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A r q u i v o s b r a s i l e i r o s d e

79 01publicação oficial do conselho brasileiro de oftalmologia

Janeiro/feVereiro 2016

issn 0004-2749versão impressa

indexada nas bases de dados

MEDLINE | EMBASE | ISI | SciELO

Zika virus‚ microcephaly and

macular atrophy

Zika virus and bilateral acute

hypertensive uveitis

Thermography and lacrimal system

obstruction

Intrastromal corneal ring delays

corneal grafting

Cryopreserved human corneal

endothelial cells

Frequency of publication: Bimonthly Arq Bras Oftalmol. São Paulo, v. 79, issue 1, pages 1-68, Jan/Feb. 2016

Continuous publication since 1938

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

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Editorial BoardNationalAna Luísa Höfling-Lima (São Paulo-SP)André Augusto Homsi Jorge (Ribeirão Preto-SP)André Messias (Ribeirão Preto-SP)Andrea Zin (Rio de Janeiro-RJ)Antonio Augusto Velasco e Cruz (Ribeirão Preto-SP)Ayrton Roberto B. Ramos (Florianópolis-SC)Breno Barth (Natal-RN)Cristina Muccioli (São Paulo-SP)Denise de Freitas (São Paulo-SP)Eduardo Cunha de Souza (São Paulo-SP)Eduardo Ferrari Marback (Salvador-BA)Érika Hoyama (Londrina-PR)Fábio Ejzenbaum (São Paulo-SP)Flávio Jaime da Rocha (Uberlândia-MG)João Antonio Prata Jr. (Uberaba-MG)João Borges Fortes Filho (Porto Alegre-RS)João J. Nassaralla Jr. (Goiânia-GO)João Luiz Lobo Ferreira (Florianópolis-SC)José Beniz Neto (Goiânia-GO)José Paulo Cabral Vasconcellos (Campinas-SP)Keila Monteiro de Carvalho (Campinas-SP)Lisandro Sakata (Curitiba-PR)Luiz V. Rizzo (São Paulo-SP)Marcelo Francisco Gaal Vadas (São Paulo-SP)

Marcelo Hatanaka (São Paulo-SP)Marcelo Vieira Netto (São Paulo-SP)Marcony Santhiago (Rio de Janeiro-RJ)Maria Cristina Nishiwaki Dantas (São Paulo-SP)Maria de Lourdes V. Rodrigues (Ribeirão Preto-SP)Martha Maria Motono Chojniak (São Paulo-SP)Maurício Maia (Assis-SP)Mauro Campos (São Paulo-SP)Mauro Goldchmit (São Paulo-SP)Midori Hentona Osaki (São Paulo-SP)Milton Ruiz Alves (São Paulo-SP)Mônica Alves (Campinas-SP)Mônica Fialho Cronemberger (São Paulo-SP)Newton Kara-José Júnior (São Paulo-SP)Norma Helen Medina (São Paulo-SP)Paulo E. Correa Dantas (São Paulo-SP)Procópio Miguel dos Santos (Brasília-DF)Ramon Ghanem (Joinvile-SC)Remo Susanna Jr. (São Paulo-SP)Roberto L. Marback (Salvador-BA)Roberto Pinto Coelho (Ribeirão Preto-SP)Rosane da Cruz Ferreira (Porto Alegre-RS)Rubens Belfort Jr. (São Paulo-SP)Sebastião Cronemberger (Belo Horizonte-MG)Sérgio Kwitko (Porto Alegre-RS)Sidney Júlio de Faria e Souza (Ribeirão Preto-SP)

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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. 79, issue 1, pages 1-68, Jan/Feb. 2016

PUBLICAÇÃO OFICIAL DOCONSELHO BRASILEIRO

DE OFTALMOLOGIA

EditorialV Oliver Sacks and his legacy to vision science and ophthalmology Oliver Sacks e o seu legado para a ciência da visão e a oftalmologia Eduardo Melani Rocha, Luiza Aikawa da Silveira Rocha, Galton Carvalho Vasconcelos, Monica Alves

Original Articles1 Achados oftalmológicos em lactentes com microcefalia e infecção presumida pelo vírus Zika Camila V. Ventura, Mauricio Maia, Bruna V. Ventura, Vanessa Van Der Linden, Eveline B. Araújo, Regina C. Ramos, Maria Angela W. Rocha, Maria Durce C. G. Carvalho,

Rubens Belfort Jr., Liana O. Ventura

4 A study of the vitreoretinal interface in patients with age-related macular degeneration Estudo da interface vitreorretiniana em pacientes com degeneração macular relacionada à idade Maíra de França Martins, Edio Volpatto, Paula Emery, Pedro Duraes Serracarbassa

9 Serous retinal detachment in patients with macular edema secondary to branch retinal vein occlusion Descolamento seroso de retina em pacientes com edema macular secundário à oclusão de ramo da veia retiniana Erkan Celık, Emine Doğan, Elif Betul Turkoglu, Burçin Çakır, Gursoy Alagoz

12 Mean platelet volume in patients with retinal artery occlusion Volume médio de plaquetas em pacientes com oclusão da artéria da retina Muhammed Şahin, Alparslan Şahin, Harun Yüksel, Fatih Mehmet Türkcü, Adnan Yıldırım

15 Comparison of pain scores between patients undergoing panretinal photocoagulation using navigated or pattern scan laser systems

Comparação de graduação de dor entre os pacientes submetidos à panfotocoagulação usando sistemas de laser navegado ou de padrão de varredura Umit Ubeyt Inan, Onur Polat, Sibel Inan, Safiye Yigit, Zeki Baysal

19 Congenital and developmental cataract: axial length and keratometry study in Brazilian children Catarata congênita e do desenvolvimento: estudo do comprimento axial e da ceratometria em crianças brasileiras Rodrigo Bueno do Prado, Virgílio Figueiredo Silva, Silvana Artioli Schellini, Antonio Carlos Lottelli Rodrigues

24 Sociodemographic status of severely disabled and visually impaired elderly people in Turkey Estado sociodemográfico de pacientes idosos com incapacidades graves e deficiência visual na Turquia Sertaç Argun Kıvanç, Berna Akova-Budak, Osman Okan Olcaysü, Sadık Görkem Çevik

30 Intrastromal corneal ring segments delay corneal grafting in patients with keratoconus Segmentos de anéis intracorneanos protelam o transplante de córnea em pacientes com ceratocone Luiz Arthur F. Beniz, Gustavo H. Queiroz, Carlos F. Queiroz, Wanessa L. Lopes, Leiser F. Moraes, José Beniz

33 Effects of prostaglandin analogs on blood flow velocity and resistance in the ophthalmic artery of rabbits Efeitos dos análogos da prostaglandina na velocidade do fluxo sanguíneo e resistência na artéria oftálmica de coelhos Amália Turner Giannico, Leandro Lima, Gillian C. Shaw, Heloisa H. A. Russ, Tilde Rodrigues Froes, Fabiano Montiani-Ferreira

37 Characterization of cryopreserved primary human corneal endothelial cells cultured in human serum-supplemented media Caracterização de células endoteliais corneanas humanas primárias criopreservadas cultivadas em meio suplementado com soro humano Lucas Monferrari Monteiro Vianna, Hao-Dong Li, Jeffrey D. Holiman, Christopher Stoeger, Rubens Belfort Jr., Albert S. Jun

Case Reports42 Contact lens fitting in a patient with Alport syndrome and posterior polymorphous corneal dystrophy: a case report Adaptação de lentes de contato em paciente com síndrome de Alport e distrofia polimorfa posterior: relato de caso Juliana Maria da Silva Rosa, Marcelo Vicente de Andrade Sobrinho, César Lipener

44 Aniridia after blunt trauma and presumed wound dehiscence in a pseudophakic eye Aniridia após trauma contuso e deiscência presumida da incisão em um olho pseudofácico Kyeong Hwan Kim, Wan Soo Kim

46 Using thermography for an obstruction of the lower lacrimal system Utilização da termografia de uma obstrução da via lacrimal baixa Marco Antonio de Campos Machado, João Amaro Ferrari Silva, Marcos Leal Brioschi, Norma Allemann

48 Choroidal melanoma recurrence after episcleral brachytherapy and transpupillary thermotherapy Recorrência melanoma de coroide após a braquiterapia episcleral e termoterapia transpupilar Yrbani Lantigua-Dorville, Maria Antonia Saornil, Ciro García-Alvarez, Elena García-Lagarto

50 Amputação precoce de pedículo de LASIK para o tratamento de ceratite ramificada agressiva: relato de caso John Au, Thomas Plesec, Karolinne Rocha, William Dupps Jr., Ronald Krueger

53 Combined transscleral fixation of an artificial iris prosthesis with an intraocular lens Combinação de fixação transescleral de prótese de íris artificial com lente intraocular Uzeyır Gunenc, Taylan Ozturk, Gul Arikan, Mahmut Kaya

Review Articles56 Vitamin A and the eye: an old tale for modern times A vitamina A e o olho: uma velha história em tempos modernos Jacqueline Ferreira Faustino, Alfredo Ribeiro-Silva, Rodrigo Faeda Dalto, Marcelo Martins de Souza, João Marcello Fortes Furtado, Gutemberg de Melo Rocha,

Monica Alves, Eduardo Melani Rocha

Letters to the Editor62 Preoperative usage of ultrasound biomicroscopy in pediatric cataract Uso pré-operatório de biomicroscopia ultrassônica em catarata pediátrica Abdullah Kaya

63 Iridociclite hipertensiva associada à infecção por Zika vírus Bruno M. Fontes

65 Instructions to Authors

V

Editorial

http://dx.doi.org/10.5935/0004-2749.20160001

Oliver Sacks and his legacy to vision science and ophthalmology

Oliver Sacks e o seu legado para a ciência da visão e a oftalmologia

Eduardo MElani rocha1, luiza aikawa da SilvEira rocha1, Galton carvalho vaSconcEloS2, Monica alvES3

A little boy enchanted by chemistry and the periodic table elements, a motorcycle young man who crossed a continental country in so many directions, scuba diver and olympic weightlifter, an obsessive re searcher and a dedicated physician. These are some facets of a brilliant human being. Oliver Wolf Sacks was born in London in July 9, 1933, graduated in Medicine at Oxford University, England, specialized in Neurology in California, USA, and worked most of his life in New York City, USA(1). The reason to bring him to an editorial in ABO (Arquivos Brasileiros de Oftalmologia), a journal dedicated to vision and ophthalmology, is because early in his professional career he became a writer, describing neurological patients, with particular and talented reports on ocular conditions, visual symptoms and neuro-ophthalmologic correlations in his writings.

Talented clinicians are becoming rare, talented clinicians with writing talent are even more so. Dr. Oliver Sacks must be known by the present and future generations of physicians as a writer that wrote in a way that allowed the reader to know about the disease, but, more importantly, to know how the patient felt and dealt with his condition, through poetic lines of his numerous books and articles

He became a bestselling and awarded author all over the world, with writings that gave voice, face and action to patients with chronic, sometimes uncommon, and severe diseases. He published 14 books and authored or co-authored 58 papers. So far, 14 of his writings became documentaries and three of his tales, including the famous “Awakenings” inspired films(2).

Overall, he taught the physicians to consider the patient’s perspective in the first place. In his recent publi-shed autobiography “On the Move: a life”, he revealed that his style was inspired by medical writers of the XIX century(3). This influence was clear in references used in his books, in particular in “An Anthropologist on Mars”, where in seven dramatic stories, he revealed his deep sensitivity to the vision complaints of his patients. The first case described the suffering of a painter who became color blind after a car accident. The fourth case described a middle age individual who experienced to see again after decades of blindness. In the fifth and sixth cases he described patients with different conditions that had in common an intense visual memory and capacity to draw these views. All of those reports were fulfilled with beautiful wording and illustrations, as well as detailed local descriptions and medical references, dating back to the beginning of the XVIII century(4).

Among the visual symptoms addressed in his papers were visual hallucinations, metamorphosis and visual agnosia(5-7). These papers are strongly recommended reading, not just because of the clear and thoughtful presentation, but also because these subjects are challenging and usually neglected during medical training.

For those who read the “The Island of Colorblind” it will be always engraved on our minds the intriguing condition of a society where total congenital colorblindness is the norm, and how adaptation may occur(8). These reflections may teach how to cope with patient fragilities face to a condition that leads to visual deficiency and how adaptation and acceptance may improve their lives.

Other books, including “Migraine”, his first one, addressed the visual symptoms of this condition with a rich description and interpretation of the mechanisms, but even for those not related to the eye care, it is certainly worthwhile reading (Table 1). As he wrote in his autobiography “It seems to me that I discover my thoughts through the act of writing, in the act of writing”(3).

To understand his patients conditions profoundly he used to search their symptoms and diseases pathways. This was beautifully reflected in the many partnership he had along his career, such as Crick, Hubel, Wiesel and Edelman; Nobel laureates who were also important contributors in his works, as many other that influenced him such as Thom Gun, Luria and Auden. He showed a wonderful way to go further and a great example to be followed by researchers and clinicians.

His last book was originated by articles published in the New York Times, describing his joy with the life experience apart from his own drama fighting against an ocular melanoma, first diagnosed in 2006, which revealed metastases on January 2015(9). It was called “Gratitude” and was a posthumous publication. Sadly, Dr. Oliver Sacks died on August 30 of 2015. Based on the last words of his autobiography, it is clear that his literature legacy is not yet finished(3).

Sumitted for publitcation: November 13, 2015 Accepted for publitcation: November 17, 20151 Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de

Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil.2 Departamento de Oftalmologia e Otorrinolaringologia, Faculdade de Medicina da Universidade

Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.3 Departamento de Oftalmologia e Otorrinolaringologia, Faculdade de Ciências Médicas, Universidade

Estadual de Campinas (UNICAMP), Campinas, SP, Brazil.

Funding: Financial Support: CNPq, NAP-FTO USP.

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

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

Oliver Sacks and his legacy to vision science and ophthalmology

VI

REFERENCES 1. Wikipedia: the free encyclopedia [Internet]. St. Petersburg (FL): Wikimedia Founda-

tion; 2001. Oliver Sacks.[cited 2015 Nov 17]. Available from: https://en.wikipedia.org/wiki/Oliver_Sacks

2. Oliver Sacks, M.D [Homepage]. [Cited 2015 Nov 15]. Available from: http://www. oliversacks.com/inspired-by-sacks/

3. Sacks OW. On the move: a life. Canada: Alfred Knopf; 2015. 4. Sacks OW. An Anthropologist on mars. New York: Alfred Knopf; 1995. 5. Sacks O. Regaining binocular stereoscopic vision in adulthood. A case report. A neu-

ro logist’s notebook. Stereo Sue. Why two eyes are better than one. (Reprinted with

per mission from The New Yorker, June 19, 2006). Binocul Vis Strabismus Q. 2006;21(3): 160-9. Comment in: Binocul Vis Strabismus Q. 2006;21(3):170.

6. Herrmann C Jr, Aguilar MJ, Sacks OW. Hereditary photomyoclonus associated with diabe-tes mellitus, deafness, nephropathy, and cerebral dysfunction. Neurology. 1964; 14:212-21.

7. Blom JD, Sommer IE, Koops S, Sacks OW. Prosopometamorphopsia and facial halluci-nations. Lancet. 2014;384(9958):1998.

8. Sacks, O. The Island of the colorblind. New York: Alfred Knopf; 1997. 9. Sacks O. My own life: Oliver Sacks on learning he has terminal cancer. New York Times

[Internet]. 2015 Feb 19. [Cited 2015 Nov 15]. Barczyk H. The opinion pages. Available from: http://www.nytimes.com/2015/02/19/opinion/oliver-sacks-on-learning-he-has-terminal-cancer.html?_r=1

Table 1. Oliver Sacks books related to visual symptoms and ocular diseasesTitle Year published

Migraine 1970

The man who mistook his wife for a hat 1985

Seeing voices 1989

An anthropologist on Mars 1995

The island of the colorblind 1997

The mind’s eye 2010

Hallucinations 2012

On the move: a life 2015

Original Article

1Arq Bras Oftalmol. 2016;79(1):1-3http://dx.doi.org/10.5935/0004-2749.20160002

INTRODUCTIONZika virus (ZIKV) is a neurotropic flavivirus related to the Dengue,

Yellow Fever and West Nile viruses(1). Even though it was first identi-fied in the world in 1947(1), the first autochthone transmission in Brazil was confirmed only in April 2015(2). Since then, it is estimated that more than one million Brazilians had ZIKV infection, reflecting the virus’ capacity to cause large-scale outbreaks where the biological vector Aedes aegypti is endemic(2,3).

Six months following the beginning of the ZIKV outbreak, there was an unusual increase in newborns with microcephaly in Brazil.

In 2015, 1,248 new suspect cases were registered, representing a twenty-fold increase when compared to recent years(3).

Maternal-fetal transmission of ZIKV has been previously demons-trated(4). In Brazil, ZIKV has been detected in the amniotic fluid of two pregnant women of babies with microcephaly and in the tissue of a newborn with microcephaly that died after birth(3). Thus, the Brazi-lian Ministry of Health has associated this malformation with ZIKV in tra-uterus infection(3).

Our group recently published the first report on retinal findings of three infants with microcephaly and presumed ZIKV vertical infec-

Ophthalmological findings in infants with microcephaly and presumable intra-uterus

Zika virus infection

Achados oftalmológicos em lactentes com microcefalia e infecção presumida pelo vírus Zika

caMila v. vEntura1-3, Mauricio Maia3, Bruna v. vEntura1-3, vanESSa van dEr lindEn4, EvElinE B. araújo1,2, rEGina c. raMoS5, Maria anGEla w. rocha5,

Maria durcE c. G. carvalho5, ruBEnS BElfort jr.3, liana o. vEntura1,2

Submitted for publication: January 15, 2016 Accepted for publication: January 17, 20161 Fundação Altino Ventura (FAV), Recife, PE, Brazil. 2 Hospital de Olhos de Pernambuco (HOPE), Recife, PE, Brazil. 3 Department of Ophthalmology and Visual Sciences, Escola Paulista de Medicina (EPM), Universidade

Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil.4 Hospital Barão de Lucena, Recife, PE, Brazil. 5 Hospital Universitário Oswaldo Cruz (HUOC), Recife, PE, 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: Rubens Belfort Jr. Departamento de Oftalmologia. Escola Paulista de Me-dicina. Rua Botucatú, 831 - São Paulo, SP - 04023-062 - Brazil - E-mail: [email protected]

Approved by the following research ethics committee: Altino Ventura Foundation (protocol #1.361.143) and was conducted at the Altino Ventura Foundation.

ABSTRACTPurpose: In 2015, a twenty-fold increase in the prevalence of microcephaly in Brazil was reported, and the Ministry of Health associated this abnormal prevalence with the maternal-fetal Zika virus (ZIKV) transmission. Methods: We assessed the ophthalmological findings of ten mothers and their infants that had been clinically diagnosed with ZIKV-related microcephaly and presented ocular abnormalities, born from May to December 2015. Results: Seven mothers (70.0%) referred symptoms during pregnancy (malaise, rash and arthralgia), of which six (85.7%) were in the first trimester. At the time of exam, no ophthalmological abnormalities were identified in the mothers and they did not report ocular symptoms during pregnancy. Serology was negative in all infants for Toxoplasmosis, Rubella, Cytomegalovirus, Syphilis and Human Immunodeficiency Viruses. Ocular findings included macular alterations (gross pigment mottling and/or chorioretinal atrophy) in fifteen eyes (75.0%), and optic nerve abnormalities (hypoplasia with double-ring sign, pallor, and/or increased cup-to-disk ratio) in nine eyes (45.0%). Conclusions: Patients presented normal anterior segment and important macular and optic nerve abnormalities. Further studies will assess the visual significance of these alterations.

Keywords: Microcephaly; Zika virus; Ocular findings; Vertical transmission; Retina

RESUMOIntrodução: No ano de 2015, foi identificado no Brasil um aumento da prevalência de microcefalia em vinte vezes. Esta malformação foi associada pelo Ministério da Saúde à transmissão vertical do Zika vírus (ZIKV). Método: Investigamos dez lactentes com diagnóstico clínico presumido de microce-falia relacionada à ZIKV, que apresentavam anormalidades oculares, nascidos entre maio e dezembro de 2015. Resultados: Sete mães (70,0%) relataram sintomas (mal-estar, rash e artralgia) durante a gestação, sendo seis (85,7%) no primeiro trimestre. No dia da avaliação nenhuma alteração ocular foi identificada nas mães e elas não relataram sintomas oculares durante a gestação. Sorologia foi negativa para toxoplasmose, rubéola, citomegalovírus, sífilis e vírus da imunodeficiência adquirida (HIV) em todos os lactentes. Os achados oculares incluíram alterações maculares (depósito pigmentar grosseiro e/ou atrofia coriorretiniana) em 15 olhos (75,0%) e alterações do nervo óptico (hipoplasia do disco com sinal do duplo anel, palidez e/ou aumento da escavação papilar) em nove olhos (45,0%). Conclusões: Os pacientes apresentaram segmento anterior normal e importantes e anormalidades maculares e do nervo óptico. Estudos futuros vão avaliar a importância destas alterações visuais.

Descritores: Microcefalia; Zika vírus; Achados oculares; Transmissão vertical, Retina

Ophthalmological findings in infants with microcephaly and presumable intra-uterus Zika virus infection

2 Arq Bras Oftalmol. 2016;79(1):1-3

tion.(5) Here we assessed more patients through a complete ophthal-mological exam and report our findings.

METHODSWe report the findings of 10 infants with microcephaly, as defined

by an occipitofrontal circumference more than two standard devia-tions below the mean for age and sex(3), with clinical diagnosis of ZIKV vertical infection, and previously diagnosed with ophthalmological abnormalities referred to the Altino Ventura Foundation, in Recife, Brazil, for ophthalmologic examination on December 14, 2015.

RESULTSSix (60.0%) were female. Their mean age at the day of the exam

was 1.9 ± 0.9 months (range: 0.7 to 2.9 months). Computerized to-mography scans evidenced cerebral calcifications in all patients. They were born during the ZIKV infection outbreak, and seven (70.0%) of the mothers had dengue-like symptoms (malaise, rash and arthralgia) during pregnancy, of which six (85.7%) were in the first trimester. The mean age of mothers’ at labor was 29.1 ± 7.3 years (range: 19 to 42 years). Since the infants had negative serology for Toxoplasmosis, Rubella, Cytomegalovirus and Human Immunodeficiency Virus (HIV), they were clinically diagnosed with presumable intra-uterus ZIKV in-

fection. At birth, their mean gestational age was 38.3 ± 0.5 weeks (ran-ge: 37.6 to 39 weeks), their mean cephalic perimeter was 28.8 ± 1.5 cm (range: 26 to 31.5 cm), and their mean weight was 2,901 ± 461.6 g (range: 2,105 to 3,800 g).

The mothers’ ocular examinations were normal. The infants had normal anterior segment structures; a mean axial length measured with immersion ultrasound of 18.4 ± 0.6 mm (range: 17.6 to 19.3 mm) in the right eye (OD) and 18.3 ± 0.4 mm (range: 17.6 to 19.1 mm) in the left eye (OS).

Horizontal nystagmus was observed in one infant (10.0%). Pupils were normally reactive, with no afferent pupillary defect, and Hirschberg testing revealed exophoria in four patients (40.0%) and esophoria in two (20.0%). Cycloplegic refraction showed a mean spherical equi-valent of -0.40 ± 2.40 diopters (D) (range: -3.50 to +2.00) in OD and 0 ± 2.50 D (range: -3.00 to 3.50 D) in OS. The preferential looking behavior of all infants was present.

Retinal evaluation revealed, optic nerve and macular alterations were 17 eyes (85%) (Table 1). Optic nerve findings consisted of hy-poplasia with the double-ring sign, pallor, and increased cup-to-disk ratio. The macular abnormalities were foveal reflex loss, mild to gross pigment mottling and sharply demarcated circular areas of choriore-tinal atrophy (Figure 1-3). In all eyes, the retina and choroid were atta-ched, and the retinal vessels had normal distribution and appearance.

Table 1. Funduscopic findings in ten infants with microcephaly and presumable intra-uterus Zika virus infection

Infant 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10

Eye D S D S D S D S D S D S D S D S D S D S

Optic nerve head hypoplasia X X X X X

Optic nerve double-ring sign X X

Optic nerve head pallor X X X

Cup-to-disk ratio >0.5 X X

Cup-to-disk ratio >0.7 X X

Foveal reflex loss X X X X X X X X X X X X X X X

Mild macular pigment mottling X X X X X

Gross macular pigment mottling X X X X X X X X

Chorioretinal macular atrophy* X X X

No ophthalmic abnormalities X X X

*= sharply demarcated circular area of chorioretinal atrophy on the macula.

Figure 1. Wide-angle fundus image (Retcam®) of the right eye of infant number 8 showing an optic disc hypoplasia with double-ring sign associated with one sharply demarcated chorioretinal atrophy on the macula.

Figure 2. Wide-angle fundus image (Retcam®) of the right eye of infant number 10 with microcephaly showing an optic disc hypoplasia associated with gross macular pigment mottling.

Ventura CV, et al.

3Arq Bras Oftalmol. 2016;79(1):1-3

DISCUSSIONThe 2015 Brazilian ZIKV infection outbreak was the first to have

an association between this virus and the severe complication of newborns with microcephaly(2,3). In January 2016, we published the first report of funduscopic lesions related to this condition(5). In the present paper, we report the ophthalmologic assessment of 10 infants with abnormal ophthalmic exam, born with ZIKV-related microcephaly.

Seven mothers had dengue-like symptoms in the first or second trimester of pregnancy, and Toxoplasmosis, Rubella, Cytomegalovirus and HIV were ruled out by serology. Since approximately 80% of pa-tients with ZIKV infection are asymptomatic, the lack of symptoms does not rule out the infection(3). Additionally, the only available method to diagnose ZIKV infection is real time polymerase chain reaction (PCR), which is useful to detect the virus in the acute pha-se of illness (first 5 days of acute infection). Since the dengue-like symptoms were present months before labor, this test is not helpful in confirming the infection in our infants(3). Thus, the diagnosis of Zika-related microcephaly was considered when the clinical criteria of the Brazilian Ministry of Health was fulfilled(3).

All patients had normal anterior segment structures and axial length(6). Four patients (40.0%) presented myopia, differently than the hyperopia usually seen in infants(6).

The West Nile Virus, another flavivirus, can cause chorioretinal scars and granularity when maternal-fetal transmission occurs(7). In our previous report of three cases of intra-uterus ZIKV infection, gross macular pigment mottling and macular chorioretinal atrophy were detected(5). Similarly, in the present report, fifteen eyes (75.0%) had these macular abnormalities, which had not been reported in other

Figure 3. Wide-angle fundus image (Retcam®) of the left eye of infant number 10 with microcephaly showing an optic disc hypoplasia associated with gross macular pigment mottling and two juxtafoveal chorioretinal atrophic lesions.

ZIKV outbreaks worldwide(5). In addition, optic nerve alterations were observed for the first time. Nine eyes (45.0%) had optic nerve hypo-plasia, pallor and increased cup-to-disk ratio. Optic nerve hypoplasia has been previously associated with cytomegalovirus intra-uterus infection(8). However, in the present series, these other causes of the chorioretinal and optic nerve abnormalities were ruled out(9).

The physiopathology of the lesions presented by these infants may be related to the virus or toxin leading to an inflammatory reaction. This could result in severe cerebral findings (abnormal development and cerebral calcification), as well as ocular lesions. We hypothesize that ZIKV may cause more severe ocular abnormalities when the infection occurs in the first or second trimester of preg-nancy, following the reasoning of other vertical infections, such as Toxoplasmosis, Rubella and Cytomegalovirus(9). Furthermore, other unknown factors such as the amount of viral circulation and the immunologic response of mother and fetus, may play an important role on the abnormalities observed in the newborns.

In conclusion, we reported the ophthalmologic findings of 10 infants with ZIKV-related microcephaly born during the ZIKV infection outbreak in Brazil with abnormal ocular exams. The patients had nor-mal anterior segment structures, and important macular and optic nerve abnormalities. Further studies will assess the visual significance of these alterations, which will be important to understand the natural history of this new and devastating manifestation of the ZIKV disease.

REFERENCES 1. Balm MN, Lee CK, Lee HK, Chiu L, Koay ES, Tang JW. A diagnostic polymerase chain

reaction assay for Zika virus. Journal of medical virology 2012;84:1501-5. 2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de

Vigilância das Doenças Transmissíveis. Protocolo de vigilância e resposta à ocorrência de microcefalia relacionada à infecção pelo vírus Zika / Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Vigilância das Doenças Transmissíveis. – Brasília: Ministério da Saúde; 2015:1-55. Available at: http://portalsaude.saude.gov.br/images/pdf/2015/dezembro/09/Microcefalia---Protocolo-de-vigil--ncia-e-resposta---vers--o-1----09dez2015-8h.pdf [Accessed: January 15, 2015].

3. Centro de Operações de Emergências em Saúde Pública sobre Microcefalias (COES). Monitoramento dos casos de microcefalia no Brasil até a Semana Epidemiológica 47. Informe Epidemiológico - Semana Epidemiológica 47. 2015. Available at: http://portalsaude.saude.gov.br/images/pdf/2015/novembro/30/coes-microcefalias---informe-epidemiol--gico---se-47.pdf. [Accessed: December 17, 2015].

4. Besnard M, Lastère S, Teissier A, Cao-Lormeau VM, Musso D. Evidence of perinatal transmission of Zika virus, French Polynesia, December 2013 and February 2014. Euro Surveill. 2014;19(13):pii=20751. Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20751

5. Ventura CV, Maia M, Bravo-Filho V, Gois AL, Belfort Jr R. Zika virus in Brazil and macular atrophy in a child with microcephaly. Lancet. 2015. Published Online: 07 January 2016. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736 (16)00006-4/abstract

6. Gordon RA, Donzis PB. Refractive development of the human eye. Archives of ophthal-mology 1985;103:785-9.

7. Alpert SG, Fergerson J, Noel LP. Intrauterine West Nile virus: ocular and systemic fin-dings. American journal of ophthalmology 2003;136:733-5.

8. Kaur S, Jain S, Sodhi HB, Rastogi A, Hamlesh. Optic nerve hypoplasia. Oman J Oph thal-mol. 2013 May; 6(2)77-82.

9. Mets MB, Chhabra MS. Eye manifestations of intrauterine infections and their impact on childhood blindness. Survey of ophthalmology 2008;53:95-111.

Original Article

4 Arq Bras Oftalmol. 2016;79(1):4-8 http://dx.doi.org/10.5935/0004-2749.20160003

INTRODUCTIONAge-related macular degeneration (AMD) is a disease initially cha-

racterized by the presence of drusen and abnormal pigmentation of the retinal pigment epithelium (RPE) and later by geographic atrophy, choroidal neovascularization, RPE detachment, and fibrosis. Of the four leading causes of blindness, AMD is the only one for which pro-phylaxis and treatment remains unclear. This is mainly because of a lack of knowledge with regard to its etiology and pathophysiological

mechanisms involved in the different stages of the disease(1). Currently, there are several treatments; however, none of these appear to be sufficiently effective. Therefore, a more extensive study of AMD pa-thophysiology is necessary to optimize treatment(2-9).

AMD appears to be a multifactorial disease. Genetics is likely to play a key role in its occurrence; furthermore, oxidative stress, ischemia, aging of RPE, and inflammation were other possible etiological factors(10,11). A tyrosine-histidine change at the 402th amino acid position in the

A study of the vitreoretinal interface in patients with age-related macular degeneration

Estudo da interface vitreorretiniana em pacientes com degeneração macular relacionada à idade

Maíra dE frança MartinS1, Edio volpatto2, paula EMEry3, pEdro duraES SErracarBaSSa3

Submitted for publication: May 27, 2015 Accepted for publication: November 6, 20151 Curitiba, Paraná, PR, Brazil.2 Campo Grande, Mato Grosso do Sul, MS, Brazil.3 Department of Ophthalmology, Retina section, Hospital do Servidor Público do Estado de São

Paulo, HSPE, São Paulo, SP, Brazil.



Corresponding author: Maíra de França Martins. Rua Capitão Souza Franco, 95 - Curitiba, PR 80730-420 - Brazil - E-mail: [email protected]

Approved by the following research ethics committee: Hospital do Servidor Público do Estado de São Paulo. CEEA: 17729713.0.0000.5463.

ABSTRACTPurpose: To assess whether hyaloid adhesion is more prevalent in patients with age-related macular degeneration (AMD) than in control patients and to evalua-te whether it is more prevalent in exudative AMD than in non-exudative AMD.Methods: This was a cross-sectional, controlled analytical study. Patients from the Ophthalmology Department of the Public Service Hospital of the State of São Paulo were included if they were diagnosed with AMD that was confirmed by fundus biomicroscopy and fluorescein angiography. Patients were divided into three groups: patients without a vitreoretinal disease (controls), patients with exudative AMD, and patients with non-exudative AMD. For the optimal study of the vitreoretinal interface, all patients were subjected to spectral-domain optical coherence tomography (SD-OCT; Cirrus HD-OCT, version 4000; Carl Zeiss Meditec) and ultrasonography (UltraScan®, Alcon). Results with p values of ≤0.05 were con-sidered statistically significant. Results: We assessed 75 eyes of 23 patients with AMD (14 women and nine men) and 15 the control patients (11 women and four men). In total, 33 eyes had AMD that was consistent with the inclusion criteria, of which 11 had the non-exudative form (non-atrophic) and 22 had the exudative form (11 active and 11 disciform scars). Adherence was observed in eight eyes in the control group (26.67%), in seven eyes with exudative AMD (31.82%), and in five eyes with non-exudative AMD (45.45%). Conclusion: Patients with exudative and non-exudative forms of AMD did not present with higher vitreoretinal adhesion than control patients as assessed by SD-OCT and ultrasound. Moreover, patients with exudative AMD (neovascular membrane and disciform scar) did not reveal a higher adherence than those with non-exudative AMD when evaluated by the same methods.

Keywords: Macular degeneration/ultrasonography; Macula lutea; Tomography optical coherence/methods; Tissue adhesion

RESUMOObjetivo: Avaliar se a adesão hialoidea é mais prevalente em pacientes com degene-ração macular relacionada a idade (DMRI) (exsudativa e não exsudativa) comparado ao grupo controle e avaliar se a prevalência é maior na forma exsudativa comparada a forma não exsudativa. Métodos: Trata-se de um estudo transversal, analítico, de grupo controle, com os pa-cientes atendidos no Departamento de Retina do Serviço de Oftalmologia do Hospital do Servidor Público Estadual de São Paulo (HSPE), que tiveram o diagnóstico de DMRI confirmado após a biomicroscopia de fundo e angiofluoresceinografia. Os pacientes foram divididos em três grupos, um composto por pacientes sem doenças vitreorreti-nianas (30 olhos), outro pacientes com DMRI exsudativa (22 olhos) e o terceiro grupo por pacientes com DMRI não exsudativa (11 olhos). Para melhor estudo da interface vitreorretiniana, todos os pacientes foram submetidos aos exames de SD-TCO (Cirrus HD-TCO, versão 4000; Carl Zeeis Meditec) e ultrassonografia (UltraScan®, Alcon). Foram considerados significativos os resultados com valor de p≤0,05. Resultados: Foram avaliados 75 olhos de 23 pacientes com DMRI e 15 no grupo con-trole, sendo que apenas 33 olhos que apresentavam DMRI obedeciam aos critérios de inclusão, sendo 11 pertencentes à forma seca (nenhuma forma atrófica) e 22 à forma exsudativa (11 de forma ativa e 11 disciforme). A adesão foi encontrada em oito olhos no grupo controle (26,67%), em sete olhos com DMRI exsudativa (31,82%) e em cinco olhos no grupo DMRI não exsudativa (45,45%). Conclusão: Neste estudo, pacientes com DMRI (formas exsudativa e não exsudativa) não apresentaram maior adesão vitreorretiniana quando comparados ao grupo controle, ao serem avaliados através SD-TCO (Cirrus HD-TCO, versão 4000; Carl Zeeis Meditec) e ultrassonografia (UltraScan®, Alcon). Neste estudo, pacientes com DMRI exsudativa (ativa e disciforme) não apresentaram maior adesão quando comparados à forma seca, ao serem avaliados pelos mesmos métodos.

Descritores: Degeneração macular/ultrassonografia; Macula lútea; Tomografia de coerência óptica/métodos; Aderências teciduais

Martins MF, et al.


complement factor H on the chromosome 1 is strongly associated with AMD(12-14), along with factors such as race, age, and smoking. An inflammatory cycle is also believed to be involved (including immune complex formation, complement activation, extracellular matrix pro-teolysis, and choroidal T cell and other cell activations), which damages RPE with concomitant degeneration of photoreceptor cells that can extend into more internally located retinal layers.

Although AMD primarily comprises the external layers of the re tina, the vitreous may play a role in its etiopathogenesis and/or pro -gression and that inflammation most likely begins in RPE and may even reach the vitreoretinal interface(15). Moreover, some reports have demonstrated a higher rate of vitreoretinal adhesion in AMD(16-22), perhaps contributing to the unfavorable evolution in some cases and/or an insignificant response to intravitreal anti-vascular endothelial growth factor (anti-VEGF).

This study aimed to assess whether hyaloid adhesion is more pre-valent in patients with AMD than in control patients and to evaluate whether the prevalence is higher in exudative or non-exudative AMD.

METHODSThis is a cross-sectional analytical study with a control group.

Patients were recruited from the Ophthalmology Department of the Public Service Hospital of the State of São Paulo. Patients who recei-ved a diagnosis of AMD that was confirmed by fundus biomicroscopy and fluorescein angiography from May 2010 to November 2014 were included. Eyes in all stages of non-exudative (drusen, pigment altera-tions, and atrophy) and exudative AMD (active or disciform scar) were included. The study was approved by the Ethics Committee of Hospi-tal do Servidor Público do Estado de São Paulo and all patients read and then signed a consent form prior to the initiation of the study.

We excluded all patients presenting with other vitreoretinal afflic-tions concomitant with AMD and/or previous eye surgery and/or any previous intraocular treatment, such as laser or intravitreal injection and/or previous history of ocular trauma or myopia equal or higher than two diopters.

For optimal study of the vitreoretinal interface, all patients un der-went ultrasonography (USG; UltraScan®, Alcon) and spectral-domain optical coherence tomography (SD-OCT) imaging (Cirrus HD-OCT, version 4000; Carl Zeiss Meditec). All USG examinations were per-formed by the same examiner using the transpalpebral contact technique with a 10-MHz probe and 75-dB gain in modes A and B. SD-OCT was performed by a different examiner following drug-indu-ced mydriasis (10% phenylephrine, 3 drops); however, with res pect to the USG examinations, all procedures were performed by the same examiner. We used the 5-line raster scan mode (4,096 A-scans on each of the five lines) and Macular Cube 512 × 128. Only the macular area was evaluated.

Adherence was considered when an average reflectivity line was observed to be partially adherent to the nerve fiber layer. Adhesion was excluded when this line was observed above the nerve fiber layer. When the line was not observed, USG was evaluated to determi-ne whether the hyaloid was anterior or not detached. We considered adherence to be present when the hyaloid was visually adherent to the retinal surface of the macular area in SD-OCT, when it was visually adherent to the macula in USG and SD-OCT, and when the hyaloid was not visible by either method. Non-adherence was considered when the hyaloid was visually non-adherent to the retinal surface in the macular area in the SD-OCT, when it was visually non-adherent to the macula in USG and SD-OCT, whether by total or partial hyaloid detachment (adherent to the optic nerve).

For comparative analysis, we selected patients without vitreoreti-nal alterations, with similar average ages, and who did not meet the exclusion criteria.

To investigate the relationship between vitreoretinal adhesion and AMD, we performed a non-parametric Fisher’s exact test consi-

dering two forms of the disease: exudative (active membrane or dis-ciform scar) and non-exudative AMD (drusen or geographic atrophy), with a third group serving as the control. Age uniformity was verified by analysis of variance (F=1.959, p=0.131). Results with p values of ≤0.05 were considered statistically significant.

RESULTSWe assessed 75 eyes of 23 patients with AMD (14 women and

nine men) and 15 in control group (11 women and four men). In total, 33 eyes had AMD that was consistent with the inclusion criteria; of which 11 had the non-exudative form (non-atrophic) and 22 had the exudative form (11 active and 11 disciform scars).

In the AMD group, we observed two patients with the non-exu-dative form in one eye each and the disciform scar in the contralateral eye, one patient with disciform scars in both eyes, three patients with the non-exudative form in one eye each and a choroidal neovascular membrane (CNVM) in the other eye, five patients with disciform scars in one eye each and CNVM in the other eye, one patient with the non- exudative form in both eyes, and one patient with CNVM in both eyes.

Twelve eyes were excluded from the study for the following rea-sons: Ten were pseudophakic (three disciform, one atrophic, and six active CNVM) and two had already received an anti-VEGF injection. One was excluded for having received intravitreal injections (active form) and another for undergoing laser treatment (disciform scar).

The average age of the patients was similar across the groups (Table 1).

All eyes were assessed by SD-OCT and USG in a complementary manner, and adhesion was found in 7/22 (31.82%) eyes with exudati-ve AMD, in 5/11 (45.45%) eyes with non-exudative AMD, and in 8/30 (26.67%) eyes in the control group. Non-adhesion was diagnosed in 15/22 (68.18%) eyes with exudative AMD, in 6/11 (54.55%) eyes with non-exudative AMD, and in 22/30 (73.33%) eyes within the control group (Table 2). While separately evaluating cases of exudative AMD, we found adhesion in 6/22 (27.27%) eyes with active neovascular membranes and in 1/22 (4.54%) eyes with disciform scars. Adhesion was absent in 5/22 (22.72%) eyes with active neovascular membranes and in 10/22 (45.45%) eyes with disciform scars.

Table 1. Average age, standard deviation, and 95% confidence inter-vals for patients in each study group. Analysis of variance (F=1.959, p=0.131) was used for verification, and no difference in age was obser-ved the three groups

Group Average ± standard deviation 95% confidence interval

Control 69.64 ± 06.19 67.24-72.04

Dry AMD1 77.18 ± 09.61 70.72-83.64

Exudative AMD 72.45 ± 11.64 67.01-77.901AMD= age-related macular degeneration.

Table 2. Comparison1 of vitreoretinal adhesion rates between age-rela-ted macular degeneration (AMD) and control groups

Group

Vitreoretinal adhesion

TotalAdhesion No adhesion

Control 8 (26.67%) 22 (73.33%) 30

Exudative AMD (p=0.762) 7 (31.82%) 15 (68.18%) 22

Dry AMD (p=0.280) 5 (45.45%) 06 (54.55%) 11

Total 20 43 631Absolute frequency and percentage within each group [control, non-exudative age- related (dry) macular degeneration and exudative age-related macular degeneration] related to vitreoretinal adhesion, evaluated by spectral domain optical coherence to-mography and ultrasonography.



In six patients with AMD, SD-OCT revealed vitreoretinal adhesion (Figure 1), whereas USG detected two cases of partial posterior vi-treous detachment (PVD), with both being adherent to the macula, as shown in figure 2 (in four cases, there was no PVD). In the 25 cases of AMD in which the hyaloid was not visible by SD-OCT (Figure 3), USG detected total PVD in five eyes, mobile vitreous membranes in six eyes, and partial PVD in 14 eyes (adherent to the optic nerve). In one of the two cases in which SD-OCT revealed total detachment of the hyaloid in the macular area, while USG revealed no detachment.

USG detected mobile vitreous membranes in all nine cases in the control group that had hyaloid adhesion in the macula on SD-OCT examination. In 19 cases in which the hyaloid was not visualized in SD-OCT, USG detected eight cases of partial PVD (adherent to the optic nerve), eight cases of total PVD, and three cases with mobile vitreous membranes. In the two cases in which the hyaloid was non-adherent, USG revealed partial PVD in one case (adherent to the optical nerve) and total PVD in the other case.

Moreover, vitreoretinal adhesion was not associated with AMD presence. The proportion of patients with and without adhesion who were evaluated by SD-OCT and USG did not differ between the AMD (non-exudative and exudative) and control groups (X2=0.682;

p=0.432). Thus, given the study conditions, vitreoretinal adhesion was neither higher nor lower in patients with AMD than in control pa tients.

The proportion of patients with and without adhesion who were evaluated by SD-OCT and USG did not differ between the non-exu-dative and exudative AMD groups (X2=0.589; p=0.471). Thus, given the study conditions, vitreoretinal adhesion was neither higher nor lower in patients with the exudative form than in those with the non-exudative form.

The proportion of patients with and without adhesion who were evaluated by OCT and US did not differ between the non-exudative AMD and control groups (X2=1.312, p=0.280) or between the exuda-tive AMD and control groups (X2=0.164, p=0.762).

DISCUSSIONThere is still much speculation regarding the role of hyaloid in

AMD. The vitreous is an important component in the pathophysio-logy of several retinal diseases, and hyaloid adhesion is a poor prog-nostic factor in some. Consequently, questions have been raised regarding the supposed role of hyaloid adhesion in AMD, with several theories being postulated. On the one hand, hyaloid adhesion has been only considered as a risk factor of AMD progression, whereas on the other hand, it has been only considered to be part of its pa-thophysiology. In other studies, it has been considered as a poor pro gnostic factor, predisposing either to the development of the exudative form or to a worse response to treatment.

Some studies suggest that hyaloid adhesion may induce a mild chronic retinal inflammation(18,19). This is then posited to hinder oxy-gen penetration and to cause chronic ischemia or VEGF retention in the macular area. Furthermore, hyaloid traction may lead to RPE dis-ruption, which is known to induce the appearance of the neovascular membrane. Embryological, molecular, and structural similarities have been demonstrated between Bruch’s membrane and the internal limiting membrane, thus supporting the theory that hyaloid may play a role in AMD(23).

We assessed the presence of vitreoretinal adhesion in patients with AMD to test its prevalence against that of a control group. When the hyaloid detachment develops close to the retina, the presence of vitreoretinal adhesion or traction can be difficult to diagnose using USG; therefore, we used SD-OCT for optimal assessment. However, SD-OCT images in cases with either total hyaloid adhesion in the ma-cular area or total detachment with hyaloid anteriorization are similar (the hyaloid is invisible); thus, the use of USG becomes indispensable.

Figure 1. Image obtained with spectral domain optical coherence tomography (Cirrus HD-OCT), showing the hyaloid adhering to the macular area (arrows).

Figure 2. Image obtained by ultrasonography using a 10-MHz transducer. The hyaloid adhering to the neovascular membrane is visible.

Figure 3. Image obtained by spectral domain optical coherence tomography (Cirrus HD-OCT). The hyaloid is not evident.

Martins MF, et al.


Furthermore, we chose not to distinguish between adhesion and traction because it has already been performed in some studies. The-refore, the objective was limited to assessing whether the prevalence of adherent hyaloid was higher in patients with AMD than in patients of the same age without AMD because it is known that the incidence of PVD increases with age.

In this analysis, we did not observe a higher vitreoretinal adhesion in patients with AMD than in the control patients, and we did not determine higher adhesion rates in patients with the exudative form than in those with the non-exudative form.

However, the evidence for a higher prevalence of vitreous adhe-sion in AMD remains conflicting. Some studies demonstrated higher hyaloid adhesion at all stages of AMD(17,19,20), whereas others demons-trated higher adhesion rates in the initial phases only(18).

Vitreomacular adhesion was assessed in patients with AMD(17) by dividing patients into exudative AMD, non-exudative AMD, and con-trol groups. The presence of hyaloid adhesion in the macular area was analyzed by OCT/confocal scanning laser ophthalmoscopy, whereas the presence of total PVD was evaluated by fundus biomicroscopy. Adhesion in patients with AMD was higher than in control patients; however, there was no difference between patients with exudative AMD and those with non-exudative AMD.

In another study(20), patients were divided in the same manner; however, only the presence of total PVD was assessed with USG. This approach also led to identifying a higher percentage of total PVD in the control group; however, no difference was observed when non-exu dative and exudative AMD were compared.

In another analysis(24), when adhesion was assessed by SD-OCT (Spectralis OCTTM; Heidelberg Engineering, Heidelberg, Germany) and fundus biomicroscopy in patients with active exudative AMD only, the result was different because of the higher rate of non-adhesion within the study group.

Another study(25) evaluated cases of non-exudative AMD that were classified as high risk (i.e., category IV according to the Age-Rela-ted Disease Study) using patients with a CNVM in one eye and non-exu dative high-risk AMD in the contralateral eye. Hyaloid adhesion was assessed by the time-domain OCT (OCT3, Carl Zeiss, Meditech, Dublin, CA), SD-OCT (Cirrus Version, Carl Zeiss) and the presence of the Weiss ring on biomicroscopy examination, thus concluding that there was no significant influence of vitreomacular adhesion on the development of the exudative form.

Furthermore, another study with a similar design(22) assessed hya-loid adhesion by SD-OCT (Stratus OCT3, Zeiss Humphrey, San Lean dro, CA) in patients with CNVM in one eye and no signs of CNVM or drusen in the contralateral eye. The authors concluded that vitreo retinal adhesion might be a risk factor for exudative AMD because most eyes with adhesion exhibited active exudative AMD.

In another study(19), patients were divided in a similar manner as in previous studies(17,20) but with the control group comprising contralateral eyes, as detailed elsewhere (22,25). Using USG and SD-OCT (Stratus III, Carl Zeiss, San Leandro, California, USA) to verify the sta-tus of the hyaloid, the authors discovered higher adhesion rates in patients with exudative AMD than in controls and patients with non-exu dative AMD.

In an alternative assessment of hyaloid adhesion in AMD(18), two groups were formed; one with druse in one eye and CNVM in the con-tralateral eye and another with atrophy in one eye and disciform disease in the contralateral eye. The presence of vitreomacular adhesion was evaluated by SD-OCT (OCT-SLO, OCT1000, and Stratus III OCT), and the presence of PVD was evaluated by USG. Similar to a previous study(22), it was concluded that total PVD might be protective against CNVM, whereas adhesion may be a risk factor for CNVM.

Further, in an evaluation of cases of CNVM using SD-OCT (OCT3, Carl Zeiss)(21), it was reported that most cases presented with abnor-malities in the vitreoretinal interface.

When analyzing the existing studies, one will notice contradicto-ry and inconclusive results, with many different methodologies, appa-ratuses, and groups being analyzed.

Given the results of this study, we believe that the hyaloid does not have a significant role in AMD pathophysiology. However, in cases of adhesion and CNVM, we observed that the hyaloid was always adherent in the membrane area, suggesting that a relationship could indeed exist between CNVM and hyaloid adhesion, as demonstrated in other studies(15,18,19,21,22).

A possible explanation is that a more intense retinal inflammation could be present in some cases of exudative AMD.

Nevertheless, questions remain as to whether such an inflam-mation would be a cause or consequence. Similarities in molecular composition and structural organization of the vitreoretinal interface and between the retina and RPE suggest that both interfaces may be subject to the same aging processes and that abnormalities of the first may alter or amplify the degenerative processes of the latter and vice-versa(23).

In this study, AMD stages (CNVM vs. disciform) were not sepa-rately evaluated; however, the percentage of adhesion in eyes with CNVM (27.7%) was higher than in eyes with disciform disease (4.54%). We failed to determine higher adhesion rates in the exudative group because of perhaps the high incidence of non-adhesion in the dis-ciform group (10/22).

Moreover, it is possible that hyaloid detachment is a natural pro-cess in AMD evolution, such as atrophy and disciform scar formation, which develops once the appearance of Muller cells would affect the integrity of the internal limiting membrane, thereby promoting hyaloid detachment. This hypothesis is consistent with previous ob-servations(18) and with our finding that adhesion occurred in 27.7% of the eyes with CNVM and in only 4.54% of those with disciform di-sease. However, further discussion is beyond the scope of this paper.

As demonstrated by a few studies, the hyaloid may only act as a poor prognostic factor for improving visual acuity following treatment, particularly when there is a traction in the macular area(24,26-28). In those cases, there is a disruption of the retinal layers that was caused not only by CNVM but also by hyaloid traction, thus leading to a worse visual prognosis. Alternatively, if the hypothesis of inflammation equally developing in the vitreoretinal interface and between the retina and RPE is confirmed, it would be conceivable that more severe degrees of inflammation result in both CNVM and in adhesion/traction/epireti-nal membranes, as observed in a study(21). To improve visual prog nosis of those cases, removal of the hyaloid may be justifiable.

We believe that despite the limited sample size of this study, the role of the hyaloid remains questionable. Further research must con-tinue with greater degrees of standardization in the groups evaluated and in the methods used.

It is important to pay special attention to the study of the hyaloid in cases with high-risk non-exudative AMD, as performed by a previous study(25), particularly before recommending vitrectomy as a preventi-ve measure against CNVM or macular atrophy(29).

Thus, it must be evaluated whether performing vitrectomy would adequately treat AMD. Finally, it is necessary to clarify whether remo-ving the vitreous would reduce the incidence of AMD or just that of CNVM or if it would affect visual prognosis.

CONCLUSIONIn this study, when assessed by SD-OCT and USG, patients with exu-

dative and non-exudative forms of AMD did not present with higher vitreoretinal adhesion than control patients without AMD. Moreover, exudative AMD (CNVM and disciform) was not associated with higher levels of adhesion when compared with non-exudative AMD.

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Original Article


INTRODUCTIONBranch retinal vein occlusion (BRVO) is the second most common

retinal vascular disorder after diabetic retinopathy(1,2). The typical presentation of BRVO is painless visual loss with flame-shaped reti-nal hemorrhages, cotton wool spots, and venous dilatation largely localized to the area drained by the occluded branch retinal vein(3). In BRVO, increased intravascular pressure causes dysfunction of the endothelial blood-retinal barrier, resulting in increased vascular per meability, eventually leading to cystoid macular edema (CME). In creased interstitial oncotic pressure can also interrupt capillary per-fusion and lead to ischemia(4,5).

Macular edema is the most frequent cause of visual loss in pa-tients with BRVO. Optical coherence tomography (OCT) studies have

demonstrated that macular edema secondary to BRVO is frequently associated with CME, serous retinal detachment (SRD), and inner re-tinal thickening. SRD has been reported in 15%-80% of patients with BRVO(6-8). Although the mechanism underlying SRD has yet be fully elucidated, extensive leakage of fluid from capillaries in the ischemic retina affected by BRVO may lead to accumulation in the subretinal space and thus cause serous detachment(9). Recently, studies have demonstrated that SRD and the loss of the photoreceptor layer leads to damage to the retinal pigment epithelium and neurosensory reti-na, contributing to the poor visual prognosis of BRVO(10-12).

In the present study, we aimed to assess the effect of SRD on both visual acuity (VA) and central macular thickness (CMT) in patients with BRVO and macular edema.

Serous retinal detachment in patients with macular edema secondary to

branch retinal vein occlusion

Descolamento seroso de retina em pacientes com edema macular secundário à oclusão de ramo

da veia retiniana

Erkan cElik1, EminE Doğan1, Elif BEtul turkoGlu1, Burçin çakir1, GurSoy alaGoz1

Submitted for publication: April 14, 2015 Accepted for publication: October 20, 20151 Sakarya University Medical Education and Research Hospital, Sakarya, Turkey.


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

Corresponding author: Elif Betul Turkoglu. Akdeniz University Medical Education and Research Hospital. Antalya, 07100 - Turkey - E-mail: [email protected]

ABSTRACTPurpose: The aim of the present study was to evaluate visual acuity (VA) and central macular thickness (CMT) to assess the influence of serous retinal detachment (SRD) in eyes with macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Methods: Sixty-one eyes with BRVO from 61 patients with ME were analyzed and divided into two groups according to the spectral domain optical coherence tomography (OCT) findings of SRD and cystoid macular edema (CME). All patients underwent complete ophthalmic examinations and OCT measurements (Cirrus, Carl Zeiss Meditec Inc, Dublin, CA). Patients with marked retinal hemorrhage, diabetic retinopathy, previous laser photocoagulation, and/or intravitreal injection were excluded. Results: The mean age of included patients (37 males, 24 females) was 65.4 ± 11.4 (53-77) years. There were 21 patients with SRD and 40 patients with CME. All of the 21 patients with SRD had CME. VA was significantly worse in the SRD group compared with the CME (non-SRD) group (0.82 ± 0.34 logMAR vs 0.64 ± 0.38 logMAR; P=0.005). Conversely, CMT was significantly greater in the SRD group than in the CME group (465 ± 115 µ vs 387 ± 85 µ; P=0.00004). Conclusion: SRD may be associated with decreased VA. The prognosis of patients with BRVO and SRD requires further investigation.

Keywords: Macular edema/etiology; Retinal detachment; Retinal vein occlusion/complications; Optical coherence tomography; Visual acuity

RESUMOObjetivo: O objetivo deste estudo foi investigar a acuidade visual (VA) e espessura macular central (CMT ) para avaliar a influência do descolamento seroso da retina (SRD) em olhos com edema macular (ME) secundário a oclusão de ramo da veia da retina (BRVO). Método: Sessenta e um olhos de 61 pacientes com oclusão de ramo da veia da retina e edema macular foram analisados e divididos em dois grupos, de acordo com os achados na a tomografia de coerência óptica por domínio espectral (OCT ), de edema macular cistóide (CME) e descolamento seroso da retina. Todos os pacientes foram submetidos a exame oftalmológico completo e exame de tomografia de coerência óptica (Cirrus, Carl Zeiss Meditec Inc, Dublin, CA). Os pacientes com hemorragia acen-tuada da retina, retinopatia diabética, fotocoagulação a laser e/ou injeção intravítrea prévia foram excluídos. Resultados: A idade média dos pacientes (37 homens, 24 mulheres) foi de 65,4 ± 11,4 (53-77) anos. Havia 21 pacientes com SRD e 40 pacientes com edema macular cistóide. Todos os 21 pacientes com SRD também apresentaram edema macular cistóide. VA foi significativamente pior no grupo SRD do que no grupo edema macular cistóide (non-SRD) (0,82 ± 0,34 vs 0,64 ± 0,38 logMAR, p=0,005). Por outro lado, a espessura macular central foi significativamente maior no grupo descolamento seroso da retina do que no grupo edema macular cistóide (465 ± 115 μ vs 387 ± 85 μ, p=0,00004). Conclusão: Observou-se que o descolamento seroso da retina em si pode estar re-lacionado à diminuição de acuidade visual. Os prognósticos dos pacientes com oclusão de ramo da veia da retina e descolamento seroso da retina precisam ser adequadamente investigados.

Descritores: Edema macular/etiologia; Descolamento retiniano; Oclusão da veia retiniana/complicações; Tomografia de coerência óptica; Acuidade visual

Serous retinal detachment in patients with macular edema secondary to branch retinal vein occlusion


METHODSWe retrospectively reviewed the medical records of 61 eyes of 61

patients with macular edema secondary to BRVO, previously exami-ned at the Department of Ophthalmology, Sakarya University Medi-cal Education and Research Hospital, from February 2010 to January 2014. The present study was approved by the Institutional Review Board and adhered to the tenets of the Declaration of Helsinki.

Each patient had unilateral BRVO. All patients had CME and/or SRD (≥300 µ on OCT). Patients were divided into two groups accor-ding to the spectral domain OCT findings of SRD and CME: patients with CME (Group 1) and patients with SRD (Group 2). All eyes in the SRD group had CME. CME was defined as hypo-reflective intraretinal cavities on OCT. On the other hand, SRD was defined as the presence of a non-reflective cavity with minimal shadowing of the underlying tissues due to subretinal fluid accumulation leading to the detach-ment of the neurosensory retina. The exclusion criteria included prior ocular surgery, diabetic retinopathy, previous laser photocoagulation and/or intravitreal injection, history of ocular inflammation, and marked retinal hemorrhage, including macular bleeding involving the subfo-veal or intrafoveal spaces.

At initial examination, patients underwent complete ophthal-mologic examinations, including VA, slit-lamp biomicroscopy, fun-duscopy, fundus color photography, fluorescein angiography, and spectral-domain OCT (Cirrus, Carl Zeiss Meditec Inc, Dublin, CA) ana-lysis to measure the CMT and evaluate the presence or absence of CME/SRD. OCT images were obtained from each eye following pupil dilation by the same operator using the Macular Cube 512*128 scan

protocols. Scans with a signal strength of ≥7 were used for analysis. Retinal thickness was defined as the distance between the inner re-tinal surface of the neurosensory retina and the retinal pigment epi-thelium. Best-corrected VA was measured using a Snellen Chart and then converted into a logarithm of the minimum angle of resolution (logMAR) for statistical comparison.

Statistical analysis was performed with Python version 2.7.6 and scipy library version 0.13.3. The results are presented as the mean ± standard deviation. Welch’s test was used to compare normally dis-tributed unpaired continuous variables between groups. Two-tailed P-values of less than 0.05 were considered statistically significant.

RESULTSThe characteristics of the CME and SRD groups are summarized

in table 1. Of the 61 patients with BRVO, 40 were assigned to the CME group and 21 to the SRD group. All 21 patients in the SRD group had both SRD and CME.

No differences in mean age, female/male ratio, duration of BRVO, and prevalence of hypertension were observed between the CME and SRD groups (P=0.611, P=0.887, P=0.684, and P=0.885, respecti-vely; Table 1).

VA was significantly worse in the SRD group compared with the CME (non-SRD) group (0.82 ± 0.34 logMAR vs 0.64 ± 0.38 logMAR, P=0.005). Conversely, CMT was significantly greater in the SRD group than in the CME group (465 ± 115 µ vs 387 ± 85 µ, P=0.00004; Figure 1).

DISCUSSIONThis retrospective study evaluated the relationship between the

presence of SRD and VA and CMT in BRVO patients with macular edema. Although SRD is a common feature on OCT images, there is a lack of data regarding the influence of SRD on VA, CMT, and response to therapies in BRVO patients. In the present study, 21 of 61 eyes (34%) with macular edema secondary to BRVO demonstrated retinal swelling with SRD. Additionally, all SRD patients also had CME. Eyes with SRD had greater foveal thickness with CME. We also observed significantly lower mean VA (logMAR) in the SRD group compared to the CME group, corroborating previous reports(10-13).

Macular edema is the leading cause of visual impairment in BRVO and may be accompanied by various morphological changes. The application of OCT imaging has provided qualitative analysis of the

Table 1. Clinical features of the CME and SRD groups

Findings CME (N: 40) SRD (N: 21) P value

Age (years) 65.2 ± 6.3 65.8 ± 5.6 0.611

Gender (female/male) 16/24 8/13 0.887

Duration of BRVO (months) 04.4 ± 1.9 04.2 ± 2.2 0.684

Hypertension 28 15 0.885

BRVO= branch retinal vein occlusion; CME= cystoid macular edema; SRD= serous retinal detachment.

VA= visual acuity; CMT= central macular thickness, SRD= serous retinal detachment; CME= cystoid macular edema.Figure 1. VA and CMT in the SRD and CME (non-SRD) groups. VA was significantly worse in the SRD group compared with the CME (non-SRD) group. CMT was significantly greater in the SRD group than in the CME group.

Celık E, et al.


different retinal layers(14). The morphological diversity of the retinal changes associated with macular edema include sponge-like retinal swelling, cystic changes, and SRD(15). Retinal swelling and CME are typically caused by leakage from retinal vessels observed as retinal thickening and oval hyporeflective areas with intraretinal cystoid spaces on OCT. In SRD, fluid accumulates between the neurosensory retina and the RPE, seen as hyporeflective spaces on OCT(14,15).

A variety of mechanisms have posited to underlie the pathoge-nesis of SRD. It was previously thought that SRD was associated with hemodynamic overload and disrupted function of the retinal pig-ment epithelium due to retinal ischemia(16). Marmor and Murakami speculated that vitreal hyperosmolarity may be a possible mecha-nism underlying the development SRD by allowing the flow of fluid from the vitreous to the choroid(17,18). Ota suggested that small breaks on the external surface of the neurosensory retina, which connects the swollen outer retina, may also be responsible for SRD(7). In the present study, we performed a detailed analysis of the macula and inner/outer segment of photoreceptors by OCT and found no defects on the external surface of the retina above the site of SRD in any of the evaluated eyes.

The inner half of the fovea includes an inverted cone-shaped zone of Müller cells (the Müller cell cone), the apex of which is located at the external limiting membrane (ELM) of the fovea centralis. The cytoplasm of cells in the Müller cell cone extends obliquely outward and forms the internal limiting membrane at the clivus of the foveal depression(19,20). In eyes with BRVO, leakage from the affected retinal capillaries accumulates around the fovea and causes retinal thickening, which may cause the internal limiting membrane at the clivus of the fovea to protrude, leading to the development of CME(15). In this case, the cytoplasm of the Müller cell cone extends perpendicularly in the walls of the foveal cystoid spaces. When leakage increases, further traction on the Müller cell cone leads to traction on the inner and outer segments of the foveal photoreceptors resulting in a small area of retinal detachment at the fovea. Subsequently, SRD occurs when the ELM barrier breaks down at the fovea(15). Loss of the ELM barrier often results in damage to foveal photoreceptors in the outer segment and VA impairment(10). Thus, the mean VA of the SRD group may have been significantly worse as a result of damage to foveal photoreceptor cells due to foveal detachment. In addition, all SRD patients in the present study also had CME. Therefore, we believe SRD itself may decrease VA.

In the present study, we observed greater CMT in the SRD group compared to the CME group, corroborating previous reports. In BRVO patients, SRD occurs as a result of transudation of extracellular fluid into the subretinal space with the site of detachment being deter-mined by foveal architecture, particularly the presence of the Müller cell cone(21,22). Furthermore, when the barrier function of the ELM breaks down due to traction on the Müller cell cone, intraretinal fluid moves into the subretinal space resulting in an increase of SRD and alleviation of retinal edema(12,15). This process may have contributed to the greater CMT in the SRD group compared to the CME group.

Inflammatory factors may be strongly associated with the occur-rence of SRD in BRVO patients. Noma et al.(23) reported that vitreous fluid levels of VEGF and sICAM-1, potent vasopermeability factors, were higher in BRVO patients with SRD compared to those with CME. They also reported significantly worse VA in the SRD group compared with the CME group and significantly greater CMT in the SRD group. They proposed that worse VA in the SRD group may be related to photoreceptor cell damage caused by macular detachment and/or functional impairment secondary to ischemia with high vitreous fluid levels of VEGF and ICAM-1(23). In another study evaluating the efficacy of intravitreal triamcinolone acetonide for CME with SRD in BRVO, triamcinolone acetonide was thought to reduce CMT by decreasing retinal capillary permeability via an effect on tight junctions and/or

inhibition of signaling cascades involving VEGF and the VEGF re-ceptor(13). Moreover, decreased retinal capillary permeability may relieve traction on the Muller cell cone resulting in decreased SRD. Corticos teroids may also prevent the production of various inflamma-tory mo lecules that promote leukocyte adhesion and breakdown of the blood-retinal barrier(13).

The limitations of the present study were its retrospective nature, small sample size, lack of functional mapping by microperimetry (ma-cular sensitivity), and lack of BRVO patients with SRD only.

In conclusion, the mean VA was significantly worse in the SRD group compared with the CME group, and eyes with SRD had greater CMT. We observed that SRD itself may be related to decreased VA. Further detailed studies with a larger number of patients are required to confirm the role of SRD as a predictive factor of VA and prognosis.

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Original Article


RESUMOObjetivo: O objetivo deste estudo foi investigar o volume plaquetário médio (MPV) de pacientes com oclusão da artéria da retina (RAO). Métodos: Trinta e sete pacientes com diagnóstico de RAO e 32 indivíduos do grupo controle foram incluídos neste estudo retrospectivo. A oclusão da artéria da retina foi diagnosticada com base em exame clínico e angiofluoresceinografia. Todos os partici-pantes foram submetidos ao exame ocular completo. MPV, hematócrito, hemoglobina e contagem de plaquetas dos participantes foram registrados. Os dados dos pacientes com RAO foi comparado com os de sujeitos do grupo controle.Resultados: Pacientes com RAO apresentaram valores significativamente mais eleva-dos MPV (7,96 ± 1,2 fL) em comparação aos indivíduos do grupo controle (7,33 ± 0,7 fL) (p<0,001). Nenhuma diferença significativa foi encontrada no número de plaquetas entre os grupos RAO e controle (262 ± 70,1 109/L and 251 ± 56,6 109/L, respectivamente, p=0,50). MPV foi um preditor independente de RAO (odds ratio (OR)=0,50; intervalo de confiança de 95% (IC)=0,28-0,89; p=0,019).Conclusões: Os resultados demonstraram que os valores de MPV foram significati-vamente maiores nos pacientes com RAO, sugerindo que plaquetas maiores podem contribuir na patogênese da RAO.

Descritores: Volume plaquetário médio; Plaquetas; Oclusão da artéria retiniana; Doen -ças retinianas; Vasos retinianos

Mean platelet volume in patients with retinal artery occlusion

Volume médio de plaquetas em pacientes com oclusão da artéria da retina

muhammED Şahin1, alparslan Şahin1, harun yükSEl1, fatih MEhMEt türkcü1, adnan yildiriM1

Submitted for publication: May 13, 2015 Accepted for publication: November 9, 20151 Departments of Ophthalmology, School of Medicine, Dicle University, Diyarbakir, Turkey.



Corresponding author: Muhammed Şahin. Department of Ophthalmology, School of Medicine, Dicle University - Diyarbakir - Turkey - E-mail: [email protected]

ABSTRACTPurpose: The aim of this study was to investigate the mean platelet volume (MPV) of patients with retinal artery occlusion (RAO). Methods: Thirty-seven patients diagnosed with RAO and 32 control subjects were included in this retrospective study. Retinal artery occlusion was diagnosed on the basis of clinical examination and fundus fluorescein angiography. All participants underwent complete ocular examination, and MPV, hematocrit, hemoglobin, and platelet counts were recorded. RAO patient data were compared with those of the control subjects. Results: Patients with RAO had significantly higher MPV values (7.96 ± 1.2 fL) com pared with control subjects (7.33 ± 0.7 fL, p<0.001). No significant difference was found with regard to platelet count between the RAO group and the control group (262 ± 70.1 × 109/L and 251 ± 56.6 × 109/L, respectively, p=0.50). MPV was an independent predictor of RAO [odds ratio (OR)=0.50; 95% confidence interval (CI)=0.28-0.89; p=0.019). Conclusions: Our results demonstrated that MPV values were significantly higher in patients with RAO, suggesting that larger platelets may contribute to the pa-thogenesis of the RAOs.

Keywords: Mean platelet volume; Blood platelets; Retinal artery occlusion; Retinal diseases; Retinal vessels

INTRODUCTIONRetinal arterial occlusion (RAO) is a rare cause of irreversible and

profound vision loss, particularly in patients over the age of 60 years of age, despite the existence of various treatment modalities(1,2). RAOs are classified according to the anatomic region of the occlusion as central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO), and cilioretinal artery occlusion (CLRAO)(3).

CRAO was first described by von Graefes in 1859(4). Patients with CRAO present with sudden, painless, severe visual loss. BRAO causes sudden segmental visual loss associated with visual field damage(5). The incidence of CRAO has been estimated to be approximately 0.85 in 100,000 per year(6). CRAO constitutes 57% of acute RAOs, whereas BRAO and CLRAO constitute 38% and 5% of acute RAOs, respectively(7). CRAO by virtue of its pathogenesis shares important risk factors with other vascular diseases such as ischemic heart disease and cerebro-vascular disease(8). The majority of RAOs are either thrombotic or embolic in nature(6). Arterial occlusions in the eye are almost always due to micro-embolism and the major source of micro-emboli is plaque(s), which may be present with or without significant stenosis of the carotid artery. Therefore, absence of significant stenosis of the carotid artery does not necessarily rule out the carotid artery as the source of micro-embolism(9). The most frequent retinal emboli are

represented by cholesterol emboli (74.0%), platelet fibrin emboli (15.5%), and calcific emboli (10.5%)(10).

Platelets have an important role in the pathogenesis of throm-bo-occlusive disease. Mean platelet volume (MPV) is an indicator of platelet size and has been known to be a marker of platelet activity. Large platelets are more reactive than small platelets and produce more thromboxane A2, express more glycoprotein Ib and glycoprotein IIb/IIIa receptors, and aggregate more easily(11,12).

In the present study, we aimed to investigate the platelet activity in the development of RAO through MPV. To the best of our knowledge, we are the first to report MPV in patients with RAO.

METHODSThe study protocol was approved by the local ethic committee,

and the study was performed in accordance with the Declaration of Helsinki. The patients who were diagnosed with RAO (i.e., CRAO, BRAO, or CLRAO) between January 2011 and December 2014 were reviewed retrospectively. All subjects underwent a full ocular exami-nation, including measurement of visual acuity and intraocular pres-sure (IOP), slit lamp biomicroscopic anterior segment, and fundus examination. We also performed fundus fluorescein angiography (FFA) and optic coherence tomography in all patients.

Şahin M, et al.


Age, gender, ocular pathology, systemic disease, and complete blood count (CBC) parameters [i.e., MPV, hemoglobin (hb), hematocrit (htc), and platelet count] were recorded. The diagnosis was based on the sudden visual loss accompanied by one or more of the following signs as observed by slit-lamp biomicroscopy with a 90-diopter lens: (1) reduced and thinned retinal artery flow; (2) fragmentation of the blood column in retinal arterioles; (3) retinal opacification combined with absent or poor residual retinal blood flow; and (4) the presence of a cherry-red spot (for CRAO). FFA revealed diminished blood flow in the retinal arteries. These findings were compared with the fellow unaffected eye. Patients with any systemic disease other than hyper-tension (HT) and diabetes mellitus (DM) were excluded from the study. Patients with anemia (htc <38.0%), any cardiovascular disease, such as heart valve disease treated with anticoagulant, congestive heart failure, chronic renal failure, stroke, history of smoking, and history of alcohol consumption were excluded; patients with glau-coma and with a history of any ocular surgery or trauma, and giant cell arteritis were also excluded. Age- and gender-matched subjects in the control group were recruited from an outpatient clinic of the same ophthalmology department.

Blood samples were taken at the time of RAO diagnosis. CBC samples drawn into vacutainer tubes containing 0.04 mL of 7.5% K3 salt of EDTA were analyzed within an hour after sampling with a commercially available analyzer (CELL-DYN 3700, Abbott Diagnostics, Abbott Park, IL, USA). MPV, platelet count, hb, and htc were recorded. Normal MPV values ranged between 7.0 and 10.4 fL.

STATISTICAL ANALYSIS All values are given as means ± SD. For statistical analysis, the

SPSS statistical software package version 18.0 for Windows (SPSS, Chicago, IL) was used. The Kolmogorov-Smirnov test was applied to test the distribution pattern of each data. Student’s t-test was used for normally distributed data in the group comparisons. P value <0.05 was considered statistically significant. Univariate logistic regression analysis was used to assess associations among MPV, htc and hb levels, HT, DM, age, and gender with RAO.

RESULTSOf the 45 patients with RAO that were consecutively examined,

37 patients were eligible for the study. The control group consisted of 32 subjects, and the mean age of the RAO group and the control group was 55.4 ± 18.9 and 57.7 ± 13.1 years, respectively. The male-to- female ratio was 17:20 in the RAO group and 18:14 in the control group. There were no statistical difference in age and sex between the groups (p=0.41 and p=0.22, respectively) (Table 1). There was no

difference between the control and the RAO groups with respect to the presence of HT and DM.

Mean platelet volume was significantly higher in patients with RAO than in the control group (7.96 ± 1.2 fL vs. 7.33 ± 0.7 fL, p<0.001). In contrast, the mean platelet count was higher in the control group compared with the RAO group, although not statistically significant (p=0.50). Logistic regression analysis showed that MPV was an in-dependent predictor of RAO [odds ratio (OR)=0.50; 95% confidence interval (CI)=0.28-0.89; p=0.019].

DISCUSSIONThe present study showed increased levels of MPV in patients with

RAO. To the best of our knowledge, this is the first study that shows the relationship between high MPV values and RAO.

Several mechanisms such as thrombosis, embolization, vasculitis, and vasospasm are attributed to RAO(13). Thrombosis resulting from atherosclerotic plaques is the major cause of CRAO(14). Rupture of an atherosclerotic plaque triggers platelet aggregation and consequen-tly thrombus formation. It is likely that most CRAOs are due to a throm-bosis at the level of the lamina cribrosa(15). Emboli may be seen in up to 20% of patients with CRAO and up to 68% of those with BRAO(16). These emboli are believed to typically arise from ulcerated atheros-clerotic plaques or thrombi within internal or carotid arteries, or from cardiac valves.

The platelets have a key role in the pathogenesis of thrombo-em-bolic disorders. Since larger platelets store and release larger amounts of serotonin, β-thromboglobulin, and thromboxane A2, they are more reactive and prone to aggregation(12,17). MPV is an indicator of the size and activity of platelets. Increased values of MPV have been shown to be a risk factor for deep venous thrombosis, acute myocardial in-farction, stroke, and acute ischemic cerebrovascular events(18-21). Bath and Butterworth reported that platelet hyperactivity results in an increase in MPV(22). In our study, the MPV values were significantly higher compared with the control group, suggesting that large pla-telets may contribute to the pathogenesis of RAO. Logistic regression analysis revealed that MPV is an independent predictor of RAO. The presence of high MPV in these patients may have increased their risk of developing RAO.

Platelets have an important role in the initiation of atherosclerotic lesions and subsequent complications(23). Their role in carotid athe-rosclerosis has been demonstrated in previous studies. P-selectin sto-red in the secretory granules of the platelets is crucial for the growth and maturation of atherosclerosis plaques, including the presence of smooth muscle cells and calcification(24). Burger and Wagner sugges-ted that platelets and their P-selectin also actively promote advanced development of atherosclerotic lesions.

Heidrich et al. reported that platelet aggregation test (PAT III) values were elevated in all patients with acute RAO(25). Therefore, high platelet aggregation can be one cause of long-term retinal capillary occlusion in patients with RAOs. Paterson et al. studied the role of platelets in retinal circulation and suggested that platelet aggregates cause vessel occlusion either by embolization or by localized throm-bosis of the arterial or venous branch of retinal vessels(25,26). Moreover, BRAO has been observed following platelet transfusion in humans(27). Finally, in an experimental study, RAO was developed by infusing aggregated platelets(28). These studies suggest a role for platelets in the development of retinal artery occlusions.

Serotonin, a vasoconstrictor amine, is released by platelet aggre-gation on atherosclerotic plaques in the carotid artery. It was demons-trated in an experimental model that serotonin can cause transient or complete occlusion or impaired blood flow in the central retinal artery by producing a transient spasm in atherosclerotic monkeys; this may contribute to the development of RAO(29).

MPV has been studied in a few ocular vascular disorders. Our team reported an increase in MPV in patients with retinal vein occlusion (RVO) and ocular Behçet’s disease(30,31). Ateş et al. found a significant

Table 1. Demographic and clinical features of RAO patients and control individuals

RAO Control P valueAge 55.4 ± 18.9 57.7 ± 13.1 0.410

Gender (M/F) 17/20 18/14 0.220

HT 6/37 4/32

HT and DM 2/37 2/32

Hb (g/dL) 13.7 ± 1.7 14.2 ± 1.2 0.180

Hct (%) 41.2 ± 4 41.9 ± 3.8 0.470

Plt (103/µL) 262.2 ± 70.1 251.7 ± 56.6 0.500

MPV (fL) 7.96 ± 1.2 7.33 ± 0.7 <0.001

IOP (mmHg) 14.6 ± 2.9 13.9 ± 2 0.100

VA (Snellen) 0.18 ± 0.3 0.75 ± 0.3 <0.001

RAO= retinal artery occlusion; HT= hypertension; DM= diabetes mellitus; Hb= hemoglo-bin; Hct= hematocrit; Plt= platelet count; MPV= mean platelet volume; VA= visual acuity; IOP= intraocular pressure.

Mean platelet volume in patients with retinal artery occlusion


increase in MPV in patients with diabetic retinopathy(32). In addition, the role of platelets in RVO was also studied by Leoncini et al.(33), who reported an increased platelet response to thrombin in patients with RVO. Moreover, they suggested that platelet hyperaggregability in-ducing thrombus formation is an important factor in the onset and/or development of RVO.

Our study has some limitations: it was a retrospective analysis with a relatively small number of patients, which is inherent to investi-gations of rare diseases. With the lack of data on body mass index and lipid profiles, thrombin time, prothrombin time, and INR and no carotid artery Doppler ultrasound performed on patients, the results merely demonstrate the hematologic status at the acute stage of RAO within 48 hours. Thus, these results may not reflect the status of the patients over longer periods.

In conclusion, the present study demonstrated that MPV values were significantly higher in patients with RAO than in controls. Des-pite the retrospective design of our study, we suggest that MPV may be used as a predictive tool for identifying the risk of developing RAO. Further studies are needed to confirm the predictive value of MPV in RAO risk assessment.

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Original Article


INTRODUCTION

Diabetic retinopathy is the leading cause of vision loss in the elder-ly(1). Almost 95% of diabetes-related visual impairment, however, is preventable by early diagnosis and photocoagulation therapy(2). A number of multi-center trials have consistently demonstrated the benefits of photocoagulation in high-risk patients with proliferative diabetic retinopathy (PDR)(3,4).

Panretinal photocoagulation (PRP) is painful, and a substantial num-ber of patients are therefore undertreated and at an increased risk of developing blindness(5). Compared with the widely used conventional

laser, new technologies provide more comfortable, less harmful and time-saving treatments because of sub-threshold and multi-shot laser photo coagulators(6,7).

The pattern scan laser (PASCAL; Opti-Medica Corp., Santa Clara, California, USA) is a new generation semi-automatic and multi-shot photocoagulator, which uses either a single or predetermined pattern array with pulse durations as short as 10-30 ms(8,9). Navigated laser pho tocoagulation (NAVILAS; OD-OS GmbH, Teltow, Germany) is ano-ther novel computer-based double-frequency ND:YAG laser photo-coagulation system (532 nm), which, apart from offering retina navi-gation, has similar technical specifications as PASCAL (single or prede-

Comparison of pain scores between patients undergoing panretinal

photocoagulation using navigated or pattern scan laser systems

Comparação de graduação de dor entre os pacientes submetidos à panfotocoagulação

usando sistemas de laser navegado ou de padrão de varredura

uMit uBEyt inan1, onur polat2, SiBEl inan1, SafiyE yiGit1, zEki BaySal1

Submitted for publication: October 9, 2015 Accepted for publication: November 12, 20151 Department of Ophthalmology, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar,

Turkey.2 Ophthalmology Clinic, Afyonkarahisar State Hospital, Afyonkarahisar, Turkey.



Corresponding author: Onur Polat. Ophthalmology Clinic. Afyonkarahisar State Hospital, Afyonka-rahisar - 03200 - Turkey - E-mail: [email protected]

ABSTRACTPurpose: To compare the pain responses of patients with proliferative diabetic retinopathy (PDR) undergoing panretinal photocoagulation (PRP) using either pattern scan laser (PASCAL) or navigated laser photocoagulation (NAVILAS). Methods: Patients diagnosed with PDR were randomly assigned to undergo either PASCAL or NAVILAS photocoagulation treatment. PRP was performed using the multi-shot mode with a spot size of 200-400 µm and a pulse duration of 30 ms to obtain a white-grayish spot on the retina. Parameters were identical in both pro-cedures. After 30 min of PRP application, patients were asked to verbally describe their pain perception as either “none,” “mild,” “moderate,” “severe,” or “very severe” using a verbal rating scale (VRS) and visual analog scale (VAS) by indicating a score from “0” to “10,” representing the severity of pain from “no pain” to “severe pain.” Results: A total of 60 eyes of 60 patients (20 females and 40 males) diagnosed with PDR were treated. The mean age of patients was 62.22 ± 9.19 years, and the mean diabetes duration was 195.47 ± 94.54 months. The mean number of laser spots delivered during PRP was 389.47 ± 71.52 in the NAVILAS group and 392.70 ± 54.33 in the PASCAL group (p=0.57). The difference in pain responses between patients in the NAVILAS and PASCAL groups was significant with regard to the mean VRS (1.10 ± 0.67 and 1.47 ± 0.69, respectively; p=0.042) and mean VAS (2.13 ± 1.17 and 2.97 ± 1.35, respectively; p=0.034) scores. Conclusions: Pain responses in patients undergoing PRP with a 30-ms pulse du-ration were significantly milder in the NAVILAS group than in the PASCAL group.

Keywords: Diabetic retinopathy; Equipment design; Laser coagulation; Pain mea-surement

RESUMOObjetivo: Comparar as respostas de dor de pacientes com retinopatia diabética pro-liferativa (PDR) submetidos à panfotocoagulação retiniana (PRP) usando laser de padrão de varredura (PASCAL) ou fotocoagulação navegada a laser (NAVILAS). Métodos: Pacientes com diagnóstico de PDR foram aleatoriamente designados para submeter-se ao tratamento de fotocoagulação com PASCAL ou NAVILAS. A PRP foi realizada no modo “multi-shot” com diâmetro do laser de 200-400 µm e duração do pulso de 30 ms, utilizados para se obter uma mancha branca-acinzentada na retina. Os parâmetros foram idênticos em ambos os procedimentos. Após 30 minutos da PRP, os pacientes foram solicitados a descrever verbalmente a sua percepção da dor como quer “nenhuma,” “leve,” “moderada,” “intensa” ou “dor muito intensa” por meio de uma escala de avaliação verbal (VRS) e também por meio de uma escala visual analógica (VAS), indicando uma pontuação de “0” a “10” representando a intensidade da dor de “nenhuma dor” a “dor intensa.”Resultados: Um total de 60 olhos de 60 pacientes (20 mulheres e 40 homens) com diagnóstico de PDR foram tratados. A média de idade dos pacientes foi de 62,22 ± 9,19 anos e a média de duração da diabete foi 195.47 ± 94,54 meses. O número médio de pulsos de laser emitidos durante a PRP foi 389,47 ± 71,52 no grupo NAVILAS e 392,70 ± 54,33 no grupo PASCAL (p=0,57). A diferença nas respostas de dor entre os pacientes nos grupos NAVILAS e PASCAL foi significativa em relação às médias de VRS (1,10 ± 0,67 e 1,47 ± 0,69; p=0,042) e VAS (2,13 ± 1,17 e 2,97 ± 1,35; p=0,034). Conclusões: As respostas de dor em pacientes submetidos à PRP com pulsos de 30 ms de duração foram significativamente menores nos pacientes do grupo NAVILAS em relação ao grupo PASCAL.Descritores: Retinopatia diabética; Desenho de equipamento; Fotocoagulação a la ser; Medição da dor

Comparison of pain scores between patients undergoing panretinal photocoagulation using navigated or pattern scan laser systems


termined pattern array, 10-30-ms pulse duration)(10,11). Compared with conventional lasers, both modalities use shorter laser pulses, cause rela-tively less thermal damage to adjacent retinal tissues and are therefore possible to produce relatively less painful photocoagulation. Whether one of these new laser platforms produce less pain than the other during the panretinal photocoagulation is not extensively investigated.

In this study, we sought to compare pain responses in patients un dergoing PRP with either PASCAL or NAVILAS for PDR.

METHODSPATIENTS

Among patients presenting with visual complaints between June and September 2014, those diagnosed with PDR were enrolled in the study. Patients were randomly assigned to receive either NAVILAS or PASCAL photocoagulation therapy. Ethical committee approval and informed consent from patients were obtained, and the study adhered to the tenets of the Helsinki Declaration.

The inclusion criteria were as follows: being older than 18-years, having a diagnosis of diabetes mellitus type 1 or 2, and presenting with a high risk of PDR. A high risk of PDR was defined as neovascula-rization of the optic disc, neovascularization associated with vitreous or preretinal hemorrhages (NVEs), or neovascularization greater than one-half of the disk area in size accompanying vitreous or preretinal hemorrhage regardless of NVE location.

Patients with a low risk of PDR, those with poor compliance, and pregnant women were excluded. Additionally, patients with a history of focal/grid photocoagulation or PRP, orbital trauma or surgery; those presenting with inflammatory signs; those with significantly increa-sed corneal or lens thickness; and those with vitreous hemorrhage were also excluded.

All patients were subject to the following assessments: slit-lamp biomicroscopy, intraocular pressure measurement with Goldmann applanation tonometry, fundus fluorescein angiography, and ophthal-mologic examination including fundus assessment.

LASER APPLICATION

Patients were randomly assigned to either the PASCAL (30 pa-tients) or NAVILAS (30 patients) groups. All patients were treated by the same surgeon and underwent a single PRP session. Treatments were performed under topical anesthesia.

The spot size (200-400 µm) and pulse duration (30 ms) used to obtain a white-grayish spot on the retina were identical in both pro-cedures. To objectively compare pain responses, PRP was used in the multi-shot mode and was applied within similar retinal areas, and the total number of spots delivered was equivalent.

PAIN PERCEPTION

After 30 min of PRP application, patients were asked to verbally describe their pain perception as either “none,” “mild”, “moderate”, “se vere”, or “very severe” through a verbal rating scale (VRS). Additio-nally, they were asked to specify the severity of pain through a visual analog scale (VAS) by indicating a score from “0” to “10,” representing the severity of pain from “no pain” to “severe pain.”

STATISTICAL ANALYSIS

Statistical analyses were performed using the SPSS (Statistical Packa-ge for Social Sciences Inc., Chicago, IL, ABD) version 17.0 software. Data distribution was assessed by the Kolmogorov-Smirnov test. Compa-risons were performed using the Mann-Whitney U test and t-test for independent samples.

RESULTSA total of 60 eyes of 60 patients (20 females and 40 males) diag-

nosed with PDR were treated. The mean age of patients was 62.22 ± 9.19 years, and the mean duration of diabetes was 195.47 ± 94.54

months. Patient demographics are presented in table 1. There were no significantly differences between the groups in terms of mean age, gender, and mean diabetes duration.

The mean number of laser spots delivered during PRP was 389.47 ± 71.52 in the NAVILAS group and 392.70 ± 54.33 in the PASCAL group. The difference was not significant (p=0.57).

The difference in pain response between patients in the NAVILAS and PASCAL groups was significant with regard to both mean VRS (1.10 ± 0.67 vs. 1.47 ± 0.69, respectively; p=0.042) and mean VAS (2.13 ± 1.17 vs. 2.97 ± 1.35, respectively; p=0.034) scores (Table 2).

While no patients in the PASCAL group reported “no pain” in the VRS assessment, four (13.3%) in the NAVILAS group reported “no pain” associated with PRP application. A total of 11 of 30 patients reported experiencing moderate or severe pain during PASCAL laser treatment compared with 6 of 30 treated with the NAVILAS laser. None of the patients in either groups reported “very severe pain.” Patient distribu-tion according to VRS is presented in figure 1.

DISCUSSIONThe advent of photocoagulation in 1967 was a critical step in the

treatment of diabetic retinopathy and maculopathy(12). PRP treatment may cause considerable pain and discomfort in some patients and

Table 1. Demographic characteristics of study individuals

NAVILAS PASCAL P

Gender (F/M) 8/22 12/18 0.270**

Age (mean ± SD) 063.3 ± 009.4 061.1 ± 9.1 0.351**

Duration of diabetic disease (mean ± SD)

206.8 ± 101.1 184.1 ± 87.8 0.480**

*= chi-square test; **= independent t-test.

Table 2. Pain scores associated with NAVILAS laser and PASCAL laser treatments

NAVILAS PASCAL P

Verbal score 1.10 ± 0.67 1.47 ± 0.69 0.042

VAS 2.13 ± 1.17 2.97 ± 1.35 0.034

VAS= visual analog scale; p= Mann-Whitney U test.

Figure 1. Number of patients subject to photocoagulation treatment by the two laser systems (PASCAL or NAVILAS) according to expressed verbal score.

Inan UU, et al.


may consequently yield reluctance to continuing treatment sessions, thus leading to visual deterioration. By changing laser parameters, however, it may be possible to improve comfort and reduce pain(13). In the current study, we found that patients undergoing PRP treatment with the NAVILAS system experienced significantly less pain than those treated with the PASCAL system with a pulse duration of 30 ms.

The Diabetic Retinopathy and Early Treatment Diabetic Retinopa-thy studies, using a single-shot conventional laser device, established the minimum laser power levels in PRP treatment with a spot size of 200-500 mm and a pulse duration of 100-200 ms(14,15). Novel laser treatment systems, however, use the multi-shot mode with short pulse duration, thereby providing shorter, less demanding, and less painful treatment sessions(16). Furthermore, studies have shown that a short pulse duration does not negatively influence PRP treatment efficacy(16-18).

Targeting the retinal pigment epithelium while preserving adja cent photoreceptors through micro-air bubble formation formed around melanosomes is a novel target therapy modality of laser photocoagulation. The critical threshold between thermal and me-chanical damage is 50 ms(19-21). Owing to the use of shorter pulses, novel laser therapy techniques cause only mechanical but not ther-mal damage, limiting the damage to the retinal pigment epithelium and preserving the inner retinal layers and sensory-rich chorioretinal tissues(17). Consequently, patients usually report less pain, most pro-bably because retinal sensitivity is better preserved as compared with pain in conservative approaches(9,17). Recent studies have consistently shown that patients treated with either the PASCAL or NAVILAS laser system modalities experienced less pain as compared with those treated with conventional laser treatment modalities(9,10,17,22).

The reason why patients treated with the NAVILAS system expe-rience less pain than those treated with the PASCAL system may in part be attributed to the fact that the former uses infrared light instead of the bright slit-lamp light used in the latter. Infrared light is known to cause less photostimulation(16).

Additionally, both conventional and PASCAL treatment systems require the tilting and moving of a contact lens for treating the peri-pheral retina, which may cause discomfort(23). The NAVILAS system, on the contrary, uses a specifically designed contact lens and does not require tilting of the lens for the examination and treatment of the retinal periphery(24). The tilting of the lens is also related to laser focusing, significantly influencing spot size and energy density at the level of the retina(23). Focusing is performed by moving the slit lamp closer or further away from the eye in the PASCAL laser system, where laser and image foci may not be identical. On the other hand, the NAVILAS laser system enables the documentation of focus settings adjusted prior to treatment to achieve a clear focused retinal image and focused laser beam(25). As a recent study revealed, laser spots deli-vered during NAVILAS photocoagulation are more accurate than those delivered using the PASCAL system. Thus, inadvertent laser application is minimized, collateral damage within the retina is decreased, and the preservation of retinal sensitivity is improved, eventually resulting in more comfort and less pain(24).

Response to pain among individuals may vary depending on factors such as culture, gender, threshold of pain, degree of fundus pigmenta-tion, and history of previous laser treatment(17,26). None of the patients included in this study had a previous history of laser treatment. Addi-tionally, randomization provided a more objective assessment of pain. Nevertheless, these factors may still, in part, account for the difference observed in the perception of pain.

Our review of literature identified two additional trials, both con-ducted by Chablani et al.(16,24), comparing differences in the perception of pain between patients with PDR undergoing NAVILAS or PASCAL photocoagulation. In both studies, a pulse duration of 100 ms was used, and it was found that treatment-related pain was significantly milder following NAVILAS than following PASCAL photocoagulation(24). In the current study, however, we found that treatment with a pulse duration of 30 ms also resulted in milder pain in patients treated with

NAVILAS compared with those treated with PASCAL. This issue has rarely been investigated and merits further consideration with long-term follow-up studies on larger groups.

While the relatively small number of spots delivered may appear to be a limitation, the main purpose of the study was to compare pain responses and not treatment efficacy. In the Diabetic Retinopathy Cli-nical Research Network (DRCR.net) clinical trial, no clinical difference was found when comparing PRP in one session versus that in four sessions in terms of pain perception(27). One limitation was the small sample size. Additionally, we followed all patients and performed the second and third treatment sessions after one week at the latest and eventually completed PRP treatments within one month at the latest.

To conclude, the new, navigated laser approach provided by the NAVILAS system enables the delivery of multiple laser spots in a rela-tively shorter time with improved accuracy and efficacy, significantly reducing pain and improving patient compliance.

REFERENCES 1. Congdom NG, Frieman DS, Lietman T. Important causes of visual impairment in the

world today. JAMA. 2003;290(15):2057-60. 2. Ferris FL Ill. How effective are treatments for diabetic retinopathy? JAMA. 1993;269(10):

1290-1. 3. Diabetic Retinopathy Study Research Group. Preliminary report on effects of photo-

coagulation therapy. Am J Ophthalmol. 1976;81(4):383-96. 4. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application

of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. Diabetic Reti-nopathy Study Research Group. Ophthalmology. 1981;88(7):583-600.

5. Lucena CR, Ramos Filho JA, Messias AM, Silva JA, Almeida FP, Scott IU, et al. Panretinal photocoagulation versus intravitreal injection retreatment pain in high-risk proliferative diabetic retinopathy. Arq Bras Oftalmol. 2013;76(1):18-20.

6. Nakamura Y, Mitamura Y, Ogata K, Arai M, Takatsuna Y, Yamamoto S. Functional and mor phological changes of macula after subthreshold micropulse diode laser photo-coagulation for diabetic macular oedema. Eye (Lond). 2010;24(5):784-8.

7. Bolz M, Kriechbaum K, Simader C, Deak G, Lammer J, Treu C, et al. In vivo retinal morphology after grid laser treatment in diabetic macular edema. Ophthalmology. 2010;117(3):538-44.

8. Jain A, Blumenkranz MS, Paulus Y, Wiltberger MV, Andersen DE, Huie P, et al. Effect of pulse duration on size and character of the lesion in retinal photocoagulation. Arch Ophthalmol. 2008;126(1):78-85.

9. Blumenkranz MS, Yellachich D, Andersen DE, Wiltberger MV, Mordaunt D, Marcellino GR, et al. Semiautomated patterned scanning laser for retinal photocoagulatiom. Retina. 2006;26(3):370-6.

10. Kernt M, Cheuteu RE, Cserhati S, Seidensticker F, Liegl RG, Lang J, et al. Pain and accu-racy of focal laser treatment for diabetic macular edema using a retinal navigated laser (Navilas). Clin Ophthalmol. 2012;6:289-96.

11. Kozak I, Oster SF, Cortes MA, Dowell D, Hartmann K, Kim JS, et al. Clinical evaluation and treatment accuracy in diabetic macular edema using navigated laser photoco-agulator NAVILAS. Ophthalmology. 2011;118(6):1119-24.

12. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Early Treat-ment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991;98(5 Suppl): 766-88.

13. Friberg TR, Venkatesh S. Alteration of pulse configuration affects the pain response during diode laser photocoagulation. Lasers Surg Med. 1995;16(4):380-3.

14. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Early Treatment Diabetic Retinopathy Study research group. Arch Ophthalmol. 1985;103(12):1796-806.

15. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report n. 4. The Early Treatment Diabetic Retinopathy Sudy research Group. Int Ophthalmol Clin. 1987;27(4):265-72.

16. Chhablani J, Sambhana S, Mathai A, Gupta V, Arevalo JF, Kozak I. Clinical efficacy of navigated panretinal photocoagulation in proliferative diabetic retinopathy. Am J Ophthalmol. 2015;159(5):884-9.

17. Al-Hussainy S, Dodson PM, Gibson JM. Pain response and follow-up of patients un-dergoing panretinal laser photocoagulation with reduced exposure times. Eye(Lond). 2008;22(1):96-9. Comment in: Eye (Lond). 2009;23(2):491.

18. Mirshahi A, Lashay A, Roozbahani M, Fard MA, Molaie S, Mireshqhi M, et al. Pain score of patients undergoing single spot, short pulse laser versus conventional laser for diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol. 2013;251(4):1103-7.

19. Schuele G, Rumohr M, Huettmann G, Brinkmann R. RPE damage thresholds and me-chanisms for laser exposure in the microsecond-to-millisecond time regimen. Invest Ophthalmol Vis Sci. 2005;46(2):714-9.

20. Mainster M. Decreasing retinal photocoagulation damage: principles and techniques. Semin Ophthalmol. 1999;14(4):200-9.

21. Luttrull JK, Musch DC, Spink CA. Subthreshold diode micropulse panretinal photo coagulation for proliferative diabetic retinopathy. Eye (Lond). 2008;22(5):607-12. Comment in: Eye (Lond). 2009;23(11):2122-3; author reply 2123.

Comparison of pain scores between patients undergoing panretinal photocoagulation using navigated or pattern scan laser systems


22. Ober MD, Kernt M, Cortes MA, Kozak I. Time required for navigated macular laser photocoagulation treatment with the Navilas®. Graefes Arch Clin Exp Ophthalmol. 2013;251(4):1049-53.

23. Pomerantzeff O, Schepens CL. Variation of energy density in argon laser photocoa-gulation. Arch Ophthalmol. 1975;93(10):1033-5.

24. Chhablani J, Mathai A, Rani P, Gupta V, Arevalo JF, Kozak I. Comparison of conventional pattern and novel navigated panretinal photocoagulation in proliferative diabetic retinopathy. Invest Ophthalmol Vis Sci. 2014;55(6):3432-8.

25. Hoeh AE, Pollithy S, Dithmar S. Factors affecting laser power in retinal Navilas laser treatment. Graefes Arch Clin Exp Ophthalmol 2015;253(6):849-54.

26. Fillingim RB. Sex, gender, and pain: women and men really are different. Curr Rev Pain. 2000;4(1):24-30.

27. Diabetic Retinopathy Clinical Research Network; Brucker AJ, Quin H, Antoszyk AN, Beck RW, Bressler NM, Browning DJ, et al. Observational study of the development of diabetic macular edema following panretinal (scatter) photocoagulation Given in 1 or 4 sittings. Arch Ophthalmol. 2009;127(2):132-40. Comment in: Arch Ophthalmol. 2010;128(2):262; author reply 262.

Original Article


INTRODUCTIONCongenital cataracts are the major cause of preventable and/or

treatable childhood blindness(1,2), accounting for 8%-39% of cases of childhood blindness(3). The worldwide prevalence of congenital cataracts has been estimated to be between 1 and 15 per 10,000 children(1).

Surgical treatment for congenital cataract has developed over the last few decades, allowing cataract removal in children younger than 1 year. Congenital cataract deprives the retina of light during periods of greater neural plasticity, and surgery is the primary treat-

ment to prevent amblyopia; however, it only partially solves the problem because the aphakic eye has a refractive error that must be corrected(4,5).

Biometric calculation of a growing eye is challenging, and intrao-cular lenses (IOLs) implanted for emmetropia will produce a myopic shift with axial growth(6). Portable devices for biometric calculation may not be available for some of congenital/developmental cata-ract surgeons. Therefore, the selection of the IOL power at the time of implantation is based on tables of biometric measurements by age in normal eyes, which have biometric characteristics that may

Submitted for publication: 17 November, 2014 Accepted for publication: November 2, 20151 Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Botucatu Medical

School, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.

Funding: This study was supported by Research program for the Brazilian National Health System (PPSUS-SP), National Council for Scientic and Technological Development- Brazil (CNPq), and São Paulo Research Foundation-Brazil (FAPESP).


Corresponding author: Antonio Carlos Lottelli Rodrigues. Faculdade de Medicina de Botucatu - UNESP. Depto. OFT/ORL/CCP. Rubião Júnior, s/n, Botucatu, SP - 18618-970 - Brazil

E-mail: [email protected]

Approved by the following research ethics committee: Botucatu Medical School Ethics Committee under number 3358.

ABSTRACTPurpose: To evaluate the ocular axial length (AL) and keratometry (K) in Brazilian children with congenital/developmental cataract, assess the differences and evolution of AL and K according to age, and establish functional models of AL and K as function of age. Methods: Children with congenital/developmental cataract aged 1.5 months old to 8 years old and no other ocular diseases were included. All eyes with unilateral cataract, the left eyes from children with bilateral cataracts, and healthy eyes from children with unilateral cataract were analyzed. After the administration of anesthesia, K was measured with a portable automatic keratometer, and AL was measured with a contact biometer. Cataract surgery was performed immediately after the measurements were taken. The data were statistically analyzed, and a linear regression with an age logarithm was used to model the relationship. Results: Forty-four eyes with cataract were included in this analysis, comprising 15 eyes with unilateral cataract and 29 left eyes from children with bilateral cataracts. The mean age was 27.3 months with a mean AL of 20.63 ± 2.11 mm and a mean K of 44.94 ± 2.44 D. The K value was significantly steeper and the AL value was significantly shorter in younger children (P<0.001). No significant differences were found neither between eyes with unilateral and bilateral cataracts nor between eyes with unilateral cataract and their corresponding healthy eyes (P>0.05). Conclusion: The values of K and AL significantly change with age, especially during the first 6 months of life. A linear functional relationship between K and AL with the logarithm of age and between K and AL was established.

Keywords: Cataract/congenital; Cornea/pathology; Axial length, eye; Lenses, in-traocular; Corneal topography/methods

RESUMO Objetivo: Avaliar o comprimento axial (AL) e a ceratometria (K) de olhos de crianças brasileiras com catarata congênita/desenvolvimento, analisar diferenças e evoluções de acordo com a idade e estabelecer modelos funcionais de comprimento axial e ceratometria em função da idade e entre eles. Métodos: Crianças com catarata congênita/desenvolvimento com idade de 1,5 meses a 8 anos de idade e sem outras doenças oculares foram incluídas. Todos os olhos com catarata unilateral, o olho esquerdo de crianças com catarata bilateral e o olho sadio de crianças com catarata unilateral foram analisados. Após a administração de anestesia, a ceratometria foi obtida com um ceratômetro automático portátil e o comprimento axial medido com um biômetro de contato. Em seguida, a cirurgia de catarata foi realizada. Os dados foram analisados estatisticamente, a regressão linear com o logaritmo da idade foi utilizado para modelar os relacionamentos. Resultados: Todos os olhos com catarata unilateral (n=15) e um olho selecionados aleatoriamente a partir dos casos bilaterais (n=29) foram incluídos na análise (total= 44 olhos). A idade média foi de 27,3 meses, as médias do comprimento axial e da ceratometria foram respectivamente 20,63 ± 2,11 mm e 44,94 ± 2,44 dioptrias. A ce-ratometria foi significativamente mais curvo e comprimento axial significantemente mais curto em crianças mais jovens (P<0,001). Não foram encontradas diferenças sig nificativas na comparação entre os olhos com cataratas unilaterais e bilaterais e com-parando os olhos com catarata unilateral a correspondentes olhos saudáveis (P>0,05). Conclusão: Os valores de ceratometria e comprimento axial mudam significativamente com a idade, principalmente nos primeiros seis meses de vida. Foi estabelecida uma relação funcional linear entre comprimento axial e ceratometria com o logaritmo da idade e entre ceratometria e comprimento axial.

Descritores: Catarata/congênito; Córnea/patologia; Comprimento axial do olho; Lentes intraoculares; Topografia da córnea/métodos

Congenital and developmental cataract: axial length and keratometry study in

Brazilian children

Catarata congênita e do desenvolvimento: estudo do comprimento axial e da ceratometria em

crianças brasileiras

rodriGo BuEno do prado1, virGílio fiGuEirEdo Silva1, Silvana artioli SchEllini1, antonio carloS lottElli rodriGuES1

Congenital and developmental cataract: axial length and keratometry study in Brazilian children


differ from the characteristics of eyes with cataracts, or on tables of biometric data in cataract eyes collected from populations in specific ethnicity (5,7).

The objective of this study was to evaluate the ocular axial length (AL) and keratometry (K) in Brazilian children with congenital/deve-lopmental cataract to assess the differences and evolution according to age as well as to establish functional models of AL and K in function of age and between K and AL.

METHODSThis retrospective observational study was approved by the

Botucatu Medical School Ethics Committee; we analyzed the medi-cal records of patients undergoing cataract surgery for congenital/developmental cataract at the Clinical Hospital of Botucatu Medical School, São Paulo, Brazil.

Prematurely born children as well as those with glaucoma, retinal disease, microphthalmia, traumatic cataract, pathological myopia, lens subluxation, or other ocular diseases were not included.

Ocular biometric data were obtained under general anesthesia by an experienced ophthalmologist, and cataract surgery was per-formed immediately after these measurements were made. The keratometric measurements were obtained using a regularly calibra-ted handheld autorefract keratometer (Retinomax K-Plus 2; Righton, Tokyo, Japan). AL measurement was performed with a contact ultrasonic biometer (model 1000A; Sonomed, New York, NY, USA). The ultrasound velocity used was 1532 m/s for the anterior chamber, 1641 m/s for the lens, and 1532 m/s for the vitreous.

All eyes with unilateral cataract and the left eyes in children with bilateral cataracts were selected and included in the analysis. In chil-dren with unilateral cataract, the affected eyes were compared with the healthy eye. The biometric data were transferred to Microsoft Excel 2007 (Redmond, WA, USA). The statistical analyses for the paired samples were performed using Student’s t-test.

The assessment of the relationship between the child’s age in months and the ocular biometric measurements was calculated with Pearson’s correlations. The linear regression analysis using the logarithm of a patient’s age as an independent variable was adjusted to obtain the estimates of the mean ocular parameters (K and AL). We considered P values <0.05 as statistically significant.

RESULTSA total of 44 children were included in the study, and 28 (63%)

were male. The median and mean age at the time of cataract sur-gery were 12.5 months and 27.3 months, respectively (range: 1.5-92 months). Twenty-nine children (66%) had bilateral cataracts, and 15 children (34%) had a unilateral cataract.

The eyes with unilateral cataract were not significantly different in terms of the mean AL and K with the left eyes in the bilateral cases (P>0.05) (Table 1).

The 44 analyzed eyes had a mean AL of 20.63 mm (range 17.27 mm- 24.96 mm) and a mean K of 44.94 D (range 40.00 D-53.00 D). The calculations of the mean, standard deviation, confidence interval, median, and variable range for AL and K according to the age groups are shown in table 2. The mean of AL increased with age, whereas the mean of K decreased. These relationships were statistically significant (P<0.001). If the AL observations were divided into those from chil-dren under and over 12 months old, the relative variability expressed by the coefficient of variation showed homogeneity of the response between the two age groups.

The linear regression analyses performed using the natural logarithm (ln) of the patient’s age (in months) as an independent variable are shown below by the following equations: AL=16.66 + (1.476 × ln age); R2=0.74, P<0.001 and K=46.97 + (-0.752 × ln age); R2=0.14, P<0.001.

A graphical representation of AL and K according to the patients’ age and the fitted curves derived from the model above are shown in figures 1 and 2. AL and K change markedly with an increase in age.

Table 1. Axial length (AL) and mean keratometry (K) values according to the laterality of the cataracts

Groups n Age (months) AL (mm) K (D)

Unilateral 15 Mean ± SD 27.7 ± 27.1 20.6 ± 2.0 44.8 ± 2.7

Median 18 20.8 44.5

Range 2-75 17.9-24.7 41.7-53.0

Bilateral 29 Mean ± SD 27.1 ± 27.7 20.6 ± 2.2 45.0 ± 2.4

Median 10 19.9 45.0

Range 1-92 17.3-25.0 40.0-51.0

P value 0.960 0.990 0.629AL= axial length; K= keratometry; D= diopter; SD= standard deviation; Student’s t-test.

Table 2. Mean, standard deviation, confidence interval, median, and range of the axial length (AL) and keratometry (K) values according to the age group of 44 eyes with unilateral cataract and one randomly chosen eye from the bilateral cataract cases

Age groups (months) n Mean ± SD 95% CI Median RangeAL (mm)

0-5 09 18.45 ± 0.77 17.95-18.95 18.43 17.27-19.83

6-17 15 19.34 ± 0.90 18.89-19.79 19.64 17.85-21.22

18-59 11 22.19 ± 0.92 21.62-22.76 21.93 20.80-23.36

60-96 09 22.07 ± 1.53 22.08-23.06 22.74 20.82-24.96

Total 44 20.63 ± 2.11 20.01-21.25 19.97 17.27-24.96

K (D)

0-5 09 46.86 ± 3.30 44.71-49.01 46.00 43.00-53.00

6-17 15 44.83 ± 1.86 43.89-45.77 45.00 41.75-49.00

18-59 11 44.18 ± 1.40 43.28-45.08 44.25 41.75-46.25

60-96 09 44.16 ± 2.60 42.47-45.85 44.50 40.00-49.00

Total 44 44.94 ± 2.44 44.22-45.66 44.75 40.00-53.00AL= axial length; K= keratometry; D= diopter; SD= standard deviation; CI= confidence interval; Student’s t-test.

AL=16.66 + (1.476 × ln age); R2=0.74; P<0.001.Figure 1. Distribution of axial length (AL) values of 44 eyes of children with unilateral cataracts and randomly selected eyes in the bilateral cases.

Prado RB, et al.


The highest rates of ocular axial growth and corneal flattening are observed in the first 6 months of life.

The dispersion values of AL according to K and the inverse rela-tionship between them are shown in figure 3. The equation provided for the graph is K=52.91 -0.385 × AL (mm), with R2=0.11 (P<0.05).

Table 3 shows a comparison of the biometric measurements between eyes with a unilateral cataract and the corresponding healthy eye, with no significant differences found in the AL and K values (P>0.05).

Tests of the two regressions for the AL and K logarithm models showed that there were no statistically significant differences bet-ween eyes with cataract from different genders, eyes with unilateral cataract and the ones with bilateral cataracts, and normal eyes and eyes with cataract in children with unilateral cataract (P>0.05).

Table 4 estimates AL and K according to age (in months) based on the following equations: AL=16.66 + (1.476 × ln age) and K=46.97 + (-0.752 × ln age), from figures 1 and 2 and the IOL for emmetropia and

for minimizing myopic shift in adulthood, using suggestions from some authors(8), according to age, based on the estimated values of AL and K.

DISCUSSIONThe development of cataract surgery in children has created the

need to study the biometric and refractive changes that occur with ocular growth(9,10). In the first months of extra-uterine life, the human eye experiences axial growth accompanied by flattening of the corneal curvature(11,12). When this process occurs uneventfully, the decrease of the refractive power of the lens focuses the image on the retina because of the increased AL. During this rapid biometric change, emmetropia is maintained(13).

Eyes presenting cataract have different biometric measurements from normal eyes, and various factors, such as the child’s age at surgery, aphakia, pseudophakia, cataract laterality, and visual depri-vation have been reported to influence axial growth(12).

K=46.97 + (-0.752 × ln age); R2=0.14; P<0.001.Figure 2. Distribution of the mean keratometry (K) values of 44 eyes of children with unilateral cataracts and randomly selected eyes in the bilateral cases.

K=52.91-0.385 × AL; R2=0.11; P<0.05.Figure 3. Distribution of the mean keratometry (K) values for axial length (AL) values.

Table 3. Comparison of the mean, median, and standard deviation of axial length (AL) and the mean keratometry (K) values of both eyes of 15 children with unilateral cataract

n AL (mm) K (D)

Cataract eye 15 Mean ± SD 20.6 ± 2.0 44.8 ± 2.7

Median 20.8 44.5

Range 17.9-24.7 41.7-53.0

Healthy eye 15 Mean ± SD 21.3 ± 1.7 44.4 ± 1.5

Median 20.9 44.5

Range 18.8-24.8 42.0-48.5

P value 0.061 0.649AL= axial length; K= keratometry; mm= millimeter; D= diopter; SD= standard deviation. Student’s t-test.

Table 4. Axial length (AL) and keratometry (K) values estimated by age according to the linear regression analysis performed using the natural logarithm (ln) of the patient’s age as an independent variable: AL=16.66 + (1.476 × ln age) and K=46.97 + (-0.752 × ln age), as well as the intraocular lens (IOL) power calculated for emmetropia based on the values of K and AL using the Hoffer Q formula with pACD=5.26 (A-constant=118.5). The indicated desired refraction to minimize late myopia shift8 and the ideal IOL power to obtain the desired refraction are also demonstrated

Age (months)

AL (mm) K (D)

IOL to emmetropia

(D)

Desired refraction

(D)

Ideal IOL power for desired

refraction (D)

3 18.28 46.14 +41.36 +9.00 +26.90

6 19.30 45.62 +35.73 +8.00 +23.11

9 19.90 45.32 +32.95 +7.00 +22.06

12 20.33 45.10 +31.14 +6.00 +21.93

18 20.93 44.80 +28.81 +6.00 +19.53

24 21.35 44.58 +27.31 +5.00 +19.67

30 21.68 44.41 +26.18 +5.00 +18.51

36 21.95 44.28 +25.29 +5.00 +17.58

42 22.18 44.16 +24.56 +5.00 +16.82

48 22.37 44.06 +23.97 +4.00 +17.87

54 22.55 43.97 +23.42 +4.00 +17.30

60 22.70 43.89 +22.97 +3.00 +18.45

66 22.84 43.82 +22.56 +3.00 +18.03

72 22.97 43.75 +22.19 +2.00 +19.21AL= axial length; K= keratometry; mm= millimeter; D= diopter; IOL= intraocular lens.

Congenital and developmental cataract: axial length and keratometry study in Brazilian children


Researchers have reported the existence of a passive ocular-stret ching component that is genetically determined and an active component that is observed when the image is not formed on the retina(13). Supporting this hypothesis, several studies have observed increased AL in eyes with visual deprivation(14). This increase occurs in human eyes as well as in the eyes of primates and other animals(6,13).

Several studies have demonstrated flattening of the K values in ol-der children(11,15). A previous study reported mean K values of 47.50 D in newborns and 43.69 D in children aged 2-4 years and concluded that K values reach adulthood values at the age of approximately 3 years (16). In the present study, the eyes with congenital and develop-mental cataract showed K values that were significantly more curved in children younger than 6 months old. Although it presented a poor correlation (R2=0.14), the value of K was inversely related to the ages of the children up to 18 months. After this age, corneal flattening tends to stabilize.

It has been demonstrated that normal eyes have a smaller myopic shift in comparison to aphakic eyes(11). The reason for this difference is that phakic eyes exhibit a decline in the refractive power of the crystalline lens from +34.4 D to +18.8 D with growth, which does not occur with an implanted IOL(11). Therefore, children with pseudophakia might present a large myopic change in adulthood if the implanted IOL aims for emmetropia at the time of surgery(6).

Two papers have described K and AL measurements in North American children with congenital cataract(5,17). Further, a study in Italy showed the AL and K values of a Caucasian pediatric population with congenital/developmental cataract(7). Databanks containing biometric information from eyes with pediatric cataract allow esti-mation of the ocular values of AL and K based on age. These data facilitate the selection of IOL power in children with cataract when it is not possible to measure AL and K.

In accordance with the results from another study(18), Brazilian children showed corneal flattening and increased AL with age. In the study by Ingaki(18), there was no significant difference between K and AL in a comparison of eyes with unilateral and bilateral cata-racts. The same results were obtained from comparing healthy eyes and affected eyes in children with unilateral cataract. Additionally, in studies of AL and K in North American children, lower AL and greater K were found in eyes with unilateral cataract compared with the AL and K values in healthy eyes, although the difference in the K value was not statistically significant(5,17). As visually impaired eyes tend to have greater axial growth(12), the absence of differences between the AL value of healthy eyes and that of eyes in children with unilateral cataract might have resulted from later diagnosis and treatment in our sample, which could have resulted in worsened visual prognosis for these eyes(19).

Regarding gender, previous studies have reported steeper corneas and shorter AL in girls than in boys; however, these results were not observed in our sample(5,17).

To avoid the development of high myopia with axial growth, some authors recommend that after the calculation of the IOL for emmetropia, 20% of the IOL power should be subtracted in young children (<8 months of age), and 10% should be subtracted in chil-dren aged between 2 and 3 years(16). Others propose tables with residual hyperopia from +12.00 to +0.50 based on the age of the chil-dren, from 3 months to 14 years(8). After the surgical treatment, optical correction or contact lenses are prescribed for residual hyperopia, which decreases with age. Table 4 shows suggestions, based on our data, for IOL implantation according to age for emmetropia and for minimizing late myopia using the suggestions from some authors(8) when AL and K cannot be measured.

When K measurement is not possible because of the unavailabi-lity of manual keratometers, refractive powers of 28, 27, 26, 24, and 22 of the implanted IOL are suggested for ALs of 17, 18, 19, 20, and 21 mm, respectively(20). We suggest that when only AL can be mea-sured, the K value should be calculated using the equation: K=52.91-0.385 × AL (mm) (Figure 3) or based on age.

The selection of the power of the IOL for implantation in a gro-wing eye represents a major challenge. The use of a published table alone to decide IOL power is not recommended. The tables are only intended as a starting point toward appropriate IOL power selection, which is a multifactorial decision customized for each child based on many variables, particularly age, laterality, amblyopia status, likely compliance with glasses, and a family history of myopia(8).

The main limitation of this study is the K values. The measure-ments were performed with a manual keratometer which, although reproducible in awake patients, may not be as reliable in our sample where most of the measurements were performed on patients under anesthesia without fixation. These conditions probably influenced these values and their relationships with age and AL, generating a poor correlation (R2=0.11). These findings have already been descri-bed by other authors, who also found weaker relationships between K and age, with R2 varying from 0.31(17) to 0.20(7), as well as between K and AL (R2=0.32)(17), despite the larger sample sizes. Due to the difficulty of obtaining these values, the measurement method used in the present study still seems to be the best manner to obtain K values; however, a device that allows more accurate measurements may establish prediction models with more precise estimates of K in relation to age and AL.

CONCLUSIONThe values of K and AL change significantly with age, especially

in the first 6 months of life. A linear functional relationship between K and AL with the logarithm of age and between K and AL was established for this Brazilian pediatric sample with congenital/deve-lopmental cataract.

ACKNOWLEDGMENTResearch program for the Brazilian National Health System (PPSUS-

SP), National Council for Scientific and Technological Development-Bra zil (CNPq), and São Paulo Research Foundation-Brazil (FAPESP).

REFERENCES 1. Foster A, Gilbert C, Rahi J. Epidemiology of cataract in childhood: a global perspective.

J Cataract Refract Surg. 1997;23(1):601-4. 2. Trivedi RH, Wilson ME. Childhood blindness and pediatric cataract. J Cataract Refract

Surg. 2005:52-4. 3. Trivedi RH, Wilson ME. Epidemiology of pediatric cataract and associated blindness.

In: Wilson ME, Trivedi RH, Pandey SK, editors. Pediatric Cataract Surgery: techniques, complications and management. Baltimore, Maryland: Lippincott Williams & Wilkins; 2005. p.18-22.

4. Wright KW. Visual development, amblyopia, and sensory adaptations. In: Wright KW, editor. Pediatric Ophthalmology and Strabismus. New York: Springer-Verlag; 2003. p.157-71.

5. Trivedi RH, Wilson ME. Biometry data from Caucasian and African- American catarac-tous pediatric eyes. Invest Ophthalmol Vis Sci. 2007;48(10):4671-8.

6. Dahan E, Drusedau MU. Choice of lens and dioptric power in pediatric pseudophakia. J Cataract Refract Surg. 1997;23 Suppl 1:618-23.

7. Capozzi P, Morini C, Piga S, Cuttini M, Vadalà P. Corneal curvature and axial length values in children with congenital/infantile cataract in the first 42 months of life. Invest Ophthalmol Vis Sci. 2008;49(11):4774-8.

8. Trivedi RH, Wilson ME. Pediatric cataract: preoperative issues and considerations. In: Wilson ME, Saunders RA, Trivedi RH, editors. Pediatric Ophthalmology: Current Thought and A Practical guide. Heidelberg, Germany: Springer; 2009. p. 311-24.

9. Flitcroft DI, Knight-Nanan D, Bowell R, Lanigan B, O’Keefe M. Intraocular lenses in children: changes in axial length, corneal curvature, and refraction. Br J Ophthalmol. 1999;83(3):265-9.

10. Rabin J, Van Sluyters RC, Malach R. Emmetropization: a vision-dependent phenomenon. Invest Ophthalmol Vis Sci. 1981;20(4):561-4.

11. Gordon RA, Donzis PB. Refractive development of the human eye. Arch Ophthalmol. 1985;103(6):785-9.

12. Vasavada AR, Raj SM, Nihalani B. Rate of axial growth after congenital cataract surgery. Am J Ophthalmol. 2004;138(6):915-24.

13. Brown NP, Koretz JF, Bron AJ. The development and maintenance of emmetropia. Eye (Lond). 1999;13(Pt 1):83-92.

14. Tartarella MB, Carani JC, Scarpi MJ. The change in axial length in the pseudophakic

Prado RB, et al.


eye compared to the unoperated fellow eye in children with bilateral cataracts. J AAPOS. 2014;18(2):173-7.

15. Asbell PA, Chiang B, Somers ME, Morgan KS. Keratometry in children. CLAO J. 1990;16(2):99-102.

16. Ehlers N, Sorensen T, Bramsen T, Poulsen EH. Central corneal thickness in newborns and children. Acta Ophthalmol (Copenh). 1976;54(3):285-90.

17. Trivedi RH, Wilson ME. Keratometry in pediatric eyes with cataract. Arch Ophthalmol. 2008;126(1):38-42.

18. Inagaki Y. The rapid change of corneal curvature in the neonatal period and infancy. Arch Ophthalmol. 1986;104(7):1026-7.

19. Rodrigues AC, Prado RB, Miguel L. Implementation of red reflex exam in children in the area of Botucatu Medical School--São Paulo, Brazil. Arq Bras Oftalmol. 2012;75(5): 337-40.

20. Wilson ME, Pandey SK, Thakur J. Paediatric cataract blindness in the developing world: surgical techniques and intraocular lenses in the new millennium. Br J Ophthalmol. 2003;87(1):14-9.

Original Article


ABSTRACTPurpose: To identify the prevalence of ophthalmologic diseases in elderly patients who had been classified as severely disabled and to identify the ophthalmologic conditions leading to visual impairment and blindness. Methods: The medical records of 2806 patients who had applied to the Health Board of the Erzurum Region Training and Research Hospital between January 2011 and December 2012 were reviewed. One hundred ninety-nine patients aged >64 years who were classified as severely disabled with disability rates of over 50%, and who were unable to care for themselves or to move and/or communicate without help were included in the study. Results: The most frequently seen disabilities were neurological (47.2%) and those resulting from eye diseases (17.1%). The most common ophthalmologic diseases were cataract, glaucoma, and age-related macular degeneration. The mean right and left eye visual acuities were 1.17 ± 1.10 logMAR and 1.13 ± 1.0 logMAR, respectively. Of the 60 patients with ophthalmologic diseases or conditions, 33 were blind (visual acuity worse than 20/400) and 10 were visually impaired (visual acuity worse than 20/70 but better than 20/400). Cataracts were the main cause of blindness. The mean age of the patients who were still being followed up at the time of application to the disability board was significantly lower than that of the others (p=0.015). Seventy-nine percent of the blind patients were from rural areas, and 88% of these had no regular follow-up. Among the blind and visually impaired, significantly more patients from urban areas had social security insurance (SSI) than those from rural areas (p=0.043). Nearly 64% of the blind patients were women. The follow-up rate was significantly lower in women (p=0.025). According to multinomial logistic regression analysis, the visually impaired and blind patients were more likely to have lower follow-up rates than the other types of severely disabled patients (OR: 0.231, 95% Cl: 0.077-0.688, p=0.009). Conclusions: Blindness gives rise to severe disability, and the most common oph-thalmologic diseases that cause severe disabilities in elderly patients are ca taract, glaucoma, and age-related macular degeneration. Sociodemographic factors that may affect the accessibility of visually impaired and blind people to health services include their place of residence and gender.

Keywords: Blindness; Cataract; Disabled people; Aging

RESUMOObjetivo: Identificar a prevalência de doenças oftalmológicas em pacientes idosos que tinham sido considerados como incapacitados graves, e para identificar as con-dições oftalmológicas que levam à deficiência visual e cegueira. Métodos: Prontuários de 2806 pacientes que tinham solicitado ao conselho de saúde do hospital de treinamento e pesquisa da região de Erzurum entre janeiro de 2011 e dezembro de 2012, foram revistos. Cento e noventa e nove idosos com mais de 64 anos, que foram considerados como incapacitados graves nos quais as taxas de incapacidade são mais de 50% e não são capazes de cuidado próprio e não são capazes de mover-se e/ou comunicar-se sem ajuda, foram incluídos no estudo. Resultados: As deficiências mais frequentemente observados são neurológicas (47,2%) e doenças oculares (17,1%). As doenças oftalmológicas mais frequentemente observadas foram catarata, glaucoma e degeneração macular relacionada à idade. Média de acuidade visual em olho direito e esquerdo foram 1,17 ± 1,10 e 1,13 ± 1,0 logMAR, respectivamente. Dos 60 pacientes, 33 apresentaram cegueira (acuidade visual pior que 20/400), 10 tinham deficiência visual (acuidade visual pior do que 20/70, melhor do que 20/400). A catarata foi a principal causa de cegueira. A idade média dos pacientes com acompanhamento no momento da solicitação ao conselho foi significativamente menor do que os demais (p=0,015). Setenta e nove por cento dos pacientes cegos eram da área rural e 88% deles não tinham acompanhamento regular. Entre cegos e deficientes visuais, a taxa de posse do seguro de segurança social (SSI) foi significativamente maior em pacientes de área urbana (p=0,043). Quase 64% dos pacientes cegos eram mulheres. A taxa de acompanhamento foi significativamente menor nas mulheres (p=0,025). De acordo com a análise de regressão logística mul-tinominal, os pacientes com deficiência e cegos visuais eram mais propensos a ter menor taxa de acompanhamento do que os outros pacientes com deficiência grave (OR: 0,231, 95% Cl: 0,077-0,688, e p=0,009). Conclusões: A cegueira gera incapacitação grave. As doenças oftalmológicas mais frequentemente observadas que causam deficiência grave em pacientes idosos são a catarata, glaucoma e degeneração macular relacionada à idade. O local de residência e o gênero são fatores sociodemográficos que podem ter impacto sobre o acesso à saúde de pessoas com deficiência visual e cegos.

Descritores: Cegueira; Catarata; Pessoas com deficiência; Envelhecimento

INTRODUCTIONThe mean expected lifespan for humans rose from the 40s at the

beginning of the 20th century to the 80s at the beginning of the 21st century(1). Populations are increasingly aging worldwide, and the high rates of development of chronic health conditions over the aging process increase the rates of morbidity and mortality and are associated with disability(2-3). The Global Burden of Disease estimated that 190 million individuals had a severe disability in 2010, including conditions such as quadriplegia, severe depression, and blindness(4).

Blindness has socioeconomic consequences in all societies, with the costs of lost productivity, rehabilitation, and education of the blind constituting a significant economic burden for individuals, their fami-lies, and societies(5). Visually impaired and blind elderly people usually face restrictions in their ability to participate in various activities. De-creased participation and activity loss are associated with increased risk of functional and cognitive decline; in addition, these patients are at risk of social isolation and may suffer from loneliness(6-10). Worldwide, 161-258 million individuals are estimated to be visually impaired, and

Sociodemographic status of severely disabled and visually impaired

elderly people in Turkey

Estado sociodemográfico de pacientes idosos com incapacidades graves e deficiência visual na Turquia

SErtaç arGun kivanç1,2, BErna akova-Budak2, oSMan okan olcaySü1, Sadik GörkEM çEvik3

Submitted for publication: May 19, 2015 Accepted for publication: October 20, 20151 Department of Ophthalmology, Erzurum Region Training and Research Hospital, Erzurum, Turkey.2 Department of Ophthalmology, School of Medicine, Uludag University, Bursa, Turkey.3 Department of Ophthalmology, Şevket Yılmaz Training and Research Hospital, Bursa, Turkey.



Corresponding author: Sertaç Argun Kıvanç. Department of Ophthalmology, School of Medicine, Uludag University - Gorukle, Bursa - Turkey - E-mail:[email protected]

Kıvanç SA, et al.


in 33-39 million of this population, vision is reduced to the level of blindness(11-13). In Turkey, according to the Turkish Statistical Institute, 85.7% of the disabled do not work, with half of these not able to work due to severe disability. Further, 37.2% of these individuals do not work due to ocular disability. According to the 2011 data from the Social Security Institution of the Republic of Turkey, approximately $2.9 billion was allocated for disabled people, with $2 billion (71.5%) spent on the severely disabled and their relatives. Ophthalmologic disability accounted for 8.4% of the total disabilities(14,15). Therefore, blindness and visual impairment are amongst the most important public health problems. An international, comprehensive classifica-tion system has been developed by the World Health Organization (WHO) to define health and health-related conditions, as well as the functionality and limits of humans, in standard language and settings. This system, called the International Classification of Functioning, Disability, and Health, has been used as a classification system in studies of disabled individuals. In Turkey, a disability rate determined by a regional health board, including physicians specialized in rela-ted diseases, is taken into account. In addition to the international standards, these measures are used along with the Balthazar formula when assessing the total disability level of an individual(16). In order to receive disability and nursing care benefits, the disability level of the individual must be at least 50% for them to be evaluated as “severely disabled” by the board. In this study, we aimed to identify the rate of ophthalmologic diseases in patients who had been evaluated as being severely disabled and to identify the specific ophthalmologic conditions leading to visual impairment and blindness among sub-jects aged 65 years or older.

METHODSPATIENT SELECTION

The medical chart records of patients who had applied to the Health Board of the Erzurum Region Training and Research Hospi-tal between January 2011 and December 2012 were reviewed. One hundred ninety-nine patients aged over 64 years who were assessed as being “severely disabled” out of 2806 patients(17) were included in the study and were retrospectively analyzed following approval of the Ethics Board of the Erzurum Region Training and Research Hospital. The present study complied with the tenets of the Declaration of Helsinki. The health insurance status, number of visits, time spent under the supervision of a physician, patient’s place of residence (urban/rural), age, gender, whole body functional disability rate, medical branch of disability, ophthalmologic functional disability rate, vision, and ante-rior/posterior segment examination were recorded.

DISABILITY RATE

The total body disability rate (TBDR) and severity of disability were determined by a health board in a tertiary center. The disability rate is determined by the board, which includes physicians specializing in internal medicine, ophthalmology, ear nose throat, general surgery or orthopedics, neurology, and psychiatry, in addition to the interna-tional standards; these measures are used along with the Balthazar for-mula when identifying the TBDR of an individual(17). “Severely disabled” is defined as individuals with a disability rate over 50% who are not

able to care for themselves (feeding, dressing, bathing, etc.) and are not able to move and/or communicate without help.

HEALTH INSURANCE STATUS

The patients were divided into two groups in terms of health in-surance status. The first group had social security insurance (SSI) and was defined as those who had a job or whose close relatives had a job with a fixed amount of tax from their salaries allocated to the Social Security Insurance. Patients in this group can apply to a tertiary medical center or hospital without official referral. The second group did not have social security insurance (No-SSI), had a low income, and many of them did not have a job. They lack social security insurance, so the government provides them with health insurance. However, according to the health regulations, if they want access to a tertiary medical center or hospital, they need to be referred officially by a local physician. Otherwise, they would need to pay all health expenses themselves without the support of insurance from the government.

PATIENT GROUPS

The patients were divided into two groups according to the num-ber of physician visits per year. The first group included the patients who visited their physicians at least once a year. The second group included patients who only visited the hospital when applying to the disability board. The patients were also grouped according to whether their place of residence was in a rural or urban area.

ASSESSMENT OF VISUAL IMPAIRMENT AND BLINDNESS

Vision was defined and classified according to the WHO recom-mendations. Visual impairment was defined as a visual acuity of worse than 20/70 but equal to or better than 20/400, or a correspon-ding visual field loss of less than 20°, in the better eye with the best possible correction. Blindness was defined as a visual acuity of worse than 20/400, or a corresponding visual field loss to less than 10°, in the better eye with the presenting distance visual acuity.


We analyzed the data using the SPSS 17 (SPSS, Inc., Chicago, IL, USA) program. For quantitative data, we used t-tests to compare groups with normally distributed parameters.

Pearson’s chi-square test was performed to compare qualitative data. The statistical significance was set at p<0.01 and p<0.05.

RESULTSA total of 199 severely disabled patients who were over 64 years

old were included in the present study, with 125 women (62.8%) and 74 men (37.2%). In terms of insurance, 89 were in the No-SSI group, and 110 were in the SSI group. Fifty-six individuals applied to the disability board from urban areas, and 143 patients applied from rural areas. The mean age was 79.29 ± 6.92 years (range: 65-97 years). The mean TBDR was 88.75 ± 7.96 (range: 60-100). All the patients had the mean major disability rate (MDR) (Table 1). The most common disabilities according to the medical specialty are shown in table 2. Neu rological diseases were the most common, with 94 patients (47.2%),

Table 1. Demographics of severely disabled patients

Age (years) TBDR Place of residence Social security status Regular follow-up

N % Mean ± SD Mean ± SD Urban Rural SSI No-SSI Yes No

Gender

Male 074 037.2 79.3 ± 7.0 89.6 ± 7.0 19 055 037 37 22 052

Female 125 062.8 79.3 ± 6.9 88.3 ± 8.5 37 088 073 52 29 096

Total 199 100.0 79.3 ± 6.9 88.8 ± 8.0 56 143 110 89 51 148

P value 0.552 0.249 0.308

TBDR= total body disability rate; N= number; SD= standard deviation; SSI= social security insurance; No-SSI= no social security insurance.

Sociodemographic status of severely disabled and visually impaired elderly people in Turkey


followed by eye diseases, with 34 patients (17.1%). The most common ophthalmologic diseases were cataract, glaucoma, and age-related macular degeneration (AMD). Table 3 shows the ocular diseases, causes of blindness, and visual impairment, as well as their rates for each eye. The mean right and left eye visual acuities were 1.17 ± 1.10 logMAR and 1.13 ± 1.0 logMAR, respectively. Of the 60 patients with ophthalmologic diseases or conditions, 33 were blind and 10 had visual impairment. In total, 90 eyes suffered from blindness (63 eyes) and visual impairment (27 eyes). Cataract was the main cause for blindness, followed by glaucoma. However, seven eyes had neovas-cular glaucoma, and the cause of neovascularization was unclear from the medical charts.

Cataract was the most common cause for visual impairment. No significant differences were noted in the age, TBDR, ophthalmologic disability rate, visual acuity of the right eye, and visual acuity of the left eye between the sexes. Further, there were no significant differences in TBDR, ophthalmologic disability rate, and the visual acuities of the right and left eyes between the patients who were being followed up at the time of application to the disability board and the ones who were not. Further, the mean age of the patients who were being followed up at the time of application to the disability board was significantly lower than that of the patients who were not being followed up at the time of application (p=0.015) (Table 4).

The mean MDR of the patients with eye disorders was statis ti cally significantly higher than that of the patients with other di sorders; the mean MDRs were 92.82 ± 4.50 and 87.92 ± 8.27, respectively (p=0.001). The number of patients without SSI was significantly higher in rural areas than in urban areas (85%, p<0.001). No statistical sig-nificance was detected in terms of the other parameters (Table 5). The sociodemographic and economic characteristics of the patients who were blind and visually impaired are shown in table 6. Seventy-nine percent of the blind patients were from rural areas, and 88% of the blind patients had no regular follow-up. Nearly 64% of the blind pa tients were women.

Of the 199 patients, 60 (30%) had ophthalmologic conditions or diseases. Thirty-four (57%) had applied to the disability board be cause of eye disease and 22% because of neurological disorders. Forty-three of the 199 patients (22%) were blind or visually impaired. The mean age of the blind or visually impaired patients was 81.4 ± 6.9 years. Among the blind and visually impaired patients, the rate of those with SSI was significantly higher in women (75%; p=0.037) and patients from urban areas (73%; p=0.043). The follow-up rate was significantly lower in women (p=0.025).

Among the 199 severely disabled patients, we compared the cha-racteristics of the 60 patients with visual impairment or blindness with the other severely disabled patients by univariate analysis. There was a significant difference in terms of the follow-up status (Table 7). To assess the associations of the place of residence, SSI status, follow-up status, and gender with visual condition, we performed a multinomial logistic regression analysis. The visually impaired and blind patients were more likely to have a lower follow-up rate than the other severely disabled patients (OR: 0.231, 95% Cl: 0.077-0.688, p=0.009).

DISCUSSIONAging is a natural process, and the increased rates of age-related

diseases due to this increase in life expectancy are currently an im-portant public health issue. Individuals aged 65 years or older now comprise 14.7%, 12.5%, and 13% of the whole population of the Netherlands, Australia, and the USA, respectively(18). While the current population aged 65 years or older is 5.9 million (approximately 8%) in Turkey, it has been extrapolated to reach over 8.5 million (approxima-tely 10%) in 10 years’ time(19). According to data released in 2011, there are 30,318 patients aged over 65 years receiving disability benefits who are severely disabled(15). The individuals aged 65 years or older who received care services at home or special care centers constitute 6.6%, 6.0%, and 3.5% of the total population in the Netherlands, Aus-tralia, and the USA, respectively(18).

In the present study, we noticed that ophthalmology is among the first three major disciplines related to severe disability. Globally, there are 32 million blind people and 153 million people with visual impairment who are 50 years old or older. In Europe, there are 3000 blind people and 25,500 people with visual impairment per one million people(12). The burden of visual impairment is greatest amongst those 50 years of age and older. Globally, 84.6% of blind people and 77.5% of visually impaired people are in these age groups(13). A study from the Netherlands reported prevalence rates in 2008 of 2.4% for blindness and 7.8% for visual impairment in people aged 65 years and over(20). The prevalence of blindness in adult individuals has been assessed as varying between 0.5% and 3% in different studies(21,22).

In our study, we found that the major causes for blindness and visual impairment were cataract, glaucoma, AMD, retinal detachment, and neovascular glaucoma, in descending order. Pascolini and Mariotti reviewed studies on this topic and found that cataract (51%) was the most common cause of blindness(12).

Moreover, cataract has been found to be the most common cause of blindness in various population-based studies. However, the cau-

Table 2. Percentages of patients with eye diseases, visual impairment, and blindness in different medical specialties

Patients Patients with eye diseases Visual impairment Blindness

Medical specialty N % N % DR N % N %

Endocrinology 01 00.5 01 01.7 17

Physical medicine and rehabilitation 29 14.6 02 03.3 28 1 10

Chest diseases 09 04.5 03 05.0 28 1 10

Ophthalmology 34 17.1 34 56.7 84 2 20 32 97

Hematology 01 00.5 00 0

Cardiology 10 05.0 02 03.3 40 01 03

Ear nose throat 04 02.0 01 01.7 35 1 10

Nephrology 06 03.0 01 01.7 35 1 10

Neurology 94 47.2 13 21.7 20 4 40

Oncology 06 03.0 01 01.7 35

Psychiatry 04 02.0 01 01.7 36

Urology 01 00.5 01 01.7 36

N= number; DR= mean disability rate from eye diseases.

Kıvanç SA, et al.


Table 3. Ocular diseases causing visual impairment and blindness

Ocular diseases

Patients with eye diseases Blindness Visual impairment

N % N % N %

Lens-related diseases

Cataract 46 38.4 17 24.0 11 50.0

Aphakia 01 00.8 01 01.4

Total 47 39.2 18 25.4 11 50.0

Cornea-related diseases

Corneal leucoma 03 02.5 02 02.8 01 04.5

Corneal dystrophies 02 01.7 02 02.8

Bullous keratopathy 01 00.8 01 01.4

Total 06 05.0 05 07.0 01 04.5

Glaucoma-related diseases

Glaucoma 14 11.7 14 19.7

Neovascular glaucoma 07 05.8 07 10.0

Total 21 17.5 21 29.7

Retina-related diseases

Age-related macular degeneration 19 15.8 05 07.0 08 36.4

Retinal detachment 07 05.8 07 09.9

Degenerative myopia 06 05.0 05 07.0

Diabetic retinopathy 04 03.3 02 009.1

Macular dystrophies 02 01.7 02 02.8

Retinitis pigmentosa 02 01.7 02 02.8

Total 40 33.3 21 29.5 10 45.5

Optic nerve-and globe-related diseases

Optic atrophy 03 02.5 03 04.2

Phthisis bulbi 02 01.7 02 02.8

Exenteration 01 00.8 01 01.4

Total 06 05.0 06 08.4

Table 4. Associations of social security status, place of residence, regular follow-up, and gender with age, disability rates, and vision

Age (Years) TBDR (%) DR (%) Right visual acuity (logMAR) Left visual acuity (logMAR)

mean ± SD mean ± SD mean ± SD mean ± SD mean ± SD

Place of residence Rural 79.54 ± 7.09 88.87 ± 7.89 57.54 ± 31.98 1.19 ± 1.1 1.10 ± 0.92

Urban 78.68 ± 6.48 88.46 ± 8.24 64.67 ± 26.88 1.52 ± 0.9 1.59 ± 1.01

P value 0.432 0.749 0.48 0.386 0.154

Social security status SSI 78.85 ± 6.88 88.93 ± 8.05 61.03 ± 30.62 1.45 ± 1.14 1.32 ± 1.05

No-SSI 79.85 ± 6.97 88.54 ± 7.90 56.76 ± 31.68 1.06 ± 0.95 1.11 ± 0.85

P value 0.308 0.734 0.597 0.218 0.47

Regular follow-up Yes 77.27 ± 6.18 88.55 ± 8.11 48.70 ± 36.60 1.06 ± 1.02 0.76 ± 1.12

No 79.99 ± 7.04 88.82 ± 7.95 61.02 ± 29.69 1.31 ± 1.07 1.29 ± 0.92

P value 0.015 0.832 0.254 0.544 0.21

Gender Women 79.29 ± 6.88 88.26 ± 8.48 64.91 ± 29.21 1.50 ± 1.11 1.47 ± 1.05

Men 79.31 ± 7.03 89.58 ± 7.00 51.70 ± 31.99 1.01 ± 0.96 0.91 ± 0.73

P value 0.988 0.261 0.1 0.125 0.056

TBDR= total body disability rate; DR= disability rate from ophthalmologic conditions; SD= standard deviation; SSI= social security insurance; No-SSI= no social security insurance; logMAR= logarithm of the minimum angle of resolution.

ses of blindness and its prevalence vary in countries depending on their levels of economic development and even within different re-gions of the same country(13,14,23,24). A study on Latin American countries reported that unoperated cataract is the main cause of blindness(22). In

the Barbados eye study, the most common causes of blindness were, in descending order, cataract (58.3%), glaucoma (14.3%), diabetic re tinopathy (8.7%), optic atrophy (7.1%), and AMD (2.4%)(23). Cataract is also the main cause of blindness in Paraguay(24). In several studies

Sociodemographic status of severely disabled and visually impaired elderly people in Turkey


performed in European countries and the USA, which are places with high life expectancy, the most common cause of visual impairment has been shown to be AMD(25,26). In a study conducted in 2008 the Netherlands, the main cause of blindness was macular degeneration, followed by cataract, refractive errors, glaucoma, and diabetic retino-pathy(18). In the present study, we studied severely disabled elderly patients, and our study was not population based, as the aforementio-ned studies were; therefore, we were not able to compare our results with those from the previous studies.

In Turkey, there are more than 400,000 visually impaired individuals according to data from 2002. Of these, 48,500 (11.8%) individuals were blind, while 162,000 (39%) individuals had visual impairment. In Eastern Turkey, of 35,000 visually impaired, 9400 (26.7%) individuals were blind, and 11,000 (31.1%) individuals had visual impairment, whereas in industrialized and developed regions of Western Turkey, 13% were blind, and 34% had visual impairment. Forty-nine percent

of the visually impaired in Eastern Turkey and 33% in Western Turkey did not undergo treatment for their visual impairment(14). Our study was performed by retrospective analysis of two years of data from the disability board of a tertiary hospital in Eastern Turkey. Seven percent of the disabled were over 65 years old, and were classed as severely disabled. Thirty percent of these patients had ophthalmo-logic diseases, and 17% were identified as being severely disabled due to ophthalmologic diseases. In a study that assessed blindness globally, the largest proportion of blind people resided in South Asia, followed by East Asia and Southeast Asia. The prevalence of blindness varied from 0.1% in the high-income North America region to 0.7% in the North Africa and Middle East regions. Moreover, the prevalen-ce of blindness among older adults was greater than 4% in Western Sub-Saharan Africa, Eastern Sub-Saharan Africa, South Asia, North Afri-ca, and the Middle East. The prevalence of blindness was lowest in high-income regions, with percentages of 0.4% or lower(13,27).

Table 6. Comparison of blind patients with visually impaired patients according to their sociodemographic characteristics

Social security status Place of residence Regular follow-up Gender

SSI No-SSI Urban Rural Yes No Men Women

N % N % N % N % N % N % N % N %

Visual impairment 06 60.0 04 40.0 4 40.0 06 60.0 0 0 10 100.0 06 60.0 04 40.0

Blindness 17 51.5 16 48.5 7 21.2 26 78.8 4 12.1 29 087.9 12 36.4 21 63.6

P value 0.801 0.715 0.248 0.184

N= number; SSI= social security insurance; No-SSI= no social security insurance.

Table 7. Comparison of blind or visually impaired patients with other severely disabled patients in terms of place of residence Place of residence SSI Status Regular follow-up Gender

Rural Urban SSI No-SSI Yes No Women MenN R% C% N R% C% N R% C% N R% C% N R% C% N R% C% N R% C% N R% C%

Blind or visually impaired patients

032 74.4 22.4 11 25.6 19.6 23 53.5 20.9 20 46.5 22.5 04 09.3 07.8 039 90.7 26.4 025 58.1 20 18 41.9 24.3

Others 111 71.2 77.6 45 28.8 80.4 87 55.8 79.1 69 44.2 77.5 47 30.1 92.2 109 69.9 73.6 100 64.1 80 56 35.9 75.7

P value 0.848 0.863 0.005 0.481N= number; R%= row percentage; C%= column percentage; SSI= social security insurance; No-SSI= no social security insurance.

Table 5. Interrelationships of social security status, place of residence, regular follow-up, and gender

Place of residence Social security statusPatients with regular hospital

follow-up Gender

Rural Urban SSI No-SSI Yes No Women Men

N % N % N % N % N % N % N % N %

Place of residence Rural 143 100.0 00 0 67 046.9 76 053.1 32 022.4 111 077.6 88 061.5 55 038.5

Urban 0 0 56 100.0 43 076.8 13 023.2 19 033.9 037 066.1 37 066.1 19 033.9

P value N/A 0.000 0.093 0.552

Social security status SSI 67 060.9 43 039.1 110 100.0 00 0 29 026.4 081 073.6 73 066.4 37 033.6

No-SSI 76 085.4 13 014.6 0 0 89 100.0 22 024.7 067 075.3 52 058.4 37 041.6

P value 0.000 N/A 0.792 0.249

Regular follow-up Yes 32 062.7 19 037.3 29 056.9 22 043.1 51 100.0 000 0 29 056.9 22 043.1

No 111 75.0 37 25.0 81 054.7 67 045.3 0 0 148 100.0 96 064.9 52 035.1

Pvalue 0.093 0.792 N/A 0.308

Gender Women 88 070.4 37 029.6 73 058.4 52 041.6 29 023.2 096 076.8 125 100.0 0 0

Men 55 074.3 19 025.7 37 050.0 37 50.0 22 029.7 052 070.3 0 0 74 100.0

P value 0.552 0.249 0.308 N/A

N/A= not available; N= number; SSI= social security insurance; No-SSI= no social security insurance.

Kıvanç SA, et al.


In the Netherlands, an estimated 311,000 people are visually im-paired, and the visual loss is thought to be treatable or preventable in 174,000 (56%) of these people(18). The most common preventable and treatable cause of blindness throughout the world is cataract, and this is particularly true in developing countries. When cataracts are left untreated, the relatives of the patients, and eventually, society as a whole, face economic and moral burdens(13). It has been calculated that blindness and visual impairment constitute a financial burden of 15-73 billion US dollars per year(28,29).

According to the data from the TSI, 42.4% of all the disabled peo ple in Turkey have a disability rate of 70% or more. The percentages of disabled people living in urban areas, aged 65 years and over, and who are females constitute 62.4%, 15.2%, and 41.4%, respectively, out of all the disabled people in Turkey(14). Apart from the official data of Turkey, in our study, 27% of the individuals who received the severely disabled rating for ophthalmologic reasons came from urban areas, and 73% came from rural areas. Additionally, 79% of the blind patients came from rural areas, and the patients living in rural areas had signi-ficantly lower rates of having SSI. Health access and utilization of eye care services may be influenced by various sociodemographic factors such as age, sex, and education level(30). In our study, we found that having SSI was associated with patients’ place of residence. Patients with no SSI have to pay their own health expenses when they seek medical care in tertiary centers if they are not referred officially by a local physician, which may be an obstacle to health services. Therefore, the place of residence as a sociodemographic factor might have affected health access in our study, particularly in blind patients. In our study, we noted a higher rate of females than males aged over 65 years who were classed as severely disabled due to blindness; further, females had significantly lower rates of follow-up. Thus, gender affects health access. In all regions worldwide, women have a higher age-standardized prevalence of vision impairment and blindness than men(13). Globally, 4.2% of males and 5.3% of females aged over 70 years are blind, and 18.8% of males and 20.9% of females aged over 70 years are visually impaired,(13) suggesting lower accessibility to health for women compared with that for men. Multivariate analysis showed that patients who were severely disabled due to their ophthalmologi-cal conditions were less likely to visit hospitals than the other severely disabled patients. Compatible with this finding, it was shown that elderly people with visual impairment and/or blindness have partici-pation restrictions and activity loss that are associated with functional and cognitive decline(6-10).

In conclusion, blindness gives rise to severe disability and consti-tutes a large proportion of the diseases that lead to severe disability. The most common ophthalmologic diseases that cause severe disa-bility are cataract, glaucoma, and AMD. Sociodemographic factors that may affect the accessibility to health services of visually impaired and blind people include their place of residence and gender. Finally, visually impaired and blind people are more likely to have lower follow-up rates than other severely disabled people.

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296(5570):1029-31. 2. Luigi F. Modulating human aging and age-associated diseases. Biochim Biophys Acta.

2009;1790(10):1133-8. 3. World Health Organization. The global burden of disease: 2004 update. Geneva: WHO

Press;2008.

4. World Health Organization. World Health Organization Report on Disability 2011. Geneva: WHO Press; 2011.

5. World Health Organization. Global Initiative for the Elimination of Avoidable Blindness action plan 2006-2011. Geneva: WHO Press; 2007.

6. Alma MA, Van der Mei SF, Feitsma WN, Groothoff JW, Van Tilburg TG, Suurmeijer TP. Loneliness and self-management abilities in the visually impaired elderly. J Aging Health. 2011;23(5):843-61.

7. Avlund K, Lund R, Holstein BE, Due P. Social relations as determinant of onset of disability in aging. Arch Gerontol Geriatr. 2004;38(1):85-99.

8. Glei DA, Landau DA, Goldman N, Chuang YL, Rodriguez G, Weinstein M. Participating in social activities helps preserve cognitive function: an analysis of a longitudinal, population based study of the elderly. Int J Epidemiol. 2005;34(4):864-71.

9. Rovner BW, Casten RJ, Leiby BE, Tasman WS. Activity loss is associated with cognitive decline in age-related macular degeneration. Alzheimers Dement. 2009;5(1):12-7.

10. Newall NE, Chipperfield JG, Clifton RA, Perry RP, Swift AU, Ruthig JC. Causal beliefs, social participation, and loneliness among older adults: a longitudinal study. J Soc Pers Rel. 2009;26(2-3):273-90.

11. Resnikoff S, PascoliniD, Etya’ale D.Global data on visual impairment in the year 2002. Bull World Health Organ. 2004;82(11):844-51.

12. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2012;96(5):614-8.

13. Stevens GA, White RA, Flaxman SR, Price H, Jonas JB, Keeffe Jet al. Global prevalence of vision impairment and blindness: magnitude and temporal trends, 1990-2010. Oph thalmology. 2013;120(12):2377-84.

14. Turkish Statistical Institute [Internet]. Turkey Disability Survey 2002. 2nd ed. State Institute of Statistics, Printing Division - Ankara, September 2009. [cited 2015 Nov 2]. Available from: http://www.die.gov.tr

15. Republic of Turkey. Social Security Instutition [Internet] 2011. Statistical yearbook. [cited 2015 Nov 2]. Available from: http://www.ssk.gov.tr/wps/portal/tr/kurumsal/istatistikler/sgk_istatistik_yilliklari

16. Üstün T, Chatterjı S, Bıckenbach J, Kostanjsek N, SchneıderM. The International Classi-fication of Functioning, Disability and Health: A new tool for understanding disability and health. Disabil Rehabil. 2003;25(11-12):565-71.

17. Olcaysü OO, Kıvanç SA, Altun A, Çinici E, Altınkaynak A, Ceylan E. Causes of disability, low vision and blindness in old age. 2014;17(1):44-9

18. Limburg H, Keunen JE. Blindness and low vision in The Netherlands from 2000 to 2020-modeling as a tool for focused intervention. Ophthalmic Epidemiol. 2009;16(6): 362-9.

19. Turkish Statistical Institute [Internet]. Statistics by Theme; Population projections. [cited 2015 Nov 2]. Available from: http://www.turkstat.gov.tr/PreTablo.do?alt_id=1027.

20. Limburg JJ, Keunen JE, van Rens GH. Elderly people with visual impairment in the Netherlands. Tijdschr Gerontol Geriatr. 2009;40(4):149-55.

21. Nowak MS, Smigielski J. The prevalence and causes of visual impairment and blind-ness among older adults in the city of Lodz, Poland. Medicine (Baltimore). 2015;94(5): e505.

22. Silva JC, Mújica OJ, Vega E, Barcelo A, Lansingh VC, McLeod J et al. A comparative assessment of avoidable blindness and visual impairment in seven Latin American countries: prevalence, coverage, and inequality. Rev Panam Salud Publica. 2015;37(1): 13-20.

23. Hennis AJ, Wu SY, Nemesure B, Hyman L, Schachat AP, Leske MC. Barbados Eye Stu-dies Group. Nine-year incidence of visual impairment in the Barbados Eye Studies. Ophthalmology. 2009;116(8):1461-8.

24. Duerksen R, Limburg H, Lansingh VC, Silva JC. Review of blindness and visualimpair-ment in Paraguay: changes between 1999 and 2011. Ophthalmic Epidemiol. 2013; 20(5):301-7.

25. Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477-85.

26. Klaver CC, Wolfs RC, Vingerling JR, Hofman A, de Jong PT. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol. 1998;116(5):653-8.

27. Bourne RR, Stevens GA, White RA, Smith JL, Flaxman SR, Price H, et al. Causes of vision loss worldwide, 1990-2010: a systematic analysis. Lancet Glob Health; 2013;1(6):e339-49.

28. Roberts CB, Hiratsuka Y, Yamada M, Pezzullo ML, Yates K, Takano S, et al. Economic cost of visual impairment in Japan. Arch Ophthalmol. 2010;128(6):766-71.

29. Cruess AF, Gordon KD, Bellan L, Mitchell S, Pezzullo ML. The cost of vision loss in Canada. 2. Results. Can J Ophthalmol. 2011;46(4):315-8.

30. Rim TH, Choi M, Yoon JS, Kim SS. Sociodemographic and health behavioural factors associated with access to and utilisation of eye care in Korea: Korea Health and Nutrition Examination Survey 2008-2012. BMJ Open. 2015;16;5(7):e007614.

Original Article


INTRODUCTION Keratoconus is a common, non-inflammatory, progressive cor-

neal disorder with a typical onset in early adulthood(1). Keratoconus that is characterized by thinning and protrusion of the central cornea frequently leads to a mild-to-severe decrease in best-corrected visual acuity (BCVA). Loss of visual acuity can be improved with contact len-ses or spectacles in the early stages of the disease; however, patients may eventually require corneal grafting as their condition progresses. Keratoconus is the single most common reason for keratoplasty in the developed world(1-3).

Penetrating keratoplasty is associated with a high success rate and continues to play an important role in keratoconus management. However, it is also associated with significant complications, in clu-ding immunological rejection, secondary cataract, glaucoma, and mi-

cro bial keratitis(4,5). Moreover, visual rehabilitation or recovery of visual acuity following transplantation may be slow and unsatisfactory. There is a growing interest in treatment options that may delay or defer corneal grafting, including the use of intrastromal corneal ring segments (ICRS)(6).

Originally used to correct mild-to-moderate myopia, ICRS exert an ‘‘arc-shortening” effect on the corneal lamellae, thus reducing steepening of the central cornea(3). This decreases refractive errors and improves corneal surface regularity. Moreover, there is evidence to suggest that implanting an ICRS may delay the requirement for penetrating keratoplasty(7-9).

There are several commercially available ICRS that vary with regard to curvature, width, and zone of implantation(3). One such ICRS is the Keraring (Mediphacos, Belo Horizonte, Brazil), a small, arc-like segment made of po lymethyl methacrylate. It is characterized by a unique pris-

Intrastromal corneal ring segments delay corneal grafting in patients

with keratoconus

Segmentos de anéis intracorneanos protelam o transplante de córnea em pacientes com ceratocone

luiz arthur f. BEniz1, GuStavo h. QuEiroz1, carloS f. QuEiroz1, wanESSa l. lopES1, lEiSEr f. MoraES1, joSé BEniz1

Submitted for publication: February 20, 2015 Accepted for publication: November 6, 20151 Centro de Referência em Oftalmologia, Universidade Federal de Goiás, Goiânia, GO, Brazil.


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

Corresponding author: José Beniz Neto. Av. T-2, no 401- Goiânia, GO - 74210-010 - Brazil E-mail: [email protected]

Approved by the following research ethics committee: Hospital das Clínicas, Universidade Federal de Goiás (219.191).

ABSTRACTPurpose: To assess the impact of intrastromal corneal ring segments (ICRS) as a surgical alternative to corneal grafting in patients with keratoconus who were scheduled for a corneal transplant. Methods: This single-surgeon, single-center, retrospective, observational case series study included 19 eyes of 18 patients (mean age, 23.36 ± 6.22 years) with a confirmed diagnosis of keratoconus. These patients were enrolled from the State of Goiás, Brazil corneal graft waiting list. Following extensive pre-operative testing, including the measurement of best-corrected visual acuity (BCVA), applanation tonometry, biomicroscopy, funduscopy, pachymetry, and corneal topography, patients were implanted with Keraring® ICRS. Patients underwent clinical exa-mination at postoperative days 1, 7, 30, 90, and 180 and were examined again 2 years following surgery. Results: At the 2-year cut-off following ICRS implantation (mean follow-up, 28.72 ± 4.71 months), there was a statistically significant improvement in BCVA (logMAR) from 0.59 ± 0.35 preoperatively to 0.35 ± 0.45 postoperatively (p<0.01). Three of 19 eyes (15.8%) still required keratoplasty. In the remaining patients (84.2%), BCVA was managed with spectacles (52.6%) or contact lenses (31.6%). One patient de-veloped infectious keratitis, requiring removal of ICR at the first postoperative visit. Conclusion: ICRS implantation may be a surgical alternative to keratoplasty in patients with keratoconus. This procedure may delay or even eliminate the need for keratoplasty in such patients.

Keywords: Keratoconus; Corneal transplantation; Corneal stroma; Eye banking; Vi sual acuity

RESUMOObjetivo: Avaliar o impacto do implante de anéis corneanos intraestromais como alternativa cirúrgica à ceratoplastia, em pacientes com ceratocone previamente inscritos na fila de espera para transplante de córnea. Métodos: Este estudo unicêntrico, retrospectivo, observacional analisou prontuá-rios de 19 olhos de 18 pacientes (idade média de 23,36 ± 6,22) com diagnóstico de ceratocone, incluídos na lista de espera para transplante de córnea do estado de Goiás, Brasil. Após realização de exame oftalmológico completo pré-operatório, in-cluindo acuidade visual (AV) corrigida, tonometria de aplanação, biomicroscopia, fun doscopia, paquimetria e topografia corneana, os pacientes foram submetidos a cirurgia para implante de anel intracorneano Keraring®. Os mesmos foram submeti-dos a exame oftalmológico no 1o, 7o, 30o, 90o, 180o dias de pós-operatório, e também após 2 anos da cirurgia. Resultado: Após a visita final de 2 anos de acompanhamento (média de seguimento de 28,72 ± 4,71 meses), houve melhora estatisticamente significativa da AV corrigida (logMAR): 0,59 ± 0,35 no pré-operatório para 0,35 ± 0,45 do pós-operatório (p<0,01). Três dos 19 olhos (15,8%) permaneceram com a indicação de ceratoplastia. A conduta para os demais (84,2%) foi correção óptica com óculos (52,6%) ou lente de contato (31,6%). Um paciente evoluiu com ceratite infecciosa no pós-operatório, tendo seus anéis removidos. Conclusão: O implante de anéis intraestromais mostrou ser uma alternativa eficaz ao transplante de córnea nesta série de casos. Esse procedimento pode ajudar a retardar ou eliminar a necessidade de indicação de ceratoplastia em pacientes com ceratocone.

Descritores: Ceratocone; Transplante de córnea; Banco de olhos; Estroma corneano; Acuidade visual

Beniz LAF, et al.


matic design that flattens the cornea and reduces the incidence of glare and halos. Several clinical studies have demonstrated their effi-cacy in improving visual function, reducing the magnitude of corneal astigmatism, and flattening the central corneal surface(10-14). Although previous studies have evaluated ICRS efficacy in patients who were intolerant to rigid contact lenses (and therefore potential candidates for a corneal transplant)(15-17), to the best of our knowledge, there are no published data regarding Keraring ICRS efficacy in patients with keratoconus who were already scheduled for penetrating kera-toplasty. Consequently, we performed a small case series study to determine whether Keraring ICRS implantation might represent a surgical alternative to corneal grafting in patients with keratoconus who were awaiting penetrating keratoplasty.

METHODSWe conducted a retrospective observational case series study

on the basis of an analysis of records of patients included in the State of Goiás corneal graft waiting list. These patients underwent Kera-ring ICRS implantation as a potential alternative to keratoplasty. All procedures were performed by the same surgeon at the Centro de Referência em Oftalmologia UFG, Goiânia, Brazil between June and December 2008. Written informed consent was obtained prior to study and data collection.

The study included 18 patients (19 eyes) with a mean age of 23.36 ± 6.22 years and with keratoconus varying from Grade II to IV (Amsler-Krumeich scale). Patients were included if they had evidence of topographical alteration that was compatible with keratoconus, a minimal corneal thickness of 380 µm, low BCVA with spectacles, and intolerance to contact lenses. Exclusion criteria included topographic curves over 70 D, apical opacity, and external ocular infection. Baseline characteristics of the patients are summarized in table 1.

Prior to ICRS implantation, all patients underwent a detailed preo-perative clinical assessment, including the measurement of BCVA (logMAR), applanation tonometry, biomicroscopy, fundoscopy, pa-chymetry, and corneal topography. Patients were postoperatively evaluated for BCVA.

ICRS selection was based on the Mediphacos nomogram for the Keraring® calculation system (Belo Horizonte, Brazil). All surgeries were performed on an outpatient basis under topical anesthesia (5 mg/mL proxymetacaine HCl and 5% povidone iodine). The ICRS tunnel was manually created. The center of the visual axis on the cornea was marked, and an initial perpendicular corneal incision was made at the 5-7-mm zone with an adequate depth for each case. This was followed by radio intrastromal channelization. Appropriate ICRS was finally placed inside the corneal tunnels.

Following the procedure, patients were administered Maxitrol® eye drops (Alcon Laboratories, Brazil) every 2 h for 2 weeks, followed by Florate® (Alcon Laboratories, Brazil) four times daily, also for 2 weeks.

Postoperative outcomes were evaluated at postoperative days 1, 7, 30, 90, 180, and eventually 2 years following implantation. BCVA was measured and biomicroscopy and applanation tonometry were per-formed at each follow-up visit, whereas fundoscopy was performed at the 6-month follow-up visit. The effectiveness of ICRS in terms of preventing corneal grafting was evaluated at the 2-year follow-up visit.

RESULTSPre- and postoperative BCVA (logMAR) data of each patient are

displayed in table 2. Mean preoperative BCVA was 0.59 ± 0.35. At the 2-year cut-off point following ICRS implantation (mean follow-up, 28.72 ± 4.71 months), mean BCVA was 0.35 ± 0.45 (Figure 1). This im-provement in BCVA was statistically significant (p<0.01). One patient developed infectious keratitis on postoperative day 1. Consequently, this patient had his corneal rings removed, and his data excluded from the statistical analysis of BCVA. The patient subsequently un-derwent corneal grafting.

At the 2-year cut-off point, 3/19 eyes (15.8%) were still considered candidates for penetrating keratoplasty because they did not achieve significant corneal applanation or regularity. However, the remaining patients (84.2%) maintained BCVA with spectacles (52.6% patients) or contact lenses (31.6% patients). Apart from one case of infectious keratitis, no other relevant complications occurred.

DISCUSSIONAlthough initially approved by the US Food and Drug Administra-

tion as a treatment for myopia, ICRS has become a mainstay in mana-ging keratoconus. Since Colin et al. first reported regarding the use of ICRS in keratoconus more than a decade ago(7), a plethora of studies have demonstrated their ability to effectively reduce refractive errors and safely improve corneal surface regularity. While there is also increasing evidence to suggest that ICRS may delay the requirement for penetrating keratoplasty(5,18), published evidence describing ICRS effects in patients with keratoconus already scheduled to undergo penetrating keratoplasty is limited.

Table 1. Patient characteristics

N (%)

No patients 18

Gender

Female 12*

Male 6

No of eyes 19

Right eyes 09

Left eyes 10

Age (years)

Mean 23.36 e 6.22

Range 14-32

*= one female was subject to bilateral implantation with ICRS.

Table 2. BCVA (logMAR) pre- and post-ICRS implantation

Eye Preoperative BCVA Postoperative BCVA*

01 0.15 0.15

02 0.53 0.30

03 0.30 1.00

04 1.00 0.30

05 0.70 0.22

06 0.70 0.53

07 0.30 0.14

08 0.70 0

09 1.60 1.80

10 0.40 0.15

11 0.27 0

12 0.40 0.53

13 0.82 0.70

14 0.10 0.10

15 0.70 0.15

16 0.70 0.04

17 0.40 0.04

18 0.40 0.20

*= two-year cut-off point (mean follow-up, 28.72 ± 4.71 months); NB= one of 19 eyes included in the study was excluded from BCVA statistics.

Intrastromal corneal ring segments delay corneal grafting in patients with keratoconus


The results of our case series of 18 patients (19 eyes) who awaited corneal grafting suggest that ICRS may be an efficacious alternative to penetrating keratoplasty. At the 2-year data cut-off point, we noted that 84% eyes maintained BCVA with spectacles (52.6%) or contact lenses (31.6%), whereas 3/19 eyes (15.8%) still required keratoplasty because they did not achieve significant corneal applanation or regularity.

Data from a previously published, one-year, 50-eye study de-monstrated that Keraring ICRS implantation improved both uncor-rected visual acuity and BCVA in patients with keratoconus (17). Similarly, in a 35-eye study, Coimbra et al. demonstrated that Keraring ICRS im-proved visual acuity and topographic data in patients with secondary corneal ectasia at a 3-month postoperative follow-up(11). However, to the best of our knowledge, no reports on the use of Keraring ICRS as a treatment for patients who have already been triaged for corneal transplantation are available. Consequently, it is somewhat difficult to discuss our findings within the context of others. However, there is a comparative case study of 76 eyes with advanced keratoconus. These patients received either ICRS implantation or deep anterior la-mellar keratoplasty. ICRS effected a statistically significant increase in visual acuity (corrected and uncorrected distance visual acuity) from baseline to postoperative 24 months (p<0.001)(19). Similarly, data from a study by El-Husseiny et al., which included 20 eyes of 16 patients, revealed that ICRS (Intacs, Addition Technology, Inc, Sunnyvale, CA) provided a viable alternative to early penetrating keratoplasty for patients with keratoconus having a clear central cornea and a history of contact lens intolerance. Specifically, the data revealed that after 6 months of follow-up, the mean uncorrected distance visual acuity

improved from 0.07 ± 0.07 preoperatively to 0.6 ± 0.26 postoperati-vely, whereas mean BCVA changed from 0.4 ± 0.15 preoperatively to 0.9 ± 0.29 postoperatively(20).

Although data from our small study suggests that ICRS may be a surgical alternative to keratoplasty in some patients with keratoco-nus, longer-term follow-up is required to determine for how long ICRS adequately maintain BCVA and whether patients for whom ICRS im-plantation was effective will eventually require penetrating ke ratoplasty.

CONCLUSIONThe results indicate that ICRS implantation may delay or even

eli minate the requirement for corneal grafting in a group of patients with keratoconus who awaited keratoplasty.

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10. Haddad W, Fadlallah A, Dirani A, El Rami H, Fahd D, Khanafer D, et al. Comparison of 2 types of intrastromal corneal ring segments for keratoconus. J Cataract Refract Surg. 2012;38(7):1214-21.

11. Coimbra CC, Gomes MT, Campos M, Figueiroa Jr ES, Barbosa EP, Santos MS. Femtose-cond assisted intrastromal corneal ring (ISCR) implantation for the treatment of corneal ectasia. Arq Bras Oftalmol. 2012;75(2):126-30.

12. Kubaloglu A, Sari ES, Cinar Y, Koytak A, Kurnaz E, Ozertürk Y. Intrastromal corneal ring segment implantation for the treatment of keratoconus. Cornea. 2011;30(1):11-7.

13. Piñero DP, Alió JL, Teus MA, Barraquer RI, Michael R, Jiménez R. Modification and refi-nement of astigmatism in keratoconic eyes with intrastromal corneal ring segments. J Cataract Refract Surg. 2010;36(9):1562-72.

14. Alfonso JF, Lisa C, Fernández-Vega L, Madrid-Costa D, Poo-López A, Montés-Micó R. Intrastromal corneal ring segments and posterior chamber phakic intraocular lens implantation for keratoconus correction. J Cataract Refract Surg. 2011;37(4):706-13.

15. Fahd DC, Jabbur NS, Awwad ST. Intrastromal corneal ring segment SK for moderate to severe keratoconus: a case series. J Refract Surg. 2012;28(10):701-5.

16. Kymionis GD, Siganos CS, Tsiklis NS, Anastasakis A, Yoo SH, Pallikaris AI, et al. Long-term follow-up of Intacs in keratoconus. Am J Ophthalmol. 2007;143(2):236-44.

17. Coskunseven E, Kymionis GD, Tsiklis NS, Atun S, Arslan E, Jankov MR, et al. One-year results of intrastromal corneal ring segment implantation (KeraRing) using femtose-cond laser in patients with keratoconus. Am J Ophthalmol. 2008;145(5):775-9.

18. Ertan A, Colin J. Intracorneal rings for keratoconus and keratectasia. J Cataract Refract Surg. 2007;33(7):1303-14.

19. Ozertürk Y, Sari ES, Kubaloglu A, Koytak A, Piñero D, Akyol S. Comparison of deep anterior lamellar keratoplasty and intrastromal corneal ring segment implantation in advanced keratoconus. J Cataract Refract Surg. 2012;38(2):324-32.

20. El-Husseiny M, Tsintarakis T, Eppig T, Langenbucher A, Seitz B. [Intacs intracorneal ring segments in keratoconus]. Ophthalmologe. 2013;110(9):823-6. German.

*= two-year cut-off point (mean follow-up, 28.72 ± 4.71 months). NB= one of 19 eyes included in the study was excluded from analysis of BCVA data.Figure 1. Change in BCVA (logMAR) following ICRS implantation.

Original Article


INTRODUCTIONGlaucoma is a multifactorial disease characterized by progressive

optic neuropathy with loss of visual field. Historically, elevated intrao-cular pressure (IOP) is regarded as the primary cause of glaucomatous optic nerve damage; however, there is now evidence that other fac-tors are involved in the pathogenesis of glaucoma, such as changes in blood flow, perfusion, and oxygen delivery(1). There is compelling accumulated evidence supporting the theory that decreased ocular blood flow contributes to glaucomatous optic neuropathy(1,2). In a model of optic nerve injury, it was demonstrated that alterations of perfusion and oxygen delivery to the retinal ganglion cells may signi-ficantly contribute to vision loss(3). Therefore, detailed hemodynamic

evaluation of the orbital circulation is needed to better understand this complex disorder.

The hemodynamics of orbital blood vessels can be quantified by color Doppler imaging (CDI), which allows estimations of velo-city and resistance to blood flow in unanesthetized subjects. This method has been widely used to study these blood flow parameters in retrobulbar blood vessels in humans and animals(4-8). The Doppler waveform represents changes in the velocity of the blood flow during the cardiac cycle, and deflections in the late systolic [peak systolic velocity (PSV)] or early diastolic flow [end diastolic velocity (EDV)] are characteristic of high resistance arterial blood flow waveforms(6,9). The resistive index (RI), also known as the Pourcelot ratio, is calculated

Effects of prostaglandin analogs on blood flow velocity and resistance in the

ophthalmic artery of rabbits

Efeitos dos análogos da prostaglandina na velocidade do fluxo sanguíneo e resistência na artéria oftálmica de coelhos

aMália turnEr Giannico1, lEandro liMa1, Gillian c. Shaw2, hEloiSa h. a. ruSS3, tildE rodriGuES froES1, faBiano Montiani-fErrEira1

Submitted for publication: May 28, 2015 Accepted for publication: October 20, 20151 Universidade Federal do Paraná, Curitiba, PR, Brazil. 2 Department of Molecular and Comparative Pathobiology, School of Medicine, Johns Hopkins Uni-

versity, Baltimore, MD, USA.3 Instituto Graefe de Oftalmologia, Curitiba, PR, Brazil.



Corresponding author: Amália T. Giannico. Rua dos Funcionários, 1.540 - Curitiba, PR - 80035-050 - Brazil - E-mail: [email protected]

Approved by the following research ethics committee: Universidade Federal do Paraná, protocol #011/2011.

ABSTRACTPurpose: The aim of this study was to investigate the effects of prostaglandin analogs on blood flow in the ophthalmic artery of clinically healthy rabbits. Methods: Fifty-five clinically healthy New Zealand white rabbits were divided into six groups, and the left eyes were treated for four weeks with the preservative benzalkonium chloride (BAK) only or a topical formulation of different prosta-glandin analogs (bimatoprost BAK, tafluprost BAK-free, travoprost BAK, travoprost POLYQUAD, and latanoprost BAK). Color Doppler imaging was performed before and after the treatments. The mean values of the peak systolic velocity (PSV) and end diastolic velocity and the resistive index (RI) were calculated. Statistical analysis was performed to compare the differences pre- and post-treatment for each drug and post-treatment among the drugs. Results: The prostaglandin analogs did not affect PSV. Bimatoprost BAK, travoprost POLYQUAD, and latanoprost BAK did not change RI. Tafluprost BAK-free and tra-voprost BAK therapy resulted in similar reductions in RI. No significant differences pre- and post-treatment were found when BAK was administered alone. Conclusion: The prostaglandin analogs tafluprost BAK-free and travoprost BAK improved blood flow in the ophthalmic artery in healthy New Zealand white rabbits, which suggests that these drugs enhance the prevention of the progres-sion the progression of glaucoma.

Keywords: Color Doppler imaging; Orbital hemodynamics; Glaucoma; Orycto-lagus cuniculus

RESUMOObjetivo: O objetivo deste estudo foi investigar os efeitos dos análogos da prosta-glandina (PGAs) no fluxo sanguíneo da artéria oftálmica em coelhos. Métodos: Cinquenta e cinco coelhos da raça Nova Zelândia clinicamente saudáveis foram divididos em seis grupos para tratamento com formulação tópica de diferentes APGs (bimatoprosta BAK, tafluprosta BAK-free, travoprosta BAK, travoprosta POLYQUAD e latanoprosta BAK) e formulações contendo apenas o conservante cloreto de benzal-cônio (BAK). Foi realizada ultrassonografia com Doppler antes e após os tratamentos. Os valores do pico da velocidade sistólica (PSV) e da velocidade diastólica final foram obtidos e o índice de resistência (RI) foi então calculado. A análise estatística foi rea-lizada para comparar as diferenças entre cada droga no pré e pós-tratamento, além das diferenças no pós-tratamento entre as drogas. Resultados: Estes colírios PGAs não afetaram o PSV. A bimatoprosta com o conservante BAK, travoprosta com o conservante POLYQUAD e latanoprosta com o conservante BAK não alteraram o RI. Já o tratamento com tafluprosta sem conservante (BAK-free) e travoprosta com o conservante BAK promoveram redução similar dos valores do RI. Não houve diferença significativa na comparação entre valores pré e pós-tratamento quando BAK foi administrado isoladamente. Conclusão: Os PGAs tafluprosta BAK-free e travoprosta BAK melhoraram o fluxo san-guíneo na artéria oftálmica em coelhos da raça Nova Zelândia sugerindo que estes medicamentos possam contribuir na prevenção da progressão do glaucoma.

Descritores: Doppler colorido; Hemodinâmica orbital; Glaucoma; Oryctolagus cuniculus

Effects of prostaglandin analogs on blood flow velocity and resistance in the ophthalmic artery of rabbits


from the blood flow velocities. This index, expressed by the formula [(PSV - EDV) / PSV], indicates the downstream resistance in arteries (ranging from 0 to 1, where 0 is no resistance and 1 is the maximum resistance)(9). CDI research has shown that through increased RI, retrobulbar blood flow is reduced in patients with glaucoma and that there may be a predictive value for the progression of the disease(10,11). A high RI value correlates with an increase in vascular resistance, leading to decreased perfusion, which may in turn contribute to glaucomatous optic neuropathy(2,5,7,9,12,13).

Prostaglandin analogs (PGAs) are IOP-lowering agents commonly prescribed in glaucoma treatment. PGAs act primarily by enhancing uveoscleral outflow of aqueous humor; however, PGAs also appear to act on the trabecular meshwork to facilitate aqueous humor outflow through the conventional outflow pathway(14).

The majority of topical treatments for elevated IOP contain a preservative, the most common of which is benzalkonium chloride (BAK), a quaternary ammonium salt. Chronic exposure to BAK has been associated with symptoms of ocular discomfort attributed to BAK-induced instability of the tear film, reduced density of superfi-cial epithelial cells, disruption of corneal epithelial barrier function, and conjunctival inflammation(15,16). These undesirable effects may be reversible in glaucoma patients who are switched to BAK-free medications(15). BAK is absorbed and accumulates in ocular structures involved in glaucoma pathogenesis, but the potential effects of pre-servatives in the vasculature of the eye are unknown(17).

Considering the growing evidence supporting a vascular patho-genesis for glaucoma, a decrease in blood flow could potentially accelerate disease development. Therefore, in addition to their IOP-lo wering capabilities, these medications may be detrimental or beneficial to ocular hemodynamics. The purpose of this investigation was to examine the potential effects of topical solutions of PGAs with and without preservatives on the blood flow of the ophthalmic artery (OA) in clinically healthy rabbits.

METHODSANIMALS

The investigation was carried out using 55 clinically healthy, six- month-old New Zealand white rabbits (Oryctolagus cuniculus), with 32 females and 23 males weighing 2.2 kg to 3.0 kg. The animals were selected randomly from a commercial breeder. All procedures using live rabbits were conducted in accordance with the Federal Universi-ty of Parana’s Animal Use Committee (Curitiba city, Paraná state, Brazil) and with the ARVO Statement for the Use of Animals in Ophthalmic and Vision Research.

The rabbits were housed under a 12:12 hour light: dark cycle for one week prior to and for the duration of the study. Food and water were given ad libitum, and the humidity (70%) and temperature (22.5°C) were controlled.

Physical examinations were performed before the ocular exami-nations to exclude animals with any indications of systemic disease. Rabbits with evidence of ocular or systemic diseases were excluded from this research. To avoid inter-investigator discrepancies, the same masked investigator performed the CDI, and another investigator, who was not masked, instilled the eye drops.

TREATMENTS

The rabbits received a number from one to 55 and were then divided into six groups using the randomized function in Microsoft Office Excel (Microsoft Office 2007 for Windows). The left eyes were treated daily for four weeks with one drop of topical PGA eye drops applied to the conjunctival fornix. The ophthalmic drugs and num-bers of females and males are listed in table 1.

COLOR DOPPLER IMAGING CDI was performed before and after the treatment with eye drops

using an ultrasound system (MyLab 30; Esaote, Genova, Italy) equip-ped with a 12-MHz linear ultrasound transducer. The animals were not anesthetized, and the eye and orbit were imaged with the animal in sternal recumbency. All CDI examinations were performed by the same two people, one of whom restrained the rabbit, while the other performed the imaging. Ultrasound gel was applied to the dorsal region and to the zygomatic arch, and the transducer was gently positioned with minimal pressure in the horizontal plane after instillation of one drop of topical anesthesia (tetracaine ophthalmic drops, Anestalcon®, Alcon). The long axis of the transducer was held horizontally between the lateral and medial canthus with the marker pointing nasally (Figure 1A).

We used the muscular cone and power Doppler mode to de-termine the relative position of the OA. After the detection of the blood flow by the power Doppler, the spectral Doppler sampling volume was placed in the center of the imaged vessel. The OA is readily identifiable by its characteristic dicrotic notch in the Doppler waveform associated with the closure of the aortic valve(5). The ultra-sound beam and the OA were parallel, and the sample volume was set at 1 mm inside the vessel (Figure 1B). The mean values of PSV and EDV from three pulse waveforms were calculated (Figure 1B), and the RI of the blood flow was calculated using the formula [(PSV - EDV) / PSV].

Table 1. Prostaglandin analog eye drops, commercial names, manufacturers, and numbers of female and male New Zealand white rabbits

Antiglaucomatous eye drops Commercial name Manufacturer

Animals

Female Male

Bimatoprost 0.03%BAK Lumigan Allergan Indústria Farmacêutica Ltda.Guarulhos, SP, Brazil

5 5

Tafluprost 0.0015%BAK-FREE Saflutan Merck Sharp & Dohme Ltda.,Guarulhos, SP, Brazil

6 4

Travoprost 0.004%BAK Travatan* Alcon Laboratórios do Brasil Ltda.São Paulo, SP, Brazil

5 5

Travoprost 0.004%POLYQUAD Travatan* Alcon Laboratórios do Brasil Ltda.São Paulo, SP, Brazil

7 3

Latanoprost 0.005%BAK Xalatan Pfizer Indústria FarmacêuticaSão Paulo, SP, Brazil

6 4

Control solutionBAK BAK Benzalkonium chloride 0.01%, “Ophthalmos” Ophthalmic Pharmaceuticals ManipulationSão Paulo, SP, Brazil

3 2

*= there is no difference in the commercial name between the eye drops TravatanBAK and TravatanPOLYQUAD.BAK= benzalkonium chloride.

Giannico AT, et al.



The Shapiro-Wilk normality test demonstrated that the data errors were normally distributed. The data were statistically analyzed using the computer software StatView (SAS Institute, Cary, NC, USA). ANOVA was used to compare the pre-treatment results to show that the groups were homogeneous. Paired t-tests were used to compare the potential differences between pre- and post-treatment results for each drug, and the Tukey-Kramer post hoc test was used to compare potential post-treatment differences among the drugs. P-values of <0.05 were considered to be statistically significant.

RESULTSThe means and standard deviations of the pre- and post-treatment

values for RI, PSV, and EDV are presented in table 2. PSV and EDV are expressed in centimeters per second (cm/s), whereas RI has no units.

No significant differences were found in the pre-treatment PSV, EDV, and RI of the left eye of all the rabbits (P>0.05), showing that these parameters were homogeneous amongst the groups before treatment.

No significant differences were found between pre- and post-treat ment PSV or EDV in all the animal groups nor for the pre- and post-treatment RI in the rabbits that received bimatoprost BAK, tra-voprost POLYQUAD, or latanoprost BAK (P>0.05) (Table 2). However,

eyes that received tafluprost BAK-free and travoprost BAK exhibited a significant RI decrease after treatment (P=0.003 and P=0.005, res-pectively) (Table 2). This decrease in RI was similar in magnitude for the two drugs because the post-treatment values in the eyes that received tafluprost BAK-free and travoprost BAK were not significan-tly different (P=0.6264).

DISCUSSIONIn general, prostaglandins play an important role in the local re-

gulation of blood flow, and both endogenous prostaglandins as well as PGAs can have potent vasodilator effects(18). Previous experiments, both in human and animal models, have reported how PGAs may affect ocular blood flow. Depending on the drug or formulation used, PGAs have been reported to increase, decrease, or not affect ocular blood flow. However, the reports are conflicting, with opposing re-sults in some cases(19,20).

In the work presented here, both tafluprost BAK-free and travo-prost BAK significantly reduced the RI of the OA in rabbits. This de-crease in RI can be interpreted as a beneficial effect on ocular blood flow. In primates, chronic optic nerve ischemia has been shown to induce retinal ganglion cell loss independently of high IOP(3). Con-sequently, this reduction of the RI of the OA could also be helpful in glaucoma treatment, by potentially preventing retinal ganglion cell

Table 2. Results of retrobulbar blood flow velocity (cm/s) and resistive index pre- and post-treatment with prostaglandin analog eye drops as mea-sured with color Doppler imaging in the ophthalmic artery of New Zealand white rabbits

Antiglaucomatous eye drops

PSV EDV RI

Pre Post P-value Pre Post P-value Pre Post P-value

BimatoprostBAK 31.19 ± 4.88 34.89 ± 07.17 0.194 08.21 ± 2.89 09.94 ± 3.38 0.234 0.74 ± 0.08 0.74 ± 0.10 0.941

TafluprostBAK-FREE 36.64 ± 5.50 30.03 ± 08.92 0.061 09.80 ± 2.81 11.22 ± 4.71 0.424 0.73 ± 0.07 0.63 ± 0.07 0.003*

TravoprostBAK 29.21 ± 5.79 31.91 ± 11.14 0.548 08.49 ± 3.45 13.62 ± 6.55 0.066 0.71 ± 0.09 0.59 ± 0.07 0.005*

TravoprostPOLYQUAD 34.81 ± 9.34 33.01 ± 10.44 0.689 09.68 ± 3.46 10.48 ± 5.29 0.694 0.72 ± 0.05 0.68 ± 0.09 0.244

LatanoprostBAK 34.57 ± 6.23 30.07 ± 08.57 0.196 10.94 ± 3.51 09.20 ± 4.73 0.362 0.69 ± 0.06 0.70 ± 0.06 0.551

Control solutionBAK 33.88 ± 7.37 34.26 ± 11.95 0.953 08.10 ± 1.67 09.10 ± 2.84 0.517 0.75 ± 0.07 0.73 ± 0.04 0.552Values are the mean ± standard deviation.PSV= peak systolic velocity; EDV= end diastolic velocity; RI= resistive index; BAK= benzalkonium chloride.*= P<0.05, paired t-test between pre- and post-treatment results.

PSV= peak systolic velocity; EDV= end diastolic velocity.Figure 1. (A) Image of a New Zealand white rabbit during the ultrasound exam. The transducer was positioned in the horizontal plane, with the long axis of the transducer held parallel with a line connecting the medial and lateral canthus, and the marker pointing nasally. (B) The top panel shows an image of retrobulbar color Doppler imaging and pulse waveform with dicrotic notches showing blood flow velocities in a rabbit’s ophthalmic artery. Blood flow toward the ultrasound transducer was encoded in red by the power Doppler mode. The ophthalmic artery was detected and the spectral Doppler sampling volume (gate of 1 mm) was placed in the center and parallel to the imaged vessel (arrow). The bottom panel is a pulse waveform showing relative blood flow velocities.

A B

Effects of prostaglandin analogs on blood flow velocity and resistance in the ophthalmic artery of rabbits


death. Although these two formulations decreased the RI to similar extents, other factors need to be considered when choosing which one to prescribe, such as which one is more effective for decreasing IOP and, in this specific case, whether the presence of a preserva tive is detrimental to each patient in question. The presence of pre servatives in topical antiglaucoma drug formulations is currently under scru-tiny(21). Chronic exposure to the preservative BAK has been associated with ocular discomfort, causing changes in the tear film, cornea (in-cluding the corneal epithelium), and conjunctiva(15,16).

No effects on CDI parameters were found for topical bimatoprost BAK, travoprost POLYQUAD, or latanoprost BAK. Some research has also revealed no changes in the blood flow in the OA in humans and rabbits in response to PGAs, although some PGAs show good results in other vascular beds, such as on the optic nerve head and in the central retinal artery(20,22-24). Nevertheless, our research showed that the results with travoprost are controversial. Interestingly, formula-tion of this drug with two different preservatives showed disparate results, and more studies are needed to confirm the effect of this drug on RI. Other research groups have shown that travoprost is effective for improving blood flow, as found in the present study with travoprost BAK(25-27). Further, in the present research, travoprost with BAK as a preservative significantly decreased RI, while travoprost with POLYQUAD did not; therefore, the preservative BAK may have some effect in this instance. Little is known about the long-term effects of different preservatives concerning their penetration and distribution in the eye, but it is recognized that BAK is itself absorbed and accu-mulates in ocular surface structures as well as in deeper structures involved in glaucoma(17). Interestingly, our findings suggest that the combination of PGA with BAK decreases RI, ultimately improving ocu-lar blood flow. Despite this RI alteration observed in the travoprost with BAK group, no significant decreases in RI were found in the other groups receiving drugs preserved with BAK or groups receiving only BAK. It is possible that BAK specifically and synergistically enhances the effect of travoprost by an as-yet-unknown mechanism. Neverthe-less, some investigators have argued that eye drops formulated with preservatives other than BAK or with no preservatives demonstrate little or no ocular toxicity, and may always be preferred(28).

Few studies have evaluated the effect of tafluprost on ocular cir-culation. In the present study, a significant decrease was found in the RI of the OA of rabbits, and similar results have also been found in the optic nerve and retinal circulation in rabbits, cats, and humans (27,29,30).

In the present study, both eyes were analyzed, but the eye drops were instilled in only one of the eyes. The main advantage of using the fellow eye as a control is that the experimental eye and the control eye are both in the same animal, therefore allowing direct comparison, balancing out any variations of the treatment and con-trol groups.

A limitation of our study is that no glaucomatous eyes were eva-luated. Healthy eyes, without increased IOP, may facilitate changes in Doppler parameters. Thus, we suggest that further studies be carried out in rabbits with induced glaucoma to assess whether the changes would be similar to those found in the present study.

Our study reveals the effect of different PGAs used to treat glauco-ma on OA blood flow in healthy New Zealand white rabbits. Further studies on human patients and patients with glaucoma (humans and animals) are necessary to establish the effects of each treatment and to assess whether improvement of retrobulbar blood flow enhance the prevention of the progression of this disease.

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Original Article


INTRODUCTIONSince Stocker et al.(1) established a human corneal endothelial cell

(HCEC) culture, the potential for cell therapy to treat corneal en-dothelial dysfunction using HCECs has demonstrated continuous development(2-8). The limitations associated with this therapy can be basically divided into two major areas: those related to culturing the cells, such as proliferation, cellular senescence, and fibroblastic transformation and those related to the logistics and techniques for transplanting the cells(2-8).

Regarding the first area, we recently published an article demons-trating the applicability of human serum-supplemented medium (HS-SM) as an alternative to fetal bovine serum-supplemented me-dia (FBS-SM), suggesting potential advantages of a medium with fewer animal-derived components(9). Regarding the second area, the cryo preservation of both corneas for transplantation(10) and cultu red HCEC using a standard medium (FBS-SM) have been already de-mons trated(11) and could potentially improve the logistics related to the distribution of cultured HCECs for clinical use. The purpose

Characterization of cryopreserved primary human corneal endothelial cells cultured

in human serum-supplemented media

Caracterização de células endoteliais corneanas humanas primárias criopreservadas cultivadas em

meio suplementado com soro humano

lucaS MonfErrari MontEiro vianna1,2,3, hao-donG li1, jEffrEy d. holiMan4, chriStophEr StoEGEr4, ruBEnS BElfort jr.2, alBErt S. jun1

Submitted for publication: July 24, 2015 Accepted for publication: November 13, 20151 Cornea and Anterior Segment Service, The Wilmer Eye Institute, Johns Hopkins University, Baltimore

(MD), USA.2 Ophhtalmology and Vision Science Department, Escola Paulista de Medicina, Universidade Federal

de São Paulo, São Paulo, SP, Brazil.3 Ophthalmology Department, Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio

de Janeiro, Rio de Janeiro, RJ, Brazil.4 Lions VisionGift, Portland, OR, USA.



Corresponding author: Lucas Monferrari Monteiro Vianna. Rua Botucatu, 821 - São Paulo, SP - 04023-900 - Brazil - E-mail: [email protected]

ABSTRACT Purpose: To compare cryopreserved human corneal endothelial cells (HCECs) grown in human serum-supplemented media (HS-SM) with cryopreserved HCECs grown in fetal bovine serum-supplemented media (FBS-SM). Methods: Three pairs of human corneas from donors aged 8, 28, and 31 years were obtained from the eye bank. From each pair, one cornea was used to start a HCEC culture using HS-SM; the other cornea was grown in FBS-SM. On reaching confluence, the six cell populations were frozen using 10% dimethyl sulfoxide-containing medium. Thawed cells grown in HS-SM were compared with those grown in FBS-SM with respect to morphology, growth curves, immunohisto-chemistry, real time-reverse transcriptase polymerase chain reaction (RT-PCR) for endothelial cell markers, and detachment time. Results: No difference in morphology was observed for cells grown in the two media before or after cryopreservation. By growth curves, cell counts after thawing were similar in both media, with a slight trend toward higher cell counts in FBS-SM. Cells grown in both the media demonstrated a similar expression of endothelial cell markers when assessed by immunohistochemistry, although HCEC marker gene expression was higher in cells grown in HS-SM than in those grown in FBS-SM as assessed by RT-PCR. With FBS-SM, there was a tendency of longer detachment time and lower cell passages. Conclusions: HS-SM was similar to FBS-SM for cryopreservation of cultured HCECs as assessed by analysis of cell morphology, proliferation, and protein expression, although marker gene expression was higher in cells grown in HS-SM than in those grown in FBS-SM. Detachment time was longer with FBS-SM and in lower passages.

Keywords: Cryopreservation; Cornea; Endothelium, Corneal; Cell culture techniques; Culture media

RESUMO Objetivo: Comparar células endoteliais de córnea humana (HCECs) criopreserva -das e cultivadas em meio suplementado com soro humano (HS-SM) com HCEC criopre servadas e cultivadas em meio suplementado com soro bovino fetal (FBS-SM). Métodos: Três pares de córneas humanas de doadores com 8, 28 e 31 anos de idade foram obtidos do banco de olhos e, de cada par, uma córnea foi utilizado para iniciar uma cultura com HS-SM e outra com FBS-SM. Ao atingir a confluência, as populações de células foram congeladas utilizando-se dimetil-sulfóxido 10% no respectivo meio de cultura. Após descongeladas, as células cultivadas em HS-SM foram comparados com as cultivadas em FBS-SM por meio de morfologia, curva de crescimento, imu-no-histoquímica, reação em cadeia de Reação em cadeia da polimerase da transcrição reversa em tempo real (RT-PCR) para marcadores de células endoteliais e tempo de descolamento.Resultado: Não foram observadas diferenças morfológicas antes ou após a criopre-servação. Curva de crescimento mostrou contagens celulares semelhantes em ambos os meios, com discreta tendência para um maior número em FBS-SM. As células culti-vadas em ambos os meios mostraram expressão semelhante de marcadores celulares endoteliais quando avaliadas por imuno-histoquímica, embora a expressão genética de marcadores para HCEC tenha sido maior em HS-SM quando avaliado por RT-PCR. Houve uma tendência de maior tempo de descolamento com FBS-SM e passagens iniciais.Conclusões: HS-SM foi semelhante ao FBS-SM na criopreservação de HCEC cultivadas in vitro quando avaliadas por morfologia celular, proliferação celular e expressão proteica, embora a expressão genética de marcadores endoteliais tenha sido maior em células cultivadas em HS-SM quando comparadas a células cultivadas em FBS-SM. O tempo de descolamento foi maior quando utilizado FBS-SM e em passagens iniciais.

Descritores: Criopreservação; Córnea; Endotélio corneano; Técnicas de cultura de cé-lulas; Meios de cultura

Characterization of cryopreserved primary human corneal endothelial cells cultured in human serum-supplemented media


of this study is to determine the ability of HCECs grown in HS-SM to be cryopreserved and maintain their characteristics compared with cryopreserved cells grown in FBS-SM.

METHODSThis study adhered to the tenets of the Declaration of Helsinki.Materials were obtained from the following sources: serum-free

medium (OptiMEM I), Dulbecco phosphate-buffered saline, Hank’s balanced salt solution (HBSS), gentamicin, trypsin-EDTA, and goat se-rum (Gibco BRL/Life Technologies, Rockville, MD); mouse submaxillary gland nerve growth factor (NGF), human epidermal growth factor (hEGF), and bovine pituitary extract (BPE) (Biomedical Technolo-gies, Stoughton, MA); FBS (Hyclone, Logan, UT); heat-inactivated human serum (HS, Valley Biomedical, Winchester, VA); ascorbic acid, chondroitin sulfate, calcium chloride, 0.02% ethylene diamine tetra acetic acid (EDTA) solution, and antibiotic/antimycotic solution (Sigma, St. Louis, MO); cell attachment reagent (FNC Coating Mix; Athena En vironmental Sciences Inc., Baltimore, MD); dimethyl sulfoxide (DMSO) (Mediatech Inc, Manassas, VA); rabbit polyclonal antibody to ZO-1 (Invitrogen, Camarillo, CA); mouse monoclonal antibody to Na+/K+-ATPase alpha 1 subunit (Santa Cruz Biotechnology, Dallas, TX); mouse monoclonal antibody to glypican 4 (GPC4) and donkey serum (Novus Biologicals, Littletown, CO); AlexaFluor 488 donkey anti-mouse IgG (Life Technologies, Eugene, OR); AlexaFluor 555 goat anti-mouse IgG and Hoechst nuclear staining (Molecular Probes, Eugene, OR); and eight-well glass chamber slides (Laboratory-Tek, Nunc, Rochester, NY).

HUMAN CORNEAL ENDOTHELIAL CELL CULTURE

Three pairs of human corneas from donors aged 8, 28, and 31 years (referred to as donor 1, 2, and 3, respectively) were obtained from Lions VisionGift (Portland, OR) and the Alabama Eye Bank (Bir mingham, AL). Donors had died from trauma, cardiomyopathy, and pneumo-nia, respectively, and death-to-preservation time was 4, 6, and 8 h, respectively. Standard eye bank protocols for informed consent and protection of donor confidentiality were used. Donor corneas were unsuitable for transplantation. Standard serologies for infectious agents were negative for the three donors. Primary cultures were initiated within 2-10 days of preservation in Optisol-GS.

CULTURE MEDIA FBS-SM was previously described in a study(12) and was used in our

laboratory(11) and comprised serum-free medium (OptiMEM-I), 8% FBS, 5 ng/mL hEGF, 20 ng/mL NGF, 100 mcg/mL BPE, 20 mcg/mL ascorbic acid, 200 mg/L calcium chloride, 0.08% chondroitin sulfate, 50 mcg/mL gentamicin, and antibiotic/antimycotic solution (diluted 1/100). HS-SM was described in our previous study(9) and comprised the same components as FBS-SM, with the exception that 8% FBS was replaced with 8% HS. The concentration of serum (both in FBS and HS) that was used to culture cells in glass chamber slides was doubled to 16%.

ISOLATION AND GROWTH OF HCECS HCEC populations were established according to published me-

thods(12). Corneas were removed from corneal preservation media (Optisol-GS, Bausch & Lomb Inc., Rochester, New York), and Descemet membranes (DM) with intact endothelium were peeled. From each pair of corneas, one DM was used to initiate an HCEC culture with HS-SM and the other DM was grown with FBS-SM, comprising a total of six cell populations. DM was placed in either FBS- or HS-SM for 24 h at 37°C under 5% CO2. Next, the tissues were incubated in 0.02% EDTA for 1 h at 37°C to loosen cell-to-cell junctions and were manually disrupted by a passage through a pipette. The dissociated cells were centrifuged at 3000 rpm for 5 min, and the pellet was gently

re-suspended in the respective medium. Isolated cells and pieces of DM were plated in a 6-well tissue culture plate that was pre-coated with undiluted cell attachment reagent (FNC Coating Mix). Initial plating density (P0) was variable and depended on the number of cells recovered from each DM. Overall, we would estimate the initial plating density as being between 100-200 cells/mm2 (approximately 104 to 2 × 104 cells/well of a 6-well plate). Cultures were then incuba-ted at 37°C in a humidified 5% CO2 incubator, and the medium was changed every other day.

CRYOPRESERVATION OF HCECS

At the day when the primary cultures [passage (P) 0] reached con-fluence, cells were trypsinized and re-suspended in their respective culture media (HS- or FBS-SM). They were then gently centrifuged and re-suspended in freezing medium comprising 90% initial me-dium and 10% DMSO. The cells were then slowly frozen overnight in an isopropanol bath freezing container at -80°C and subsequently transferred to liquid nitrogen. For recovery from cryopreservation, all cells were thawed at different time points (1, 2, and 3 months for donor 1, 2 and 3, respectively) in a water bath at 37°C, and the cells were promptly re-suspended drop-by-drop with their respective pre-warmed culture medium. The cells were then centrifuged, washed, and re-suspended in the culture medium to remove residual DMSO and were plated on pre-coated standard tissue culture plates (each cell population was seeded in two wells of a 6 well-plate). Sub-sequently, cells were passaged (P1-P5) on the day when they reached confluence, except for those used for immunofluorescence, which were maintained for 3 additional days after reaching confluence. To identify each cell population at each time point, the cells were named according to the passage by which they had been generated (e.g., P1 cells originated from the first passage). To enhance the understan-ding of the methodology, the process is shown in figure 1.

REAL TIME-REVERSE TRANSCRIPTASE POLYMERASE CHAIN REACTION

For each donor and medium, total RNA was extracted from con-fluent cultures in a single well of a 6-well plate at passage 2 (as des-cribed in Figure 1) using a commercially available kit (RNeasy Mini Kit; Qiagen, Valencia, CA) and stored at -80°C. The concentration and purity of the isolated RNA were determined using a NanoDrop instrument (Thermo Fisher Scientific Inc., Waltham, MA). Comple-mentary DNA (cDNA) was obtained using the commercially available High Capacity RNA-to-cDNA™ kit (Life Technologies) and was stored at -20°C. Polymerase chain reaction (PCR) was conducted in a StepOne-

P= passage; FBS-SM= fetal bovine serum-supplemented media; HS-SM= human serum-supplemented media; RT-PCR= real time-polymerase chain reaction.Figure 1. Flow chart of HCEC passaging and cell use.

Vianna LMM, et al.


Plus Real Time PCR System (Life Technologies) with the prepared cDNA and commercially available TaqMan primer-probe sets (Life Techno logies), targeting 1) ZO-1, tight junction protein 1 (TJP1); Na+/K+-ATPase, Na+/K+ transporting, alpha 1 polypeptide (ATP1A1); and GPC4. Gene expression was assessed by the comparative CT (∆∆CT) method with β-actin as the normalizing gene. Assays were perfor-med in triplicates for all samples.

IMMUNOHISTOCHEMISTRY

For immunohistochemical analysis, cells were grown (using 16% serum-supplemented media) in chamber slides that were pre-coated with FNC Coating Mix, fixed in 4% paraformaldehyde for 15 min, and treated with 0.1% Triton X-100 for 10 min at room temperature. Non-specific binding was blocked by incubating cells in 10% donkey or goat serum for 1 h before incubation overnight at 4°C with the primary antibodies (all 1:100, ZO-1, Na+/K+-ATPase, and GPC4). Se-condary staining was performed with secondary antibodies (1:500) for 1 h at room temperature, and cells were counterstained with Hoechst nuclear staining (1:2500). Cells were analyzed using a Zeiss LSM 510 Meta Confocal Microscope (Carl Zeiss, Berlin, Germany).

GROWTH CURVE

As shown in figure 1, 30,000 cells for each donor and medium were recovered from P2 and were used to seed 5,000 cells in five different wells of a 24-well plate (for counting on days 1, 2, 3, 5, and 7) and in one well of a 6-well plate (for counting on day 10). Thus, each well contained the same number of cells at different densities depending on the size of the well in which they were placed. At specified times, on plating (days 1, 2, 3, 5, 7, and 10), cells were trypsinized and counted using a microscope (IMT-2, Olympus, Tokyo, Japan) and a hemocytometer (Hausser Scientific, Horsham, PA). Three counts were performed in triplicates for each well, and the results were averaged to construct the growth curve.

MORPHOLOGY ASSESSMENT (PHASE CONTRAST MICROSCOPY)A phase-contrast microscope with a digital camera (ProgResC5,

Jenoptik, Jena, Germany) was used to image confluent cells for each donor, media, and passage from P0 to P5 to document morphology data. The well was randomly placed under the microscope, and ima-ges were taken at 20× magnification from each passage.

DETACHMENT TIME ASSESSMENT

For each donor, the medium was aspirated, and cells were washed with HBSS, with the same amount of trypsin solution being added to all plates, at each passage. A standard amount of tapping was applied to the plate every 30 s to facilitate detachment. The time taken for complete cell detachment was counted for each of the media. If the detachment period amounted to 5 min and complete detachment was not achieved, cells were mechanically detached by adding media using a pipette.

STATISTICS

A two-tailed Mann-Whitney U test was performed to compare detachment times. For gene expression, probability (P) values were generated using ∆∆CT mode of the Expression Suite Software (Life Technologies). P values of <0.05 were considered statistically signi-ficant.

RESULTSMORPHOLOGY

Typical endothelial-cell polygonal morphology was observed for cells grown in both FBS- and HS-SM at passage 1 (P1) for all three pairs of cell populations, and a typical spindle-shape transformation

could be initially observed for both FBS- and HS-SM at P5 (Figure 2). No difference in morphology could be observed at P0, P1, P5 or at any other passages for cells grown in the two media before or after cryopreservation.

GROWTH CHARACTERISTICS The time from initial plating (P0) to confluence was 7, 17, and 14

days for donor 1, 2, and 3, respectively, when grown in FBS-SM and 5, 15, and 14 days, respectively, when grown in HS. For subsequent pas-sages, times were slightly different between cell populations when comparing FBS- and HS-SM for a given passage and cell population. Using growth curves, cell counts after thawing were similar for FBS- and HS-SM from days 1 to 10, with a slight trend toward higher cell counts in FBS-SM (Figure 3).

IMMUNOFLUORESCENCE AND REAL TIME-PCRCells grown in both FBS- and HS-SM demonstrated similar staining

of functional (ZO-1 and Na+/K+-ATPase) and endothelial cell (GPC4) markers when assessed by immunohistochemistry (Figure 4). Negative controls using only secondary antibodies AlexaFluor 488 and 555 demonstrated no staining (Figure 4). When assessed by real time (RT)-PCR, gene expression of HCEC markers was higher in HS-SM than in FBS-SM: TJP1 (1.3-fold, P=0.083), ATP1A1 (two fold, P=0.031), and GPC4 (3-fold, P=0.064) (Figure 5).

Figure 2. Phase-contrast images of confluent passage 0 (before cryopreservation) and passages 1 and 5 (after cryopreservation) HCECs cultured in fetal bovine serum-su pple-mented medium (FBS-SM) and human serum-supplemented medium (HS-SM). Similar cell morphologies were observed for the two media for the same cell populations and passages. All pictures were taken using 20× magnification. Scale bar=200 μm.

Characterization of cryopreserved primary human corneal endothelial cells cultured in human serum-supplemented media


Figure 3. Ten-day growth curve comparing cells cultured in fetal bovine serum-supple-mented medium and human serum-supplemented medium starting at passage 2. On days 1, 2, 3, 5, and 7 counts were obtained for cells seeded in a 24-well plate; at day 10, counts for cells seeded in a 6-well plate were obtained. Error bars represent standard deviations.

Figure 4. Immunostaining for zonula occludens-1 (ZO-1), sodium-potassium ATPase (Na+/K+-ATPase), and glypican 4 (GPC4) of confluent passage-2 HCECs cultured in media with fetal bovine serum (FBS-SM) or human serum (HS-SM). Staining for ZO-1 is from the 31-year-old donor; Na+/K+-ATPase and Negative Control [secondary antibodies AlexaFluor 488 (above) and 555 (below) only] from the 8-year-old donor, and GPC4 from the 31-year-old donor. Scale bars=50 micrometers.

DETACHMENT TIME

All cell populations from both the media reached the maximum time allowed for detachment from P0 to P1; thus, there was no diffe-rence between the populations at these passages. However, for P2 and for all subsequent passages, there was a trend toward longer detachment time with FBS-SM and lower passages (Figure 6), with statistical significance for passages 4 (P=0.0268), 5 (P=0.0279), and 6 (P=0.0098).

DISCUSSIONThe development in surgical treatment of corneal endothelial

diseases, with progressive thinning of grafts and its related advanta-ges(13,14), leads us to conclude that transplantation with cultured en- *= P<0.05.

Figure 5. RT-PCR of tight junction protein 1 (TJP1); ATPase, Na+/K+ transporting, alpha 1 polypeptide (ATP1A1); and glypican 4 (GPC4) of passage-2 HCECs cultured in media with fetal bovine serum (FBS-SM) and human serum (HS-SM). FBS-SM is presented as the reference (RQ=1).

*= P<0.05.Figure 6. Average detachment time of all cell populations from passage 1 (P1) to passage 6 (P6), comparing cells cultured in FBS-SM and HS-SM. Maximum time allowed to detach was 5 min. Error bars represent standard deviations.

Vianna LMM, et al.


dothelial cells may represent the next advance in this field(2-9). Animal studies have demonstrated promising results(15,16). An important issue that may arise if this approach becomes feasible is cell maintenance and distribution to surgeons. Cryopreservation can mitigate these issues with some additional advantages, such as the long-term pre-servation of the endothelial cell source(5). We have recently demons-trated that human serum can be used as a supplement for HCEC cul ture, conferring the added advantage of a medium with a lower content of animal derivatives. In this study we demonstrated the ability of HCECs grown in HS-SM to be cryopreserved and maintain their characteristics by comparing them with cells grown in FBS-SM.

No evident difference in morphology of the cells could be observed when comparing FBS- and HS-SM cultures from P0 to P5 across all cell populations studied. Growth rates were also similar between the two media using passage-2 cultures, with a slight trend toward higher cell counts in FBS-SM. Both FBS- and HS-SM demonstrated similar immunostaining for functional (ZO-1 and Na+/K+-ATPase) and endothelial cell (GPC4) markers of passage-2 cultures. However, HCEC marker gene expression was higher in HS-SM when assessed by RT-PCR. The impact of this finding on the suitability of cryopreserved HCECs grown in HS-SM for use in cell therapy is unclear and warrants further study with an expanded number of cell populations and markers. Further testing should include physiological assays, such as the use of an Ussing chamber(17), to determine any differences in the pumping activity of HCECs grown in FBS- and HS-SM with and without cryopreservation.

Unpublished observations during our previous study(9) have de-monstrated that cells grown in HS-SM detach faster than those grown in FBS-SM. Similarly, in this study, we observed a tendency of longer detachment time with FBS-SM and lower passages. Moreover, we ob-served that when cells are plated in glass chamber slides with HS-SM (8% as standard), they can spontaneously detach even with the use of a cell-attachment reagent, which does not occur when 16% HS-SM or 8% FBS-SM is used. Further studies are warranted to establish the cause of this finding and its potential clinical implications.

In summary, we demonstrated that on cryopreservation, HS-SM was similar to FBS-SM for HCEC culture as assessed by comparison of cell morphology, proliferation, and protein expression, although marker gene expression by RT-PCR was higher in HS-SM-based cultu-res than in FBS-SM-based cultures. Detachment time was longer with FBS-SM and lower passages. To establish the relevance of our findings with regard to the potential clinical use of cryopreserved HCECs cul-tured in HS-SM, follow-up studies should be conducted that which would further contribute to the progress toward the ultimate goal of endothelial cell therapy.

ACKNOWLEDGMENTSThe authors acknowledge the Brazilian government CAPES

Foundation and State University of Rio de Janeiro for supporting Dr. Vianna’s research fellowship, Norman Barker, MS, for assistance with the figures, and Lions VisionGift (Portland, OR) and the Alabama Eye Bank (Birmingham, AL) for providing corneas.

REFERENCES 1. Stocker FW, Eiring A, Georgiade R, Georgiade N. A tissue culture technique for growing

corneal epithelial, stromal, and endothelial tissues separately. Am J Ophthalmol. 1958; 46(5 Part 2):294-8.

2. Okumura N, Kinoshita S, Koizumi N. Cell-based approach for treatment of corneal endothelial dysfunction. Cornea. 2014;33 Suppl 11:S37-41.

3. Engelmann K, Bednarz J, Valtink M. Prospects for endothelial transplantation. Exp Eye Res. 2004;78(3):573-8.

4. Joyce NC. Proliferative capacity of the corneal endothelium. Prog Retin Eye Res. 2003; 22(3):359-89.

5. Proulx S, Brunette I. Methods being developed for preparation, delivery and trans-plantation of a tissue-engineered corneal endothelium. Exp Eye Res. 2012;95(1):68-75.

6. Koizumi N, Okumura N, Kinoshita S. Development of new therapeutic modalities for corneal endothelial disease focused on the proliferation of corneal endothelial cells using animal models. Exp Eye Res. 2012;95(1):60-7.

7. Joyce NC. Proliferative capacity of corneal endothelial cells. Exp Eye Res. 2012;95(1): 16-23.

8. Peh GS, Beuerman RW, Colman A, Tan DT, Mehta JS. Human corneal endothelial cell expansion for corneal endothelium transplantation: an overview. Transplantation. 2011;91(8):811-9.

9. Vianna LM, Kallay L, Toyono T, Belfort R Jr, Holiman JD, Jun AS.se of human serum for human corneal endothelial cell culture. Br J Ophthalmol. 2014;0:1-5.

10. Brunette I, Le François M, Tremblay MC, Guertin MC. Corneal transplant tolerance of cryopreservation. Cornea. 2001;20(6):590-6.

11. Suh LH, Zhang C, Chuck RS, Stark WJ, Naylor S, Binley K, Chakravarti S, Jun AS. Cryopre-servation and lentiviral-mediated genetic modification of human primary cultured corneal endothelial cells. Invest Ophthalmol Vis Sci. 2007;48(7):3056-61.

12. Zhu C, Joyce NC. Proliferative response of corneal endothelial cells from young and older donors. Invest Ophthalmol Vis Sci. 2004;45(6):1743-51.

13. Dapena I, Ham L, Melles GR. Endothelial keratoplasty: DSEK/DSAEK or DMEK-the thinner the better? Curr Opin Ophthalmol. 2009;20(4):299-307.

14. Ple-Plakon PA, Shtein RM. Trends in corneal transplantation: indications and techniques. Curr Opin Ophthalmol. 2014;25(4):300-5.

15. Koizumi N, Sakamoto Y, Okumura N, Tsuchiya H, Torii R, Cooper LJ, Ban Y, Tanioka H, Kinoshita S. Cultivated corneal endothelial transplantation in a primate: possible future clinical application in corneal endothelial regenerative medicine. Cornea. 2008;27 Suppl 1:S48-55.

16. Mimura T, Yamagami S, Usui T, Seiichi, Honda N, Amano S. Necessary prone position time for human corneal endothelial precursor transplantation in a rabbit endothelial deficiency model. Curr Eye Res. 2007;32(7-8):617-23.

17. Bonanno JA, Giasson C. Intracellular pH regulation in fresh and cultured bovine corneal endothelium. I. Na+/H+ exchange in the absence and presence of HCO3-. Invest Ophthalmol Vis Sci. 1992;33(11):3058-67.

Case Report


INTRODUCTIONArthur Alport first published his description of a triad of symp-

toms in a family with hereditary congenital hemorrhagic nephritis, deafness, and ocular changes in 1927. To this day, Alport syndrome may still inevitably leads to end-stage renal disease and the need for renal replacement therapy, starting in young adulthood(¹). Alport syndrome has a prevalence of 1 in 5,000, and 85% of patients have the X-linked form, which mainly affects males. The typical ocular associations are a dot-and-fleck retinopathy that occurs in approxi-mately 85% of affected adult males, anterior lenticonus that occurs in approximately 25%, and the rare posterior polymorphous corneal dystrophy (PPCD). The retinopathy and anterior lenticonus do not usually appear during childhood but tend to worsen with time so that the retinal lesions are often present at the onset of renal failure; the anterior lenticonus develops later. The presence of anterior lenti-conus or posterior polymorphous corneal dystrophy in any individual is highly suggestive for the diagnosis of Alport syndrome. Additional ocular features described in X-linked Alport syndrome include other corneal dystrophies, microcornea, arcus juvenilis, iris atrophy, cata-racts, spontaneous lens rupture, spherophakia, posterior lenticonus, a poor macular reflex, fluorescein angiogram hyperfluorescence, electrooculogram and electroretinogram abnormalities, and retinal pigmentation. All mutations that have been detected to date in X-linked Alport syndrome have affected the COL4A5 gene, which en-

codes the alpha-5 chain of type IV collagen. This protein plays a role in the basement membranes of the glomerulus, cochlea, retina, lens capsule, and cornea, resulting in abnormal ultrastructures(2).

CASE REPORT RCBL, a 33-year-old female, with previously diagnosed Alport syn-

drome, was referred to the contact lenses sector complaining of poor vision in OU. She had presented chronic renal failure (two kidney transplantations), and had undergone cataract surgery in both eyes one year ago due to anterior lenticonus (Figure 1-3).

Ophthalmological examination denoted bilateral posterior poly-morphous dystrophy (PPD), intraocular lenses that were in the bag in both eyes, as well as multiple perimacular changes on fundoscopy (dot-and-fleck retinopathy). Her refraction was OD: -7.00 -1.00 @ 180 (VA: 0.30 - LogMAR) and OS: -3.25 -4,00 @ 125 (VA: 0.40 - logMAR). Her corneal topography showed an irregular astigmatism with superior steepening in both eyes (Figure 4).

After comprehensive ophthalmological examination and rigid gas permeable contact lens fitting, we were able to improve her visual acuity to 0.18 in OD and 0.30 in OS (logMAR). The prescribed contact lens had the following parameters:

-ter: 9.4 mm.

-ter: 9.4 mm.

Contact lens fitting in a patient with Alport syndrome and posterior polymorphous

corneal dystrophy: a case report

Adaptação de lentes de contato em paciente com síndrome de Alport e distrofia polimorfa posterior: relato de caso

juliana Maria da Silva roSa1, MarcElo vicEntE dE andradE SoBrinho1, céSar lipEnEr1

Submitted for publication: October 27, 2014 Accepted for publication: February 6, 20151 Setor de Lentes de Contato e Refração, Universidade Federal de São Paulo (UNIFESP) - São Paulo,

SP - Brazil.



Corresponding author: Juliana Maria da Silva Rosa. Avenida João Carlos Machado, 455/202 - Rio de Janeiro, RJ - 22620-081 - Brazil - E-mail: [email protected]

Approved by the following research ethics committee: UNIFESP - number 871432.

ABSTRACTAlport Syndrome is a hereditary disease that is caused by a gene mutation and affects the production of collagen in basement membranes; this condition causes hemorrhagic nephritis associated with deafness and ocular changes. The X-linked form of this disease is the most common and mainly affects males. Typical ocular findings are dot-and-fleck retinopathy, anterior lenticonus, and posterior polymor-phous corneal dystrophy. Some cases involving polymorphous corneal dystrophy and corneal ectasia have been previously described. Here we present a case report of a 33-year-old female with Alport syndrome, posterior polymorphous corneal dystrophy, and irregular astigmatism, whose visual acuity improved with a rigid gas permeable contact lens.Keywords: Collagen diseases; Nephritis, hereditary; Corneal dystrophies, heredi-tary/etiology; Contact lenses

RESUMOA síndrome de Alport é descrita como uma doença hereditária que afeta um gene relacionado à produção de colágeno das membranas basais causando nefrite hemorrágica associada com surdez e alterações oculares. A forma ligada ao X é a mais comum e afeta principalmente homens. Os achados oculares típicos são retinopatia em ponto-mancha, lenticone anterior e distrofia polimorfa posterior. Alguns casos foram descritos de associação entre a distrofia polimorfa posterior e ectasia corneana. Nós apresentamos um caso de paciente do sexo feminino, 33 anos, diagnóstico de síndrome de Alport, distrofia polimorfa posterior e astigmatismo irregular, que apresenta melhora da acuidade visual após adaptação com lentes de contato rígidas gás permeáveis.Descritores: Doenças do colágeno; Nefrite hereditária; Distrofias hereditárias da cór-nea/etiologia; Lentes de contato

Rosa JMS, et al.


tinopathy (85%), and PPCD(3). Aldave et al suggested that there was a gene (ZEB1) involved in keratocyte function that may play a role in both the corneal stromal and endothelial development and function. The identification of abnormally steep corneal curvatures in 37% of all individuals with PPCD and in 86% of affected individuals with PPCD secondary to ZEB1 mutations confirms this association(4). Many gene-tically determined corneal dystrophies can occur in association with keratoconus including PPCD, lattice dystrophy, granular dystrophy, and Fuchs endothelial dystrophy. The association with so many cor-neal dystrophies and ocular abnormalities implies either a similarity in the underlying genetic defect or a tightly-linked network of interac-ting proteins, with a final common developmental pathway(5). PPCD and keratoconus share a potential common area of involvement (the posterior corneal surface, specifically Descemet’s membrane) and/or an underlying commonality for the pathophysiology of corneal dystrophies. A recent paper characterized the cornea in patients with PPCD and demonstrated that the topographic parameters were significantly steeper but had no clinical or topographical evidence of keratoconus. The authors accumulated a cohort of patients who pre-sented between 1982 and 2004 with a mean topographic simulated keratometry reading of 52.21 D, ranging from 46.47 D to 59.86 D, with no slit lamp or topographic findings suggestive of keratoconus(6). In this particular case, our patient had Alport Syndrome, PPCD, irregular astigmatism with superior steepening in both eyes; however, her visual acuity was improved with rigid gas permeable (RGP) scleral CLs despite other findings.

REFERENCES 1. Kruegel J, Rubel D, Gross O. Alport syndrome-insights from basic and clinical research.

Nat Rev Nephrol. 2013;9(3):170-8. 2. Colville DJ, Savige J. Alport syndrome. A review of the ocular manifestations. Ophthal-

mic Genet. 1997;18(4):161-73. 3. Xu JM, Zhang SS, Zhang Q, Zhou YM, Zhu CH, Ge J, Wang L. Ocular Manifestations of

Alport Syndrome. Int J Ophthalmol. 2010;3(2):149-51. 4. Aldave AJ, Ann LB, Frausto RF, Nguyen CK, Yu F, Raber IM. Classification of Posterior Poly-

morphous Corneal Dystrophy as a Corneal Ectatic Disorder Following Confirmation of Associated Significant Corneal Steepening. JAMA Ophthalmol. 2013;131(12):1583-90.

5. Gasset AR, Zimmerman TJ. Posterior polymorphous dystrophy associated with kera-toconus. Am J Ophthalmol. 1974;78:535-7.

6. Raber IM, Fintelmann R, Chhabra S, Ribeiro MP, Eagle RC Jr, Orlin SE. Posterior polymor-phous dystrophy associated with nonkeratoconic steep corneal curvatures. Cornea. 2011;30:1120-4.

Figure 1. Anterior lenticonus - picture before cataract surgery.

Figure 2. Anterior lenticonus in OD before cataract surgery.

Figure 3. Anterior lenticonus OS - picture before cataract surgery.

DISCUSSIONThe main features of Alport Syndrome are kidney failure, hearing

loss, and ocular features, such as anterior lenticonus (15%-25% of patients, and may also be associated with cataract), dot-and-fleck re-

Figure 4. Corneal topography, after cataract surgery, shows irregular astigmatism with superior steepening OU.

Case Report


INTRODUCTIONThe advances in cataract surgery have made small, self-sealing clear

corneal incisions (CCIs) a standard surgical technique. Furthermore, a study using cadaveric eyes showed that this type of incision was highly stable under substantial external pressure(1). Here we describe a patient with a history of uneventful cataract surgery using a small CCI who experienced isolated total aniridia, without damage to other intraocular structures after blunt trauma to the eye.

CASE REPORTA 71-year-old male presented at our clinic with dazzling in his left

eye. He reported that he had fallen down 15 days earlier while drunk and struck his left eye against a stone on the road. For about 10 days following this incident, he had slightly blurred vision and dazzling in his left eye but no other specific symptoms. Although his vision had improved considerably without treatment, the residual dazzling prompted his visit to the hospital. He had undergone cataract surgery on his left and right eyes 9 and 15 months before the accident, res-pectively, at another eye clinic. At examination, he had 20/20 vision

ABSTRACTThis was a report about a pseudophakic patient who experienced isolated total aniridia without damage to other intraocular structures following blunt trauma to the eye. This patient had a history of uneventful cataract surgery using a small clear corneal incision (CCI). This 71-year-old male presented at our clinic with glare in his left eye. He reported that he had fallen down while drunk and struck his left eye against a stone on the road 15 days earlier. He had undergone cataract surgery on his left eye nine months before the accident at another eye clinic. Slit-lamp examination showed total aniridia in his left eye, but there was no hyphema or cells in the anterior chamber. The intraocular lens in his left eye was stable, without decentration, dislocation, or zonular dehiscence and remained in an intact capsular bag. Review of the medical records from the surgical clinic at which he had undergone cataract surgery indicated no specific findings for any intraocular structure including the iris. He had previously undergone an uneventful phacoemulsification for his left eye through a 2.2 mm CCI, followed by the implantation of a single piece acrylic intraocular lens inside an intact capsular bag. This report showed that small-sized CCIs can be opened postoperatively by trauma and that this can result in isolated total aniridia without damage to other intraocular structures.

Keywords: Aniridia; Phacoemulsification; Eye injuries; Cornea; Wound and injuries; Case reports

RESUMORelatamos um paciente com história de cirurgia de catarata sem intercorrências usan do uma pequena incisão na córnea clara (CCI), que apresentou aniridia total isolada, sem danos a outras estruturas intraoculares, após trauma contuso no olho. Um homem de 71 anos de idade apresentou-se em nossa clínica referindo brilho no olho esquerdo. Ele relatou que, 15 dias antes, havia caído enquanto estava bêbado e atingiu seu olho esquerdo contra uma pedra na estrada. Ele havia passado por uma cirurgia de catarata no olho esquerdo, nove meses antes do acidente em outro serviço. Exame de lâmpada de fenda mostrou aniridia total de olho esquerdo, sem hifema ou células na câmara anterior. A lente intraocular no olho esquerdo ficou estável, com o saco capsular restante intacto, sem descentralização, luxação ou deiscência zonular. O exame dos registros médicos do serviço em que ele havia se submetido a uma cirurgia de catarata não mostraram relatos específicos a qualquer estrutura intraocular, incluindo a íris. O olho esquerdo fora submetido à facoemulsificação sem complicações, através de um CCI de 2,2 mm, seguido pela implantação de uma lente intraocular acrílica peça única dentro do saco capsular intacto. Este relatório mostra que, mesmo pequenas CCIs podem ser abertas no pós-operatório por trauma e que isso pode resultar em aniridia total isolada, sem danos a outras estruturas intraoculares.

Descriotres: Aniridia; Facoemulsificação; Traumatismos oculares; Córnea; Ferimentos e lesões; Relatos de casos

in each eye and an intraocular pressure of 18 mmHg, as measured by Goldmann applanation tonometry. There was no bruising or edema in the periorbital area. Slit-lamp examination showed total aniridia in his left eye, but there was no hyphema or cells in the anterior chamber. The intraocular lens in his left eye was stable without decen tration, dislocation, or zonular dehiscence and remained in an intact capsular bag (Figure 1). A Seidel test was negative, but the deposition of a few granules of iris pigment was observed in the CCI wound. Other than the CCI wound, there was no evidence of open wounds throughout the entire cornea and sclera. Gonioscopy and fundus examination revealed no iris remnants or tissues suspected of being iris (Figure 2). His right eye was completely normal.

Examination of the medical records from the clinic at which he had undergone cataract surgery showed no specific findings for any intraocular structure including the iris. He had previously undergone an uneventful phacoemulsification of his left eye through a 2.2 mm CCI, followed by the implantation of a single piece acrylic intraocular lens (IOL) (Akreos Adapt; Bausch & Lomb Inc., Rochester, NY, USA) inside an intact capsular bag.

He did not come for his scheduled follow-up visits for 5 months after his initial visit. However, he reported negligible dazzling and

Aniridia after blunt trauma and presumed wound dehiscence in a pseudophakic eye

Aniridia após trauma contuso e deiscência presumida da incisão em um olho pseudofácico

kyEonG hwan kiM1,2, wan Soo kiM1,2

Submitted for publication: October 9, 2014 Accepted for publication: February 25, 20151 Department of Ophthalmology, Haeundae Paik Hospital, Busan, South Korea.2 Department of Ophthalmology, Inje University College of Medicine, Busan, South Korea.



Corresponding author: Wan Soo Kim. Department of Ophthalmology. Haeundae Paik Hospital - Inje University College of Medicine - Busan - South Korea - E-mail: [email protected]

Kim KH, et al.


denied the need for treatment during a telephone interview that encouraged a follow-up visit.

DISCUSSIONThere have been few reported cases of total aniridia caused by blunt

trauma in pseudophakic patients who have undergone phacoemul-sification using a CCI since the first report in a patient with a 4.0-mm sized incision and the implantation of a multipiece IOL(2). Although a previous report had described total aniridia in patients who had undergone implantation of a single piece IOL into an intact capsular bag(3), our case was unique in that the wound size (2.2 mm) was the

smallest to be reported till date and there was no damage to the zonules, capsular bag, or IOL despite the single piece design of the latter. Furthermore, to our knowledge, this was the first such case in an Asian patient. In addition, our patient was distinguished by his initially mild symptoms and symptom alleviation within 5 months following the blunt trauma.

The mechanism underlying isolated total aniridia following blunt trauma remains to be fully understood. According to one hypothesis, the significant increase in pressure caused by the blunt trauma could reopen the previous corneal incisional wound, inducing a complete iris avulsion and its expulsion through the wound. In this situation, the small incision may function as a release valve, preventing global rupture(2). However, another hypothesis is that the disinserted iris remains within the eye and is phagocytosed by macrophages and/or trabecular meshwork cells, as shown by the presence on UBM ima-ging of echogenic particles at the anatomic position of the iris(4). This second hypothesis was formulated based on the observation of the phagocytic properties of the iris and trabecular meshwork in animal experiments; however, since the disinserted iris is an immunological self-material and considering the immunologic privileges of intraocu-lar structures, it seems unlikely that inflammatory reactions, including phagocytosis, associated with a disinserted iris would be sufficient to absorb all structures within the 1 week in their case report. Furthermo-re, our patient initially presented with mild symptoms, allowing him to delay his initial visit to the hospital for 2 weeks. This suggested that any hyphema or inflammation in the anterior chamber was insignificant after the trauma. This finding, together with the deposition of some iris pigment within the CCI wound, strengthened the hypothesis that the disinserted iris was expelled through the wound.

This report demonstrated that even small sized CCIs can be ope-ned postoperatively by trauma and that this can result in isolated total aniridia without damage to other intraocular structures.

REFERENCES 1. Ernest PH, Fenzl R, Lavery KT, Sensoli A. Relative stability of clear corneal incisions in a

cadaver eye model. J Cataract Refract Surg. 1995;21(1):39-42. 2. Ball J, Caesar R, Choudhuri D. Mystery of the vanishing iris. J Cataract Refract Surg. 2002;

28(1):180-1. 3. Oltra EZ, Chow CC, Lunde MW. Bilateral traumatic expulsive aniridia after phacoemul-

sification. Middle East Afr J Ophthalmol. 2012;19(3):334-6. 4. Parmeggiani F, Mantovani E, Costagliola C, Campa C, Steindler P. Total aniridia after

nonperforating trauma of a pseudophakic eye: ultrasound biomicroscopic findings. J Ultrasound Med. 2007;26(12):1795-7.

Figure 1. Anterior segment photo showing total aniridia with an intact ciliary body, intraocular lens, and capsular bag.

Figure 2. Gonioscopic examination showing total aniridia with an intact ciliary body and no iris remnant.

Case Report


INTRODUCTIONTemperature is an important health indicator and can be asses-

sed using the wavelength of the infrared rays between 700 nm and 100,000 nm that are released by the human body as heat(1). The hu-man body reflects its surface temperature because it is an excellent infrared energy emitter(2).

Thermography is a diagnostic imaging method that can capture and record the heat emitted from the body surface, allowing both non-invasive and safe investigation(3,4). The thermography diagnostic method is based on the detection of infrared images that are emitted from the patient’s body surface in real time. A thermographic camera captures the infrared radiation emission patterns, which are invisible to the naked eye and imperceptible to touch, and translates them into information encrypted in colors that can help to detect changes in normal patients(4).

In this report, we have demonstrated the recurrent acute inflam-matory process in a case of lower tear obstruction and the use of ther mal imaging.

CASE REPORTA 56-year-old woman (MAS) visited the Ophthalmology Emergency

Room with a complaint of epiphora and swelling in the lacrimal sac region of the right eye. She had experienced the same symptoms on two previous occasions at an interval of 3 years and had been treated with systemic antibiotics. The patient had undergone radioiodine therapy for 6 months at the same institution due to thyroid carcino-ma associated with a thyroid nodular goiter and follicular adenoma. It was first believed to be an acute case of dacryocystitis. After the prescription of 500 mg of cephalexine, 4 times a day for 7 days, she

ABSTRACTObstructions in the lacrimal pathways quite often require accurate and reliable image scanning for confirmation and documentation. Infrared thermal imaging, known as thermography, is a resource that complements diagnosis; it does not require touching the patient or applying contrast materials and has been used in various medical procedures for decades. However, there have been few studies in the literature about its use in ophthalmology. In this paper, the authors have presented a case of dacryocystitis where the obstruction of the lacrimal punctum was so acute that conventional dacryocystography could not be used. The authors have successfully reported the use of thermography as a complementary propae-deutic and will discuss the method they used.

Keywords: Thermography/methods; Dacryocystitis/diagnosis; Case reports

RESUMOAs obstruções de vias lacrimais muitas vezes necessitam de exames de imagem precisos e confiáveis para confirmação e documentação diagnóstica. A imagem térmica por infravermelho, conhecida como termografia, é um recurso complementar diagnóstico sem contato e sem contraste, utilizada há décadas em diversas aplicações médicas. Porém, ainda são poucos os estudos na literatura sobre seu uso na oftalmologia. Neste trabalho os autores apresentam um caso de dacriocistite com obstrução dos pontos lacrimais onde não foi possível utilizar a técnica convencional de dacrioscistografia relatando o uso com sucesso da termografia como propedêutica complementar e discutem o método.

Descriotres: Termografia/métodos; Dacriocistite/diagnóstico; Relatos de casos

was referred to the Lacrimal System Service at the Department of Oph thalmology.

Ectoscopic evaluation revealed a substantial tumefaction of the lacrimal sac area and an apparent occlusion of both the upper and lower tear puncta in the right eye, which was probably related to the radioiodine therapy. Dacryocystography is typically the standard procedure for diagnosing this type of obstruction, but was con-traindicated in this case. In order to evaluate the nasolacrimal duct, infrared thermography was used as a complementary propaedeutic.

The examination was performed with a thermal camera T650 sc model (FLIR Systems Inc., Portland, USA), which promoted high defi-nition images (620 × 420 pixels) with high sensitivity and allowed the detection of differences at 0.03°C in tissue temperature (Figure 1). The patient was positioned in front of the camera, which was placed on a support 80 cm away from the lacrimal sac area.

The room temperature was maintained at 23°C throughout the evaluation and the images were captured 15 min after the tempera-ture of the patient’s face matched the temperature of the environ-ment (thermalization). One drop of saline solution (sodium chloride 0.9%) cooled to 18°C had been previously applied to both eyes; a sequence of thermographic images was then shot with the eyes open 3 s after a blink. Care was taken not to allow excessive saline solution to run onto her face, thus preventing any thermal artifact from interfering with the local thermographic images. The camera allowed image magnification of up to eight times and fusion of the thermal and visual images in 3D mode, with optimal heat contrast that corresponded with the photographic image.

The thermographic image captured hypo-radiation in the area corresponding to the dilatation of the right lacrimal sac and appeared as a blue coloration (Figures 2 A and 2 B). The hypo-radiation obser-

Using thermography for an obstruction of the lower lacrimal system

Utilização da termografia de uma obstrução da via lacrimal baixa

Marco antonio dE caMpoS Machado1, joão aMaro fErrari Silva1, MarcoS lEal BrioSchi2, norMa allEMann1

Submitted for publication: September 29, 2014 Accepted for publication: March 11, 20151 Department of Opthalmology and Visual Sciences, Escola Paulista de Medicina (EPM), Universidade

Federal de São Paulo (UNIFESP). 2 Termologia Clínica e Termografia, School of Medicine, Universidade de São Paulo (USP).



Corresponding author: Norma Allemann. Rua Olimpíadas, 134, cj. 51 - São Paulo, SP - 04551-000 - Brazil - E-mail: [email protected]

Machado MAC, et al.


Figure 1. Thermographic camera, T650 sc model (FLIR Systems Inc., Portland, USA) that is used for diagnostic thermography examinations with 620 × 420 pixel definition, and that is capable of detecting differences in temperature with 0.03°C sensitivity.

Figure 2. A) Thermographic image of the patient’s face, showing inflammation around the lacrimal sac of the right eye that reached the lower eyelid that was observed as a bluish warm halo (hyper-radiation); this corresponded to hyper-radiation or local heating, which was not observed in the lacrimal sac of the left eye. B) Magnified image of 2A, showing blue coloration where the dilatation of the lacrimal sac indicated local edema from chronic inflammation (hypo-radiation).

A B

ved in the thermography image could be associated with the degree of edema caused by tissue inflammation. The same bluish image was not captured in the area corresponding to the left lacrimal sac. After a dynamic examination that included the instillation of cooled drops in the eyes, the left normal eye presented with lacrimal sac cooling with bluish coloration. No local cooling was observed in the right la crimal sac.

Diagnosed with chronic dacryocystitis, the patient was referred for surgical intervention with an external right dacryocystorhinosto-my, which included the surgical opening of the upper and lower ipsilateral lacrimal puncta.

DISCUSSIONFirst described by Raflo et al. in 1982, the use of thermal imaging

for the lacrimal system is an investigative method without known side effects(5). Unlike the dacryocystography exam, there is no need to touch the patient or to use a contrast substance. This allows for safer and faster assessment of the drainage system, with a higher degree of patient cooperation.

Blood flow is the major mechanism of heat transfer in the human body(5) and thermography can use images to document the effects

on the microcirculation and vasomotor activity involved in the in-flammatory process as well as in superficial tumors(6).

Thermal imaging of the lacrimal drainage allows confirmation and assessment of the degree of tissue inflammation. The thermogra-phic images are compared to determine the bilateral asymmetry of the thermal capture and the hyper-radiation or heat. In cases of acute dacryocystitis crises, the finding of the thermal imaging will be a hy-per-radiation of the lacrimal sac(7). Even when relying on an apparatus that had lower definition than that described in this case, Rosenstock et al. found a sensitivity of 42% and a specificity of 60%(8) for the de-tection of inflammatory processes in the lacrimal drainage system. In the case presented, the static thermal image highlighted a chronic inflammation of the lacrimal sac that already contained edema; this appeared bluish (cold) in the thermographic examination.

In this case, the dynamic examination using the cold drop was crucial. The lacrimal sac has an average diameter of 1.5 cm and is lo cated in the tear sac at a distance of approximately 0.5 cm from the skin; these factors allow medical thermography to provide a reliable thermal evaluation(9). Cooling of the medial corner of the orbits is the expected normal response to the instillation test of cooled drops(4). When no local cooling is observed, it is identified as a pathologic fin -ding, and may suggest the existence of an obstruction.

The clinical presentation of a lacrimal obstruction in the reported case may have been due to radioiodine therapy for thyroid carcino-ma. This association has been described in the literature(10), or com-bined with other conditions that jointly acted to produce lacrimal obstruction.

In the present case, we chose to use the thermography method due to the presence of a tumefaction in the lacrimal sac area that could preclude cannulation in dacryocystography. This method also had the advantage of avoiding additional radiation exposure, lowering cost, and improving ease of use compared to radiologic methods such as computed tomography (CT) and magnetic resonance ima-ging (MRI). In the event there was any suspicion of a possible invasion of the lacrimal system by a neoplastic process, CT or MRI scans would be mandatory.

Thermography is a non-contact diagnostic technique that does not require the use of radiation and that provides objective eviden-ce about the permeability of the lacrimal drainage system. This in -for mation is particularly useful when there is clinical suspicion of in flammation.

REFERENCES 1. Hardly JD. The radiating power of human skin in the infrared. Am J Physiol. 1939;127:

454-62. 2. Hagblad J, Folke M, Lindén M. Long term monitoring of blood flow at multiple depths -

observations of changes. Stud Health Technol Inform. 2012;117:107-12. 3. Farid KJ, Winkelman C, Rizkala A, Jones K. Using temperature of pressure-related

intact discolored areas of skin to detect deep tissue injury: an observational, retros-pective, correlational study. Ostomy Wound Manage. 2012;58(8):20-31.

4. Brioschi ML, Teixeira MJ, Yeng LT, Silva FM. Manual de termografia médica São Paulo: Editora Andreoli; 2012.

5. Raflo GT, Chart P, Hurwitz JJ. Thermographic evaluation of lacrimal drainage system. Ophthalmic Surg. 1982;13(2):119-24.

6. Anbar M. Hyperthermia of the cancerous breast: analysis of mechanism. Cancer Lett. 1994;84(1):23-9.

7. Hinton P, Hurwitz JJ, Chart PL. Liquid crystal contact thermography and lacrimal tract inflammation: a preliminary report. Can J Ophthalmol. 1984;19(4):176-7.

8. Rosenstock T, Chart P, Hurwitz JJ. Inflammation of the lacrimal drainage system-assess-ment by thermography. Ophthalmic Surg. 1983;14(3):229-37.

9. Fayet B, Racy E, Assouline M, Zerbib M. Surgical anatomy of the lacrimal fossa A pros-pective computed tomodensitometry scan analysis. Ophthalmology. 2005;112(6): 1119-28.

10. Fonseca FL, Lunardelli P, Matayoshi S. Obstruction of lacrimal system associated with radioiodine therapy of thyroid carcinoma. Arq Bras Oftalmol. 2012;75(2):97-100.

Case Report


INTRODUCTIONExtraocular extension of choroidal melanoma (CM) is the primary

presentation in 2.5-28% of cases of CM. Extraocular extension of CM as a secondary presentation is even more rare and occurs following the failure of conservative treatment (e.g., brachytherapy, radiothe-rapy, surgical resection, and transpupillary thermotherapy [TTT])(1). Massive orbital invasion, reported in 0.5% of cases, occurs rarely with small CM lesions(1). Massive orbital invasion has been reported as a strong negative prognostic factor with a 5-year survival rate of less than 11% due to increased risk of metastatic disease(2).

Herein, we describe an unusual case of CM presenting with mi-nimal intraocular recurrence and massive orbital spread following conservative treatment.

CASE REPORTWe report the case of a 68-year-old man diagnosed with CM (9.9 mm

base x 2.9 mm height) of the right eye (located at the superior temporal edge) initially treated at another hospital with episcleral brachytherapy (I125) and TTT. The initial therapeutic outcome was favorable; i.e., tumor regression on ultrasound was observed after six months of treatment. The patient was referred to our institution 2 years

after initial diagnosis due to proptosis and decreased visual acuity of the right eye. Upon examination, proptosis of the right eye was ob-served with limitation of up-gaze and adduction (Figure 1 A). Fundus examination revealed a pigmented nodular lesion. Ultrasonography revealed a choroidal mass consistent with recurrent melanoma and a large extraocular shadow with extraocular extension (Figure 1 B). Computed tomography and magnetic resonance imaging demons-trated an extraocular mass involving the optic nerve and inferior and inner rectus muscles (Figure 1 C and D). There was no evidence of systemic disease with liver test or ultrasonography. Extended enucle-ation was performed. Macroscopic examination revealed a choriore-tinal scar, pigmented nodules, an amelanotic mass surrounding the optic disc, and a retroocular pigmented multinodular tumor measu-ring 25 mm x 19 mm (Figure 2 A). Light microscopy demonstrated that the tumor was composed of epithelioid cells found to express Melan A and HMB45 by immunohistochemical analysis. The tumor was found to have infiltrated the emissary channels and optic nerve and reached the retroocular space where wide areas of necrosis were observed with presumed tumoral tissue occupying the orbit (Figure 2 B-D). Fluorescence in situ hybridization analysis of the tumor with probes against chromosomes 3q27 and 8q24 found no cytogenetic abnormalities.

Choroidal melanoma recurrence after episcleral brachytherapy and transpupillary

thermotherapy

Recorrência melanoma de coroide após a braquiterapia episcleral e termoterapia transpupilar

yrBani lantiGua-dorvillE1, Maria antonia Saornil1, ciro García-alvarEz1, ElEna García-laGarto2

Submitted for publication: January 12, 2015 Accepted for publication: April 18, 20151 Ophthalmology Department (Ocular oncology unit), Hospital Clínico Universitario de Valladolid,

Valladolid, Spain.2 Pathology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.



Corresponding author: Yrbani Lantigua Dorville. Ophthalmology Department, Hospital Clínico Universitario de Valladolid - R. Ramón y Cajal 3 - Valladolid - 47005 - Spain

E-mail: [email protected]

ABSTRACTA 68-year-old man diagnosed with choroidal melanoma (CM) in the right eye underwent treatment with episcleral brachytherapy (I125) and transpupillary ther-motherapy. Ultrasound, computed tomography, and magnetic resonance imaging were performed and revealed ocular recurrence of CM. Treatment with extended enucleation was performed. Macroscopic and microscopic examinations revealed extraocular extension and malignant cells, respectively. Immunohistochemistry demonstrated tumoral Melan-A and HMB-45 expression. No cytogenic abnormalities were detected with fluorescence in situ hybridization of tumor cells using probes against chromosomes 3q27 and 8q24. The patient underwent adjuvant external beam radiotherapy for treatment of residual tumor tissue. This case represents the first reported case of recurrent CM with no cytogenetic abnormalities and the absence of metastatic disease, despite a number of the poorest prognostic factors.

Keywords: Choroid neoplasms; Melanoma; Neoplasm recurrence, local; Brachy-therapy; Case reports

RESUMOUm homem de 68 anos de idade com diagnóstico de melanoma de coroide no olho direito foi submetido a tratamento com braquiterapia episcleral (I125) e termoterapia transpupilar. Ultrassonografia, tomografia computadorizada e ressonância magnética foram realizadas para avaliar a presença de recorrência ocular ou doença sistêmica. Enucleação ampliada foi realizada para tratar a recorrência ocular. O exame ma-croscópico e microscópico revelou o tipo de célula tumoral e a extensão extraocular. Colorações por Melan-A e HMB-45 foram realizadas. A fluorescência por hibridização in situ com sondas para os cromossomos 3q27 e 8q24 não mostraram anormalidades citogenéticas. O paciente foi submetido a radioterapia externa adjuvante para o trata-mento de tumor residual orbitário. Este caso representa a o primeiro relato de paciente sem anomalias citogenéticas e sem doença metastática, apesar de demonstrar alguns dos mais pobres fatores prognósticos.

Descritores: Neoplasias da coroide; Melanoma; recidiva local de neoplasia; Braqui-terapia; Relatos de casos

Lantigua-Dorville Y, et al.


Figure 2. Histopathological and inmunohistochemical findings. (A and B) Macroscopic and lower magnification examination demonstrated a large retroocular pigmented multinodular tumor enveloping the optic nerve. Intraocular pigmented nodules were observed with an amelanotic mass enveloping the optic disc. (C) Border of the treated choroid area with extensive fibrosis and tumor recurrence (H&E x40). (D) Tumor samples from the intraocular recurrence and extraocular extension were found to be composed of small epithelioid cells (H&E x400).

C D

A B

sequently, the patient underwent adjuvant external beam radiothe-rapy to treat the residual tumor and had no signs of local recurrence or metastatic disease at 18 months of follow-up.

DISCUSSIONSecondary extraocular extension following conservative treatment

of CM is extremely rare(3) and usually small in size. Historically, this pre sentation has been associated with surgical resection and TTT without adjuvant brachytherapy thought to result in insufficient elimination of tumor margins and intrascleral tumor cells. Combined plaque radiotherapy and TTT has been shown to provide excellent control of intraocular tumors. Shields et al.(3) and Bartlema et al.(4) reviewed 270 and 50 cases, respectively, and found recurrence rates at 5 years after treatment of up to 3%. However, neither study found any cases of extraocular extension. In the present case, brachytherapy was initially performed with a 2 mm tumor margin resulting in diffuse recurrence that extended to the orbit through emissary channels surrounding the optic nerve. The extra ocular lesion had grown subs-tantially larger than the intraocular lesion during the postoperative period. Recurrence in this case may be attributable to incomplete prior treatment of tumor margins allowing residual tumor regrowth. However, extraocular spread has been shown to be strongly asso-ciated with the histological and cytogenetic features of the index tumor(5). In the present case, several of the poorest CM prognostic factors were present including disease recurrence, massive orbital invasion, and epithelioid tumor cell type, which tend to occur with cytogenetic abnormalities, such as monosomy of chromosome 3 and polysomy of chromosome 8, associated with more aggressive melanoma, greater risk of metastases, and decreased survival. Howe-ver, no cytogenetic abnormalities or signs of metastatic disease were observed at 18 months of follow-up.

To our knowledge, this is the first reported case of CM with minimal intraocular recurrence and massive extraocular extension following combination treatment with TTT and episcleral brachythe-rapy. Moreover, cytogenetic abnormalities and metastatic disease were not identified in this case despite the presence of several of the poorest CM prognostic factors.

REFERENCES 1. Blanco G. Diagnosis and treatment of orbital invasion in uveal melanoma. Can J Ophthal-

mol. 2004;39(4):388-96. 2. Coupland SE, Campbell I, Damato BE. Routes of extraocular extension of uveal mela-

noma. Risk factors an influence on survival probability. Ophthalmology. 2008;115(10): 1778-85.

3. Shields CL, Carter J, Shields JA, Chao A, Krema H, Materin M, et al. Combined plaque radiotherapy and transpupillary thermotherapy for choroidal melanoma: tumor control and treatment complications in 270 consecutives patients. Arch Ophthalmol. 2002;120(7):933-40.

4. Bartlema YM, Oosterhuis JA, Journée-De Korver JG, Tjho-Heslinga RE, Keunen JE. Combi-ned plaque radiotherapy and transpupillary thermotherapy in choroidal melanoma: 5 years’ experience. Br J Ophthalmol. 2003;87(11):1370-3.

5. Damato B, Duke C, Coupland SE, Hiscott P, Smith PA, Campbell I, et al. Cytogenetics of uveal melanoma: a 7-year clinical experience. Ophthalmology. 2007;114(10):1921-35.

The final diagnosis was recurrence of CM with massive extraocu-lar extension and presumed residual tissue occupying the orbit. Con-

Figure 1. Clinical and imaging findings. (A) Right eye proptosis and limited up-gaze. (B-D) magnetic resonance imaging studies demonstrating recurrence (B), extraocular extension, and superior and inner rectus muscle involvement of the right eye (C), and a small intraocular mass (arrow) with extraocular extension (D).

D

B

C

A

Case Report


INTRODUCTIONInfectious keratitis following laser vision correction is uncommon(1,2).

The estimated incidence as reported by the 2008 American Society of Cataract and Refractive Surgery (ASCRS) survey was 19 of 20,941 eyes (0.09%). The most commonly cultured organism in this series was methicillin-resistant Staphylococcus aureus. One case was con-firmed to be caused by a fungal infection(1). We wish to share our experience with a case of Aspergillus flavus keratitis following laser in situ keratomileusis (LASIK), in association with a potential environ-mental risk factor.

CASE REPORTA 24-year-old female with low myopia was treated with wave-

front-optimized femtosecond-LASIK on the WaveLight FS-200 and Allegretto Eye-Q laser platform (Alcon, Fort Worth, TX, USA). Her initial manifest refraction was -1.25 D sphere in both eyes. Central corneal thickness was 508 µm in OD and 505 µm in OS, as measured with ultrasound pachymetry. The remainder of her ophthalmic exami-nation and corneal tomography were normal. Her history included prior right V1 dermatome herpes zoster without ophthalmic involve-ment. The LASIK procedure was uneventful, and she was started on ciprofloxacin 0.3% (Ciloxan®) and dexamethasone 0.1% drops four times daily. On postoperative day 1, the uncorrected distance visual acuity (UDVA) was 20/15 in each eye, and the ophthalmic exam was unremarkable.

On postoperative day 2, the patient experienced severe pain, photophobia, and decreased vision in the right eye. UDVA was 20/50 in the right eye and 20/15 in the left eye. Ophthalmic exam with a slit lamp revealed a dense, branching, feathery infiltrate within the flap

interface of the right eye (Figure 1). Given this appearance, the clinical suspicion for fungal keratitis was high.

The patient provided informed consent, and was immediately taken to the operating room for flap-lift, culture, irrigation of the flap interface, and potential flap amputation. The flap was lifted and a gelatinous branching infiltrate was observed, extending superficially into the flap and posteriorly into the stromal bed. After bacterial and fungal culture samples were obtained, the interface was extensively irrigated with a balanced salt solution. The infiltrate penetrated into the flap stroma, and because of the rapid progression (<24 h) of fungal keratitis, a decision was made to amputate the flap. Hourly topical fortified tobramycin (13.5 mg/ml), vancomycin (25 mg/ml), and voriconazole (1%) were immediately started. Although the infil-trate was clearly in the flap interface and not involving the overlying epithelium, 1 g of oral valacyclovir three times daily was also started for 10 days because of the patient’s history of right V1 herpes zoster. Prednisolone therapy was discontinued.

The infiltrate remained prominent on the day following flap amputation. The patient was followed-up very closely for the first 3 weeks postflap amputation. Four days postflap amputation, UDVA was 20/100-1. The infiltrate was improving and the epithelium had healed approximately 85% over the stromal bed (Figure 2 A). Bacte-rial cultures from the samples taken during flap amputation were ne gative. Nine days after these were taken, fungal cultures showed A. flavus growth. Histopathology of the flap showed fungal elements within the undersurface of the flap stroma (Figure 3). Fungal sensiti-vities were requested and hourly topical voriconazole was continued, while the fortified vancomycin and tobramycin were tapered. On day 11 postflap amputation, UDVA in the right eye had improved to 20/40. Photography (Figure 2 B) and corneal SD-OCT (Figure 4) were

Early post-LASIK flap amputation in the treatment of aggressive, branching keratitis:

a case report

Amputação precoce de pedículo de LASIK para o tratamento de ceratite ramificada agressiva: relato de caso

john au1, thoMaS plESEc1, karolinnE rocha2, williaM duppS jr.1, ronald kruEGEr1

Submitted for publication: December 11, 2014 Accepted for publication: February 2, 20151 Cleveland Clinic Foundation, Cole Eye Institute, Cleveland, OH.2 Medical University of South Carolina, Storm Eye Institute.



Corresponding author: John Au. 3.501 Jamboree Road #1.100 - Newport Beach, CA 92660 E-mail: [email protected]

ABSTRACTInfectious keratitis is rare following laser vision correction. We present a case of aggressive fungal keratitis caused by Aspergillus flavus, following laser in situ ke ratomileusis (LASIK) in the setting of a unique environmental risk factor. We describe the key features of the acute case presentation, which guided empirical medical and surgical treatment, resulting in the most favorable outcome found in the literature, to date.

Keywords: Keratomileusis, laser in situ/adverse effects; Keratitis/etiology

RESUMOCeratites infecciosas são raras após a correção da visão a laser. Apresentamos um relato de caso de uma ceratite fúngica agressivo por Aspergillus flavus, após cerato-mileuse a laser “in situ” (LASIK) em situação peculiar de fator de risco ambiental. Nós descrevemos as principais características da apresentação caso agudo, que orientou tratamento médico e cirúrgico empírico, demonstrando resultado mais favorável do que o encontrado na literatura até o momento.

Descritores: Ceratomileuse assistida por excimer laser in situ/efeitos adversos; Ceratite/etiologia

Au J, et al.


with a corrected distance visual acuity of 20/20-3. Voriconazole was tapered and prednisolone acetate was slowly added in an attempt to decrease corneal haze. At 5 months postoperatively, UDVA was 20/15 in the right eye. Ophthalmic exam at that time showed a per-sistent but improved 1+ corneal haze. She has not required further intervention to date.

DISCUSSIONA review of the literature shows a generally poor outcome for

post-LASIK Aspergillus keratitis(2-4). Of the published cases, one requi-red a penetrating keratoplasty(2); another resulted in corneal perfora-tion, requiring glue patching(3); and the third resulted in a final pinho-le vision of 20/40(4). Our case demonstrated an aggressive nature of A. flavus keratitis, which resulted in lifting of the flap and irrigation of the

Table 1. The minimum inhibitory concentration (MIC) of antifungal agents for use against Aspergillus flavus cultured in this patient

Antifungal agent MIC (µg/ml)

Amphotericin B 2

Natamycin 32

Fluconazole >64

Itraconazole 1

Posaconazole >0.5

Voriconazole 1

Figure 1. The day 2 postoperative appearance of branching feathery interface infiltrate

Figure 3. Histology of the amputated corneal flap showing fungal elements in the stroma (black arrows).

Figure 4. A day 11 postflap amputation SD-OCT image showing dense central hyper-re-flectivity, representing the residual infiltrate and surrounding haze. Reepithelialization is noted.

repeated at that time. Antifungal sensitivity testing confirmed that voriconazole was appropriate for the isolated strain (Table 1).

After 3 weeks of hourly voriconazole, UDVA had improved to 20/25 (-2) in the right eye. The manifest refraction was -0.50 D sphere

Figure 2. A) The day 2 postflap amputation slit lamp appearance with refor-mation of dense feathery infiltrate. B) The day 11 postflap amputation slit lamp appearance showing improvement of the infiltrate with decreasing density.

A

B

Early post-LASIK flap amputation in the treatment of aggressive, branching keratitis: a case report


interface, as well as complete amputation of the flap. Ultimately, this decision in conjunction with proper empirical medical intervention has allowed for a remarkably good visual result for our patient.

During the week prior to this case, a new wall was built within the refractive suite waiting area, which was not directly connected with the laser suite. However, on the day prior to the case, construction workers had removed some ceiling tiles in the laser suite, in prepara-tion for the upcoming construction and removal of an internal wall.

It is well established in the literature that construction is a risk factor for aerosolized dissemination of spore-forming organisms including fungi(5-9). Several cases and outbreaks of Aspergillus in asso-ciation with hospital construction have been described, resulting in pulmonary aspergillosis in immunocompromised patients. Primarily, A. flavus and A. fumigatus are the responsible organisms in these cases(6-9). A prior outbreak of Aspergillus endophthalmitis has been described in association with hospital construction(5). To the best of our knowledge, this is the first reported case of post-LASIK A. flavus keratitis with construction in the laser suite as a potential risk factor.

Although the presentation of this patient was early for fungal infection, the steroids administered to the patient could have allowed for a more rapid progression of the fungal infection. In addi-tion, we considered that the recent construction in the laser suite could have released fungal organisms. We also considered bacterial, including mycobacterial, and herpetic etiologies. Given the rapid progression, the possibility of bacterial infection remained reasona-bly high. Therefore, fortified antibiotics were prescribed on an hourly basis from the day of flap amputation until the cultures proved fungal etiology. Atypical mycobacterium should always be considered in LASIK-related infections. However, these infections typically present weeks after the procedure. Finally, we empirically treated the patient for herpetic disease as well because she had a history of herpes zoster. The location of the infiltrate was within the flap interface and not intraepithelial; this led us to favor a fungal or bacterial etiology over a herpetic one.

One valuable clinical lesson gained from this experience is to avoid surgical cases in the setting of recent construction. We are una-ware of a specific recommended time period to wait to perform fur-ther refractive surgery following such construction events. It is encou-raged to cover or move equipment prior to construction. In addition, after construction is complete, a thorough cleaning of all dust-co vered surfaces in the area is necessary prior to any further surgery.

A second equally important lesson focuses on trusting clinical judgment based upon physical findings in the absence of more de-finitive data (i.e., cultures). The initial clinical appearance must guide therapy when more definitive data is lacking. Based on the earliest finding on slit lamp exam, we surmised that flap amputation was indi-cated, which ultimately led to a good rather than poor postoperative outcome. Several considerations led to this decision: 1) Penetration of the antibiotics and antifungal medication to the infiltrate would be improved. 2) The patient had a low myopic correction with robust residual stromal bed thickness for possible future refractive treatment. 3) The flap was created with a femtosecond laser; therefore, it had a uniform planar shape when amputated, allowing for minimal refracti-ve change when compared with a meniscus-shaped microkeratome flap. These factors, along with prompt, appropriate medical therapy, contributed to this most favorable reported outcome in post-LASIK fungal keratitis.

ACKNOWLEDGMENTSThank you to University of Texas Health Science Center at San An-

tonio, Department of Pathology for antifungal susceptibility testing.

REFERENCES 1. Solomon R, Donnenfeld ED, Holland EJ, Yoo SH, Daya S, Güell JL, Mah FS, Scoper SV,

Kim T. Microbial keratitis trends following refractive surgery: Results of the ASCRS Infectious keratitis survey and comparisons with prior ASCRS surveys of infectious keratitis following keratorefractive procedures. J Cataract Refract Surg. 2011;37(7): 1343-50.

2. Sridhar M, Garg P, Bansal A, Gopinathan U, Aspergillus flavus Keratitis After Laser in Situ Keratomileusis. Am J Ophthalmol. 2000;129(6):802-4

3. Kuo I, Margolis T, Cevallos V, Hwang D, Aspergillus fumigatus Keratitis After Laser In Situ Keratomileusis. Cornea. 2001;20(3):342-4.

4. Sun Y, Jain A, Ta C, Aspergillus fumigatus keratitis following laser in situ keratomileusis. J Cataract and Refract Surg. 2007;33(10):1806-7.

5. Tabbara KF, al Jabarti AL. Hospital construction-associated outbreak of ocular asper-gillosis after cataract surgery. Ophthalmology. 1998;105(3):522-6.

6. Krasinski K, Holzman RS, Hanna B, Greco MA, Graff M, Bhogal M. Nosocomial fungal infection during hospital renovation. Infect Control. 1985;6(7):278-82.

7. Arnow PM, Andersen RL, Mainous PD, Smith EJ. Pulmonary aspergillosis during hos-pital renovation. Am Rev Respir Dis. 1978;118(1):49-53.

8. Vonberg RP, Gastmeier P. Nosocomial aspergillosis in outbreak settings. J Hosp Infect. 2006;63(3):246-54.

9. Lentino JR, Rosenkranz MA, Michaels JA, Kurup VP, Rose HD, Rytel MW. Nosocomial aspergillosis: a retrospective review of airborne disease secondary to road construction and contaminated air conditioners. Am J Epidemiol. 1982;116(3):430-7.

Case Report


INTRODUCTIONPost-traumatic iris defects combined with crystalline lens abnor-

malities are among the major complications of globe injuries. Pu-pillary defects may cause glare and photophobia to various degrees; however, traumatic aniridia may lead to severe visual deterioration. Because corneal endothelial cell density is reduced in eyes with a trau-matic cataract, every surgical trauma entails a potential risk of aggra-vating corneal decompensation(1-3). After custom-tailored iris pros-thesis became available for ocular implantation, some authors have described a combined surgical approach for treating aphakia and aniridia with haptic fixation of an intraocular lens (IOL) on artificial iris implants prior to intraocular placement(4,5). Herein we describe a new surgical technique for simultaneously treating aniridia and aphakia. A sclerally sutured rigid IOL was first fixated on a custom-tailored ar tificial iris prosthesis by both of its haptics, after which intraocular implantation was performed by suturing IOL to the scleral wall.

CASE REPORTA 56-year-old otherwise healthy female had experienced total iris

emanation and crystalline lens luxation secondary to a blunt trauma to her left eye. She had previously undergone lensectomy and pars plana vitrectomy at another center. A complete ophthalmologic exa-mination revealed a clear cornea with a normal fundus and a visual acuity of 20/20 with +12.0 diopters correction in the affected eye. The combined transscleral fixation of a single-piece polymethylmetha-

crylate (PMMA) IOL (CZ70BD; Alcon Laboratories, Fort Worth, TX, USA) with the implantation of a custom-tailored artificial iris prosthesis (Dr. Schmidt Intraocularlinsen GmbH, HumanOptics AG, Erlangen, Germany) was scheduled for simultaneously treating aniridia and apha kia. In order to match the color of the healthy iris, a custom-tai-lored artificial iris prosthesis was produced.

Under topical anesthesia, two conjunctival peritomies were made at the 3 and 9 o’clock meridians before performing a superior 7.0-mm clear corneal incision. Subsequently, an ophthalmic viscosurgical device (OVD) was injected to protect the corneal endothelium. After hitching the 9-0 polypropylene looped-sutures with a long-curved needle (PC-9; Alcon Surgical, Fort Worth, TX, USA) to the haptic eye lets of PMMA IOL, both pairs of such needles passed through the periphery of the artificial iris prosthesis (Figure 1 A). The haptics were tightly attached to the back of the iris implant. Next, IOL and artificial iris complex were ab-internally fixed to the scleral wall at the 3 and 9 o’clock meridians, approximately 1 mm posterior to the limbus. After passing the needles through the marked scleral points, IOL and the artificial iris complex were implanted. The complex was retracted to be stabilized and well-centered after the withdrawal of both needles through the pars plana. Polypropylene sutures were tied to the sclera, and the suture knots were buried into the sclera at both sides. To ensure placement within the sclera, the suture end and knot were buried into the created scleral tunnel using a PC-9 needle after knotting the suture onto itself. The artificial iris did not interfere with this process because there was no knot between the

Combined transscleral fixation of an artificial iris prosthesis with an intraocular lens

Combinação de fixação transescleral de prótese de íris artificial com lente intraocular

uzEyir GunEnc1, taylan ozturk1, Gul arikan1, MahMut kaya1

Submitted for publication: December 9, 2014 Accepted publication: March 18, 20151 Department of Ophthalmology, Dokuz Eylul University School of Medicine, Izmir, Turkey.



Corresponding author: Taylan Ozturk. Albatros-9, 152, Daire: 26 - Mavisehir, Karsiyaka - 35540, Izmir - Turkey - E-mail: [email protected]

ABSTRACTPost-traumatic aniridia combined with aphakia may be seen after globe injury. Aside from esthetic aspects, partial or total loss of the iris tissue may also be related to various degrees of glare and photophobia. Such patients suffer from severe visual impairment secondary to aphakia. Herein we describe a novel surgical technique for the management of an aphakic eye with traumatic aniridia for a patient who underwent transscleral fixation of a custom-tailored artificial iris prosthesis com-bined with a rigid intraocular lens (IOL). Tight suturing of the IOL haptic eyelets on the silicone iris prosthesis and fixation of such a complex to the scleral wall may provide excellent cosmetic and functional outcomes in aphakic eyes with aniridia.

Keywords: Aniridia; Aphakia; Postcataract; Cataract extraction; Iris/injuries; Eye in-juries; Lens implantation, Intraocular; Prosthesis design

RESUMOAniridia pós-traumática combinada com afacia pode ser observada após lesões do globo ocular. Além do ponto de vista estético, a perda parcial ou total do tecido da íris também pode estar relacionada com vários graus de ofuscamento e fotofobia. Estes pacientes sofrem de deficiência visual grave secundária a afacia. Relata-se uma técnica cirúrgica inovadora para tratamento de um olho com afacia associada à aniridia traumática que foi submetido à fixação transescleral de uma prótese de íris artificial feita sob medida combinada com uma lente intraocular rígida (IOL). A sutura das alças da IOL sobre a prótese iriana de silicone, e a fixação desse complexo na parede escleral podem proporcionar excelente resultado estético e funcional em olhos afácicos com aniridia.

Descritores: Aniridia; Afacia pós-catarata; Extração de catarata; Íris/lesões; Trauma-tismos oculares; Implante de lentes intraocular; Desenho de prótese

Combined transscleral fixation of an artificial iris prosthesis with an intraocular lens


artificial iris and ciliary body. The corneal incision was sutured with a 10-0 non-absorbable nylon suture, and OVD was gently removed from the anterior chamber. The conjunctiva was subsequently closed with 80 polyglactin 910 (Vicryl®, Ethicon Inc) sutures (Figure 1 B). The patient was satisfied with the cosmetic appearance from the early postoperative period (Figure 2). Over the first postoperative week, the patient had no complaints of any persisting glare and photophobia, and visual acuity was found to be 20/20 with -0.50 diopters of astig-matism in her left eye.

DISCUSSION Iris defects combined with aphakia are serious problems frequen-

tly encountered after globe injuries. Aside from esthetic aspects, par-tial or total loss of iris tissue may also be related to various degrees of glare, photophobia, and visual impairment. In patients with major

iris defects, an artificial iris prosthesis provides satisfactory anterior segment reconstruction with a remarkable functional outcome(3-10).

Various implants have been developed for the treatment of aphakia with aniridia. Some authors reported on effective and safe surgical intervention with Morcher black-diaphragm IOL (Morcher 67F BDI, Morcher GmBH, Stuttgart, Germany) for the treatment of both total or partial aniridia in aphakic cases(6,7). The Ophtec iris reconstruction lens with the color options of brown, blue, and green (Ophtec USA, Boca Raton, FL, USA) has also been reported to provide better cosme-tic outcomes as well as remarkable visual improvement(8,9). In cases with partial iris defects, intraocular implantation of the Artisan iris reconstruction implant (Ophtec, Groningen, The Netherlands) may be chosen for cosmetic and functional improvement. Such a device can be attached to the remaining iris tissue at its periphery; however, an optical lens system enabling various dioptric powers is placed in its center(10). A custom-tailored artificial iris prosthesis provides a much

Figure 1. (A) Haptics of a single-piece polymethylmethacrylate (PMMA) intraocular lens (IOL) were tightly attached to the back of the iris implant using 9-0 polypropylene looped-sutures with a long-curved needle (PC-9; Alcon Surgical). (B) Operated eye at the end of the surgery.

A B

Figure 2. Operated eye at postoperative day one (A) and after first week (B). Acceptable cosmetic appearance of the left eye (C).

A

C

B

Gunenc U, et al.


better cosmetic outcome because it is produced according to the exact iris color of the fellow eye. Because the management of aphakia is not possible with such artificial iris implants, the transscleral fixation of IOL has to be scheduled in aphakic eyes with a lack of a sufficient capsular support. Hence, many authors have published an excellent visual prognosis with transsclerally fixated IOLs in aphakic cases without any capsular support(2-5). In order to reduce the risk of both corneal decompensation and macular edema, transscleral fixation of a standard IOL in combination with a custom-tailored artificial iris pros-thesis in the same surgical session has been published very recently in cases with concomitant aniridia and aphakia(4,5). Forlini et al. fixed a monopiece foldable IOL centrally on the back side of the artificial iris prosthesis(4), and Spitzer et al. reported on the implantation of such a custom-tailored prosthesis combined with a three-piece foldable IOL through a superior corneoscleral tunnel with a length of 5 mm(5). Ho-wever, we used PMMA IOL that was tightly sutured onto the back side of the artificial iris prosthesis with 9-0 polypropylene looped-sutures in its haptic eyelets in order to provide the best fixation. Although a major disadvantage of such a procedure was the necessity of exten-ded corneal incision, a visual acuity of 20/20 with -0.50 diopters of astigmatic correction in the affected eye was achieved only one week after the operation.

Herein we presented a novel surgical technique for managing an aphakic case with traumatic aniridia undergoing transscleral fixation of a Dr. Schmidt custom-tailored artificial iris prosthesis combined with PMMA IOL. Suturation of the IOL haptics on the artificial iris pros thesis and the transscleral fixation of this complex to the scleral wall provide a good cosmetic and functional outcome in aphakic cases with aniridia.

REFERENCES 1. Yeniad B, Corum I, Ozgun C. The effects of blunt trauma and cataract surgery on cor neal

endothelial cell density. Middle East Afr J Ophthalmol. 2010;17(4):354-8. Comment in: Middle East Afr J Ophthalmol. 2012;19(2):269-70; author reply 270.

2. Lockington D, Ali NQ, Al-Taie R, Patel DV, McGhee CN. Outcomes of scleral-sutured con-ventional and aniridia intraocular lens implantation performed in a university hospital setting. J Cataract Refract Surg. 2014;40(4):609-17.

3. Hanumanthu S, Webb LA. Management of traumatic aniridia and aphakia with an iris reconstruction implant. J Cataract Refract Surg. 2003;29(6):1236-8.

4. Forlini C, Forlini M, Rejdak R, Prokopiuk A, Levkina O, Bratu A, et al. Simultaneous correction of post-traumatic aphakia and aniridia with the use of artificial iris and IOL implantation. Graefes Arch Clin Exp Ophthalmol. 2013;251(3):667-75. Comment in: Gra e-fes Arch Clin Exp Ophthalmol. 2013;251(10):2493-4. Graefes Arch Clin Exp Ophthalmol. 2013;251(10):2491.

5. Spitzer MS, Yoeruek E, Leitritz MA, Szurman P, Bartz-Schmidt KU. A new technique for treating posttraumatic aniridia with aphakia: first results of haptic fixation of a foldable intraocular lens on a foldable and custom-tailored iris prosthesis. Am J Ophthalmol. 2012;130(6):771-5.

6. Aslam SA, Wong SC, Ficker LA, MacLaren RE. Implantation of the black diaphragm intraocular lens in congenital and traumatic aniridia. Ophthalmology. 2008;115(10): 1705-12.

7. Beltrame G, Salvetat ML, Chizzolini M, Driussi GB, Bussato P, Di Giorgio G, et al. Implanta-tion of a black diaphragm intraocular lens in ten cases of post-traumatic aniridia. Eur J Ophthalmol. 2003;13(1):62-8.

8. Price MO, Price FW Jr, Chang DF, Kelley K, Olson MD, Miller KM. Ophtec iris reconstruction lens United States clinical trial phase I. Ophthalmology. 2004;111(10):1847-52.

9. Mashor RS, Bahar I, Kaiserman I, Berg AL, Slomovic A, Rootman DS. Combined pene-trating keratoplasty and implantation of iris prosthesis intraocular lenses after ocular trauma. J Cataract Refract Surg. 2011;37(3):582-7.

10. Smina ML, Odenthal MT, Gortzak-Moorstein N, Wenniger-Prick LJ, Völker-Dieben HJ. Im-plantation of the Artisan iris reconstruction intraocular lens in 5 children with aphakia and partial aniridia caused by perforating ocular trauma. J AAPOS. 2008;12(3):268-72.

Review Article


INTRODUCTIONNight blindness, xerophthalmia, Bitot’s spot, keratitis, and kera-

tomalacia are well-known clinical manifestations of hypovitaminosis A(1). However, this condition is classically related to food deprivation associated with malabsorption syndrome resulting from poverty and/or chronic disease(1-3).

The present review aims to inform health professionals of the modern presentations, causes, associated systemic diseases, and risk factors of hypovitaminosis A. The utility of retinoic acid application for the treatment of skin diseases and dry eye is also discussed(4). Herein, we present the clinical presentation of hypovitaminosis A and discuss strategies for the investigation and treatment of the causes and consequences of hypovitaminosis A and side effects of the use of retinoic acid (a form of vitamin A) in dermatological and oncological therapies.

HISTORYThe classical clinical presentation of the disease currently known

as vitamin A deficiency was first described in antique medical docu-ments of the ancient Egyptian civilization, although underlying me-

ABSTRACTClinical presentations associated with vitamin A deficiency persist in poor regions globally with the same clinical features as those described centuries ago. However, new forms of vitamin A deficiency affecting the eyes, which have become wides-pread, as a result of modern societal habits are of increasing concern. Ophthalmic conditions related to vitamin A deficiency require the combined attention of ophthalmologists, pediatricians, internists, dermatologists, and nutritionists due to their potential severity and the diversity of causes. As the eyes and their adnexa are particularly sensitive to vitamin A deficiency and excess, ocular disturbances are often early indicators of vitamin A imbalance. The present review describes the clinical manifestations of hypovitaminosis A with an emphasis on so-called modern dietary disorders and multidisciplinary treatment approaches. The present review also discusses the relationship between retinoic acid therapy and dry eye disease.

Keywords: Vitamin A deficiency/complications; Eye manifestations; Bariatric surgery; Blepharoplasty; Refractive surgical procedures; Xerophthalmia

RESUMOAs apresentações clínicas associadas à deficiência de vitamina A persistem em regiões pobres ao redor do mundo com os mesmos achados clínicos descritos há séculos. No entanto, novas formas de problemas causados pela vitamina A afetam os olhos, estão associados com os hábitos da sociedade moderna e tem causado preocupação. Eles exigem a atenção dos oftalmologistas, pediatras, internistas, dermatologistas e nutricionistas, devido à sua gravidade e diversidade de causas. Uma vez que os olhos e seus anexos são órgãos muito sensíveis à deficiência e excesso de vitamina A, mani-festações oculares podem ser indicadores precoces do desequilíbrio de vitamina A. Essa revisão traz as manifestações clínicas de hipovitaminose A enfatizando os chamados distúrbios dietéticos modernos e formas de abordagem multidisciplinar. E também traz evidências sobre a relação entre a terapia com ácido retinóico e doença do olho seco.

Descritores: Deficiência de vitamina A/complicações; Manifestações oculares; Cirurgia bariátrica; Blefaroplastia; Procedimentos cirúrgicos refrativos; Xeroftalmia

chanisms were elucidated more recently. The causes of deficiencies in the micronutrient vitamin A, the biochemical vitamin A pathway, food sources of retinol (vitamin A) and its metabolites, and the phy-siological roles of vitamin A have only begun to be understood since the 20th century(5-9) (Figure 1; Table 1).

Interestingly, one of the most complete and objective des-criptions of the clinical manifestations of hypovitaminosis A was published decades before the specific underlying cause was known by the Brazilian ophthalmologist, Manoel da Gama Lobo, in 1865(10). Dr. Gama Lobo reported four cases of children, all descendants of slaves, with ocular disease who subsequently developed lung and digestive disorders before ultimately dying. In this report, the disea-se was termed Ophthalmia Braziliana, and the clinical progression was comprehensively detailed. Food deprivation was identified and credited to the practice of extensive monoculture in the farms of Southeast Brazil, in that century dedicated to the production of coffee and sugar.

Dr. Gama Lobo attributed the signs and symptoms observed in his patients to the poor diet of slaves and their descendants, a problem that he never saw in his homeland to north of the country

Vitamin A and the eye: an old tale for modern times

A vitamina A e o olho: uma velha história em tempos modernos

jacQuElinE fErrEira fauStino1, alfrEdo riBEiro-Silva2, rodriGo faEda dalto1, MarcElo MartinS dE Souza1, joão MarcEllo fortES furtado1, GutEMBErG dE MElo rocha3, Monica alvES4, Eduardo MElani rocha1

Submitted for publication: September 8, 2015 Accepted for publication: October 20, 20151 Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade de

Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.2 Departamento de Patologia e Medicina Legal, Faculdade de Medicina de Ribeirão Preto, Universidade

de São Paulo, Ribeirão Preto, SP, Brazil.3 Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Universidade de São

Paulo, Ribeirão Preto, SP, Brazil.4 Departamento de Oftalmologia e Otorrinolaringologia da Faculdade de Ciências Médicas, Univer-

sidade Estadual de Campinas, Campinas, SP, Brazil.

Funding: This study was supported by CAPES, CNPq, FAPESP, FAEPA, and NAP-FTO-USP.


Corresponding author: Eduardo Melani Rocha. Department of Ophthalmology, Otorhinolaryngology and Head & Neck Surgery, School of Medicine at Ribeirao Preto, University of Sao Paulo. Av. Bandeirantes, 3.900 - Ribeirão Preto, SP - 14049-900 - Brazil - E-mail: [email protected]

Faustino JF, et al.


where agriculture production was dedicated to local consumption and therefore more variable and abundant. At the end of his report, Dr. Gama Lobo called the attention of legislators to the need for laws aimed at preventing the sequence of problems he outlined. His paper was published in Portuguese and in German but is relatively unknown to the majority of the medical community, although it is now freely available online(11,12).

Recent epidemiologic data from Brazil in a study population of 3,499 children aged between 6 and 59 months and 5,698 women aged between 15 and 49 years revealed that hypovitaminosis A is present in all five regions of Brazil with a prevalence of 17.4% and 12.3% among children and women, respectively(13). The highest prevalence was found to be in urban areas and the northeastern and southeastern regions of the country.

CLASSIC DISEASEThe typical medical scenarios leading to hypovitaminosis A are

low food intake, intestinal parasitosis, malabsorption syndromes, and diets containing low amounts of vitamin A (Figure 2).

Hypovitaminosis A is classically caused by food deprivation. It is present in rural areas and the peripheries of large cities in South Asia, Africa, and Latin America, and the poor communities of large cities of developed countries(14-17). The most vulnerable individuals are chil-dren and pregnant women. The prevalence of hypovitaminosis A can reach 50% in children under 6 years of age in certain areas(18). Labo-ratory confirmation of the diagnosis of hypovitaminosis A is defined as a serum retinol level <0.3 mg/l or 0.7 µM(19).

In addition to ocular problems, hypovitaminosis A also predispo-ses individuals to retarded growth, infertility, congenital malforma-tions, infections, and early mortality(18,20). The issue of vitamin A defi-ciency in these populations, distributed in more than 45 countries, has been the target of international preventive programs of vitamin A supplementation and periodic evaluation(16,18,19).

Individuals suffering from food deprivation and malabsorption are often infected with intestinal parasite diseases, such as Ascaris lumbricoides and Ancilostomides, Giardia lamblia, which may aggra-vate the inflammatory background and the signs and symptoms of hypovitaminosis A(21-24).

Other well-known causes of vitamin A deficiency can be grouped into conditions associated with malabsorption syndrome. The treat-ments of several diseases that cause digestive disturbances and/or absorption of lipids and vitamin A have improved in recent decades leading to increased life expectancy and improved the clinical con-trol of hypovitaminosis A allowing the majority of patients to lead a normal life. However, the majority of these patients will develop xerophthalmia (the specific term for hypovitaminosis A-related dry eye), which may progress to more severe ocular damage and other clinical manifestations of vitamin A depletion(25-27).

Acquired diseases associated with malabsorption syndrome known to cause hypovitaminosis A include chronic pancreatitis caused by chronic alcoholism, liver and pancreas autoimmunity, Crohn’s disease, and ulcerative colitis, among other diseases affecting the digestive system(28).

Congenital diseases associated with malabsorption syndrome and hypovitaminosis A include cystic fibrosis and short bowel syndrome, among other genetic diseases that may impair intestinal vitamin A absorption in individuals with normal or high oral intake of retinoid and carotenoids(2,29,30).

The fourth group of conditions that classically cause hypovitami-nosis A is those that may initially lead to malabsorption syndrome but later progresses to impaired hepatic storage of vitamin A. Biliary cir-rhosis, chronic hepatitis, and chronic cirrhosis caused by toxic agents, viruses, and other causes may lead to hypovitaminosis A and should be screened for and treated by parenteral vitamin A supplementation according to body mass index and level of vitamin A deficiency(31).

MODERN DISEASES ASSOCIATED WITH HYPOVITAMINOSIS AIn recent decades, the conditions known to induce hypovitami-

nosis A have been classified into four groups. Despite their varying prevalence, such conditions should be carefully considered by ophthalmologists during routine clinical practice.

Modern causes of hypovitaminosis A that may also lead to xe-rophthalmia and other eye diseases and cause blindness are shown in (Figure 2 and Table 2) and comprising voluntary ingestion of low vitamin A diets or restrictive diets (e.g., vegetarian or cafeteria diets), psychiatric eating disorders (e.g., anorexia and bulimia), bariatric

Figure 1. Metabolic steps underlying vitamin A deficiency from the dietary level to tar-get cells.

Table 1. Vitamin A nomenclature

Name Group Characteristics

Retinoids Vitamin A and natural or synthetic derivate Similar chemical polyenes and polar end groups

Carotenes α-Carotene, β-carotene, γ-carotene, and the xanthophyll β-cryptoxanthin Β-ionine rings

Vitamin A Group of lipophilic nutritional compounds Essential and broad effects on chordate animal bodies

Provitamin A Carotenes and retinyl esters Dietary and pharmaceutical sources of vitamin A

Retinoic acid Metabolite of vitamin A Transcription factor binding to cell nuclear receptors

Retinal Form of vitamin A Essential for vision function

Retinol Form of vitamin A Growth and development functions

Tretinoin All trans retinoic acid Pharmaceutical formulas

1 IU of vitamin A = 0.3 μg retinol = 0.34 μg retinil acetate = 0.6 μg β-carotene.



surgeries mimicking malabsorption syndrome, and chronic diseases that affect organs involved in vitamin A digestion or clearance (e.g., Sjögren’s syndrome and kidney failure).

Restrictive diets resulting from dietary behaviors may lead to a status of hypovitaminosis A and the consequences mentioned above. Diets adopted in conjunction with drugs to reduce appetite, diets with monotonous ingredients, and diets with limited sources of animal ingredients containing retinol and beta carotene (meat and

dairy products such as milk, eggs, and their derivatives) are typically followed in the belief they will offer better control or prevention of certain diseases or improve general health(32-35).

Exclusively vegetarian diets particularly put children and pregnant woman at increased risk of hypovitaminosis A as the conversion of beta carotenes present in vegetables to retinol is limited during di-gestion and the availability of vitamin A for absorption and hepatic storage is <20% of dietary vitamin A content(1).

The so-called cafeteria diet or competitive food, based on re-freshing sodas and industrialized food, is predominantly composed of carbohydrates and lipids of vegetal source and provides insuffi-cient amounts of dietary vitamin A. Accordingly, such diets could be con-sidered causes of hypovitaminosis A and associated ocular problems in patients with excessive habits related to these diets(36).

The second group of causes of hypovitaminosis A includes the psychiatric eating disorders, anorexia, and bulimia nervosa, recogni-zed as major, growing health problems with severe clinical compli-cations, and high mortality. Both can cause hypovitaminosis A due to chronic dietary disturbances. The complexity of such conditions must be recognized in the context of early signs of xerophthalmia and should be managed in parallel with psychiatric specialists(37,38).

Bariatric techniques for the treatment of obesity include jejunoi-leal bypass and stomach reduction to induce weight loss by malab-sorbtive and restrictive mechanisms(39-41). Patients require vitamin su-pplementation following these procedures; however, a recent study in Brazil demonstrated that even before bariatric surgery a re lative amount of patients already have hypovitaminosis A, and that this pre-valence increases 30 and 180 days after the procedure(42). In patients with no compliance for a period of weeks or months, ophthalmolo-gists may evaluate the initial manifestations of hypovitaminosis A. Special attention should be paid to patients undergoing oculoplastic or refractive surgeries as their nutritional status may be subclinical Figure 2. Classic and modern causes of hypovitaminosis A.

Table 2. Major causes of hypovitaminosis A and diagnosis guidelines

Major causes of deficiency of vitamin A Description

Primary deficiency Low dietary intake of vitamin AFood source: liver beef, damascus, spinach, cabbage, milk, carrot, and butterDiagnosis: food intake history, liver function, and vitamin A serum levels

Restrictive and monotonous diets Restricted intake of sources of vitamin A and consumption of the same group of food for many monthsEating disorders: psychiatric, cafeteria diet, and vegetarianDiagnosis: food intake history. Physical signs. Blood vitamin A levels

Malabsorption syndrome Reduction in uptake and mucosa transport of digested nutrients to the blood streamDiagnosis: diarrhea, steatorrhea, weight loss, anemia, hyperkeratosis, and acrodermatitis. Blood examination to check pancreas and liver function. Stool analysis (fat, parasites)

Bariatric surgery Surgery to treat obesity and associated diseases is divided into restrictive, disabsorptive, and mixed techniques and often mimics malabsorption syndromeDiagnosis: surgical history, use of vitamin supplements, bowel habits. Food intake history. Physical signs. Blood levels of vitamin A. Stool analysis (fat)

Short bowel syndrome Mesenteric vascular disease typically caused by congenital obstruction, thrombosis, and other diseases requiring bowel resectionDiagnosis: diarrhea, fatigue. Blood levels of vitamin A. Stool analysis (fat)

Liver failure Loss of liver digestive and storage functions due to alcohol toxicity, virus infection, or other causes. Malabsorption mechanisms and signs may be present.Diagnosis: blood levels of liver enzymes and vitamin A, virus serology. Stool analysis (fat)

Chronic pancreatitis Loss of pancreas exocrine function affecting digestion. Malabsorption mechanisms and signs may be presentDiagnosis: blood levels of pancreas enzymes and vitamin A. Stool analysis (fat)

Cystic fibrosis Inherited disease affecting chloride channels leading to exocrine gland dysfunction. Malabsorption mechanisms and signs may be presentDiagnosis: low weight gain in infancy, progressive malnutrition, chronic cough with hypersecretion, chronic sinusitis, biliary cirrhosis, diabetes, respiratory infections and infertility. Sodium and chloride levels in sweat

Salivary and deglutition diseases Swallowing problems due to xerostomia, tooth problems, and/or muscular deglutition dysfunction. Example: Sjögren’s syndromeDiagnosis: oral and dental examination and salivary flow rate

Faustino JF, et al.


and cause disturbances in ocular surface homeostasis and wound healing leading to poor outcomes and serious ocular com plications(40).

Patients with the above-mentioned conditions may share a number of characteristics including individual concern and anxiety regarding body image, health, and satisfaction with food consumption.

The fourth class of modern causes of hypovitaminosis A that may contribute to or worsen ocular surface diseases is the chronic disease leading to chronic impairment of the organs involved in digestion and clearance of vitamin A metabolites (Figure 1). Although the ma jority of these diseases are not new, improvements in therapeutic approach have allowed affected patients to lead longer and more acti-ve lives. Similarly, vitamin A deficiency may be neglected in patients receiving frequent healthcare.

Within this group, the diseases causing severe dry mouth, such as head and neck radiotherapy and Sjögren’s syndrome, may limit deglutition and digestion and impose dietary restrictions that may lead to hypovitaminosis A(43,44). Therefore, dietary habits and vitamin A levels should be evaluated in patients presenting the diseases des-cribed above and ocular surface complications. Although patients commonly present with dry eye disease associated with these con-ditions, the clinical picture may be aggravated by hypovitaminosis A.

Renal failure and hemodialysis are associated with dry eye disease and ocular surface changes in diabetic and nondiabetic patients(45,46). There is currently controversy regarding lower vitamin A levels in such patients as renal failure reduced the reliability of traditional me-thods of measuring vitamin A levels. However, lower blood vitamin A levels have been shown to be associated with higher morbidity and mortality in these patient populations(47,48). Recently, a case of night blindness and compatible retinal changes was described in a he-modialysis patient with apparent normal levels of serum retinol that were corrected with retinol palmitate treatment(49).

SIDE EFFECTS OF VITAMIN A MEDICAL USEThe utility of vitamin A topical eye drop administration in treating

dry eye has been comprehensively investigated(50,51). Vitamin A topi-cal eye drops may also have utility in the treatment of skin diseases and specific types of cancer including ocular surface neoplasia(52,53). However, excessive vitamin A intake is known to induce gastric and neural side effects such as abdominal and head pain, nausea, and irritability(54,55). These symptoms may be aggravated by chronic use of vitamin A eye drops and lead to the development of blurred vision and pseudotumor cerebri(56-58). A clinical history of dry skin and mucosa, nausea, and retinoic acid intake in meals or pharmaceutical formu-lations should inform suspicion of acute and chronic side effects or consequences of excessive vitamin A dosing.

Recently, two publications reviewed the mechanisms underlying the induction of meibomian gland dysfunction and dry eye symptoms by systemic retinoic acid therapy for acne. The authors discussed the effects of systemic and topical skin or ocular application of diffe-rent forms and doses of vitamin A formulations. Moreover, it was persistent meibomian gland dysfunction after systemic retinoic acid discontinuation was reported(4,52).

CASE REPORTSCase report 1: A 2-year-old boy presented with a history of con-

se cutive episodes of hordeola affecting the upper and lower lids of both eyes over the preceding 12 months. The patient had a history of photophobia and crying without tears. Previous ocular treatment included lubricants and antiallergic eye drops. The patient was an only child with no other personal or family antecedents. His dietary habits were based on soft drinks and junk food between meals with deficient intake of meat, milk derivatives, vegetables, and fruits. Swollen lids and hordeola affecting both eyes were observed on exa-mination. He was able to fix and follow light projection with both eyes

but was unable to perform visual acuity testing. Slit lamp examination demonstrated mild punctate keratitis and an epithelial defect in the right cornea. The rest of the ocular examination was normal. His body weight matched the 50th percentile for age and sex (12.7 kg); however, his height was in the tenth percentile (84 cm). Laboratory testing was requested and identified hypochromic and microcytic anemia with low blood levels of iron and retinol (32.7 μg/dl and 0.20 mg/l, where the normal levels for children are 50-150 μg/dl and 0.30-0.80 mg/l, respectively).

Clinical findings and laboratory testing indicated the chronic pre-sence of hordeola, syndrome sicca, growth retardation, and anemia were all consequences of a diet deficient in essential elements such as vitamin A and iron (Fe). The diet was reoriented, and the child was maintained under close observation by his pediatrician until clinical signs improved fully.

Case report 2: A 71-year-old woman presented with decreased vision and pain in the left eye (OS) for 20 days and a diagnosis of corneal ulcer. She was receiving antibiotic and corticosteroids eye drops at the time of presentation. She had previously undergone cataract surgery in both eyes 2 months prior to this presentation. Her medical history was noncontributive except for inappetence and weight loss of approximately 10 kg over the preceding year. Her visual acuity was 0.5 in her right eye (OD) and counting fingers at 1 m OS. Biomicroscopic examination revealed conjunctiva hyperemia and a 1.5 mm by 2.5 mm corneal ulcer without secretion or infiltration. A diagnosis of microbial keratitis was made, and eye drops were chan-ged accordingly. During follow-up, she developed a corneal ulcer OD and the ulcer in the OS worsened. Severe corneal punctate fluores-cein staining and conjunctival Rose Bengal staining were observed in both eyes. The Schirmer test without anesthesia was zero in both eyes. Her salivary flow was 0.06 ml/min (normal values >0.1 ml/min; Figure 3). Laboratory tests were positive for SSa and SSb (anti-Ro and anti-La antibodies, respectively), and blood levels of vitamin A were 0.2 mg/l. A minor salivary gland biopsy demonstrated leukocyte infil-tration with focal organization, ductal dilation, and extensive fibrosis replacing acinar structures. The focus score was graded 4. During eva-luations, the patient developed corneal melting OD and underwent penetrant keratoplasty. The present findings indicated a diagnosis of Sjögren’s syndrome aggravated by hypovitaminosis A. After a period of corticosteroids and vitamin A therapy, her general and ocular symptoms improved. Her case illustrates a delicate combination of causes of sicca syndrome (Sjögren’s syndrome and hypovitaminosis A) leading to a severe presentation. The extensive fibrosis of salivary gland structures, almost completely replaced by fibrosis, may be a consequence of concurrent disease and ageing (Figure 3 D).

Case report 3: A 22-year-old woman presented with ocular pain, lid edema, and thick tearing for 5 months not improved by lubricants, cyclosporine eye drops, or bandage contact lenses. She reported a habit of mucous fishing. Her previous medical history included myo-pia, allergy, and acne vulgaris. She had been prescribed a 6-month course of oral isotretinoin 6 years previously without side effects and again 6 months prior to the current complaint. Examination revealed skin scarring, meibomian gland dysfunction, and punctate and filamentary keratitis that was worse OD (Figure 4). The tear film breakup time was 3 s in both eyes and the tarsal conjunctiva presen-ted papillary reaction. The Schirmer test without anesthesia was zero in OD and 2 mm in OS, and her salivary flow rate was 0.033 ml/min. Laboratory testing was negative for hormonal abnormalities, and cystic fibrosis and her vitamin A blood levels were 0.4 mg/l. Tests for autoimmune diseases were negative for SSa and SSb, rheumatoid factor, and antinuclear antibody. Her condition was attributed to a side effect of isotretinoin treatment that had persisted after an 18-month interruption of oral isotretinoin intake. Her case corrobo-rates previous reports of vitamin A-induced dry eye and represents a severe form of this condition that persisted after discontinuation of the causative medication.



INVESTIGATIONHypovitaminosis A should be suspected in all cases of night blindness,

ocular surface foreign body sensation, and photophobia without other evident causes. Crying without tearing is another relevant symptom of hypovitaminosis A. Recurrent hordeolum, meibomian gland dysfunc-tion identified by gland dropout or inflammation with thickened lipid secretion, corneal epithelial defect, conjunctiva metaplasia (where Bitot’s spot is an advanced form and a hallmark), and diffuse punctate keratitis also represent signs suspicious for hypovitaminosis A.

In all patients suspected to have hypovitaminosis A, a dietary intake and nutritional habits enquiry must be conducted, with previously validated evaluation models available. In children, investigations of height and weight gain during the management period may also have utility.

The utility of blood vitamin A levels measurements is broadly accepted, and a classification system established by the World Health Organization has defined low vitamin A levels as serum retinol con-centrations <0.3 mg/l or 0.7 µM. There have been concerns regarding

the reliability of blood concentration measurements as the liver is able to sustain normal levels even in extremely vitamin A-deficient states(19,59,60).

Other blood tests including complete blood count, protein, albu-min, micronutrients, electrolyte concentrations, and stool fat micros-copy have all demonstrated utility in assessing vitamin A deficiency severity. In addition, liver function tests, serology for hepatitis, and sweat sodium chloride test values >60 mM may aid in distinguishing between liver diseases and cystic fibrosis, respectively.

Ocular surface assessments may be performed with vital staining and tear secretion measurements (fluorescein dye and Schirmer’s test). Corneal and conjunctival impression cytology allows documen-tation of ocular surface epithelial metaplasia, square and speculate cells morphology, reduced nuclear size, and the absence or paucity of goblet cells on microscopy. Ocular surface assessments have de-monstrated utility as simple and mildly invasive methods of recor-ding and monitoring hypovitaminosis A in early xerophthalmia(61).

CONCLUSIONThe major aim of treatment is to restore vitamin A levels in cases

of hypovitaminosis and reduce exposure in conditions associated with side effects of oral or skin topical vitamin A use. Details regarding dosage and administration routes are outside the scope of the pre-sent review, as they are dependent on the underlying cause, patient characteristics, and severity of individual cases.

Healthcare professionals attending poor populations and pa-tients with chronic malabsorption syndrome, hepatic, and other re-lated diseases should be familiar with the classic causes of hypovita-minosis A. The modern causes of hypovitaminosis A do not have the same magnitude in terms of prevalence but should be considered by ophthalmologists in daily clinical practice. Hypovitaminosis A can cause blindness and corneal opacity, but it is also an important cause of morbidity and mortality.

Increased suspicion of hypovitaminosis A due to ocular surfa ce symptoms and signals should direct prompt investigation of nu tritional and digestive problems followed by interdisciplinary management allowing early diagnosis and treatment of the causes and effects of the majority of diseases related to hypovitaminosis A.

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Figure 3. A 71-year-old woman with bilateral corneal ulcers, weight loss, and features of autoimmune disease affecting her hands. (A) Slit lamp examination demonstrating a corneal ulcer OD. (B) OD corneal melting. (C) Body aspect of weight loss. (D) Histology of a minor salivary gland with leukocyte focal infiltration, ductal dilation, and extensive fibrosis replacing acinar structures (200×). Her condition was attributed to a combination of dryness caused by Sjögren’s syndrome and hypovitaminosis A.

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55. Oliveira MR. The neurotoxic effects of vitamin A and retinoids. An Acad Bras Cienc. 2015:97(2):1361-73.

56. Tan X, Takahashi H, Nishida J, Aoki A, Inoue T, Yanagi Y. Excessive retinol intake exacer-bates choroidal neovascularization through upregulated vascular endothelial growth factor in retinal pigment epithelium in mice. Exp Eye Res. 2015;131:77-83.

57. Fraunfelder FT, LaBraico JM, Meyer SM. Adverse ocular reactions possibly associated with isotretinoin. Am J Ophthalmol. 1985;100(4):534-7.

58. McGeeney BE, Friedman DI. Pseudotumor cerebri pathophysiology. Headache. 2014; 54(3):445-58.

59. Tanumihardjo SA. Vitamin A: biomarkers of nutrition for development. The Am J Clin Nutr. 2011;94(2):658S-65S.

60. Sommer A, Davidson FR; Annecy Accords. Assessment and control of vitamin A de-ficiency: the Annecy Accords. J Nutr. 2002;132(9 Suppl):2845S-50S.

61. Wittpenn JR, Tseng SC, Sommer A. Detection of early xerophthalmia by impression cyto-logy. Arch Ophthalmol. 1986;104(2):237-9.

Letters to the Editor

62 Arq Bras Oftalmol. 2016;79(1):62 http://dx.doi.org/10.5935/0004-2749.20160019

Preoperative usage of ultrasound

biomicroscopy in pediatric cataract

Uso pré-operatório de biomicroscopia ultrassônica

em catarata pediátrica

Dear Editor:I read the article “Epilens membrane simulating cataract in children

with uveitis: a report of three cases” by Paiva et al. with great interest(1). Three cases were presented that were diagnosed as cataract secon-dary to uveitis but that were understood to have received treatment for pupillary membrane intraoperatively. I congratulate the authors for their attention and good management.

Cataract surgery is a radical operation in children(2) and may cause quite a few complications; patients will also require follow-up after operation. The indication for cataract surgery in children should be evaluated carefully. Preoperative examination and imaging are critical for deciding on whether to operate or not and to identifying opera tion strategy. Ultrasound biomicroscopy (UBM) could be a good ima ging method to diagnose epilens membrane in these cases(3).

UBM is a non-invasive method that allows imaging of structural details of the anterior segment and the lens. UBM could visualize the epilens membrane and divulge the transparency of the lens. Ne vertheless, it is a great advantage to be able to differentiate the membrane intraoperatively without damaging the anterior capsule.

Abdullah Kaya1

Submitted for publication: October 26, 2015 Accepted for publication: November 9, 20151 Department of Ophthalmology, Anittepe Military Dispensary, Cankaya, Ankara, Turkey.



Corresponding author: Abdullah Kaya. Anittepe Military Dispensary. Department of Ophthalmology Cankaya, Ankara - Turkey - E-mail: [email protected]

REFERENCES 1. Paiva R, Nascimento H, Salomão G, Freitas L, Muccioli C, Belfort R Jr. Epilens membra-

ne simulating cataract in children with uveitis: a report of three cases. Arq Bras Oftal mol. 2015;78(5):326-7.

2. Pavlović S. [Cataract surgery in children]. Med Pregl. 2000;53(5-6):257-61. Review. Croa tian.

3. Ünsal E, Eltutar K, Muftuoglu I, Akcetin TA, Acar Y. Ultrasound biomicroscopy in pa-tients with unilateral pseudoexfoliation. Int J Ophthalmol. 2015;8(4):754-8.

Letters to the Editor

63Arq Bras Oftalmol. 2016;79(1):63http://dx.doi.org/10.5935/0004-2749.20160020

Zika virus-related hypertensive

iridocyclitis

Iridociclite hipertensiva associada à infecção por

Zika vírus

Dear Editor:The epidemic of Zika virus infection in Brazil has lead to the des-

cription of new complications and manifestations such as Guillain-Barré syndrome in adults and microcephaly in newborns(1,2). Zika virus is a flavivirus transmitted to humans primarily through the bite of an infected Aedes species mosquito(3). It was first isolated and described in Africa, later spreading to Asia, Micronesia, Oceania, and to the Americas(2).

It is thought that only 1 in 5 people infected with the Zika virus will become symptomatic(3). The most common systemic manifestations include: fever, arthralgia, malaise, and skin rash(4,5). More recently, retinal abnormalities were described in children with microcephaly attributed to Zika virus infection during pregnancy(6).

The purpose of this letter is to describe a case of bilateral hyper-tensive iridocyclitis attributed to Zika virus in an otherwise healthy young male.

A 39-year-old male physician was clinically diagnosed with Zika virus infection. This occurred in a neighborhood with an outbreak of this disease. He presented with classic signs of fever, diffuse maculo-papular rash, and severe arthralgia. Systemic work-up ruled out other possible infectious such as Dengue, CMV, Herpes Simplex, Toxoplas-mosis, Syphilis, Rubella, spondyloarthropathies, rheumatic diseases, and systemic vasculitis.

One week after the systemic manifestations the patient complai-ned of bilateral ocular discomfort for near tasks, blurry vision, and mild redness. Best-corrected visual acuity was 20/40 in each eye. Slit-lamp examination revealed moderate ciliary injection, mild anterior chamber

reaction (1+ cells), and miosis in both eyes. Intraocular pressure (Gol-dmann applanation tonometry) was 40 and 28 mmHg in right and left eyes, respectively.

He was treated with topical medications (steroids, cycloplegic and hypotensive agents) for several weeks. This achieved improve-ment of visual acuity, lowering of intraocular pressure, and complete resolution of symptoms.

Although no specific protein-chain reaction (PCR) for Zika virus has been performed, it is very likely that this bilateral hypertensive iri-docyclitis occurred secondary to Zika virus. Since it has been shown that the virus penetrates the blood-brain and ocular barriers, many other ocular findings (in addition to conjunctivitis and retinal abnormalities) might be observed in the future. Physicians should be attentive to ocular complaints when treating patients with Zika virus infection and refer patients to a specialist for complete ocular examination.

Bruno M. Fontes1

Submitted for publication: January 15, 2016 Accepted for publication: January 18, 20161 Centro de Microcirurgia & Diagnóstico, Rio de Janeiro, RJ, Brazil.



Corresponding author: Bruno Machado Fontes. Av. Ataulfo de Paiva 135/1418 - Rio de Janeiro, RJ - 22440-032 - Brazil - E-mail: [email protected]

REFERENCES 1. Fauci AS, Morens DM. Zika Virus in the Americas - Yet Another Arbovirus Threat. N Engl

J Med. 2016 Jan 13. (Epub ahead of print). 2. Zika virus outbreaks in the Americas. Wkly Epidemiol Rec. 2015 Nov 6;90(45):609-10 3. Marcondes CB, Ximenes MF. Zika virus in Brazil and the danger of infestation by Aedes

(Stegomyia) mosquitoes. Rev Soc Bras Med Trop. 2015 Dec 22 (Epub ahead of print). 4. Dyer O. Zika virus spreads across Americas as concerns mount over birth defects. BMJ.

Dec 23;351:h6983. 5. Triunfol M. A new mosquito-borne threat to pregnant women in Brazil. Lancet Infect

Dis. Published online: December 23, 2015. 6. Ventura CV, Maia M, Bravo-Filho V, Góis AL, Belfort Jr R. Zika virus in Brazil and macular

atrophy in a child with microcephaly. The Lancet, Vol. 387, No. 10015, p228. Published online: January 7, 2016.


Instructions Authors

INSTRUCTIONS TO AUTHORS

ABO-ARQUIVOS BRASILEIROS DE OFTALMOLOGIA (ABO, ISSN 0004-2749 - printed version and ISSN 1678-2925 - online version) is the official bimonthly publication of the Brazilian Council of Ophthal-mology (Conselho Brasileiro de Oftalmologia - CBO). The purpose of the journal is to publish scientific studies in Ophthalmology, Visual Sciences, and Public Health, encouraging research, as well as qualifi-cation and updating of the professionals involved in this field.

METHODSOriginal manuscripts are accepted only in English. Manuscripts

are grouped into one of the following categories, based on the me-thodology used:

CLINICAL STUDIES

Descriptive or analytical studies involving humans or evaluating the literature relevant to humans.

EPIDEMIOLOGICAL STUDIES

Analytical studies involving results from human populations.

LABORATORY EXPERIMENTAL STUDIES

Descriptive or analytical studies involving animal models or other biological, physical or chemical techniques.

THEORETICAL STUDIES

Descriptive studies involving description and theoretical analysis of new hypotheses based on the knowledge available in the literatu-re. Theoretical results must add new information to literature.

TYPES OF MANUSCRIPTSManuscripts submitted to ABO should fit into one of the follo-

wing categories according to their format. The maximum number of words, figures, tables and, references for each type of manuscript are in parentheses at the end of the description for each category. The word count of the manuscript includes the text from the beginning of the introduction up to the end of the discussion; therefore, the following items are not included: title page, abstract, references, acknowledgments, tables and figures, including legends.

EDITORIALS

Editorials are contributed by invitation and should be related to to pics of current interest, preferentially related to articles published in the same issue of ABO (title, maximum of 1,000 words, 2 figures or tables, and 10 references).

ORIGINAL ARTICLES

Original articles present complete experiments with results that have never been published before (title, structured abstract, maximum of 3,000 words, 7 figures or tables, and 30 references). The evaluation of the manuscripts will be based on the following priorities:

1. New and relevant information based on a study that uses appro-priate methodology.

2. Repetition of information available in the literature, not pre-viously confirmed locally, based on a study that uses appropriate methodology.

3. Repetition of information available in the literature and pre-viously confirmed locally, based on a study that uses appropriate methodology.

* Manuscripts containing speculative conclusions, unsubstantiated by the results or based on a study with inappropriate methodology will not be accepted.

CASE REPORTS AND CASE SERIES

Case reports or case series will be considered for publication when describing rare and original findings that have not been internatio-nally confirmed, or when presenting clinical or surgical responses that can contribute to elucidate the pathophysiology of a disease (ti tle, unstructured abstract, maximum of 1,000 words, 4 figures or tables, and 10 references).

LETTERS TO THE EDITOR

Letters to the editor are considered for publication if they contain comments related to manuscripts previously published in ABO or, exceptionally, the results of original studies with insufficient content to be submitted as Original Article. These letters should present new information or new interpretation of existing information. When the content of the letter refers to an article previously published in ABO, such article should be mentioned in the first paragraph of the letter and included in its reference list. In these cases, the letters will be linked to the article, and the authors of the article will have their right of reply guaranteed in the same issue. Congratulation letters will not be published (title, maximum of 700 words, 2 figures or tables, and 5 references).

REVIEW ARTICLES

Review articles follow the editorial line and are accepted only by invitation from the editor. Suggestions of topics for review articles should be sent directly to the editor, but manuscripts cannot be sent without an invitation (title, unstructured abstract, maximum of 4,000 words, 8 figures or tables, and 100 references).

EDITORIAL PROCESSManuscripts will only be considered for publication if they meet

all the journal’s requirements. The editorial office will inform the authors if their manuscript fails to meet such requirements. Upon notification, the corresponding author will have 30 days to make the necessary changes in the manuscript. If the deadline is not met, the manuscript will be excluded from the editorial process.

The manuscripts submitted to ABO are initially evaluated by the editors to check for content compliance with the editorial line of the journal. After this assessment, all manuscripts are sent for peer review. The anonymity of reviewers is preserved throughout the whole pro-cess. However, the authors of manuscripts do not remain anonymous.

After the initial editorial evaluation, the reviewers’ comments can be sent to the authors to guide the changes to be implemented in the text. After implementing the changes suggested by the revie-wers, the revised manuscript should be resubmitted along with a letter (which is sent as a supplementary document) with specific in dications of all changes made to the manuscript or the reasons why the suggested changes were not made. Manuscripts that are resubmitted without a letter will be withheld until the editorial office receives the letter. The deadline to submit the new version of the ma-


nuscript is 30 days after the authors are informed of the need to make changes in their manuscript. Manuscripts will be excluded from the process if authors fail to meet this deadline. The ultimate publication will be based on the final approval of the editors.

Manuscripts submitted to ABO should not be simultaneously considered for publication by other journals. In addition, total or par-tial publication or translation for publication in another language of the manuscripts submitted to ABO should not be considered without the permission of the editors of ABO.

AUTHORSHIPThe criteria for authorship of manuscripts in medical journals are

well established. Individuals who have contributed in a concrete way during the following three phases of manuscript preparation should be considered authors: I. Conception and design, acquisition of data, or analysis and

interpretation of data. II. Draft or critical revision of the article for important intellectual

content. III. Final approval of the version to be published.

The authors of manuscripts submitted to ABO should make sure that all authors meet the criteria mentioned above and that all per -sons who meet these criteria are listed. Individuals who hold head-ship positions cannot be considered authors of manuscripts based only on their positions. ABO does not accept the participation of honorary authors.

The corresponding author should complete and submit the Au-thor Contribution Statement as a supplementary document.

GUIDELINES FOR EXCELLENT RESEARCHIt is recommended that authors follow the appropriate guideline

bellow before submitting your work:CONSORT (Controlled and randomized clinical trials)STARD (Diagnostic instruments or techniques)PRISMA (Systematic reviews and meta-analyses) STROBE (Observational studies)

MANUSCRIPT PREPARATIONManuscripts should only be submitted online using the appro-

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

http://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/

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

http://www.clinicaltrials.gov

http://www.anzctr.org.au

International Standard Randomised Controlled Trial Number - ISRCTNhttp://isrctn.org/

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/

http://www.ncbi.nlm.nih.gov/sites/entrez?db=mesh&term=

http://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

Chief Executive Officer: Fernando Steven Ullmann;Commercial Director: Helen Suzana Perlmann; Art Director: Elza Rudolf;

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