Ultrastructural changes detected using swept-source optical coherence tomography in severe vitreopapillary traction: a case report / Alterações ultraestruturais detectadas pela tomografia de coerência óptica de fonte de varredura em tração vitreopapilar grave: relato de caso

ABSTRACT Vitreopapillary traction is an uncommon condition characterized by strong adhesion and the traction of the posterior hyaloid onto the optic disc and peripapillary retina, leading to optic disc elevation and visual loss. An 85-year-old man presented with a 6-month history of slow, progressive visual loss in the left eye along with optic disc edema. Swept-source optical coherence tomography B-scans revealed circumpapillary anterior-posterior persistent traction of dense vitreous strands onto the optic disc. Visual field examination demonstrated mild, generalized, diffuse sensitivity loss and blind-spot enlargement. A 25-gauge posterior vitrectomy was performed with posterior hyaloid separation from the optic disc, resulting in significant anatomical and visual improvement. In conclusion, swept-source optical coherence tomography aids in understanding the mechanism underlying visual loss in vitreopapillary traction. Moreover, posterior vitrectomy can effectively promote anatomical and visual improvements in these cases.

RESUMO A tração vitreopapilar é uma condição incomum caracterizada por forte adesão e tração da hialoide posterior no disco óptico e retina peripapilar, levando à elevação do disco óptico e à perda visual. Um homem de 85 anos apresentou uma história de 6 meses de perda visual lenta e progressiva no olho esquerdo, juntamente com edema do disco óptico. A tomografia de coerência óptica por fonte de varredura revelou tração persistente ântero-posterior peripapilar com traves vítreas densas sobre o disco óptico. Exame de campo visual demonstrou perda de sensibilidade difusa, generalizada, leve e aumento do ponto cego. Uma vitrectomia posterior de calibre 25 foi realizada com separação hialóide posterior do disco óptico, resultando em melhora anatômica e visual significativa. Em conclusão, a tomografia de coerência óptica por fonte de varredura auxilia na compreensão do mecanismo subjacente à perda visual na síndrome de tração vitreopapilar. Além disso, a vitrectomia posterior pode efetivamente promover melhorias visuais e anatômicas nesses casos.

Ultrasonographic characteristics of active ocular toxoplasmosis / Achados ultrassonográficos em toxoplasmose ocular ativa

ABSTRACT Purpose: To evaluate ophthalmic ultrasonographic findings associated with active ocular toxoplasmosis. Methods: Forty-seven eyes with active ocular toxoplasmosis in 47 patients were subjected to ocular ultrasonography using the transpalpebral technique (10-MHz transducer) and fundus photography. Patient medical records were retrospectively reviewed. Results: Ocular ultrasonography revealed vitritis, posterior vitreous detachment, retinal wall thickening, and non-rhegmatogenous retinal detachment in 47 (100%), 36 [76.6%; partial in 12 (25.5%) and total in 23 (48.9%)], 12 (25.5%), and 5 eyes (10.6%). Thirty-five of the 36 eyes with posterior vitreous detachment (97.2%) exhibited posterior hyaloid thickening; moreover, adhesion to the exudative lesion and vitreoschisis were observed in 4 (11.1%) and 12 eyes (25.5%), respectively. Ultrasonography detected the location of the exudative focus in 12 eyes (25.5%). Conclusion: Ultrasonography is helpful for detecting important intraocular findings of acute ocular toxoplasmosis that can be hindered by medial opacity or posterior synechiae.

RESUMO Objetivo: Avaliar os achados da ultrassonografia na toxoplasmose ocular ativa. Métodos: Quarenta e sete olhos com toxoplasmose ocular ativa em 47 pacientes foram submetidos à ultrassonografia ocular pela técnica transpalpebral (transdutor de 10 MHz) e fundo de olho. Os prontuários médicos foram revistos retrospectivamente. Resultados: A ultrassonografia ocular revelou vitreíte, descolamento vítreo posterior, espessamento da parede da retina e descolamento de retina não regmatogênico em 47 (100%), 36 [76,6%; parcial em 12 (25,5%) e total em 23 (48,9%)], 12 (25,5%) e 5 olhos (10,6%). Trinta e cinco dos 36 olhos com descolamento vítreo posterior (97,2%) exibiram espessamento hialoide posterior; além disso, a adesão à lesão exsudativa e vitreosquise foi observada em 4 (11,1%) e 12 (25,5%), respectivamente. A ultrassonografia detectou a localização do foco exsudativo em 12 olhos (25,5%). Conclusão: A ultrassonografia é útil na detecção de importantes achados intra-oculares de toxoplasmose ocular aguda que podem ser prejudicados pela opacidade medial ou sinéquia posterior.

Intravitreal neurodegenerative and inflammatory mediators in proliferative diabetic retinopathy / Mediadores intravítreos da neurodegeneração e inflamação na retinopatia diabética proliferativa

ABSTRACT Purpose: To compare the intravitreal concentrations of cellular mediators involved in neurodegeneration, inflammation, and angiogenesis in patients with proliferative diabetic retinopathy and other vitreoretinal diseases. Methods: A multiplex bead immunoassay was used to measure vitreous levels of pigment epithelium-derived factor, serum amyloid P, C-reactive protein, complement C4, alpha-1 antitrypsin, vascular endothelial growth factor, platelet-derived growth factor-AA, platelet-derived growth factor-BB, interleukin-6, interleukin-8, interleukin-10, tumor necrosis factor alpha and beta in patients undergoing 23-gauge vitrectomy for proliferative diabetic retinopathy and other diagnoses (control group). Results: We evaluated 55 patients, of whom 24 had proliferative diabetic retinopathy and 31 had other diagnoses including vitreous hemorrhage, retinal detachment, macular hole, and epiretinal membrane. Patients with proliferative diabetic retinopathy demonstrated increased levels of serum amyloid P (85.49 vs. 31.38 ng/mL); C-reactive protein (59.89 vs. 41.75 ng/mL), vascular endothelial growth factor (2,330.11 vs. 554.25 pg/mL; p<0.001), platelet-derived growth factor A (127.32 vs. 39.11 pg/mL), platelet-derived growth factor B (29.37 vs. 7.12 pg/mL), interleukin-6 (69.37 vs. 33.58 pg/mL), interleukin-8 (175.25 vs. 59.71 pg/mL), and interleukin-10 (3.70 vs. 1.88 pg/mL); all p<0.004 when compared with the control group. Levels of pigment epithelium-derived factor (30.06 vs. 27.48 ng/mL; p=0.295), complement C4 (570.78 vs. 366.24 ng/mL; p=0.069), and alpha-1-antitrypsin (359.27 vs. 522.44 ng/mL; p=0.264) were not significantly different between the groups. Intravitreal levels of tumor necrosis factor-alpha and tumor necrosis factor-beta were undetectable. Serum Amyloid P, C-reactive protein, platelet-derived growth factor A, platelet-derived growth factor B, interleukin-6, and interleukin-8 were correlated positively with vascular endothelial growth factor. Conclusions: Cellular mediators involved in neurodegeneration and inflammation demonstrated increased levels in the vitreous humor of patients with proliferative diabetic retinopathy and may be part of the pathogenesis of diabetic retinopathy.

RESUMO Objetivo: Comparar as concentrações intravítreas de mediadores celulares envolvidos na neurodegeneração, inflamação e angiogênese em pacientes com retinopatia diabética proliferativa e outras doenças vítreo-retinianas. Métodos: Um ensaio imunomagnético foi utilizado para medir os níveis vítreos do fator derivado do epitélio pigmentar, amilóide P sérico, proteína-C-reativa, complemento C4, e alfa-1-antitripsina, fator de crescimento do endotélio vascular, fator de crescimento derivado das plaquetas AA, fator de crescimento derivado das plaquetas BB, interleucina-6, interleucina-8, interleucina-10, fator de necrose tumoral alfa e beta em pacientes submetidos à vitrectomia 23-gauge para retinopatia diabética proliferativa ou outros diagnósticos (grupo controle). Resultados: Foram avaliados 55 pacientes, dos quais 24 tinham retinopatia diabética proliferativa e 31 tinham outros diagnósticos, incluindo hemorragia vítrea, descolamento de retina, buraco macular e membrana epirretiniana. Pacientes com retinopatia diabética proliferativa demonstraram níveis aumentados de amilóide P sérico (85,49 vs 31,38 ng/mL), proteína-C-reativa (59,89 vs 41,75 ng/mL), fator de crescimento do endotélio vascular (2.330,11 vs 554,25 pg/mL, p<0.001), fator de crescimento derivado das plaquetas-A: (127,32 vs 39,11 pg/mL), fator de crescimento derivado das plaquetas-B (29,37 vs 7,12 pg/mL), interleucina-6 (69,37 vs 33,58 pg/mL), interleucina-8 (175,25 vs 59,71 pg/mL) e interleucina-10 (3,70 vs 1,88 pg/mL), todos com p<0,004 quando comparados ao grupo controle. Níveis de fator derivado do epitélio pigmentar (30,06 vs 27,48 ng/mL; p=0,295), complemento C4 (570,78 vs 366,24 ng/mL; p=0,069), alfa-1 antitripsina (359,27 vs 522,44 ng/mL; p=0,264) não foram significativamente diferente entre os grupos. Níveis intravítreos de fator de necrose tumoral alfa e fator de necrose tumoral beta foram indetectáveis. O amilóide P sérico, a proteína C-reativa, o fator de crescimento derivado das plaquetas A e B, a interleucina-6 e a interleucina-8 correlacionaram-se positivamente com o fator de crescimento do endotélio vascular. Conclusões: Os medidores celulares envolvidos na neurodegeneração e inflamação demonstraram níveis aumentados no humor vítreo de pacientes com retinopatia diabética proliferativa e podem ser parte da patogênese da retinopatia diabética.

Initial experience with ocriplasmin in the treatment of vitreomacular traction / Experiência inicial com ocriplasmina no tratamento da tração vitreorretiniana

ABSTRACT This study aimed to report the clinical and structural outcomes of intravitreal ocriplasmin in the treatment of vitreomacular interface disorders in two tertiary centers in Brazil. A retrospective study was performed by reviewing medical records and spectral domain optical coherence tomography (SD-OCT) findings of seven patients who were treated with a single ocriplasmin injection. A total of 57.14% of patients achieved resolution of vitreomacular traction as evidenced by SD-OCT. Regarding our functional results, 87.71% maintained or improved visual acuity after follow-up. To the best of our knowledge, this is the first study reporting initial results of ocriplasmin therapy in Brazil.

RESUMO O objetivo desse estudo é relatar os resultados iniciais, tanto do ponto de vista funcional quanto anatômico, no tratamento das doenças da interface vítreo-macular com a ocriplasmina em 2 serviços terciários no Brasil. Um estudo retrospectivo foi realizado através de revisão de prontuários, além de análise de achados em tomografia de coerência óptica de domínio espectral (SD-OCT) em 7 pacientes tratados com uma única injeção intravítrea de ocriplasmina. Em nosso estudo 57,14% dos pacientes apresentaram resolução da tração vítreo-macular no SD-OCT. Em relação aos resultados funcionais, 87,71% dos pacientes mantiveram, ou melhoraram sua acuidade visual durante o acompanhamento. Para nosso conhecimento, trata-se do primeiro estudo em nosso país, mostrando resultados iniciais com ocriplasmina em pacientes tratados no Brasil.

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

ABSTRACT Purpose: To assess whether hyaloid adhesion is more prevalent in patients with age-related macular degeneration (AMD) than in control patients and to evaluate 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 considered 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.

RESUMO Objetivo: Avaliar se a adesão hialoidea é mais prevalente em pacientes com degeneração 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 pacientes 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 vitreorretinianas (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 controle, 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.

Ophthalmic Doppler in persistent hyperplastic primary vitreous atypical presentation: case report / Doppler oftálmico na persistência hiperplásica do vítreo primário de apresentação atípica: relato de caso

ABSTRACTThe purpose is to document a case of persistent hiperplastic primary vitreous (PHPV) with atypical Bergmeister's papilla and patent hialoid artery that had its conclusive diagnosis done by doppler ultrasound. We report a case of child, who had unilateral leucokoria. This child's fundoscopic examination showed a white mass on the optic nerve that extended over to adjacent retina. Performed ultrasound that remained a doubt with the following diagnostic hypotheses: persistent hiperplastic primary vitreous, granuloma (toxocara), astrocytic hamartoma and retinoblastoma. The diagnosis was only established when the doppler ultrasound showed a blood flow inside of the membrane, thus confirming the diagnosis of persistent hiperplastic primary vitreous associated with the Bergmeister'spapilla.

RESUMOO objetivo é documentar um caso de persistência hiperplásica do vítreo primário (PHPV) com papila de Bergmeister atípica e artéria hialóide pérvia que teve seu diagnóstico conclusivo feito pelo exame ultrassonográfico com Doppler colorido. Relatamos um caso de uma criança com leucocoria unilateral, apresentando massa branca sobre o disco óptico observada à fundoscopia, que se estendia à retina adjacente. Após a realização do exame ultrassonográfico foi mantida a dúvida com as seguintes hipóteses diagnósticas: persistência hiperplásica do vítreo primário, granuloma (toxocaríase) e retinoblastoma. O diagnóstico foi estabelecido após a utilização do Doppler colorido que evidenciou fluxo sanguíneo no interior da membrana, confirmando o diagnóstico de persistência hiperplásica do vítreo primário associada à papila de Bergmeister.

Effects of Vitreomacular Traction on Ranibizumab Treatment Response in Eyes with Neovascular Age-related Macular Degeneration

PURPOSE: To investigate the effects of vitreomacular traction (VMT) on ranibizumab treatment response for neovascular age-related macular degeneration (AMD). METHODS: A retrospective review of 85 eyes of 85 patients newly diagnosed with neovascular AMD was conducted. Patients were eligible if they had received more than three consecutive monthly ranibizumab (0.50 mg) treatments and ophthalmic evaluations. Patients were classified into a VMT (+) group or VMT (-) group according to optical coherence tomography imaging. Best corrected visual acuity and central retinal thickness (CRT) measurements were obtained at three and six months after initial injection. RESULTS: One month after the third injection, mean visual acuity (VA) increases of 6.36 and 9.87 letters were observed in the VMT (+) and VMT (-) groups, respectively. The corresponding mean CRT values decreased by 70.29 microm and 121.68 microm, respectively. A total 41 eyes were identified as eligible for a subsequent fourth injection; 71.1% of patients (27 eyes) in the VMT (+) group but only 29.8% of patients in the VMT (-) group needed a subsequent fourth injection. Follow-up was extended to six months for 42 of the 85 enrolled patients (49.4%). The trends in VA and optical coherence tomography were found to be maintained at six-month follow-up. CONCLUSIONS: VA and CRT appeared to be more improved after ranibizumab treatment in the VMT (-) group compared to the VMT (+) group. VMT might antagonize the effect of ranibizumab treatment in a subpopulation of AMD patients.

Redistribuição postmortem de antidepressivos e seus produtos de biotransformação em tecidos biológicos humanos / Postmortem redistribution of antidepressants and their metabolites in human biological tissues

Os antidepressivos pertencem a uma importante classe de medicamentos investigados na toxicologia forense. Em casos de amostras provenientes de cadáveres, o intervalo entre o óbito e a obtenção da espécie biológica pode proporcionar a redistribuição postmortem destes fármacos. Com o objetivo de elucidar esse fenômeno, métodos analíticos foram desenvolvidos e aplicados utilizando sangue total (ST), humor vítreo (HV) e fígado. Para as amostras de ST e HV, o método de extração escolhido e validado foi a microextração em fase líquida (LPME) trifásica. Fibras ocas constituídas de polipropileno, com a extensão de 8 cm cada, foram tratadas com o solvente orgânico dodecano (fase orgânica), resultando em um membrana com permeabilidade seletiva. No lúmen destas fibras, adicionou-se ácido fórmico 0,1 mol/L (fase aceptora). Em frasco de fundo chato com 5 mL de capacidade, pipetou-se 3,5 mL de NaOH 0,1 mol/L (fase doadora) e 0,5 mL de ST ou HV. Ao término da extração, as amostras foram introduzidas no GC-MS, sem a necessidade de reações de derivatização. O estudo com ST contemplou os antidepressivos amitriptilina (AMI), nortriptilina (NTR), imipramina (IMI), desipramine (DES), clomipramina (CLO), desmetilclomipramina (DMC), fluoxetina (FLU) e norfluoxetina (NFL). Os limites de quantificação para estas substâncias ficaram inferiores aos níveis terapêuticos (20 ng/mL). As médias dos coeficientes de variação intradia e interdia foram, respectivamente, de 9,7 e 9,8%. As curvas de calibração apresentaram linearidade entre as concentrações de 20 até 1200 ng/mL. A validação do parâmetro integridade da diluição assegurou a mensuração de quantidades superiores ao limite apresentado na curva de calibração. O método foi aplicado em sete amostras reais postmortem e em apenas um caso foi observada uma diferença significativa (300%) entre os valores quantificados no ST periférico e central. Os antidepressivos tricíclicos AMI, NTR, IMI e DES foram avaliados no HV e o efeito matriz foi detectado para os dois últimos analitos. O método foi otimizado e validado utilizando solução salina adicionada de AMI e NTR. O limite de detecção igual a 5 ng/mL, foi obtido com a redução da voltagem da fonte de íons do espectrômetro de massa para 50 eV. Coeficientes de variação foram inferiores a 15%. Os procedimentos validados foram aplicados em seis amostras reais de HV. A relação encontrada entre os valores obtidos no ST periférico e HV foi de aproximadamente 0,1. A extração acelerada por solvente (ASE) e, posteriormente, a extração em fase sólida (SPE) foram as técnicas de separação dos analitos da matriz fígado. Ao término das citadas extrações, os antidepressivos foram analisados no GC-MS. Para esta matriz sólida, são necessários mais estudos, pois os valores encontrados nos ensaios analíticos estão em desacordo com as diretrizes utilizadas na validação dos métodos

Antidepressants belong to an important class of drugs investigated in forensic toxicology. In cases of samples from corpses, the interval between death and obtaining the biological specimens can provide the postmortem redistribution of these drugs. Aiming to elucidate this phenomenon, analytical methods were developed and applied using whole blood (WB), vitreous humor (VH) and liver. For samples of WB and HV, the extraction method chosen and validated was the three-phase liquid phase microextraction (LPME). Hollow fibers consist of polypropylene, with a length of 8 cm each were treated with dodecane organic solvent (organic phase) resulting in a membrane with selective permeability. Into the lumen of these fibers was added formic acid 0.1 mol/ L (acceptor phase). In the vial containing 3.5 mL of NaOH 0.1 mol / L (donor phase) was spiked 0.5 ml of biological fluids (WB or VH). Subsequently, the samples were injected in GC-MS without derivatization reactions. The study of the ST included antidepressants amitriptyline (AMI), nortriptyline (NTR), imipramine (IMI), desipramine (DES), clomipramine (CLO), desmethylclomipramine (DMC), fluoxetine (FLU) and norfluoxetine (NFL). The quantification limits for these substances were below the therapeutic levels (20 ng / ml). The mean coefficients of variation and separate intradays were respectively 9.7 and 9.8%. The calibration curves showed linearity between concentrations of 20 to 1200 ng / mL. The validation of the integrity of the dilution parameter assured measurement higher than the limit shown in the calibration curve quantities. The method was applied to seven real postmortem samples and in one case a significant difference (300%) between the measured values in the peripheral and central ST was observed. The tricyclic antidepressants AMI, NTR, IMI and DES were evaluated in VH and the matrix effect was detected in the last two analytes. The method was optimized and validated using saline spiked AMI and NTR. The limit of detection (5 ng/ml) was obtained by reducing the voltage of the ion source of the mass spectrometer 50 eV. Coefficients of variation were below 15%. The procedures were validated in six real samples of HV. The relationship found between the values obtained in the peripheral ST and HV was approximately 0.1. Accelerated solvent extraction (ASE) and subsequently the solid phase extraction (SPE) were the techniques of separation of analytes liver matrix. At the end of the cited extractions, antidepressants were analyzed in GC-MS. To this solid tissue, further studies are needed, because the values found in the analytical tests were not in accordance with the guidelines used in the validation of the methods

Bilateral Free Floating Vitreous Cysts with Posterior Embryotoxon

No abstract available.

Asteroid hyalosis: clinical review of 58 cases / Asteroides hialoides - revisão de 58 casos clínicos

OBJECTIVE: Understand the behavior, functional repercussion and relationship with epidemiological factors of asteroid hyalosis (AH) and retrospective observational case series. METHODS: Fifty-eight patients diagnosed with AH (24 women and 34 men) were studied. All patients were submitted to a thorough ophthalmological examination. RESULTS: We observed a statistical association between the presence of AH and male sex (p=0,042). An increase in prevalence of this pathology was observed with increasing age. We determined an odds ration of 5,24 of a patient over 50 years old having AH, when compared to patients bellow this threshold. Eighty-six percent of patients had unilateral vitreous deposits. We measured a lower IOP in the affected eye, with the difference being in average 2,68 ± 1,45 mmHg (p=0,037). We observed no statistical association between AH and age related macular degeneration, diabetes or glaucoma. Five eyes were submitted to facoemulsification combined with pars plana vitrectomy with an average gain of 7 lines (Snellen) in visual acuity (p=0,03). CONCLUSION: In our sample a clear association between AH, ageing and male sex was observed. The majority of patients had unilateral vitreous deposits. Vitrectomy in association with facoemulsification is a safe and effective intervention in this group of patients.

OBJETIVO: Compreender o comportamento dos asteroides hialoides, sua repercussão funcional em relação aos fatores epidemiológicos,de modo retrospectivo e observacional de casos clínicos. MÉTODOS: Cinquenta e oito doentes com diagnóstico de asteroides hialoides (24 mulheres e 34 homens) foram estudados. Todos os doentes foram submetidos a exame oftalmológico completo. RESULTADOS: Observamos uma associação estatística entre a presença de asteroides hialoides e o sexo masculino (p=0,042). Verificamos um aumento de prevalência desta patologia com o aumento da idade sendo o risco relativo após os 50 anos de 6,25 face aos doentes abaixo desta idade. Oitenta e seis por cento dos doentes estudados apresentavam depósitos unilaterais. Não observamos associação estatística entre a presença de asteroides hialoides e a degeneração macular ligada à idade, diabetes mellitus ou glaucoma. Em 5 dos olhos estudados avaliamos o resultado funcional de cirurgia de facoemulsificação associada à vitrectomia via pars plana e observamos um ganho médio de 7 linhas de acuidade visual de Snellen (p=0,03) pós-cirurgia. CONCLUSÃO: A amostra apresenta uma clara associação entre o envelhecimento e sexo masculino e a incidência de asteroides hialoides. Na maioria dos doentes estudados os depósitos foram unilaterais. A vitrectomia via pars plana, associada à facoemulsificação é uma terapêutica segura e eficaz neste grupo de doentes.

Free-floating Vitreous Cyst in an Adult Male

A 50 year-old male patient was referred to our clinic due to a floating mass in the right eye. The uncorrected visual aquity was 10 / 10 in both eyes.The patient did not have any systemic disorder and trauma history. His ophthalmological examination revealed an unremarkable anterior segment with no signs of inflammation. Indirect opthalmoscopy and posterior segment biomicroscopy performed with 90D lens was unremarkable in the left eye, while in the right eye a single oval cyst was identified floating freely in the vitreous. The cyst was partially masking the underlying retinal vasculature. B-scan ultrasound revealed an echo-free, round-shaped cyst that was free from surrounding vitreous strands or retina localised at the posterior vitreous. Fluorescein angiography (FA) ruled out the presence of intra and overlying vascularisation of the cyst. Indeed, FA showed a clear-edged hypofluorescence due to a pre-retinal masking effect. The indirect hemaglutinin tests of the patient for ecinococcus and cysticercosis were negative. Eosinophilia was not detected in the preripheral blood smear. Based on these findings the patient was diagnosed as primary vitreal cyst. The presented case was mild symptomatic so the patient was decided to be followed up without any treatment.

Macular hole: 10 and 20-MHz ultrasound and spectral-domain optical coherence tomography / Buraco macular: ultrassonografia de 10 e 20 MHz e tomografia óptica de domínio espectral

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

OBJETIVO: A tomografia de coerência óptica (OCT) é um método diagnóstico valioso para estudo da mácula. Entretanto, por se basear na energia luminosa, não pode ser realizada quando existe opacidade de meios. Nesses casos, o ultrassom (US) pode predizer algumas características maculares. Este estudo teve como objetivos caracterizar imagens obtidas por US com transdutores de 10 e 20-MHz comparadas ao OCT, assim como analisar a relação vitreorretiniana em olhos com buraco macular (BM). MÉTODOS: Vinte e nove olhos de 22 pacientes com evidência biomicroscópica de BM em diferentes estágios foram incluídos. Todos os pacientes foram avaliados com ultrassonografia utilizando transdutores de 10 e 20-MHz e OCT de domínio espectral. RESULTADOS: OCT diagnosticou BM em 25 dentre 29 olhos estudados. Os 4 casos não identificados por US eram pseudoburacos decorrentes de membrana epirretiniana. Nos BM estágios I (2 olhos) e II (1 olho), ambos transdutores não foram úteis para analisar o espessamento macular, mas foram identificados sinais sugestivos como irregularidade macular, opérculo ou descolamento parcial do vítreo posterior (DVP). Nos estágios III (14 olhos) e IV (5 olhos), ambos transdutores identificaram irregularidade, dupla corcova e espessamento macular. O US foi capaz de medir a espessura macular e identificar outros indícios de BM, como opérculo, tração vitreorretiniana e DVP. Em pseudoburacos, o US identificou irregularidades no contorno macular e discreta depressão. CONCLUSÃO: US de 10-MHz foi útil para uma avaliação global do corpo vítreo e sua relação à retina. O US de 20-MHz forneceu informações importantes sobre a junção vitreorretiniana e contorno macular. OCT fornece qualidade superior para estudo morfológico da região macular, exceto em casos de opacidade de meios. Nesses casos, ou quando o exame tomográfico não for disponível, o estudo ultrassonográfico de 10 e 20-MHz é capaz de proporcionar análise válida da região macular e auxiliar na abordagem terapêutica.

Vitrectomia transconjuntival 25 gauge via pars plana para opacidade vítrea persistente em pacientes com implante de lentes multifocais / Transconjunctival sutureless 25-gauge vitrectomy for visually significant vitreous floaters in patients with multifocal intraocular lens

OBJETIVO: O objetivo do presente estudo é relatar o resultado visual obtido após realização de vitrectomia via pars plana 25 gauge (VVPP-25-gauge) em pacientes com opacidades vítreas persistentes e debilitantes previamente submetidos à cirurgia de facectomia com implante de lente intraocular (LIO) multifocal. MÉTODOS: Estudo prospectivo de 14 olhos com implante de LIO multifocal e presença de opacidade vítrea submetidos à VVPP-25-gauge. Foram avaliados acuidade visual sem correção (AVSC), acuidade visual com correção (AVCC) para longe, acuidade visual para perto corrigida para longe (AVPC) e equivalente esférico (EE) antes e 3 meses pós-vitrectomia. Um questionário de satisfação e melhora visual foi administrado antes e após a realização da vitrectomia para avaliar a satisfação dos pacientes. RESULTADO: Após três meses da VVPP25-gauge, a média das acuidades (logMAR) era: AVSC, 0,10 ± 0,14;AVCC, 0,02 ± 0,08;AVPC, 0,00 ± 0,0; EE, +0,16 ± 0,34. Treze olhos (92,9 por cento) apresentavam AVSC de 20/40 ou melhor, e 11 (78,5 por cento) de 20/25 ou melhor. Dez (90,9 por cento) pacientes demonstraram satisfação com o procedimento cirúrgico, obtendo eliminação de todos os floaters em 13 olhos (92,8 por cento). Apenas um paciente apresentou insatisfação com o resultado visual final devido ao aparecimento de edema macular cistóide pós-vitrectomia. CONCLUSÃO: A remoção das opacidades vítreas, usando a VVPP-25-gauge se mostrou segura, e resultou em alto nível de satisfação dos pacientes, com resolução dos sintomas na sua quase totalidade, e uma melhora subjetiva da qualidade funcional da visão.

PURPOSE: The aim of this study was to evaluate the role of 25-gauge transconjuntival sutureless vitrectomy (TSV) in patients with persistent vitreous floaters who underwent multifocal intraocular lens (IOL) implantation. METHODS: Fourteen eyes of 11 patients with multifocal IOL implant associated with vitreous opacities that underwent 25-gauge vitrectomy were prospectively analyzed. Information collected included near (UCNVA) and distance uncorrected visual acuity (UCDVA), best corrected distance visual acuity (BCDVA), and the spherical equivalent (SE) before and 3 months after vitrectomy. Patients were questioned about surgery satisfaction and visual improvement after vitrectomy. RESULTS: Three months after 25-gauge TSV the mean visual acuities were: UCDVA, 0,10 ± 0,14; BCDVA, 0,02 ± 0,08; UCNVA, 0,00 ± 0,0; SE, +0,16 ± 0,34. Thirteen eyes (92.9 percent) had a UCDVA of 0.5 (20/40) or better, and 11 (78.5 percent) achieved a UCDVA of 0.8 (20/25) or better. Ten (90.9 percent) patients demonstrated satisfaction with surgery, and floaters have gone away in thirteen eyes (92.8 percent), while one patient expressed no satisfaction with her postoperative visual acuity because of the cystoid macular edema that occurred. CONCLUSION: 25-gauge TSV was a safe and accurate option for patients with multifocal lens and visual disturbing vitreous floaters providing subjective improvement of symptoms.

Intravitreal cysticercosis presenting as neovascular glaucoma.

We report two cases of intraocular cysticercosis which showed a peculiar presentation of neovascular glaucoma which is hitherto unreported. Two young adults presented with symptoms of raised intraocular pressure due to neovascular glaucoma. On dilated fundus examination both were found to have dead intravitreal cysticercosis. The cysts were removed by a three-port vitrectomy and intracameral injection of bevacizumab was given to help in the regression of rubeosis. Trabeculectomy had to be combined in one case. The intraocular pressure returned to normal. No recurrence of rubeosis was seen even after one year.

Successful management of presumed Candida endogenous endophthalmitis with oral voriconazole.

Endogenous fungal endophthalmitis is most commonly caused by Candida species and usually occurs in patients with chronic diseases such as diabetes mellitus and renal insufficiency. Voriconazole, a broad-spectrum triazole antifungal agent, attains therapeutically significant concentrations in the vitreous cavity after systemic administration. We report, the successful management of presumed endogenous Candida endophthalmitis in a patient with multiple diseases and unstable systemic status with oral voriconazole. Though fungal endophthalmitis has been successfully treated with a combination of intravenous and intravitreal voriconazole, to the best of our knowledge this is the first report in ophthalmic literature (Medline Search) on the treatment of fungal endophthalmitis with only the oral route of administration of voriconazole.

Fuchs' Uveitis: Failure to associate vitritis and disc hyperfluorescence with the disease is the major factor for misdiagnosis and diagnostic delay

Fuchs' uveitis is often diagnosed with substantial delay at the origin of deleterious consequences such as unnecessary treatment. The aim of the study was to analyze the type and frequency of posterior inflammatory and fluorescein angiographic signs in Fuchs' uveitis in conjunction with the other clinical signs and evaluate their respective importane in the diagnosis of the disease. In particular, diagnostic delay and erroneous diagnosis were investigated. Patients seen in our centers between 1995 and 2008 with the diagnosis of Fuchs' uveitis were analyzed. The data collected included age, initial and final visual acuities; clinical findings at presentation, mean diagnostic delay, erroneous diagnosis, laser flare photometry values, fundus and fluorescein angiography manifestations and ocular complications. One hundred and five patients were included. The mean age at diagnosis was 34 years. Twelve patients [11.4%] had bilateral involvement. The mean diagnostic delay was 3.04 +/- 4.30 years. The most frequent clinical signs were vitreous infiltration [97.40%], typical Fuchs' keratic precipitates [94.90%], crystalline lens opacities or cataract [47%], heterochromia [42.60%], ocular hypertension or glaucoma [12.80%]. The mean laser flare photometry value at presentation was 9.85 +/- 6.28 ph/ms. Thirty-nine patients [37.14%] had undergone fluorescein angiography showing disc hyperfluorescence in 97.7% and peripheral retinal vascular leakage in 13.6%. Fuchs' uveitis is significantly underdiagnosed likely because vitreous involvement was previously described but not commonly recognized as an association with Fuchs' uveitis in the clinician's mind and therefore has often been given a different diagnostic label, Moreover, the very frequent inflammatory signs on fluorescein angiography such as disc hyperfluorescence and more rarely peripheral retinal vascular leakage, which has not been typically associated with Fuchs' uveitis, appear to represent an additional factors leading to misdiagnosis. Such clinical findings need to be publicized in order to reduce misdiagnosis, and diagnostic delay

Pediatric retinal detachment in the Eastern Province of Saudi Arabia: experience of a tertiary care hospital

Because no previous studies have addressed the issue, we describe clinical characteristics and surgical outcome of patients with rhegmatogenous retinal detachment [RRD] in a pediatric population of the Eastern province of Saudi Arabia. We conducted a retrospective review of all consecutive cases of pediatric RRD [0-18 years] patients presenting at Dharhran Eye Specialist Hospital, a tertiary care hospital, in the Eastern Province of Saudi Arabia over a period of 3 years. Twenty patients were included in the study, accounting for 9.4% of all retinal detachment surgery cases performed over a period of 3 years [January 2006 to December 2008]. The median age was 11.0 years, [range, birth to 18 years]. Trauma, [45%] myopia/vitreoretinal degeneration [10%] and prior ocular surgery [25%] were significant risk factors for RRD. Proliferative vitreoretinopathy [PVR] more than grade C was present in 14/20 [70%] of cases. Most patients [15/20, 75%] were treated with pars plana vitrectomy and placement of an encircling buckle, while silicone oil or gas was used as tamponade in 13/20 [65%] patients. Surgery was successful in 17/20 [85%] cases in achieving retinal re-attachment. Visual acuity improved significantly following surgery [Mean preop 2.146 LogMAR, Mean postop 1.497 LogMAR] [P=.014]. Longer duration of RRD [P=.007] and macular involvement [P=.05] were associated with worse anatomical outcomes following surgery. Pediatric RRD in the Eastern province is often associated with predisposing pathology. Surgery is successful in achieving anatomical reattachment of the retina in a majority of cases with improvement of visual acuity

Surgical treatment of macular detachment secondary to congenital pit of the optic disc: case report / Tratamento cirúrgico do descolamento macular secundário à fosseta congênita do disco óptico: relato de caso

The authors describe a patient with macular detachment in the right eye, secondary to congenital pit of the optic disc, submitted to vitrectomy, drainage of the subretinal fluid, perfluorocarbon, endolaser and perfluoropropane gas (C3F8). A sample of the vitreous humor was taken for comparative analysis with the subretinal fluid. Results of retinography, optical coherence tomography, and illustrations of the surgical procedure are presented. Optical coherence tomography revealed the detachment resolved 6 months after surgery. Visual acuity improved from 20/400 to 20/30. This surgical technique can lead to successful reattachment of the macula and improvement of central vision. Additionally, a qualitative and comparative analysis showed a similar biochemical composition of the subretinal fluid and the vitreous. Despite technical limitations, this analysis can confirm the pathophysiology of the disease, suggesting that the subretinal fluid may originate from the vitreous cavity in macular detachment secondary to congenital pit of the optic disc.

Os autores descrevem um paciente portador de descolamento macular secundário à fosseta congênita do nervo óptico no olho direito, submetido à vitrectomia, drenagem do fluido sub-retiniano, perfluorcarbono, endolaser e gás perfluoropropano (C3F8). Foi retirada amostra do humor vítreo para análise comparativa com o fluido sub-retiniano. São apresentadas retinografia, tomografia de coerência óptica e ilustrações do procedimento cirúrgico. Após 6 meses da cirurgia, houve resolução do descolamento evidenciada por meio da tomografia de coerência óptica. A acuidade visual melhorou de 20/400 para 20/30. A técnica cirúrgica utilizada pode ter melhorado os resultados obtidos. Adicionalmente, a análise bioquímica qualitativa e comparativa do fluido sub-retiniano e do vítreo mostrou composição semelhante. Apesar das limitações técnicas, esta análise pode corroborar na fisiopatogênese da doença, sugerindo que o fluido sub-retiniano pode ser originado da cavidade vítrea na fosseta congênita de papila.

Triamcinolone-assisted 3D-vitrectomy in diabetic vitreomacular traction / Vitrectomia 3D guiada por triancinolona na tração vitreomacular do diabetes

PURPOSE: To evaluate the efficacy of triamcinolone as an aid in vitreous visualization during 3D-vitrectomy for the treatment of diabetic vitreomacular traction. METHODS: Prospective interventional study in patients with symptomatic vitreomacular traction. Pre- and postoperative assessments included visual acuity, retinography, intraocular pressure and optical coherence tomography. All patients were operated by the same surgeon (OOMJ). Triamcinolone was used as a visual enhancer during surgery. The parameters of the vitreophage (Accurus 800CS, Alcon) were set to the 3D- system (dual dynamic drive), contact lenses (plain and wide angle) being used for visualization. Peripheral 360º vitreous circumcision at high cut rate was performed, carefully releasing the vitreomacular adhesion at the posterior pole by means of an appropriate pic or vitreoretinal forceps. RESULTS: The sample consisted of five consecutive patients (five eyes), three female and two male, with symptomatic vitreomacular traction. Their age ranged from 54 to 71 years (mean 62.6 ± 6.3 years). During the surgical procedure, the areas with vitreomacular traction were properly visualized and identified after the application of triamcinolone. No complications were recorded during or after surgery. There was a statistically significant improvement in visual acuity after the surgical procedure (p=0.0313). CONCLUSION: Triamcinolone facilitates the surgical treatment of vitreomacular traction by improving visibility of both the vitreous humor and the vitreous-retina interface. Triamcinolone-assisted 3D vitrectomy proved to be an effective procedure in these cases.

OBJETIVO: Avaliar a eficácia da triancinolona como marcador vítreo na vitrectomia 3D para tratamento da tração vitreomacular do diabetes. MÉTODOS: Realizou-se um estudo prospectivo intervencionista numa série de portadores de tração vitreomacular sintomática. Na avaliação pré e pós-operatória foram realizadas a medida da acuidade visual, retinografia, pressão intra-ocular e tomografia de coerência óptica. Todos pacientes foram submetidos à vitrectomia pelo mesmo cirurgião (OOMJ). No intra-operatório, utilizou-se triancinolona como marcador vítreo. Os parâmetros do vitreófago (Accurus 800CS, Alcon) foram programados no sistema 3D (dual dynamic drive), sendo utilizadas lentes de contato (grande angular e plana) para visibilização. Realizou-se circuncisão vítrea periférica 360° com alto corte, desfazendo cuidadosamente as adesões vitreomaculares no pólo posterior por meio de gancho ou pinças vítreo-retinianas adequadas. RESULTADOS: A amostra foi composta por cinco pacientes (cinco olhos) consecutivos com tração vitreomacular sintomática. Três eram do sexo feminino e dois, do masculino. A idade variou de 54 a 71 anos (média de 62,6 ± 6,3 anos). Durante o procedimento cirúrgico, os locais de tração vitreomacular foram identificados com boa visibilidade após aplicação da triancinolona. Não foram observadas intercorrências tanto no intra quanto no pós-operatório. Houve melhora estatisticamente significante na acuidade visual após procedimento cirúrgico (p=0,0313). CONCLUSÃO: A triancinolona tem ação facilitadora no tratamento cirúrgico da tração vitreomacular, por melhorar visibilização tanto do humor vítreo quanto da interface vítreo-retina. A cirurgia de vitrectomia 3D, guiada por triancinolona, mostrou-se ser um procedimento eficiente nesses casos.

Base eletrônica de dados clínicos e cirúrgicos das doenças da retina e vítreo / Electronic clinical and surgical database of retina and vitreous diseases

OBJETIVOS:A proposta deste trabalho é criar base de dados clínicos e cirúrgicos informatizada, usando programa de computador (software), no qual pacientes com 19 doenças selecionadas da retina e vítreo possam ser incluídos. MÉTODOS: Foram selecionados os principais livros-texto da especialidade para que servissem de base estrutural do protocolo. Utilizou-se também artigos retirados de revistas e de bases de dados ligados à rede internacional de computadores (Internet). A informatização dos dados foi realizada através da interface do programa SINPE© (Sistema integrado de protocolos eletrônicos), desenvolvido no Laboratório de Informática e Multimídia do Programa de Pós-Graduação em Clínica Cirúrgica do Setor de Ciências da Saúde da Universidade Federal do Paraná. RESULTADOS: Com a informatização dos dados, criou-se o protocolo mestre, o qual abrange todo o conteúdo em pastas principais, seguido de 19 protocolos específicos originados do mestre e referentes às doenças com dados individualizados de cada uma. O programa, permite coleta de dados de pacientes com suas características clínicas, exames complementares, tratamento realizado e seguimento pós-tratamento. Qualquer fonte de interesse dentro do protocolo pode ser cruzada de acordo com o tipo de estudo desejado. CONCLUSÕES: Os objetivos deste trabalho que eram criar estrutura de informação abrangente e atualizada de doenças vitreorretinianas de interesse, adaptando estes dados a um programa computadorizado (software) específico e incorporar este dispositivo no SINPE© foram atingidos.

PURPOSE: The purpose of this study is to build an automated clinical and surgical database which works with a computer-based program (software), where patients with 19 selected retina and vitreous diseases are included. METHODS: Textbooks from both international and national authors served as a basic structure for the protocol. Specific articles related to each disease, extracted from scientific journals and from specific clinical database sources, searched on the World Wide Web (the internet) were used, as well. Data automation was done by interface with SINPE© (Integrated electronic protocol system) - a software developed at the Informatics and Multimedia Laboratory of the Health Sciences Department at the Universidade Federal do Paraná. RESULTS: Along with the data automation the master protocol was created covering all contents in main folders, followed by 19 specific protocols which refer to individual specifications for each disease. The program allows to collect and record data from patients with their clinical characteristics, diagnostic aids, selected treatment as well as follow-up treatment. Likewise, any source of interest in the protocol can be crossed with the Microsoft Excel® program depending on the type of study. CONCLUSIONS: The objective of this study which was to create a wide and updated database of vitreoretinal pathologies of major importance, converting them to a specific software and interfacing it with the SINPE© has been achieved.