Bilateral acute depigmentation of the iris (BADI) and bilateral acute iris transillumination (BAIT): A case series from a center in Brazil

ABSTRACT Bilateral acute depigmentation of the iris and bilateral acute iris transillumination (BAIT) are similar clinical entities. The former causes acute-onset depigmentation of the iris stroma without transillumination, whereas the latter causes depigmentation of the iris pigment epithelium with transillumination. The etiopathogenesis of these conditions is not yet fully understood, but the proposed causes include the use of systemic antibiotics (especially moxifloxacin) and viral triggers. We present a case series of five female patients with a mean age of 41 (32-45) years, all of whom suffered acute onset of bilateral pain and redness of the eyes after moxifloxacin use (oral or topical). It is important for ophthalmologists to be aware of the two forms of iris depigmentation since this case series suggests that SARS-CoV-2 or its empirical treatment with moxifloxacin may trigger iris depigmentation. If this is the case, clinicians will likely see increased incidences of bilateral acute depigmentation of the iris and bilateral acute iris transillumination during and after the COVID-19 pandemic.

Cutting-edge issues in sympathetic ophthalmia approach and six case reports: a T cell-mediated autoimmune response / As questões de ponta na abordagem da oftalmia simpática e 6 relatos de caso: uma resposta autoimune mediada por células T

ABSTRACT Sympathetic ophthalmia is a rare and potentially devastating bilateral diffuse granulomatous panuveitis. It is caused by surgical or non-surgical eye injuries and is an uncommon and serious complication of trauma. It is diagnosed clinically and supported by imaging examinations such as ocular ultrasonography and optical coherence tomography. Its treatment consists of immunosuppressive therapy with steroids and sometimes steroid-sparing drugs, such as cyclosporine, azathioprine, cyclophosphamide, and mycophenolate mofetil. Fast and effective management with systemic immunosuppressive agents allows for disease control and achievement of good visual acuity in the sympathizing eye. By contrast, enucleation should be considered only in situations where the injured eye has no light perception or in the presence of severe trauma. In addition to a bibliographic review of this topic, we report six cases involving different immunosuppressive and surgical treatment modalities.

RESUMO A oftalmia simpática consiste em uma panuveíte granulomatosa bilateral rara e potencialmente devastadora, ocorrendo geralmente após trauma ocular cirúrgico ou não cirúrgico. O diagnóstico é baseado em aspectos clínicos e apoiado por exames de imagem, como ultrassonografia ocular e tomografia de coerência óptica. O tratamento consiste em terapia imunossupressora com esteróides e, eventualmente, drogas poupadoras de esteróides, como ciclosporina, azatioprina, ciclofosfamida e micofonato de mofetila. O manejo rápido e eficaz com agentes imunossupressores sistêmicos permite o controle da doença e a obtenção de boa acuidade visual no olho simpatizante. A enucleação, por outro lado, poderia ser considerada apenas em situações em que o olho lesado não tem percepção luminosa ou há trauma grave. Além de uma revisão bibliográfica sobre o tema, foi relatada uma série de 6 casos com diferentes modalidades de tratamento imunossupressor e cirúrgico.

Secondary glaucoma induced by bilateral acute depigmentation of the iris / Glaucoma secundário à despigmentação bilateral aguda da íris

Abstract We report a case of a middle-aged woman who developed acute, bilateral, symmetrical, slightly transilluminating depigmentation of the iris and pigment discharge into the anterior chamber following the use of oral moxifloxacin for bacterial sinusitis. She had been misdiagnosed as having autoimmune uveitis, treated with steroids and tropicamide, and underwent severe ocular hypertension and glaucoma despite posterior correct diagnosis.

Resumo Relato de um caso de uma paciente do sexo feminino de meia idade que desenvolveu despigmentação bilateral simultânea aguda com dispersão de pigmentos na câmara anterior e discreta transiluminação após o uso de moxifloxacino oral para tratamento de sinusite bacteriana. Ela Havia sido diagnosticada com uveite autoimune e tratada com corticosteroide tópico e tropicamida e evoluiu com hipertensão ocular grave e glaucoma apesar de ,posteriormente, o diagnóstico ter sido correto.

Acute dacryocystitis: another clinical manifestation of sporotrichosis

Sporotrichosis associated with exposure to domestic cats is hyperendemic in Rio de Janeiro, Brazil. A review of the clinical records at our institute revealed four patients with clinical signs of dacryocystitis and a positive conjunctival culture for Sporothrix who were diagnosed with Sporothrix dacryocystitis. Three patients were children (< 13 years of age) and one patient was an adult. Two patients reported contact with a cat that had sporotrichosis. Dacryocystitis was associated with nodular, ulcerated lesions on the face of one patient and with granulomatous conjunctivitis in two patients; however, this condition manifested as an isolated disease in another patient. All of the patients were cured of the fungal infections, but three patients had chronic dacryocystitis and one patient developed a cutaneous fistula. Sporotrichosis is usually a benign disease, but may cause severe complications when the eye and the adnexa are affected. Physicians, especially ophthalmologists in endemic areas, should be aware of the ophthalmological manifestations and complications of sporotrichosis.

Acute dacryocystitis: another clinical manifestation of sporotrichosis

Sporotrichosis associated with exposure to domestic cats is hyperendemic in Rio de Janeiro, Brazil. A review of the clinical records at our institute revealed four patients with clinical signs of dacryocystitis and a positive conjunctival culture for Sporothrix who were diagnosed with Sporothrix dacryocystitis. Three patients were children (< 13 years of age) and one patient was an adult. Two patients reported contact with a cat that had sporotrichosis. Dacryocystitis was associated with nodular, ulcerated lesions on the face of one patient and with granulomatous conjunctivitis in two patients; however, this condition manifested as an isolated disease in another patient. All of the patients were cured of the fungal infections, but three patients had chronic dacryocystitis and one patient developed a cutaneous fistula. Sporotrichosis is usually a benign disease, but may cause severe complications when the eye and the adnexa are affected. Physicians, especially ophthalmologists in endemic areas, should be aware of the ophthalmological manifestations and complications of sporotrichosis.

Genetic polymorphism for IFNγ +874T/A in patients with acute toxoplasmosis / Polimorfismo genético para IFNγ +874T/A em pacientes com toxoplasmose aguda

INTRODUCTION: A single nucleotide polymorphism (SNP) in the gene encoding gamma interferon influences its production and is associated with severity of infectious diseases. This study aimed to evaluate the association of IFNγ+874T/A SNP with duration of disease, morbidity, and development of retinochoroiditis in acute toxoplasmosis. METHODS: A case-control study was conducted among 30 patients and 90 controls. RESULTS: Although statistical associations were not confirmed, A-allele was more common among retinochoroiditis cases and prolonged illness, while T-allele was more frequent in severe disease. CONCLUSIONS: Despite few cases, the results could indicate a relation between IFNγ+874T/A single nucleotide polymorphism and clinical manifestations of toxoplasmosis.

INTRODUÇÃO: Um polimorfismo de nucleotideo único (SNP) no gene codificante para interferon gama influencia a sua produção e pode estar associado à gravidade de diversas doenças infecciosas. O objetivo deste estudo foi avaliar a associação entre SNP para IFNγ+874T/A com a duração da doença, a morbidade e o desenvolvimento de retinocoroidite na toxoplasmose aguda. MÉTODOS: Estudo de caso-controle incluindo 30 pacientes e 90 controles. RESULTADOS: Apesar da ausência de associação estatística, o alelo A foi mais comum entre os casos com retinocoroidite e doença prolongada e o alelo T nas formas mais severas. CONCLUSÕES: Os dados encontrados sugerem uma relação entre o polimorfismo de base única em IFNγ+874T/A com a morbidade e com o desenvolvimento de retinocoroidite por toxoplasmose.

Optochiasmatic tuberculoma as the sole manifestation of late recurrent tuberculosis / Tuberculoma opto-quiasmático como única manifestação de tuberculose recorrente tardia

Brain tuberculomas account for 10-20% of space occupying brain lesions in developing countries. Most lesions are observed at time of tuberculosis diagnosis or soon after starting treatment. We herein describe a 32 year-old patient with a 14-month history of headache and progressive visual loss. Her past medical history revealed pulmonary tuberculosis treated eight years before. A brain MRI showed a T1- and T2-weighted isointense contrast-enhancing lesion in the optic chiasm. A presumptive diagnosis of optochiasmatic tuberculoma was made and isoniazid, rifampin, pyrazinamide, and ethambutol were started. Despite treatment, the patient evolved to blindness. The prompt recognition of this condition is extremely important since the presence of optochiasmal enhancement is associated with blindness in patients with tuberculosis.

Tuberculomas cerebrais são responsáveis por 10-20% das lesões parenquimatosas em países em desenvolvimento. A maioria destas lesões é observada ao diagnóstico de tuberculose ou logo após o início do tratamento. Descrevemos um caso de uma paciente de 32 anos com história de 14 meses de evolução de perda visual progressiva e cefaleia. A história patológica revelou tuberculose pulmonar 8 anos antes. A ressonância magnética do crânio mostrou uma lesão isointensa nas sequências T1 e T2 captantes de contraste no quiasma óptico. Fizemos o diagnóstico presuntivo de tuberculoma ótico-quiasmático e inciamos isoniazida, rifampicina, pirazinamida e etambutol. Apesar do tratamento, a paciente evoluiu para amaurose bilateral. O rápido diagnóstico desta condição é extremamente importante já que a presença de captação de contraste está associada à amaurose em pacientes com tuberculose.

Esclerite posterior: características clínicas, associação sistêmica, tratamento e evolução de 23 pacientes / Posterior scleritis: clinical features, systemic association, treatment and evolution of 23 patients

OBJETIVOS: Documentar características clínicas, associações sistêmicas, tratamento e evolução de 23 pacientes com esclerite posterior, examinados no serviço de uveítes da Universidade Federal de Minas Gerais. MÉTODOS: Revisão de todos os pacientes com esclerite atendidos neste serviço, de 1999 até 2006, para identificar aqueles com esclerite posterior. Identificados 23 pacientes, registrados e analisados os dados com relação aos sinais e sintomas oculares, visão, alterações na ecografia, manifestações sistêmicas, tratamento e evolução. RESULTADOS: Dezesseis pacientes do sexo feminino e 7 do sexo masculino com média de idade de 44,7 anos. Esclerite posterior ocorreu associada à esclerite anterior em 10 pacientes, envolvimento unilateral em 17 pacientes e, bilateral simultâneo, em 6 pacientes. Esclerite posterior associada à doença sistêmica ocorreu em 8 pacientes (síndrome de Cogan, tuberculose, granulomatose de Wegener, herpes simples e zoster, aspergilose, retocolite-ulcerativa e sarcoidose). A principal queixa foi dor ocular seguida de embaçamento visual e o sinal fundoscópico que predominou foi o descolamento seroso de retina. O achado mais comum na ecografia foi espessamento da parede escleral observado em 18 pacientes e a principal forma de tratamento, o uso de corticóide sistêmico. Somente 4 pacientes necessitaram de imunossupressor. CONCLUSÃO: Esclerite posterior é doença de difícil diagnóstico e pode ser potencialmente devastadora. Análises estatísticas são incapazes de revelar outras características específicas da esclerite posterior, características clínicas dos pacientes e evolução da doença que poderiam ajudar na identificação dos casos com maior risco de perda visual ou com maior probabilidade de doença sistêmica.

PURPOSE: To document the clinical features, systemic association, treatment and evolution of 23 patients with posterior scleritis evaluated in the Uveitis service of the Federal University of Minas Gerais. METHODS: 23 patients were identified with the diagnosis of posterior scleritis. Signals and symptoms, visual acuity, B-mode ultrasonography signals, systemic associations, treatment and evolution were described and analyzed. RESULTS: Sixteen patients were female and seven were male with mean age of 44,7 years. Posterior scleritis occurred in association with anterior scleritis in 10 patients, unilateral involvement in 17 patients and simultaneous bilateral involvement in 6 patients. Posterior scleritis in association with systemic disease occurred in 8 patients (Cogan's syndrome, TBC, Wegener, Herpes simplex and Zoster, Apergilosis, inflamatory bowel disease and Sarcoidosis). The main symptoms were ocular pain and decrease of visual acuity and the main signal was retinal serous detachment. Increase of thickness choroidal tissue was the main signal in B-mode ultrasonography in 18 patients and the principal kind of treatment was the use of systemic corticosteroids. Only 4 patients required systemic immunosuppressive drugs. CONCLUSIONS: Posterior scleritis still represents a diagnostic challenge and is often associated with life threatening systemic disease and vision threatening ocular complications. Knowledge of posterior scleritis may aid in determining timely and accurate diagnosis and treatment of both ocular and any systemic conditions associated, thus decreasing morbidity and mortality. Elevated suspicion rate is always required to detect this condition.

Esclerite: características clínicas, associação sistêmica, tratamento e evolução de 100 pacientes / Scleritis: clinical characteristics, systemic associations, treatment and outcome in 100 patients

OBJETIVOS: Documentar características clínicas, associações sistêmicas, tratamento e evolução de 100 pacientes com esclerite, examinados no serviço de uveítes da Universidade Federal de Minas Gerais. PACIENTES E MÉTODOS: Identificados 100 pacientes com esclerite, registrados e analisados dados com relação às queixas dos mesmos, sinais oculares, visão, alterações ecográficas, manifestações sistêmicas, tratamento e evolução. RESULTADOS: Sessenta e nove pacientes eram mulheres e 31 homens. Esclerite anterior difusa e nodular ocorreu em 71 pacientes, esclerite anterior necrosante em 3, esclerite posterior em 24 e escleromalácia perfurans em 2 pacientes. Envolvimento unilateral em 79 e bilateral em 21 pacientes. A principal queixa foi dor ocular e o sinal fundoscópico predominante na esclerite posterior foi o descolamento seroso de retina. Em 13 pacientes a esclerite determinou o encontro de doença sistêmica e a principal forma de tratamento foi com droga anti-inflamatória não-esteróide oral. Dezoito pacientes precisaram de tratamento imunossupressor para o controle do quadro ocular e a incidência de complicação ocular foi de 35%. DISCUSSÃO: Esclerite é doença rara, às vezes de difícil diagnóstico e potencialmente devastadora, todos os esforços devem ser necessários para um diagnóstico rápido e correto dessa doença. O conhecimento sobre a esclerite, suas formas de apresentação, associações sistêmicas, tratamento e evolução são fundamentais para que possamos fazer este diagnóstico correto e conduzir o quadro ocular da maneira mais adequada possível tendo sempre como objetivo final o controle do quadro escleral e preservação da visão do paciente.

PURPOSE: To document the clinical features, systemic association, treatment and evolution of 100 patients with scleritis evaluated at the Uveitis Service of the Federal University of Minas Gerais. PATIENTS AND METHODS: 100 patients were identified with the diagnosis of scleritis. Signals and symptoms, visual acuity, B-mode ultrasonography signals, systemic associations, treatment and evolution were described and analyzed. RESULTS: 69 patients were female and 31 were male. Diffuse and nodular anterior scleritis occurred in 71 patients, necrotizing anterior scleritis in 3, posterior scleritis in 24 and escleromalacia perforans in 2 patients. Unilateral involvement occurred in 79 patients and bilateral involvement in 21 patients. The main symptoms were ocular pain and redness and the main signal in posterior scleritis was the serous detachment of the retina. Scleritis in association with systemic disease occurred in 35 patients and the principal kind of treatment was the use of oral NSAIDs. Only 18 patients required systemic immunosuppressive drugs. Ocular complications were detected in 35 patients. CONCLUSIONS: Scleritis may represent a diagnostic challenge and is often associated with life threatening systemic disease and vision threatening ocular complications. Knowledge of scleritis may aid in determining timely and accurate diagnosis and treatment of both the ocular and any associated systemic conditions, thus decreasing morbidity and mortality.

Cat scratch disease complicated with aseptic meningitis and neuroretinitis

Cat scratch disease (CSD) is a self limited condition characterized by fever, lymph node enlargement and less often eye involvement. Central nervous system involvement by Bartonella henselae infection is possibly an important cause of morbidity; its role as an agent of aseptic meningitis is unknown. We report a case of a 40 years-old man with CSD accompanied by aseptic meningitis and neuroretinitis. Serum indirect immmunofluorescence (IFI) assays for B. henselae were positive and the cerebrospinal fluid (CSF) analysis showed mononuclear pleocytosis and increased level of protein. Serological tests for other etiologies were negative. The patient responded well to antibiotic therapy with oral doxycicline plus rifampin and in the 12th day of hospitalization evolved to total regression of the headache and partial regression of the visual loss. Clinicians should consider CSD as a differential diagnosis when assessing previously healthy patients with aseptic meningitis associated with regional lymphadenopathy and epidemiological history of feline contact.

Tuberculous uveitis at a referral center in southeastern Brazil / Uveíte por tuberculose em um centro de referência no Sudeste do Brasil

OBJETIVO: Descrever a ocorrência de uveíte por tuberculose (UTB) em um centro de referência em Minas Gerais, Brasil. MÉTODOS: Um total de 16 pacientes (idade > 15 anos) atendidos consecutivamente de janeiro de 2001 a julho de 2004 no Centro de Referência de Uveíte do Estado de Minas Gerais para avaliação diagnóstica de uveíte foi selecionado para este estudo. Foram coletados dados demográficos e clínicos, assim como dados sobre avaliação para toxoplasmose, sífilis e doenças reumatológicas, teste tuberculínico e sorologia anti-HIV. RESULTADOS: Dos 16 pacientes, 11 (69 por cento) tinham UTB. História prévia de contato com tuberculose pulmonar foi relatada por 72 por cento (8/11) dos pacientes do grupo com UTB e por 20 por cento (1/5) dos pacientes do grupo sem UTB. Embora a razão de chances para essa associação tenha sido de 10,67 (IC95 por cento: 0,59-398,66), o valor de p apresentou significância limítrofe (0,078). Não houve diferença quanto ao quadro ocular inflamatório e ao resultado do teste tuberculínico entre os pacientes com UTB e os sem UTB. Todos os pacientes tinham sorologia negativa para o HIV e foram acompanhados por 2 anos. CONCLUSÕES: Neste estudo, a história prévia de contato com tuberculose pulmonar foi de grande ajuda para o diagnóstico da UTB.

OBJECTIVE: To describe the occurrence of tuberculous uveitis (TBU) at a referral center in the state of Minas Gerais, Brazil. METHODS: A total of 16 consecutive patients (>15 years of age) who underwent diagnostic evaluation of uveitis between January of 2001 and July of 2004 at the Minas Gerais State Referral Center were selected for study. Demographic and clinical data, as well as data related to screening for toxoplasmosis, syphilis, and rheumatologic diseases, together with the results of tuberculin skin testing and HIV testing, were collected. RESULTS: Of the16 patients evaluated, 11 (69 percent) were found to have TBU. A history of contact with pulmonary tuberculosis was reported by 8 (72 percent) of the 11 patients with TBU and by 1 (20 percent) of the 5 with non-TBU. Although the odds ratio for this association was 10.67 (95 percent CI: 0.59-398.66), the p value was borderline significant (p = 0.078). There was no difference between the patients with TBU and those with non-TBU in terms of the status of ocular inflammation or the tuberculin skin testing results. All of the patients were HIV negative and were monitored for two years. CONCLUSION: In this study, a history of contact with pulmonary tuberculosis proved to be useful in diagnosing TBU.

Blindness and total ophthalmoplegia after aesthetic polymethylmethacrylate injection: case report

A injeção de polimetilmetacrilato (PMMA) é prática difundida na medicina estética como medida rejuvenecedora. No entanto, a injeção facial do PMMA carreia sérios riscos, especialmente se realizada na região glabelar. Descrevemos o caso de uma mulher que imediatamente após injeção glabelar de PMMA apresentou amaurose e oftalmoplegia total, revendo ainda a literatura pertinente.