayed until after treatment initiation.

Thermal burns may result from contact with various materials such as steam, boiling water, fireworks explosion, and molten metal(1). The severity of the burn varies depending on the structure of the agent, duration of contact, and contact surface area(2). In particular, widespread destruction of limbal stem cells in severe cases, such as molten metal burns with high melting points, causes conjunctiva-lization of the cornea, symblepharon formation, eyelid deformities, and melting and perforation of the cornea and sclera(2). The primary aim of the treatment is to accelerate epithelialization, to suppress inflammation, and to prevent tissue melting(3).

Here we report the cases of two patients with severe ocular surfa-ce and eyelid burns with molten silver and bronze metal, describe the clinical follow-up, and discuss the possible poor prognostic factors.

CASE REPORT

caSe 1A 28-year-old male was admitted to our hospital 2 h after having

splashed molten silver metal into his right eye. On initial examina-tion, visual acuity was limited to light perception. Anterior segment

examination revealed burns of the upper and lower eyelids and eyelashes, a completely opaque cornea, 360° limbal ischemia, and severe burns in the bulbar conjunctiva. The fundus could not be visualized. Intraocular pressure (IOP) was 20 mmHg as measured by Icare Pro Tonometer (Helsinki, Finland). The ocular surface was rinsed thoroughly with 1 L of Ringer’s lactate solution over 20 min (Figure 1 A), during which a hardened silver metal, approximately 1 cm diameter, that was buried into the upper fornix was noticed and removed. B-scan ocular ultrasonography was also performed, which did not reveal any other intraocular damage. Medical treatment at this stage consisted of topical 10% acetylcysteine, 10% vitamin C, moxifloxacin, 1% cyclopentolate, preservative-free artificial tears, 1% prednisolone, and oral vitamin C 1.5 g/day. Eight hours after the in-jury, amniotic membrane transplantation (AMT) was performed, and a polymethylmethacrylate symblepharon ring (conformer, 24 mm in diameter, with a 10-mm-diameter hole in the middle) was placed in the right eye.

Visual acuity on the 20th day after the burn was still limited to light perception. Slit-lamp examination revealed an opaque cornea, chemosis, swollen eyelids, and profound mucopurulent secretion. Samples were taken for microbiological examination (swap speci-mens of the bulbar conjunctiva were obtained for microbiologic analysis. Sabouraud dextrose agar was used for fungal cultures, and liquid thioglycolate medium was used for aerobic and anaerobic bacterial cultures. Gram staining for bacteria and Giemsa staining for fungi was performed for light microscopic examination). Gram-po sitive diplococci were observed by Gram staining as were many

Molten metal-related ocular thermal burn: report on two cases Queimadura térmica ocular por metal derretido: relato de dois casos

cEyhun arici1, guzin isKElEli1, Eray atalay2, MEhMEt sErhat Mangan3, bElgin Kilic1

Submitted for publication: June 26, 2014 Accepted for publication: January 19, 20151 Department of Ophthalmology, Cerrahpasa School of Medicine, Istanbul University, Istanbul, Turkey.2 Department of Ophthalmology, Kars State Hospital, Kars, Turkey.3 Department of Ophthalmology, Okmeydani Training and Research Hospital, Istanbul, Turkey.



Corresponding author: Ceyhun Arici. Olgunlar sokak, No: 6\10 - Bakirkoy-Istanbul 34145 - Turkey E-mail: [email protected]

ABSTRACTWe report two cases of severe thermal burns on the ocular surface and its adne-xal appendages that developed secondary to exposure to molten heavy metal with a melting temperature of near-thousand degree Celsius. Despite aggressive intervention and strict monitoring, the profound inflammation caused significant damage to the ocular surface, ending up in an intractable infection with an un-favorable outcome. The heat of the molten metal at impact, the heat-retaining capacity of the heavy metal, the total area of the ocular surface exposed to the molten metal, and the duration of exposure determined the severity of the injury. The unfavorable outcome, despite an intensive treatment, in terms of visual acuity and cosmetic appearance, should be explicitly explained to the patient, and a psychiatrist consultation should be considered if necessary.

Keywords: Amniotic membrane/transplantation; Burns chemical; Eye burns; Metals, heavy; Eye infections, bacterial; Humans

RESUMORelatamos dois casos de queimaduras graves da superfície ocular e seus anexos cau sadas por exposição à metais pesados derretidos com temperatura de fusão de quase mil graus Celsius. Embora rigorosamente acompanhados, a inflamação intensa causou danos significativos para a superfície ocular, que acabou em uma infecção intratável com um resultado desfavorável. O calor do metal fundido no momento do impacto, a capacidade de retenção de calor do metal pesado, a área total da superfície ocular exposta ao metal fundido e a duração da exposição de-terminaram a gravidade da lesão que vai ocorrer. O resultado desfavorável, apesar do tratamento intensivo, em relação à acuidade visual e à aparência estética, devem ser claramente explicados ao paciente e uma consulta ao psiquiatra deve ser considerada, se necessário.

Descritores: Membrana amniótica/transplante; Queimaduras químicas; Queimaduras oculares; Metais pesados; Infecções oculares bacterianas; Acuidade visual; Humanos

Molten metal-related ocular thermal burn: report on two cases


yeast cells by Giemsa staining. Topical moxifloxacin was disconti-nued. Topical vancomycin (50 mg/mL), amphotericin B (1.5 mg/ml), 5% natamycin, and oral itraconazole (200 mg/day) were initiated. Methicillin-resistant Staphylococcus aureus (MRSA) and Candida sp. were detected by culture. One month following AMT, the residues of the amniotic membrane were removed under aseptic conditions. The conformer was removed, cleaned, and replaced. One and a half months after the ocular burn, the patient reported right ocular pain. B-scan ultrasonography was performed; however, examination of the vitreous and retina was unremarkable.

In the second month, visual acuity was light perception, and an-terior segment examination revealed corneal edema, central melting, stromal infiltration, conjunctival hyperemia, chemosis, mucopurulent secretion, and eyelid edema (Figure 1 B). Despite the medical therapy, the clinical manifestations worsened; this was ascribed to increased adhesion of microorganisms and hypoxic environment due to the presence of the conformer, which was therefore removed. Repeat samples were obtained for cultures and microscopy. No bacteria were seen on Gram stain, but yeast cells were detected by Giemsa staining. The vancomycin dosage was reduced. Cultures were nega-tive for bacteria positive for Candida sp. In the fifth month following the incident, the ocular surface infection had completely resolved. The removal of the conformer led to the inevitable consequences of severe symblepharon formation and secondary severe ocular surface damage (Figure 1 C).

caSe 2A 57-year-old man had molten bronze splashed into his right eye,

and was referred to our clinic 1 day after the first evaluation. On exa-

mination, visual acuity was finger counting at 1 m. Slit-lamp exami-nation showed that the upper and lower eyelids, along with the eye-lashes, were almost completely burned. The corneal epithelium was absent, and anterior segment details could not be visualized. Limbal ischemia was noted in the inferior half, and the bulbar conjunctiva was burned. Symblepharon formation was present in the inferior fornix. IOP was 19 mmHg as measured by the iCare Pro Tonometer (Figure 2 A). The ocular surface was rinsed with 1 L of Ringer’s lactate solution for 15 min with an eyelid speculum inserted. The same day, the patient was transferred to the operating room. Adhesions in the lower fornix were removed, AMT was performed, and a conformer was inserted. Medical treatment consisted of topical 10% acetylcystei-ne, 10% vitamin C, moxifloxacin, 1% cyclopentolate, preservative-free artificial tears, 1% prednisolone, and oral vitamin C 1.5 g/day.

At the two-weeks follow-up visit, oral acetazolamide 250 mg tablets were added due to IOP elevation to 28 mmHg. After one month, muco-purulent secretions, membranes on the upper and lower eyelids and palpebral conjunctiva, crusts, and amniotic membrane residues were removed under aseptic conditions after sampling for microbiological examination (Figure 2 B). The conformer was removed, cleaned, and replaced. Microscopy revealed gram-positive diplococci and yeast cells. Topical moxifloxacin was discontinued, and topical cefazolin (50 mg/mL), amphotericin B (1.5 mg/mL), 5% natamycin, and oral itra conazole (200 mg/day) were initiated. β-hemolytic streptococci and Candida spp. were isolated by culture.

One and half months later, despite the polymethylmethacrylate symblepharon ring (22 mm diameter, with a 10-mm-diameter hole in the middle), we found adhesions between the inferior palpebral conjunctiva and inferior corneal quadrant and intense granulation

Figure 1. A) Biomicroscopic examination showed burns of the upper and lower eyelids and eyelashes, total corneal loss of transperancy, 360° limbal ischemia, and diffuse burns in the bulbar conjunctiva approximately two and a half hours following an incidence of molten silver metal burn in the right eye. B) Central corneal melting, stromal infiltration, circumferential conjunctival hyperemia, chemosis, mucopurulent discharge, eyelid edema and eyelid hyperemia in the second month. C) Following removal of the conformer, severe symblepharon developed, resulting in total loss of the upper and lower fornices. Total corneal conjunctivalization was seen 5 months following the incidence.

A B C

Figure 2. A) External photograph 1 day after an incidence of a molten bronze metal burn in the right eye, showing burns of the upper and lower eyelids and all eyelashes. Entire corneal epithelium was damaged. Iris and lens details were hazy. 180° of the inferior limbus was ischemic and bulbar conjunctiva was burned. B) Mucopurulent secretions, membranes, crusts on the upper and lower eyelids and palpebral conjunctiva, and amniotic membrane residues on the cornea in the first month following the incidence. C) Severe hypertrophic and hyperemic conjunctiva migrated onto the opaque cornea. Symblepharon formation caused total adhesion of the superior and inferior fornix in the third month following the incidence.

A B C

Arici C, et al.


tissue in the conjunctiva; therefore, adhesions were released and gra-nulation tissue was excised. The 22-mm diameter symblepharon ring with five 2-mm-diameter holes was re-inserted. Oral non-steroidal anti-inflammatory drug was prescribed. Despite medical therapy, infiltrates developed in the superior nasal cornea. Mucopurulent secretion developed into purulent secretion, prompting a repeat of microbiologic analyses. Bacteria were not observed on Gram stain; however, yeast cells were observed in the Giemsa staining. Cefazolin dosage was reduced from the two-hourly regimen to four times a day. Topical (10 mg/mL) and oral (400 mg) voriconazole were added, whereas topical Natamycin 5% and oral topical itraconazole were stopped. While cultures were negative for bacteria, Candida spp. were isolated. Due to lack of clinical improvement, the symblepharon ring was removed. The infection improved clinically over the next month, but symblepharon formation was seen in the superior and inferior fornix. Migration of hypertrophic and hyperemic conjunctiva onto the opaque cornea was observed (Figure 2 C).

DISCUSSIONOcular thermal burns are among the most severe ocular surface

injuries and may lead to limbal stem cell deficiency(1,4). While mild burns heal within a few days, moderate to severe chemical and thermal burns cause ischemic necrosis of the cornea, conjunctiva, sclera, iris, and ciliary body by damaging the surface epithelium. It may also involve the eyelids and disrupt the ocular mechanical barrier. The inflammatory response that occurs due to leukocyte migration and inflammatory mediators causes scar tissue formation and perforation. The severity of tissue destruction in ocular thermal injury depends on at least four factors: temperature of the agent, heat-retaining capacity of the material, duration of contact, and area over which the heat is applied(2).

Ocular burns cause severe damage to ocular surface elements that provide protection against infections. Treatment in the acute period following an ocular surface burn should include topical antibiotics in an attempt to prevent opportunistic infections(4,5). Eyelids are also da-maged, the patient would require consultation with an oculoplastic surgeon if cicatricial changes ensue(5).

Several studies have investigated the impact of high tempera-ture on the ocular surface(6-8). Goldblatt et al.(8) examined the heat sensitivity of rabbit corneas with a heat conductor. Rabbit corneas were exposed to a temperature of 45°C for 15 min, but no damage was observed on light microscopy. After raising the temperature to 59°C for 15 min, diffuse corneal stromal edema and endothelial cell loss were observed. The first case in this report was admitted to the emergency department two hours after contact with molten sterling silver. Sterling silver is used in the jewelry and silverware industry and has a melting temperature of 893°C(9). During ocular surface irri gation, a hardened silver metal object of approximately 1 cm in diameter was observed buried into the upper fornix. In this case, it is possible that the heat-related damage may have been exacerbated due to longer heat conductance. The second case was exposed to liquid commercial bronze, which is an alloy of 90% copper and 10% zinc with a melting temperature of 1045°C(10). In clinical practice, molten metal or glass-like agents with high melting temperatures (1000°C) and significant heat-retaining capacity have been reported to cause severe burns and tissue opacification due to deep penetra-tion in the cornea(11).

According to the Roper Hall classification, which provides infor-mation about the extent of corneal involvement, severity of limbal ischemia, and prognosis, the first patient in this study had a stage 4 and the second had a stage 3 burn(12). In the first case, there was 360° limbal ischemia with accompanying burns in the bulbar conjunctiva, eyelids, and lashes. The second case had a relatively limited ischemia, involving 180° of the inferior limbus. Disruption of the mechanical

and secretory defense mechanisms of the ocular surface predisposed the patients to infections. In addition to severe sterile inflammation caused by thermal injury, a superimposed infection further increased the damage to the surface. Additionally, diffuse symblepharon deve-loped due to severe ocular surface inflammation.

The ocular surface should be examined daily for symblepharon formation. A symblepharon ring should be inserted as soon as possi-ble to prevent symblepharon formation. The largest size possible, allowing closure of eyelids, is preferable in order to prevent adhesions and shortening of the fornices without touching the cornea(4).

Several studies have reported successful treatment of ocular burns using AMT with or without limbal cell transplantation(13-18). AMT alone was reported to be efficient in terms of restoring ocular surfaces in cases of mild to moderate burns(14,16). In cases of severe burns, AMT restored the conjunctival surface without symblepharon and redu-ced limbal stromal inflammation but did not prevent limbal stem cell deficiency, which required further limbal stem cell transplantation(16). AMT was not successful in any of our two patients with similar results observed as in the study by Joseph et al.(19).

Despite aggressive treatment and close monitoring in in-patient settings, high-temperature ocular thermal burns may cause wides-pread damage to and severe inflammation of the ocular surface with a poor prognosis, especially in cases of superimposed infection. In these cases, appropriate expectations must be clarified and explicitly explained to the patient at the beginning, and psychiatric consulta-tion should be sought when necessary.

REFERENCES 1. Dua HS, King AJ, Joseph A. A new classification of ocular surface burns. Br J Ophthal-

mol. 2001;85(11):1379-83. Comment in: Br J Ophthalmol. 2004;88(10):1353-4; author reply 1354-5.

2. Shimazaki J, Konomi K, Shimmura S, Tsubota K. Ocular surface reconstruction for thermal burns caused by fireworks. Cornea. 2006;25(2):139-45.

3. Sharifipour F, Baradaran-Rafii A, Idani E, Zamani M, Jabbarpoor Bonyadi MH. Oxygen therapy for acute ocular chemical or thermal burns: a pilot study. Am J Ophthalmol. 2011;151(5):823-8.

4. Eslani M, Baradaran-Rafii A, Movahedan A, Djalilian AR. The ocular surface chemical burns. J Ophthalmol. 2014;2014:196827.

5. Fish R, Davidson RS. Management of ocular thermal and chemical injuries, including amniotic membrane therapy. Curr Opin Ophthalmol. 2010;21(4):317-21.

6. Campbell FW, Michaelson IC. Blood-vessel formation in the cornea. Br J Ophthalmol. 1949;33(4):248-55.

7. Lister A, Greaves DP. Effect of cortisone upon the vascularization which follows corneal burns. 1. Heat burns. Br J Ophthalmol. 1951;35(11):725-9.

8. Goldblatt WS, Finger PT, Perry HD, Stroh EM, Weiser DS, Donnenfeld ED. Hyperthermic treatment of rabbit corneas. Invest Ophthalmol Vis Sci. 1989;30(8):1778-83.

9. Untracht O. Jewelry Concepts & Technology. New York: Knopf Doubleday Publishing Group; 2011. p.393.

10. Untracht O. Jewelry Concepts & Technology. New York: Knopf Doubleday; 2011. p.52. 11. Hamill MB. Thermal burns. In: Krachmer JH, Mannis MJ, Holland EJ, editors. Cornea 3rd

ed. Philadelphia: Elsevier Mosby; 2011. p.1178-80. 12. Roper-Hall MJ. Thermal and chemical burns. Trans Ophthalmol Soc U K. 1965;85:631-53. 13. Uçakhan OO, Köklü G, Firat E. Nonpreserved human amniotic membrane transplan-

tation in acute and chronic chemical eye injuries. Cornea. 2002;21(2):169-72. 14. Gomes JA, dos Santos MS, Cunha MC, Mascaro VL, Barros Jde N, de Sousa LB. Amniotic

membrane transplantation for partial and total limbal stem cell deficiency secondary to chemical burn. Ophthalmology. 2003;110(3):466-73.

15. Tejwani S, Kolari RS, Sangwan VS, Rao GN. Role of amniotic membrane graft for ocular chemical and thermal injuries. Cornea. 2007;26(1):21-6.

16. Meller D, Pires RT, Mack RJ, Figueiredo F, Heiligenhaus A, Park WC, et al. Amniotic membrane transplantation for acute chemical or thermal burns. Ophthalmology. 2000; 107(5):980-9; discussion 990.

17. Sridhar MS, Bansal AK, Sangwan VS, Rao GN. Amniotic membrane transplantation in acute chemical and thermal injury. Am J Ophthalmol. 2000;130(1):134-7.

18. Shimazaki J, Yang HY, Tsubota K. Amniotic membrane transplantation for ocular surface reconstruction in patients with chemical and thermal burns. Ophthalmology. 1997;104(12):2068-76. Comment in: Ophthalmology. 2000;107(3):411-2.

19. Joseph A, Dua HS, King AJ. Failure of amniotic membrane transplantation in the treat-ment of acute ocular burns. Br J Ophthalmol. 2001;85(9):1065-9. Comment in: Br J Oph thalmol. 2002;86(7):831.

Case Report


INTRODUCTIONAcute lymphoblastic leukemia (ALL) is a malignant hematopoie-

tic neoplasia, which is rare in adults(1,2). In this condition, lymphoid precursors proliferate and replace normal marrow elements. Lym-phoblasts also proliferate in other organs, most commonly in the liver, spleen, and lymph nodes(1). Patients with ALL frequently present with fever and other symptoms related to either the lack of normal marrow cells (anemia, neutropenia, and thrombocytopenia) or symptoms related to the direct infiltration of the marrow or other organs by leukemic cells(1). In contrast to pediatric ALL, and despite intensive treatment, only 20%-46% of adults with ALL are cured(1,3).

Almost any ocular structure can be affected by leukemia, either through direct infiltration, hemorrhage, or ischemia (due to ane mia, thrombocytopenia, or leukostasis) or as a consequence of oppor tu nistic infections(4). The fundus of patients with ALL often exhibit in traretinal and/or white-centered hemorrhage, tortuous dilated veins, cotton wool spots, vascular sheathing, and leukemic infiltrates(4,5); mean-while, serous retinal detachment is a rare complication(4,5). Although fundus alterations are present in up to 90% of ALL patients over the course of the disease(5) and up to 50% at the time of diagnosis(6), these are usually asymptomatic and are rarely presenting sign of the disease(5).

The purpose of our study was to describe a case of ALL presenting with bilateral serous macular detachment in an adult.

CASE REPORTWe describe the case of a 63-year-old female who was admitted

to the emergency unit with bilateral, painless, and progressive loss of visual acuity developing over two weeks. The complete clinical his-tory was recorded, and physical examination revealed fever (38.3°C) and cervical lymphadenopathy.

Best-corrected visual acuity (BCVA) was 2/10 in the right eye and 3/10 in the left eye. Fundus examination (Figure 1 A, B) showed bi-lateral macular serous detachment, which was confirmed by optical coherence tomography (Figure 1 C, D). Central macular thickness on the right and left eye was 638 µm and 423 µm, respectively. Fluores-cein angiography (Figure 1 E, F) revealed hyperfluorescent pinpoints in the posterior poles. The limits of the macular detachment were revealed in the late phase of the angiogram.

Blood tests (Table 1) were performed and revealed anemia, neu-tropenia with 80% blast cells in the white cell series, thrombocyto-penia, and marginally increased C-reactive protein (CRP) levels. Based on these findings, the patient was referred to the Hematology De-partment, where bone marrow examination was performed (Figure 2), revealing increased cellularity with 97% blast cells. The patient was diagnosed with ALL type B (CD10+) using immunophenotyping.

Intensive systemic chemotherapy (rituximab-hyperCVAD (fractio-nated cyclophosphamide, vincristine, doxorubicin, and dexame tha-sone) regimen plus intrathecal therapy (methotrexate/cytara bine) was

Acute lymphoblastic leukemia presenting with bilateral serous macular detachment Leucemia linfoblástica aguda com descolamento macular seroso bilateral

luisa viEira1, nuno aguiar silva1, Marco dutra MEdEiros1,2, rita FlorEs1,2, vitor Maduro1,2

Submitted for publication: September 19, 2014 Accepted for publication: February 3, 20151 Central Lisbon Hospital Center, Lisbon, Portugal.2 NOVA Medical School, Lisbon, Portugal.



Corresponding author: Luísa Vieira. José António Serrano St. 1150-199 Lisbon, Portugal E-mail: [email protected]

ABSTRACTAcute lymphoblastic leukemia is a malignant hematopoietic neoplasia, which is rare in adults. Although ocular fundus alterations may be commonly observed in the course of the disease, such alterations are rarely the presenting signs of the disease. Here we describe the case of a patient with painless and progressive loss of visual acuity (right eye, 2/10; left eye, 3/10) developing over two weeks, accompanied by fever and cervical lymphadenopathy. Fundus examination showed bilateral macular serous detachment, which was confirmed by optical coherence tomography. Fluorescein angiography revealed hyperfluorescent pinpoints in the posterior poles. The limits of the macular detachment were revealed in the late phase of the angiogram. The results of blood count analysis triggered a thorough, systematic patient examination. The diagnosis of acute lymphoblastic leukemia B (CD10+) was established, and intensive systemic chemotherapy was immediately initiated. One year after the diagnosis, the patient remains in complete remission without any ophthalmologic alterations.

Keywords: Acute lymphoblastic leukemia; Serous macular detachment; Visual acuity; Optical coherence tomography; Fluorescein angiography

RESUMOA leucemia linfoblástica aguda é uma neoplasia maligna das células hematopoié-ticas, incomum em adultos. Apesar da maioria dos casos apresentar alterações no fundo ocular no decurso da doença, estas são raramente forma de apresentação da mesma. Descreve-se o caso de uma doente com diminuição progressiva e indolor da acuidade visual (OD 2/10 e OE 3/10), que apresentava concomitantemente febre e adenopatias cervicais, com duas semanas de evolução. À oftalmoscopia apresentava descolamento seroso macular bilateral, confirmado por tomografia de coerência ótica. A angiografia fluoresceínica revelou pequenas lesões hiperfluorescentes tipo pinpoints no polo posterior. Nos tempos médios e tardios do exame adivinham-se os limites da bolsa do descolamento do neuroepitélio. As alterações encontradas no hemograma suscitaram um estudo sistêmico extenso. O diagnóstico de leucemia linfoblástica aguda B (CD10+) foi efetuado, iniciando-se, de imediato, quimioterapia sistêmica intensiva. Um ano após o diagnóstico a doente continua em remissão e sem alterações oftalmológicas de novo.

Descritores: Leucemia linfoblástica aguda; Descolamento seroso macular; Acuidade visual; Tomografia de coerência ótica; Angiografia fluoresceínica

Vieira L, et al.


Figure 2. Giemsa-stained smear of bone marrow aspirate. A lymphoblast is indi-cated by the arrow.

Figure 3. Findings after the second cycle of chemotherapy: A) and B) Fundus photographs of the right and left eye, respectively, with no significant alterations. C) and D) Optical coherence tomography (horizontal sections) of the right and left eye, respectively, at the level of the fovea, showing reattached maculas.

A

C

B

D

A

C

E

B

D

F

Figure 1. Findings at presentation: A) and B) Fundus photographs of the right and left eye, respectively, showing shallow serous macular detachment. C) and D) Optical coherence tomography (horizontal sections) of the right and left eye, respectively, at the level of the fovea, showing neurosensory detachment, with central macular thickness of 638 µm and 423 µm in the right and left eye, respectively. E) and F) Fluo-rescein angiogram of the right and left eye, respectively, showing hyperfluorescent pinpoints in the posterior poles. The limits of the macular detachment were revealed in the late phase of the angiogram.

Table 1. Blood tests performed upon admission

Erythrocytes↓ 2.42 x 1012/L

Hemoglobin↓ 8.2 x 10g/L

Hematocrit↓ 24.7%

Mean cell volume↑ 102.1 fL

Mean cell hemoglobin↑ 33.9 pg

Red cell distribution width↑ 17.5%

Leucocytes↑↑ 25.40 x 109/L

Neutrophils↓ 0.76 x 109/L

Eosinophils 0.00 x 109/L

Basophils 0.00 x 109/L

Lymphocytes 4.32 x 109/L

Monocytes↓ 0.00 x 109/L

Blasts↑↑ 80%

Platelets↓ 66 x 109/L

Platelet distribution width↑ 18.8%

Erythrocyte sedimentation rate 12 mm/h

C-reactive protein↑ 14.4 mg/L

Liver and kidney function tests, autoimmune test, infection serological tests

No alterations

scheduled and initiated immediately. After the first che mo therapy cycle, complete remission was achieved, and a BCVA of 10/10 was obtained in both eyes with reattachment of the macula (Figure 3) after the second cycle. One year after the diagnosis, the patient remains in complete remission without any ophthalmologic alterations.

DISCUSSIONOphthalmological involvement in leukemia, which is more common

in acute than in chronic disease(4,6), is not unusual but is rarely a pre-senting sign of the disease(5). Although leukemic retinopathy (intra-retinal hemorrhages, white-centered hemorrhages and cotton-wool spots) is the most frequent fundus finding and retinal infiltrates are easily seen, choroidal infiltration is rarely observed clinically (5). Ho-wever, the choroid is affected in 30% to 93% of the cases as demons-trated by histopathological studies(2,4,7), and decreased thickness after chemotherapy has been reported by Bajenova et al.(7).

When the choroidal infiltration is severe, it leads to serous retinal detachment, which is reported to be shallow in the posterior pole, more common in adults, and bilateral(5).

Other diseases may present with serous macular detachment, such as central serous chorioretinopathy, age-related macular degenera-tion, Harada´s syndrome, melanoma, hemangioma, metastases, sympathetic ophthalmitis, posterior scleritis, and uveal effusion syn-drome. In our case, the existence of fever and cervical lymphadeno-pathy, and the absence of other relevant ophthalmologic or systemic findings, as revealed by clinical history and physical examination, led to the suspicion of hematologic neoplasia, with the angiogram results correlating with the findings described in the scientific lite-

Acute lymphoblastic leukemia presenting with bilateral serous macular detachment


rature(5). Moreover, the resolution of the macular detachment with systemic chemotherapy was in favor of our theory that serous macular detach ment was due to leukemic choroidal infiltration.

The physiopathological mechanism postulated(5) is that choroidal infiltration leads to a decreased blood flow in the choriocapillaris, re-sulting in ischemia and the disruption of the intercellular tight junctions or the necrosis of the retinal pigment epithelium, as evidenced by the multifocal hyperfluorescent pinpoints in the early phases of fluo-res cein angiography. This decompensated posterior blood-retinal barrier leads to exudation as evidenced by the diffuse subretinal accumulation of fluorescein in the late phase of the angiogram.

This rare case illustrates the importance of a systematic examina-tion in managing a case of bilateral macular serous detachment, with no other signs suggestive of local injury. This is particularly important when early treatment is imperative and is critical to patient survival.

ACKNOWLEDGEMENTSWe would like to thank the Department of Hematology for precious

contribution in the follow-up of this patient, and the Department of

Orthotics for valuable assistance in the acquisition of images for this article.

REFERENCES 1. Seiter K. Acute lymphoblastic leukemia. Available at http://emedicine.medscape.com/

article/207631-overview 2. Berthou C, Roncin S, Colin J, Abgrall JF. Ocular sites of acute leukemias. J Fr Ophtalmol.

1996;19(6-7):470-8. 3. Kim DY, Moon JH, Joo YD. Current status and future directions of clinical research and

practice in adult acute lymphoblastic leukemia patients in Korea. Blood Res. 2014 Jun; 49(2):80-2.

4. Gordon KB, Rugo HS, Duncan JL, Irvine AR, Howes EL, Jr, O’Brien JM, Carter SR. Ocular manifestations of leukemia: leukemic infiltration versus infectious process. Ophthal-mology. 2001;108(12):2293-300.

5. Riss JM, Kaplanski G, Righini-Chossegros M, Harle JR, Escoffier P, Saracco JB. Bilateral serous detachment of neuroepithelium of the posterior pole disclosing acute leuke-mia. J Fr Ophtalmol. 1990;13(11-12):563-8.

6. Reddy SC, Jackson N. Retinopathy in acute leukaemia at initial diagnosis: correlation of fundus lesions and haematological parameters. Acta Ophthalmol Scand. 2004 Feb; 82(1):81-5.

7. Bajenova NV, Vanderbeek BL, Johnson MW. Change in choroidal thickness after che-mo therapy in leukemic choroidopathy. Retina. 2012 Jan;32(1):203-5.

I Curso de Verão em Ciências da Audição, Visão, Comunicação e Estruturas Craniofaciais e Cervicais

Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço da Faculdade de Medicina

de Ribeirão Preto - USP

1 a 4 de fevereiro de 2016Campus da FMRP-USP

informações: Tel.: (16) 3602-2862


Case Report


INTRODUCTIONThe term pachychoroid neovasculopathy (PN) was first coined

by Freund(1) to describe a disease characterized by a form of type 1 (subretinal pigment epithelium) neovascularization involving dilated choroidal vessels in areas of increased choroidal thickness. Recently, it was posited that PN(1) should be grouped with macular diseases, including central serous chorioretinopathy(2) and pachychoroid pig-ment epitheliopathy(3), in which choroidal thickening of the macular region is demonstrated by enhanced depth imaging (EDI)-optical coherence tomography (OCT). In the first published paper regarding PN, Pang and Freund(1) described the occurrence of PN in three white female patients. Herein, we report the case of a male patient diagno-sed with PN and provide descriptions of our subsequent multimodal evaluation of this patient.

CASE REPORTWe report the case of a 58-year-old white male who presented

three years previously with impaired visual acuity affecting the left eye. The visual acuity was 20/25 in the right eye and 20/200 in the left eye. Ocular fundus examination revealed reduced fundus tessellation in the right eye (Figure 1 A). A semitranslucent epiretinal membrane caused macular distortion. Membrane contraction displaced the pa-

ramacular vessels toward the horizontal raphe in the left eye (Figure 1 A). Fluorescein angiography (FA) of the right eye demonstrated no window defects at any location. The left eye displayed staining in the vascular area of the epiretinal membrane (Figure 1 B). Spectral domain (SD)-OCT revealed retinal pigment epithelium abnormalities on the right eye and an epiretinal membrane with wrinkling of the inner retina of the left eye (Figure 1 C).

Two years after epiretinal membrane surgery on the left eye, the patient presented with a decrease in visual acuity of the right eye to 20/40; however, the visual acuity in the left eye had improved to 20/100. Multimodal evaluation was performed. Color photographs of the right eye revealed further reduction of fundus tessellation (Figure 2 A). In contrast to the examination at the initial presenta-tion demonstrating displacement of paramacular vessels toward the horizontal raphe, FA demonstrated poorly demarcated leakage in the right eye and regular retinal capillary calibers in the left eye (Figure 2 B). SD-OCT of the right eye revealed small pigment epithe-lial detachments and subretinal fluid. In the left eye, the epiretinal membrane and wrinkling of the inner retina had persisted from the initial presentation (Figure 3 A). By EDI-OCT, subchoroidal thicknesses in the affected right eye and normal left eye were 247 µm and 165 µm, respectively (Figure 3 B).

Pachychoroid neovasculopathy in a male patient: a case reportEspessamento de coroide com neovascularização em paciente do sexo masculino: relato de um caso

MiguEl hagE aMaro1, rubEns bElFort Matos Junior2

Submitted for publication: April 28, 2015 Accepted for publication: June 18, 20151 Instituto de Olhos e Laser de Belém, Belém, PA, Brazil.2 Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, SP, Brazil.



Corresponding author: Miguel Hage Amaro. Rua Quintino Bocaiuva, 516 - Belém, PA - 66053-240 Brazil - E-mail: [email protected]

ABSTRACTPachychoroid neovasculopathy is a form of type 1 (subretinal pigment epithelium) neovascularization characterized by the involvement of dilated choroidal vessels in areas of increased choroidal thickness. This disease was originally described in three white female patients. Here we report the multimodal evaluation of a clinical case of PN in a white male patient.

Keywords: Retinal pigment epithelium; Neovascularization; Choroid disease

RESUMOO espessamento de coroide com neovascularização é uma forma neovascularização de coroide tipo 1 (sub-epitélio pigmentar retiniano), que ocorre sobre áreas de aumen to da espessura da coroide e vasos coroidianos dilatados. Esta doença foi relatada em três pacientes brancas do sexo feminino. Descrevemos um caso clínico da doença com avaliação multimodal em um paciente do sexo masculino.

Descritores: Epitélio pigmentado da retina/patologia; Neovascularização; Doenças da coroide

Pachychoroid neovasculopathy in a male patient: a case report


Figure 3. A) SD-OCT images demonstrating a small PED and subretinal fluid in the right eye and persistence of the epiretinal membrane and wrinkling of the inner retina in the left eye. B) EDI-OCT measurement of subfoveal choroid thickness in the affected right eye and normal left eye.

B

B

C

A

Figure 1. A) Fundus tessellation in the right eye and an epiretinal membrane causing distortion of the macula in the left eye. B) Window defects in the right eye. The epiretinal membrane displaced the paramacular vessels toward the horizontal raphe in the left eye. C) SD-OCT images demonstrating RPE abnor-malities in the right eye and epiretinal membrane wrinkling of the inner retina in the left eye.

Figure 2. Progression of fundus tessellation two years later. B) FA two years later demonstrating poorly demarcated leakage in the right eye and regularity of retinal capillaries in the left eye.

A

B

Fundus autofluorescence was used to detect hyperfluorescent regions in the right eye. No abnormalities were observed in the left eye (Figure 4 A). Indocyanine green angiographic analysis of the area of hyperfluorescence in the right eye was consistent with leakage from a Type 1 occult choroidal neovascularization (CNV). No abnormalities consistent with CNV were observed in the left eye (Figure 4 B).

DISCUSSIONPN was originally reported in three white female patients(1). In

this report, we describe a case of PN in a male patient. Thus, PN does not appear to be gender-specific and may occur in white male popu-lations. The original paper(1) reported a mean subfoveal choroidal thickness in affected eyes of 310 µm with a range of 244 µm-407 µm. In our case study, a subfoveal choroidal thickness of 247 µm was re-corded in the affected eye; thus, our results corroborate the EDI-OCT findings of the original report(1).

In the original paper, polypoidal vascular lesions were observed in two of the three patients but were not observed in the patient described in this report at any point during diagnosis or treatment. Polypoidal choroidal vasculopathy, primarily a choroidal pathology, may occur as a result of long-standing Type 1 CNV in central serous

A

Amaro MH, Matos Junior RB


Figure 4. A) FAF demonstrating hypoautofluorescent regions in the right eye and no abnormalities on the left eye. B) Indocyanine green angiography revealed a region of hypofluorescence consistent with leakage from a type 1 occult CNV. No abnormalities consistent with CNV were observed in the left eye.

A

B

chorioretinopathy (CSCR)(4) or age-related macular degeneration (AMD)(4). The patient in this report had no history of AMD or pree-xisting conditions that may predispose to Type 1 CNV. An inherited

cause(5) has been posited to underlie pachychoroid retinal diseases as well as CSCR(6).

In conclusion, we present a clinical case of PN in a white male patient in contrast to the original description of PN in three white female patients.

ACKNOWLEDGEMENTSProfessor K Baylei Freund, MD, Professor of Ophthalmology at the

Vitreous Retina Macula Institute, New York reviewed and analyzed all images related to this case in collaboration with us.

REFERENCES 1. Pang CE, Freund KB. Pachychoroid neovasculopathy. Retina. 2015;35(1):1-9. 2. Spaide RF, Koizumi H, Pozzoni MC. Enhanced depth imagin spectral-domain optical

coherence tomography. Am J Ophthalmol. 2008;146(4):496-500. 3. Warrow DJ, Hoang QV, Freund KB. Pachychoroid pigment epitheliopathy. Retina.

2013;33(8):1659-72. 4. Fung AT, Yannuzzi LA, Freund KB. Type 1 (sub-retinal pigment epithelial) neovasculari-

zation in central serous chorioretinopathy masquerading as neovascular age-related macular degeneration. Retina. 2012;32(9):1829-37.

5. Lehman M, Bousquet R, Beydoun T, Behar-Cohen F. Pachychoroid. A Inherited condi-tion? Retina. 2015;35(1):10-6.

6. Schubert C, Pryds A, Zeng S,Xie Y, Freund, KB, Spaide RF, et al. Cadherin 5 is regulated by corticosteroids and associated with central serous chorioretinopathy. Human Mutat. 2014;35(7):859-67.

XXXV Congresso Internacional de OftalmologiaXXXIII Congresso Mexicano de Oftalmologia

XXXII Congresso Pan-Americano de Oftalmologia

5 a 9 de fevereiro de 2016Guadalajara - México

informações: Site: www.woc2016.org/

Review Article


Rho kinase inhibitors for glaucoma treatment - ReviewInibidores da Rho-Quinase para o tratamento do glaucoma - Revisão

rEnato antunEs schiavE gErMano1, siMonE Finzi1, PrataP challa2, rEMo susanna Junior1

Submitted for publication: August 4, 2015 Accepted for publication: October 1, 20151 Ophthalmology Department. Universidade de São Paulo (USP), São Paulo, SP, Brazil.2 Duke University Eye Center, Durham, NC, USA.



Corresponding author: Renato A. S. Germano. Av. Dr. Eneas de Carvalho Aguiar, 255 - São Paulo, SP - 05403-001 - Brazil - E-mail: [email protected]

INTRODUCTIONGlaucoma is a progressive optic neuropathy characterized by the

loss of ganglion cells and their axons, resulting in a distinctive appea-rance of the optic disc. Glaucoma is concomitant to visual loss and is the second leading cause of blindness in the world(1,2). The disease affected more than 60.5 million individuals in 2010 and is projected to reach 79.6 million by the year 2020(2). Glaucoma is almost always asymptomatic, particularly during the early stages, which is why it remains undiagnosed in up to half of the total cases in developed nations, with even higher undiagnosed rates in parts of the develo-ping world(3,4).

A major risk factor for glaucomatous visual field loss is elevated intraocular pressure (IOP)(5), and several studies have shown that lowering IOP reduces the risk of glaucomatous progression(6,7). Eye drops, oral medications, laser therapy, and surgery have all been used to decrease IOP in glaucoma patients.

Currently, there are five main classes of eye drops for IOP re-duction: cholinergic (pilocarpine), β-blockers, α-agonists, carbonic anhydrase inhibitors, and prostaglandin analogs. However, for many patients, these medications in monotherapy do not effectively control IOP, and approximately half of patients with elevated IOP are trea ted by co-administration of two or more glaucoma medica-tions(8). Further, all of these classes of eye drops present ocular and systemic adverse effects that can impair the effectiveness of the treatment. Therefore, researchers are currently searching for new IOP-lowering drugs.

ABSTRACTGlaucoma is a progressive optic neuropathy characterized by the loss of ganglion cells and their axons. A major risk factor for glaucomatous visual field loss is eleva-ted intraocular pressure (IOP), and several studies have shown that lowering IOP reduces the risk of glaucomatous progression. Currently, an increasing number of researches involve Rho kinase inhibitors, which are a new pharmacological class of hypotensive agents specifically targeting the diseased trabecular outflow pathway. Rho kinase inhibitors reduce IOP by increasing aqueous humor drainage through the primary outflow pathway in the eye, which is known as the trabe-cular meshwork. In addition to improving the outflow facility of the trabecular meshwork, Rho kinase inhibitors also enhance retinal ganglion cell survival after ischemic injury and increase ocular blood flow.

Keywords: Glaucoma; Intraocular pressure; Rho-associated kinases; Aqueous humor; Trabecular meshwork

RESUMOGlaucoma é uma neuropatia óptica progressiva, caracterizada pela perda de cé-lulas ganglionares e seus axônios. O principal fator de risco que leva à perda de campo visual relacionada ao glaucoma é a elevação da pressão intraocular (PIO) e vários estudos mostraram que a redução da pressão intraocular diminui o risco de progressão do glaucoma. Atualmente, uma nova classe de drogas hipotensoras foi desenvolvida e tem sido cada vez mais estudada, os inibidores da Rho-Kinase. Essas drogas reduzem a pressão intraocular aumentando a drenagem de humor aquoso através da via de drenagem primária do humor aquoso no olho, a malha trabecular. Além de aumentar o escoamento pela malha trabecular, inibidores da Rho-kinase também aumentam a sobrevivência das células ganglionares retinianas após isquemia e aumentam o fluxo ocular sanguíneo.

Descritores: Glaucoma; Pressão intraocular; Quinases associadas a Rho; Humor aquoso; Malha trabecular

At present, the available pharmacological treatments for glauco-ma lower IOP either by decreasing the production of aqueous humor via the ciliary process (i.e., β-blocker agents, carbonic anhydrase inhibitors, and α-agonists) or by improving aqueous humor outflow via an unconventional pathway (i.e., prostaglandin analogs)(9-12). Mus-carinic agonists, such as pilocarpine, can increase aqueous humor drainage via the conventional outflow pathway by contracting the ciliary muscle and pulling on the sclera spur to favorably change the architecture of the tissues of the conventional outflow pathway. However, there are no pharmacological agents that specifically target the diseased trabecular outflow pathway.

Small-molecule inhibitors of Rho-associated protein kinase (ROCK) are a new drug class that have recently been studied as potential glau-coma therapeutics. Honjo et al.(13) first described lowering IOP in rabbits’ eyes using a selective ROCK inhibitor, Y-27632. ROCK inhibitors reduce IOP by increasing aqueous humor drainage through the primary outflow pathway in eyes, which is known as the trabecular meshwork (TM)(14). In addition to improving the outflow facility of the TM, ROCK inhibitors also enhance retinal ganglion cell survival after ischemic injury(15,16) and increase ocular blood flow(17). Due to these functions, ROCK inhibitors have recently gained interest and are the focus of several ongoing clinical trials.

PhySiology of aqueouS humor outflow

The balance between the inflow and outflow of aqueous humor is responsible for IOP. Once produced, aqueous humor migrates from

Germano RAS, et al.


the posterior chamber to the anterior chamber, where it is drained out of the eye. There are two aqueous humor outflow pathways in the eye. Under normal conditions, the TM is responsible for the majority of the aqueous humor outflow(18,19). An auxiliary “unconventional” uveos-cleral pathway exists through the iris root and ciliary muscle, but it carries less than 10% of the total aqueous humor flow in the eye(20).

The TM can be subdivided into three regions: the uveal meshwork, corneoscleral meshwork, and juxtacanalicular connecti ve tissue (JCT). After passing through the TM, the aqueous humor drains through Schlemm’s canal (SC) and then enters the systemic circulation through the episcleral veins. An increased resistance to flow in the conventional pathway (which carries up to 90% of the total aqueous humor out of the eye) is predominantly responsible for the elevated IOP in many types of glaucoma. In primary open-angle glaucoma (POAG), the most common type, increased outflow resistance has been classically associated with the juxtacanalicular portion of the TM mediated through the extracellular matrix (ECM) as well as in the endothelial-lined SC(21,22). Morphologically, the TM is a complex tissue consisting of TM cells, ECM, and empty spaces, which the aqueous humor runs through. These spaces gradually become smaller as they get closer to SC, and the density of the TM cells and ECM is relatively high in this area, resulting in a higher resistance to flow. The tissues of the conventional outflow pathway have unique morphological and functional properties with subtle complexities(23). The functional properties of the TM are often affected in individuals of increasing age and those with ocular disease, such as POAG(24).

Besides the simple static anatomy of the aqueous humor flow, the conventional outflow pathway is also influenced by the contraction of the ciliary muscle when exposed to a muscarinic agent such as pilocarpine. When the ciliary muscle contracts, its insertions widen the intercellular spaces in the TM and the permeability of the tissue increases; simultaneously, the uveoscleral outflow decreases(25). However, other studies have shown that the TM is also thought to have a dynamic regulatory mechanism due to its smooth-muscle-like properties, as evidenced by the expression of α-smooth muscle actin and myosin, ion channels, and G-protein-coupled receptors in TM cells(26,27). Moreover, physiological contractile agonists, cytokines, growth factors, as well as pharmacological agents, have been shown to influence the contractile and relaxation properties of TM tissue(26,28). Based on perfusion studies using anterior segments of the eye, the TM alone has been shown to participate in the regulation of aqueous outflow through SC(29,30). The actomyosin system, composed of the contractile proteins actin and myosin, is responsible for regulating contraction and relaxation in muscle tissues, and this system is pre-sent in the TM and JCT/SC. In addition, the contractile and relaxation power of the TM influences aqueous humor outflow in an antagonis-tic manner(26,31). Relaxation of the TM relaxes the cellular actomyosin system, resulting in cellular relaxation and/or cell shape alteration, which increases the size of the intercellular spaces, leading to increa-sed aqueous outflow(25,26).

The concentration of transforming growth factor β (TGF-β) in the aqueous humor of glaucomatous patients is higher than that in healthy controls, and TGF-β is believed to play an important role in the patho-genesis of glaucoma(32-34). Other bioactive endogenous mediators of contractility molecules, such as cytokines and endothelin, are also present in higher concentrations in glaucomatous eyes(35).

rho kinaSe Signaling in Smooth muScle contraction

The regulation of TM contractility is controlled by both cal cium-de-pendent and calcium-independent mechanisms. Smooth muscle contraction is known to be predominantly regulated by the phos-phorylation of myosin light chain (MLC). MLC is phosphorylated by calcium/calmodulin-dependent MLC kinase (MLCK) and dephos-phorylated by calcium-independent MLC phosphatase (MLCP)(36). Besides this regulation by Ca2+ concentration, MLC phosphorylation

can be modulated via signaling pathways such as the Rho/Rho kinase pathway.

Downstream effectors of Rho include the ROCKs, which are pro-tein-serine/threonine kinases. Structurally, ROCKs are composed of three major domains: an N-terminal kinase domain that phospho-rylates protein targets, a C-terminal auto-inhibitory domain that li mits kinase activity via intermolecular interactions, and a coiled-coil Rho-binding domain that appears to facilitate the switch from the inactive to the active conformation (Figure 1)(37). ROCKs can phos-phorylate the same serine residue of MLC phosphorylated by MLCK(37) in a manner independent of calcium concentrations, leading to enhanced smooth muscle contraction. Further, ROCKs can phosphorylate myo-sin phosphatase, which leads to its inactivation.

rock inhibitorS

TM and ciliary muscle tissue are known to express many compo-nents of the Rho signaling pathway, such as ROCK1 and ROCK2, RhoA, MLC, MLCK, and MLCP(38). Thus, ROCK activity through the Rho signa-ling pathway is thought to be a key player in regulating the cellular morphology and contractility of the conventional outflow pathway. ROCK inhibitors are the first class of glaucoma drugs to increase aqueous humor outflow by working directly on the TM and SC cells, thus lowering IOP. Different ROCK inhibitors (Y-27632, H-1152, and fasudil) have been shown to induce rapid and long-lasting lowering of IOP (within 30 min and lasting for 6-12 h) in various animal models, including rabbit and monkey(39-41).

The exact mechanism by which Rho inhibitors increase the outflow facility through the conventional pathway is not completely unders-tood. It is hypothesized that by inhibiting ROCK, specific compo-nents of the cellular cytoskeleton are disrupted, thus reducing the contractile tone of the tissues of the conventional outflow pathway. The final effect of these two mechanisms would be the increase of the paracellular fluid flow through the inner wall of the SC due to the altered cell shape and cell junctions and the relaxation of the TM and JCT, thereby leading to an increase in outflow facility and a lowering of IOP.

other aPPlicationS of rock inhibitorS

Several studies have shown that ROCK inhibitors may also benefit glaucoma patients by improving the ocular blood flow as well as presenting potential neuroprotective effects; there is also evidence showing that they may prevent postoperative scarring after glauco-ma filtration surgery(42,43). ROCK inhibitors increase blood flow under systemic hypertensive conditions via relaxation of vascular endo-thelial smooth muscle. As altered ocular blood flow is believed to be key to the pathophysiology of certain types of glaucoma(44), ROCK inhibitors could provide additional benefit as therapeutics agents for glaucoma.

ROCK inhibitors have also been shown to play roles in neuron survival and axon regeneration(45). Finally, ROCK inhibitors have been

Figure 1. Structures of ROCK isoforms. Modified from Liao JK, Seto M, Noma K. Rho kinase (ROCK) inhibitors. J Cardiovasc Pharmacol 2007;50(1):17-24(37)

Rho kinase inhibitors for glaucoma treatment - Review


reported to block TGF-β myofibroblast transdifferentiation of human tendon fibroblasts, which suggests that ROCK inhibitors may reduce postoperative scarring after glaucoma filtration surgery(46).

unDeSirable effectS of rock ROCK inhibitors have been shown to be potent vasodilators, in-

cluding in the conjunctival vasculature. Arnold et al.(47) studied the effects of Y-27632 on the intraocular penetration of timolol maleate, and they found that ROCK inhibitors reduced the intraocular pene-tration of timolol, presumably due to increased systemic elimination through the conjunctival vasculature.

Bacharach et al.(48) evaluated the efficacy and safety of AR-13324 ophthalmic solution in terms of ocular hypertension (OH) compared with a control group using latanoprost in patients with open-angle glaucoma or OH. Patients were randomized to receive AR-13324 ophthalmic solution 0.01%, daily (pm), AR-13324 ophthalmic solution 0.02% daily (pm), or latanoprost 0.005% daily (pm) for 28 days. Their results showed that AR-13324 0.02% was less effective in terms of lowering OH than latanoprost by approximately 1 mmHg; the major safety finding was ocular hyperemia, which was more common for both concentrations of AR-13324 than for latanoprost.

Tanihara et al.(49) studied the dose dependency and safety of the ROCK inhibitor K-115. Two hundred ten patients with POAG or OH were subdivided into four groups and were treated with K-115 at concentrations of 0.1%, 0.2%, and 0.4% or placebo twice daily for eight weeks. The dose response of IOP reduction and the incidence of adverse events in the K-115 and placebo groups were investigated. The mean IOP reduction was -3.1 mmHg at 8 h after instillation in the 0.4% group, and all groups presented mild conjunctival hyperemia. The ROCK inhibitor SNJ-1656 was also demonstrated to be a safe hypotensive topical agent in human eyes(50).

All recent human clinical trials have showed that mild-to-mode-rate conjunctival hyperemia is the main adverse effect of ROCK inhibitors(47-52).

CONCLUSIONUnlike all other topical glaucomatous drugs, ROCK inhibitors target

the trabecular pathway and act by increasing the aqueous humor outflow. This review has also described how these drugs enhance ocular blood flow and present neuroprotective effects as well as how they may inhibit scarring after glaucoma filtration surgery. This article also presents the newest clinical trials published in the literature on this topic, thus updating the current status of these drugs for use in glaucomatous eyes.

To date, several studies have demonstrated that the efficacy of ROCK inhibitors on OH is clinically and statistically significant in patients with OH and glaucoma. However, it remains to be seen in future clinical trials whether adverse side effects, such as conjunctival hyperemia, will lower patient compliance. Finally, further research is warranted to assess whether ROCK inhibitors can be synergistically used with other IOP-lowering drugs.

REFERENCES 1. Weinreb RN, Khaw PT. Primary open-angle glaucoma. Lancet. 2004;363(9422):1711-20.

Comment in: Lancet. 2004;364(9442):1311-2. 2. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010

and 2020. Br J Ophthalmol. 2006;90(3):262-7. Comment in: Br J Ophthalmol. 2006;90(3): 253-4.

3. Quigley HA. Glaucoma. Lancet. 2011;377(9774):1367-77. 4. Budenz DL, Barton K, Whiteside-de Vos J, Schiffman J, Bandi J, Nolan W, HerndonL,

Kim H, Hay-Smith G, Tielsch JM; Tema Eye Survey Study Group. Prevalence of glau-coma in an urban West African population: the Tema Eye Survey. JAMA Ophthalmol. 2013;131(5):651-8.

5. The Advanced Glaucoma Intervention Study (AGIS):7. The relationship between con-trol of intraocular pressure and visual field deterioration. The AGIS Investigators. Am J Ophthalmol. 2000;130(4):429-40. Comment in: Am J Ophthalmol. 2000;130(4):490-1.

6. Heijl A, Leske MC, Bengtsson B, Hyman L, Hussein M; Early Manifest Glaucoma Trial Group. Reduction of intraocular pressure and glaucoma progression: results from the early manifest glaucoma trial. Arch Ophthalmol. 2002;120(10):1268-79. Comment in: JAMA. 2002;288(20):2607-8. Optom Vis Sci. 2002;79(12):741-2. Arch Ophthalmol. 2002;120(10):1371-2.

7. Lichter PR, Musch DC, Gillespie BW, Guire KE, Janz NK, Wren PA, Mills RP; CIGTS Study Group. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Stu-dy comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108(11):1943-53. Comment in: Ophthalmology. 2003;110(2):249; author reply 249. Ophthalmology. 2001;108(11):1939-40.

8. Kass MA, Gordon MO, Gao F, Heuer DK, Higginbotham EJ, Johnson CA, Keltner JK, Mil-ler JP, Parrish RK, Wilson MR; Ocular Hypertension Treatment Study Group. Delaying treatment of ocular hypertension: the ocular hypertension treatment study. Arch Ophthalmol. 2010;128(3):276-87. Comment in: Arch Ophthalmol. 2010;128(3):363-4.

9. Robin AL, Burnstein Y. Selectivity of site of action and systemic effects of topical alpha agonists. Curr Opin Ophthalmol. 1998;9(2):30-3.

10. Watanabe K, Chiou GC. Action mechanism of timolol to lower the intraocular pres-sure in rabbits. Ophthalmic Res. 1983;15(3):160-7.

11. Mincione F, Scozzafava A, Supuran CT. The development of topically acting carbonic anhydrase inhibitors as anti-glaucoma agents. Curr Top Med Chem. 2007;7(9):849-54.

12. Linden C, Alm A. Prostaglandin analogues in the treatment of glaucoma. Drugs Aging. 1999;14(5):387-98.

13. Honjo, M, Inatani, M, Kido, N, Sawamura, T, Yue, BY, Honda, Y, et al. A myosin light chain kinase inhibitor, ML-9, lowers the intraocular pressure in rabbit eyes. Exp Eye Res. 2002;75(2):135-42.

14. Tokushige H, Inatani M, Nemoto S, Sakaki H, Katayama K, Uehata M, et al. Effects of topical administration of Y-39983, a selective rho-associated protein kinase inhibitor, on ocular tissues in rabbits and monkeys. Invest Ophthalmol Vis Sci. 2007;48(7):3216-22.

15. Hirata A, Inatani M, Inomata Y, Yonemura N, Kawaji T, Honjo M, et al. Y-27632, a Rho- associated protein kinase inhibitor, attenuates neuronal cell death after tran-sient retinal ischemia. Graefes Arch Clin Exp Ophthalmol. 2008;246(1):51-9.

16. Tura A, Schuettauf F, Monnier PP, Bartz-Schmidt KU, Henke-Fahle S. Efficacy of Rho-kinase inhibition in promoting cell survival and reducing reactive gliosis in the rodent retina. Invest Ophthalmol Vis Sci. 2009;50(1):452-61.

17. Sugiyama T, Shibata M, Kajiura S, Okuno T, Tonari M, Oku H, et al. Effects of fasudil, a rho-associated protein kinase inhibitor, on optic nerve head blood flow in rabbits. Invest Ophthalmol Vis Sci. 2011;52(1):64-9.

18. Tamm ER. The trabecular meshwork outflow pathways: structural and functional aspects. Exp Eye Res. 2009;88(4):648-55.

19. Johnson M. What controls aqueous humor outflow resistance? Exp Eye Res. 2006; 82(4):545-57.

20. Bill A, Phillips CI. Uveoscleral drainage of aqueous humor in human eyes. Exp Eye Res. 1971;12(3):275-81.

21. Zhou EH, Krishnan R, Stamer WD, Perkumas KM, Rajendran K, Nabhan JF, et al. Me-chanical responsiveness of the endothelial cell of Schlemm’s canal: scope, variability and its potential role in controlling aqueous humour outflow. J R Soc Interface. 2012; 9(71):1144-55.

22. Maepea O, Bill A. Pressures in the juxtacanalicular tissue and Schlemm’s canal in monkeys. Exp Eye Res. 1992; 54(6):879-83.

23. Lutjen-Drecoll E. Functional morphology of the trabecular meshwork in primate eyes. Prog Retin Eye Res. 1999;18(1):91-119.

24. Gabelt BT, Kaufmann PL. Changes in aqueous humor dynamics with age and glau-coma. Prog Retin Eye Res. 2005;24(5):612-37.

25. Llobet A, Gasull X, Gual A. Understanding trabecular meshwork physiology: a key to the control of intraocular pressure? News Physiol Sci. 2003;18:205-9.

26. Wiederholt M, Thieme H, Stumpff F. The regulation of trabecular meshwork and ciliary muscle contractility. Prog Retin Eye Res. 2000;19(3):271-95.

27. De Kater AW, Shahsafaei A, Epstein DL. Localization of smooth muscle and nonmuscle actin isoforms in the human aqueous outflow pathway. Invest Ophthalmol Vis Sci. 1992;33(2):424-9.

28. Nakamura Y, Hirano S, Suzuki K, Seki K, Sagara T, Nishida T. Signaling mechanism of TGF-beta1-induced collagen contraction mediated by bovine trabecular meshwork cells. Invest Ophthalmol Vis Sci. 2002;43(11):3465-72.

29. Epstein DL, Rowlette LL, Roberts BC. Acto-myosin drug effects and aqueous outflow function. Invest Ophthalmol Vis Sci. 1999;40(1):74-81.

30. Wiederholt M. Direct involvement of trabecular meshwork in the regulation of aqueous humor outflow. Curr Opin Ophthalmol. 1998;9(2):46-9.

31. Rao PV, Deng P, Sasaki Y, Epstein DL. Regulation of myosin light chain phosphoryla-tion in the trabecular meshwork: role in aqueous humor outflow facility. Exp Eye Res 2005;80(2):197-206.

32. Inatani M, Tanihara H, Katsuta H, Honjo M, Kido N, Honda Y. Transforming growth factor-beta 2 levels in aqueous humor of glaucomatous eyes. Graefes Arch Clin Exp 2001;239(2):109-13.

33. Picht G, Welge-Luessen U, Grehn F, Lutjen-Drecoll E. Transforming growth factor beta 2 leves in the aqueous humor in different types of glaucoma and the relation to filtering bleb development. Graefes Arch Clin Exp Ophthalmol. 2001;239(3):199-207.

34. Tripathi RC, Li J, Chan WF, Tripathi BJ. Aqueous humor in glaucomatous eyes contains an increased level of TGF-beta2. Exp Eye Res 1994;59(6):723-7.

Germano RAS, et al.


35. Tezel G, Kass MA, Kolker AE, Becker B, Wax MB. Plasma and aqueous humor endothelin levels in primary open-angle glaucoma. J Glaucoma 1997;6(2):83-9.

36. Pfitzer G. Invited review: regulation of myosin phosphorylation in smooth muscle. J Appl Physiol. 2001;91(1):32-9.

37. Liao JK, Seto M, Noma K. Rho kinase (ROCK) inhibitors. J Cardiovasc Pharmacol 2007; 50(1):17-24.

38. Rao PV, Deng PF, Kumar J, Epstein DL. Modulation of aqueous humor outflow facility by the Rho kinase-specific inhibitor Y27632. Invest Ophthalmol Vis Sci. 2001;42(5): 1029-37. Erratum in: Invest Ophthalmol Vis Sci. 2001;42(8):1690.

39. Honjo M, Tanihara H, Inatani M, Kido N, Sawamura T, Yue BY, et al. Effects of rho-asso-ciated protein kinase inhibitor Y-27632 on intraocular pressure and outflow facility. Invest Ophthalmol Vis Sci 2001;42(1):137-44.

40. Tamura M, Nakao H, Yoshizaki H, Shiratsuchi M, Shigyo H, Yamada H, et al. Development of specific Rho-kinase inhibitors and their clinical application. Biochim Biophys Acta. 2005; 30;1754(1-2):245-52.

41. Honjo M, Inatani M, Kido N, Sawamura T, Yue BY, Honda Y, et al. Effects of protein kinase inhibitor, HA1077, on intraocular pressure and outflow facility in rabbit eyes. Arch Ophthalmol. 2001;119(8):1171-8.

42. Tokushige H, Waki M, Takayama Y, Tanihara H. Effects of Y-39983, a selective Rho-associa-ted protein kinase inhibitor, on blood flow in optic nerve head in rabbits and axonal regeneration of retinal ganglion cells in rats. Curr Eye Res. 2011;36(10):964-70.

43. Honjo M, Tanihara H, Kameda T, Kawaji T, Yoshimura N, Araie M. Potential role of Rho-associated protein kinase inhibitor Y-27632 in glaucoma filtration surgery. Invest Ophthalmol Vis Sci. 2007;48(12):5549-57.

44. Stefansson E, Pedersen DB, Jensen PK, la Cour M, Kiilgaard JF, Bang K, et al. Optic nerve oxygenation. Prog Ret Eye Res. 2005;24(3):307-32.

45. Rao VP, Epstein DL. Rho GTPase/Rho kinase inhibition as a novel target for the treatment of glaucoma. Bio Drugs. 2007;21(3):167-77.

46. Meyer-ter-Vehn T, Sieprath S, Katzenberger B, Gebhardt S, Grehn F, Schlunck G. Con-tractility as a prerequisite for TGF-beta-induced myofibroblast transdifferentiation in human tenon fibroblasts. Invest Ophthalmol Vis Sci. 2006;47(11):4895-904.

47. Arnold JJ, Hansen MS, Gorman GS, Inoue T, Rao V, Spellen S, et al. The effect of Rho-associated kinase inhibition on the ocular penetration of timolol maleate. Invest Ophthalmol Vis Sci. 2013;54(2):1118-26.

48. Bacharach J, Dubiner HB, Levy B, Kopczynski CC, Novack GD; AR-13324-CS202 Study Group. Double-masked, randomized, dose-response study of AR-13324 versus lata-noprost in patients with elevated intraocular pressure. Ophthalmology. 2015;122(2): 302-7

49. Tanihara H, Inoue T, Yamamoto T, Kuwayama Y, Abe H, Araie M; K-115 Clinical Study Group. Phase 2 randomized clinical study of a Rho kinase inhibitor, K-115, in primary open-angle glaucoma and ocular hypertension. Am J Ophthalmol. 2013;156(4):731-6.

50. Tanihara H, Inatani M, Honjo M, Tokushige H, Azuma J, Araie M. Intraocular pres su-re-lowering effects and safety of topical administration of a selective ROCK inhibitor, SNJ-1656, in healthy volunteers. Arch Ophthalmol. 2008;126(3):309-15.

51. Tanihara H, Inoue T, Yamamoto T, Kuwayama Y, Abe H, Araie M; K-115 Clinical Study Group. Phase 1 clinical trials of a selective Rho kinase inhibitor, K-115. JAMA Ophthal-mol. 2013;131(10):1288-95.

52. Williams RD, Novack GD, van Haarlem T, Kopczynski C; AR-12286 Phase 2A Study Group. Ocular hypotensive effect of the Rho kinase inhibitor AR-12286 in patients with glaucoma and ocular hypertension. Am J Ophthalmol. 2011;152(5):834-41.

VI Simpósio de Atualização do Hospital Banco de Olhos de Porto Alegre

1 e 2 de abril de 2016Sede da AMRIGSPorto Alegre - RS

informações:Site: www.hbo.br/simposio

Letters to the Editor

392 Arq Bras Oftalmol. 2015;78(6):392 http://dx.doi.org/10.5935/0004-2749.20150104

A review of “cataract surgery teaching”

Um comentário sobre o “ensino de cirurgia de catarata”

Dear Editor:I read with great interest the editorial entitled “Cataract surgery

teaching” by Soriano(1), wherein he described features of surgical trai-ning in Brazil. We congratulate the author on his extensive experience and ideas. However, I would like to offer my thoughts regarding this editorial as cataract surgery teaching is one of our research interests.

We agree with Dr. Soriano that, in accordance with scientific me thodology, goals should be established and results should be analyzed with the use of progress indicators and complication rates, such as evaluation elements. A clinical study of training surgeons at the University of São Paulo was recently published, in which senior residents were reportedly able to achieve an acceptable complica-tion rate with proper training and supervision(2).

The “backward” methodology, which involves dividing surgery into five stages, is an excellent proposal; the instructor performs the first 4 stages and the student performs the last stage. We consider capsulorhexis and the initial fracture of the lens nucleus to be the most difficult and compromising steps of cataract surgery(3).

The balance between quantity and quality will always be a dilemma. However, we emphasize the importance of theoretical knowledge in optimizing practical training. In the phacoemulsification technique, a very specific technology is used where physical concepts of fluids and vectors are important in almost all surgical maneuvers. Therefore, we hypothesize that, beyond study through textbooks, novice surgeons should receive at least 60 h of theoretical class before starting to effectively operate. These should include videos with commentary and interactive explanations of the functioning of the phacoemulsification machine, lens nucleus fracture techniques, and the management of difficult cases. Thus, the quality and safety of operations are improved, with fewer procedures required to achieve self-sufficiency(3,4).

In 2011, we evaluated the quality of cataract surgery teaching at 11 university hospitals in Brazil(4). We ascertained that, on an average, the number of phacoemulsification procedures performed by resi-dents at the end of training programs at the studied hospitals was approximately 130 surgeries, which is an excellent quantity. We then evaluated the quality indicators of surgical treatment and observed that all researched services had safe and precise phacoemulsificators.

The viability of modern technology use in public hospitals has been previously reported(5). The majority of surgeries were performed under the supervision of an expert surgeon. Nevertheless, when we evaluated theoretical load, another important indicator of surgery teaching quality, the result was below expected. We observed that the majority of teaching services offered less than 10 h of specific theory. We considered that the sophistication and improvement in this surgical technique comprised knowledge of phacoemulsifi-cation apparatus, physical and fluidic parameters, and mechanical force associated with surgical maneuvers. Accurate programming and control of phacoemulsificator functions are vital for precise and safe surgery. Careful choice of the technique used to break the nucleus and understanding of the involved maneuvers are essential for a safe and reproducible surgical strategy. Many of these valuable sources of information are not described in text books or may not be understood without special didactic resources aids, such as movies and animation, besides the possibility of a response to casual doubts.

Therefore, we believe that the current teaching of phacoemulsi-fication provided to surgical trainees in Brazil is adequate. Neverthe-less, a greater investment in theoretical information to improve trai-ning quality is yet to be observed, although the majority of university hospitals have safe and adequate surgical orientations. Furthermore, there is a lack of extra time in training curricula and the availability of motivated expert surgeons able to teach theory limiting further improvements in the sophistication and safety of surgical training.

Newton Kara-Junior1

Submitted for publication: October 2, 2015 Accepted for publication: October 20, 20151 Department of Ophthalmology, Universidade de São Paulo, São Paulo, SP, Brazil.



Corresponding author: Newton Kara-Junior. Department of Ophthalmology. Universidade de São Paulo - Av. Dr. Enéas Carvalho de Aguiar, 255 - São Paulo, SP - 04510-001 - Brazil


REFERENCES 1. Soriano ES. Cataract surgery teaching. Arq Bras Oftalmol. 2015;78(4):V-VI. 2. Barreto Jr J, Primiano Jr H, Espíndola RF, Germano RA, Kara-Junior N. [Cataract surgery

performed by residents: risk analysis]. Rev Bras Oftalmol. 2010;69(5):301-5. Portuguese. 3. Kara-Junior N, Santhiago MR, Kawakami A, Carricondo PC, Hida WT. Mini-rhexis for

white intumescent cataracts. Clinics (São Paulo). 2009;64(4):309-12. 4. Kara-Junior N. A situação do ensino da facoemulsificação no Brasil. Rev Bras Oftalmol.

2011;70(5):275-7. 5. Kara-Junior N, Espíndola RF. [Evolution and viability of an outpatient surgery center

for cataract surgery on a large scale in a university hospital]. Arq Bras Oftalmol. 2010; 73(6):494-6. Portuguese.

Letters to the Editor


Production of an intraocular device using 3D printing: an innovative technology for ophthalmology

Primeiro dispositivo intraocular utilizando impressão 3D: uma tecnologia inovadora para oftalmologia

Three-dimensional (3D) printing, also termed additive manu-facturing, allows the creation of 3D objects from digital files. In 3D printing, additive processes are used to lay down successive layers of material until the entire object is created. 3D printing technology has become widely used cost-effective alternative for small-scale productions and has numerous advantages; objects of almost any shape can be printed using extensive variety of different materials, including plastics, metals, ceramics, food, paper, wood filament, and biomaterials(1).

3D technology is opening up new perspectives in research(2) and has begun to revolutionize the field of Health Sciences by facilitating low-cost manufacturing and custom surgical devices, 3D models for use in preoperative planning and surgical education, and fabricated biomaterials. However, there is a lack of data regarding the viability of 3D printing for the production of surgical instruments(3). Methods for the printing live cells, tissues, and organs, termed 3D bioprinting, is under development, with several studies demonstrating the utility of 3D bioprinting in the successful manufacturing of replicas of bones, ears, and blood vessels. The concept of 3D printing is relatively new in the field of ophthalmology(4,5), with few publications evaluating its utility in this field(4). Increased understanding of 3D technology will be of benefit to ophthalmologists.

The ability to produce a device using 3D printing technology for use in intraocular surgery remains unclear. The major issue faced by developers is biocompatibility, particularly in the case of producing intraocular devices. Studies involving 3D printing biocompatible materials are initially required to evaluate the feasibility of this approach. The United States Pharmacopeial Convention (USP) is a scientific, nonprofit organization that sets standards for the identity, strength, quality, and purity of medicines and biomaterials. Materials are ranked in six classes (I-VI) of biocompatibility. Biocompatible materials are assessed in terms of five categories related to medical approval, comprising cytotoxicity, genotoxicity, delayed-type hy per-sensitivity, irritation, and USP class VI, which includes tests for irritation, acute systemic toxicity, and implantation.

The second step in the validation of 3D printing in ophthalmology is the demonstration of precise device modeling at a resolution of approximately 600 μm, depending on what material is being printed. 3D models can be designed using either Maya, a comprehensive 3D animation software, or directly in the solid modeling compu ter-aided design software, SolidWorks (Figure 1). Regardless of the 3D modeling software used, the models must be converted to an STL file to allow 3D printing. Stereolithography refers to the additive ma-nufacturing technology used for producing model parts one layer at a time and represents a fast prototyping process for the creation of solid physical models directly from computer data. Prior to printing 3D models from STL files, designs must be examined for manifold errors, such as surfaces that do not connect or gaps in models. After all of these requirements have been met, 3D models can be printed. Additive processes typically reduce the time required for printing to just a few hours.

This process has allowed the development of Cana’s Ring (CR), a 3D pupil expansion device; this was the first intraocular model

designed and manufactured using 3D printing technology. The CR consists of a ring segment containing eight alternate parts (one side oriented up and one side oriented down) to embrace the pupillary edge (Figure 2). It is a 300 degree VisiJet® ring with a 60 degree region allowing the insertion of the ring into the eye and positioning along the same axis as the incision used during surgery. The device is inser-ted into the anterior chamber through a triplanar clear corneal inci-sion. Immediately after the entire ring is situated within the anterior chamber, the ring is placed on the pupillary edge of the iris using the CR holes. This process is performed by inserting the down-oriented CR parts under the pupil edge and the up-oriented CR parts over the pupil edge. Pupillary dilatation to a diameter of 6.5 mm results when the entire ring is correctly placed along the pupillary edge of the iris. The use of the CR allows for the surgery for cataract to be performed using standard techniques.

Additive manufacturing represents a valid method of manufac-turing ophthalmic models, devices, and instruments using biocom-patible materials at a relatively low cost. This pioneering approach may open new perspectives for the use of 3D printing, an innovative technology with a substantial potential applicability in the field of ophthalmology.

Sérgio Canabrava1 Alberto Diniz-Filho2

Paulo Schor3 David F. Fagundes1

Amanda Lopes1 Wagner D. Batista1

Figure 1. 3D model software image.

Figure 2. Cana’s Ring 3D pupil expansion device.

Cartas ao Editor | letters to the editor


Submitted for publication: July 31, 2015 Accepted for publication: September 23, 20151 Glaucoma and Cataract Reference Center, Santa Casa de Misericórdia de Belo Horizonte, Belo

Horizonte, MG, Brazil.2 Department of Ophthalmology and Otorhinolaryngology, Universidade Federal de Minas Gerais,

Belo Horizonte, MG, Brazil.3 Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, SP, Brazil. Funding: No specific financial support was available for this study. Disclosure of potential conflicts of interest: Dr. Canabrava has a pending international patent

application (PCT-WIPO) for the pupil-expansion device. Corresponding author: Sérgio Canabrava. Santa Casa de Misericórdia de Belo Horizonte. Av.

Brasil, 84, sala 1.303 - Belo Horizonte, MG - Brazil - E-mail: [email protected]

REFERENCES

1. Chia HN, Wu BM. Recent advances in 3D printing of biomaterials. J Biol Eng. 2015; 9:4.

2. Jones N. Science in three dimensions: the print revolution. Nature. 2012;487(7405):22-3. 3. Rankin TM, Giovinco NA, Cucher DJ, Watts G, Hurwitz B, Armstrong DG. Three-dimen-

sional printing surgical instruments: are we there yet? J Surg Res. 2014;189(2):193-7. 4. Schubert C, van Langeveld MC, Donoso LA. Innovations in 3D printing: a 3D overview

from optics to organs. Br J Ophthalmol. 2014;98(2):159-61. 5. Huang W, Zhang X. 3D Printing: Print the future of ophthalmology. Invest Ophthalmol

Vis Sci. 2014;55(8):5380-1.


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priate interface of ABO. The following guidelines were based on the format suggested by the International Committee of Medical Journal Editors (ICMJE) and published in the document: Uniform Require-ments for Manuscripts Submitted to Biomedical Journals.

Only the manuscripts complying with these guidelines will be considered for analysis.

The text should be sent as a digital file. Only the following formats are accepted: .doc or .rtf. The text should be typed double-spaced, in 12 point font. The pages should be numbered in Arabic numerals, starting each section on a new page.

The sections should be presented according to the following se-quence: Title page (as a separate document); Abstract and Keywords; Introduction; Methods; Results; Discussion; Acknowledgements (if any); References; Tables (optional) and Figures (optional) including legends.

1. Title Page. It should contain: a) title (no more than 135 characters with spaces); b) running title to be used as a page heading (no more than 60 characters with spaces); c) authors’ names as they should appear in print; d) each author’s affiliation* (city, state, country and, if applicable, department, school, university); e) corresponding author’s, name, address, phone number, and email; f ) sources of fi-

nancial support (if any); g) project number and institution responsible for the approval of the Research Ethics Committee; h) statement of conflicts of interests of all authors; i) clinical trial registration number on a public trials registry.* Professional or academic degrees, as well as job position will not be published.

Approval of the Institutional Review Board (IRB). All retrospec-tive, cross-sectional, or prospective studies involving primary data collection or clinical and surgical reports should include the project number and name of the institution that provided the approval of the IRB on the title page. Studies involving humans should be compliant with the Declaration of Helsinki, whereas studies involving animals should be in accordance with the principles suggested by the Asso-ciation for Research in Vision and Ophthalmology (ARVO).

As a supplementary document, the corresponding author should send the IRB approval or its report stating that the evaluation of the project by the Committee is not necessary. The author cannot decide on the need for evaluation by the Research Ethics Committee.

Statement of Conflicts of Interest. The title page should contain the statement of conflicts of interest of all authors (even if there is no conflict of interest). For more information about potential conflicts of interest, refer to: World Association of Medical Editors: Conflict of interest in peer-reviewed medical journals.

All authors should send the Form for Disclosure of Potential Con-flicts of Interest as supplementary documents.

Clinical Trials. All Clinical Trials shall include on the title page the re-gistration number in an international registry that allows free access to trial information (examples: U.S. National Institutes of Health, Austra-lian and New Zealand Clinical Trials Registry, International Standard Randomised Controlled Trial Number - ISRCTN, University Hospital Medical Information Network Clinical Trials Registry - UMIN CTR, Ne-derlands Trial Register, Registros Brasileiros de Ensaios Clínicos).

2. Abstract and Keywords. Structured abstract (Objective, Metho-ds, Results, Conclusions) with no more than 300 words. Unstructured abstract with no more than 150 words. Five keywords in English listed by the National Library of Medicine (MeSH - Medical Subject Headings).

3. Abstract and Keywords in Portuguese. Structured abstract (Objective, Methods, Results, Conclusions) with no more than 300 words. Unstructured abstract with no more than 150 words. Five keywords in Portuguese listed by BIREME (DeCS - Descritores em Ciências da Saúde). Portuguese translation may be provided by ABO at publication.

4. Introduction, Methods, Results, and Discussion. Citations in the text should be numbered sequentially in superscript Arabic numerals and in parentheses. The names of the authors should not be cited in the text.

5. Acknowledgements. This section should include the colla-boration of people, groups or institutions that deserve to be ack-nowledged but do not meet the criteria for authorship. Statisticians and medical editors may meet the criteria for authorship and, in this case, should be acknowledged as authors. When they do not meet the criteria for authorship, they should be mentioned in this section. Writers who are not identified in the manuscript cannot be accepted as authors; therefore, professional writers should be acknowledged in this section.

6. References. Citations (references) of authors in the text should be numbered sequentially in the same order as they are cited and identified using superscript Arabic numerals. References should be in accordance with the format suggested by the International


Committee of Medical Journal Editors (ICMJE), based on the exam-ples below.

The titles of the journals should be abbreviated according to the style provided by the List of Journal Indexed in Index Medicus of the National Library of Medicine.

The names of all authors should be cited for references with up to six authors. For studies with seven or more authors, cite only the first six authors followed by et al.

Examples of references:

Journal ArticlesCosta VP, Vasconcellos JP, Comegno PEC, José NK. O uso da mitomi cina C em cirurgia combinada. Arq Bras Oftalmol. 1999;62(5):577-80.

BooksBicas HEA. Oftalmologia: fundamentos. São Paulo: Contexto; 1991.

Book ChaptersGómez de Liaño F, Gómez de Liaño P, Gómez de Liaño R. Exploración del niño estrábico. In: Horta-Barbosa P, editor. Estrabismo. Rio de Janeiro: Cultura Médica; 1997. p. 47-72.

AnnalsHöfling-Lima AL, Belfort R Jr. Infecção herpética do recém-nascido. In: IV Congresso Brasileiro de Prevenção da Cegueira; 1980 Jul 28-30, Belo Horizonte, Brasil. Anais. Belo Horizonte; 1980. v.2. p. 205-12.

DissertationsSchor P. Idealização, desenho, construção e teste de um ceratômetro cirúrgico quantitativo [dissertation]. São Paulo: Universidade Federal de São Paulo; 1997.

Electronic DocumentsMonteiro MLR, Scapolan HB. Constrição campimétrica causada por vigabatrin. Arq Bras Oftalmol. [online journal]. 2000 [cited 2005 Jan 31]; 63(5): [about 4 p.]. Available at:http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-27492000000500012&lng=pt&nrm=iso

7. Tables. Tables should be numbered sequentially using Arabic nu-merals in the order they are mentioned in the text. All tables should have a title and a heading for all columns. Their format should be simple, with no vertical lines or color in the background. All ab-breviations (even if previously defined in the text) and sta tistical tests should be explained below the table. The bibliographical source of the table should also be informed when the table is extracted from another study.Do not include tables in the main document of the manuscript, they should be uploaded as supplementary documents

8. Figures (graphs, photos, illustrations, charts). Figures should be numbered sequentially using Arabic numerals in the order they are mentioned in the text. ABO will publish the figures in black and white at no cost to the authors. Manuscripts with color figures will be published only after the authors pay a publication fee of R$ 500.00 per manuscript.

Graphs should preferably be in shades of gray, on a white background and without three-dimensional or depth effects. Instead of using pie charts, the data should be included in tables or described in the text.Photos and illustrations should have a minimum resolution of 300 DPI for the size of the publication (about 2,500 x 3,300 pixels for a full page). The quality of the images is considered in the evaluation of the manuscript.

The main document should contain all figure legends, typed dou ble-spaced and numbered using Arabic numerals.

Do not include figures in the main document of the manuscript; they should be uploaded as supplementary documents.

Supplemental files can have the following extensions: JPG, BMP, TIF, GIF, EPS, PSD, WMF, EMF or PDF.

9. Abbreviations and Acronyms. Abbreviations and acronyms should be preceded by the spelled-out abbreviation on first mention and in the legends of tables and figures (even if they have been pre-viously mentioned in the text). Titles and abstracts should not contain abbreviations and acronyms.

10. Units of Measurement: Values of physical quantities should be used in accordance with the standards of the International System of Units.

11. Language. Texts should be clear to be considered appropriate for publication in a scientific journal. Use short sentences, written in a direct and active voice. Foreign words should be in italics. Thera-peutic agents should be mentioned by their generic names with the following information in parentheses: trade name, manufacturer’s name, city, state and country of origin. All instruments or apparatus should be mentioned including their trade name, manufacturer’s name, city, state and country of origin. The superscript symbol of trademark ® or™ should be used in all names of instruments or trade names of drugs. Whenever there are doubts about style, terminology, units of measurement and related issues, refer to the AMA Manual of Style 10th edition.

12. Original Documents. Corresponding authors should keep the original documents and the letter of approval from the Research Ethics Committee for studies involving humans or animals, the con-sent form signed by all patients involved, the statement of agreement with the full content of the study signed by all authors and the state-ment of conflict of interest of all authors, as well as the records of the data collected for the study results.

13. Corrections and Retractions. Errors may be noted in published manuscripts that require the publication of a correction. However, some errors pointed out by any reader may invalidate the results or the authorship of a manuscript. If substantial doubt arises about the honesty or integrity of a submitted manuscript, it is the editor’s responsibility to exclude the possibility of fraud. In these situations, the editor will inform the institutions involved and the funding agen-cies about the suspicion and wait for their final decision. If there is confirmation of a fraudulent publication in ABO, the editor will act in compliance with the protocols suggested by the International Com-mittee of Medical Journal Editors (ICMJE) and by the Committee on Publication Ethics (COPE).

CHECKLISTBefore submitting their manuscript, authors should make sure

that all the following items are available: □ Manuscript prepared in accordance with the instructions to

authors. □ Maximum number of words, tables, figures, and references

according to the type of manuscript. □ Title page including the clinical trial registration number is not

included in the main document □ No figures and tables are included in the main document of

the manuscript. □ All figures and tables were uploaded separately as supple-

mentary documents. □ Author Contribution Statement completed and saved as a

digital file to be sent as a supplementary document. □ Form for Disclosure of Potential Conflicts of Interest of all

authors completed and saved as digital files to be sent as supplementary documents.

□ Digital version of the report provided by the Institutional Re-view Board containing the approval of the project to be sent as a supplementary document.


LIST OF WEBSITESAuthorship Principles according to the iCMJEhttp://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html

Authors’ Participation Formhttp://www.cbo.com.br/site/files/Formulario Contribuicao dos Autores.pdf

CONSOrT (Consolidated Standards of reporting Trials) http://www.consort-statement.org/consort-statement/

STArD (Standards for the reporting of Diagnostic accuracy studies) http://www.stard-statement.org/

PriSMA (Preferred reporting items for Systematic reviews and Meta-Analyses) http://www.prisma-statement.org/index.htm

STrOBE (Strengthening the reporting of Observational studies in Epidemiology) http://www.strobe-statement.org/

Online interface for submission of manuscripts to ABOhttp://www.scielo.br/ABO

international Committee of Medical Journal Editors (iCMJE)http://www.icmje.org/

uniform requirements for manuscripts submitted to biomedical journalshttp://www.nlm.nih.gov/bsd/uniform_requirements.html

Declaration of helsinkihttp://www.wma.net/en/30publications/10policies/b3/index.html

Principles of the Association for research in vision and Ophthal-mology (ArvO)http://www.arvo.org/About_ARVO/Policies/Statement_for_the_Use_of_Animals_in_Ophthalmic_and_Visual_Research/

World association of medical editors: conflict of interest in peer- reviewed medical journalshttp://www.wame.org/about/wame-editorial-on-coi

Form for Disclosure of Potential Conflicts of interesthttp://www.icmje.org/coi_disclosure.pdf

u.S. national institutes of healthhttp://www.clinicaltrials.gov

australian and new zealand clinical trials registryhttp://www.anzctr.org.au

international Standard randomised Controlled Trial Number - iSrCTNhttp://isrctn.org/

university hospital medical information network clinical trials registry - uMiN CTrhttp://www.umin.ac.jp/ctr/index.htm

Nederlands Trial registerhttp://www.trialregister.nl/trialreg/index.asp

registros Brasileiros de Ensaios Clínicoshttp://www.ensaiosclinicos.gov.br/

meSh - medical Subject headingshttp://www.ncbi.nlm.nih.gov/sites/entrez?db=mesh&term=

DecS - health Sciences Keywords in Portuguesehttp://decs.bvs.br/

Format suggested by the international Committee of Medical Journal Editors (iCMJE)http://www.nlm.nih.gov/bsd/uniform_requirements.html

list of Journal indexed in index Medicushttp://www.ncbi.nlm.nih.gov/journals

AMA Manual of Style 10th editionhttp://www.amamanualofstyle.com/

Protocols of the international Committee of Medical Journal Editors (iCMJE)http://www.icmje.org/recommendations/browse/publishing-and-editorial-issues/scientific-misconduct-expressions-of-concern-and-retraction.html

Protocols of the Committee on Publication Ethics (COPE)http://publicationethics.org/resources/flowcharts

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