Epidemiologia de ceratites fúngicas tratadas com ceratoplastia penetrante através de achados histopatológicos / Epidemiology of fungal keratitis treated with penetrating keratoplasty by means of histopathologic findings

RESUMO Objetivo: Estudar, através do exame histopatológico, a epidemiologia de ceratites fúngicas tratadas com ceratoplastia penetrante terapêutica, enfatizando a presença de cirurgia ocular prévia. Métodos: Inicialmente, o estudo foi observacional e transversal de botões corneanos provenientes de ceratoplastia penetrante no período de 2006-2015 enviados para exame histopatológico ao banco de olhos do Hospital Geral de Fortaleza. Os tecidos foram corados com Hematoxilina-eosina, PAS ou Grocott, e examinados com microscópio óptico. Foram selecionados casos com diagnóstico histopatológico de ceratite fúngica. Após a selecão, realizamos revisão de prontuários buscando idade e sexo do paciente, data(s) do(s) transplante(s) por ceratite fúngica, diagnóstico clínico précirúrgico, presença/tipo de cirurgias anteriores e/ou posteriores. Incluímos 62 botões corneanos de 55 pacientes. Resultados: A maioria dos pacientes era do sexo masculino. Apenas 7 (11,29%) casos tiveram recidiva da infecção tratada cirurgicamente. 10 (16,13%) casos possuíam cirurgia ocular prévia a ceratite fúngica tratada por transplante. Nenhum caso teve ceratite fúngica como diagnóstico clínico pré-cirúrgico. A principal forma de fungo no exame histopatológico foi forma leveduriforme isolada, seguida pela leveduriforme associada à filamentosa. O aspecto predominante da membrana de Descemet foi livre de fungos. Conclusão: Demonstramos o potencial curativo das ceratites fúngicas quando tratadas com ceratoplastia penetrante terapêutica e uma possível associação do fator cirurgia ocular prévia ao desenvolvimento dessas infecções. Características do exame histopatológico foram abordadas diferente de outros estudos que, em sua maioria, citam apenas o exame microbiológico. A dificuldade no diagnóstico clínico précirúrgico foi ressaltada, o que pode ter contribuído com a evolução dos casos estudados para tratamento cirúrgico.

ABSTRACT Objective: To study, by means of histopathological examination, the epidemiology of fungal keratitis treated with penetrating keratoplasty therapy, emphasizing the presence of previous ocular surgery. Methods: Initially, we made an observational and cross-sectional study of corneal buttons from penetrating keratoplasty in the 2006-2015 period sent for histopathological examination at the Hospital Geral de Fortaleza Eye Bank.Tissues were stained with hematoxylin-eosin, PAS or Grocott, and examined with an optical microscope. We selected the cases with histopathological diagnosis of fungal keratitis. After the selection, we carried out a review of records seeking for age and sex of patients, date(s) of the graft(s) made to treat fungal keratitis, preoperative clinical diagnosis, presence/type of earlier and/or subsequent surgeries.We included 62 corneal buttons from 55 patients. Results: Most patients were male. Only 7 (11.29%) cases had recurrence of the surgically treated infection. 10 (16.13%) cases had eye surgery prior to fungal keratitis treated by transplant. No cases had fungal keratitis as preoperative clinical diagnosis.The main form of fungus in histopathological examination was isolated yeast form, followed by the yeast form associated with the filamentous form.The predominant aspect of Descemet's membrane was free of fungus. Conclusion: We demonstrated the healing potential of fungal keratitis when treated with penetrating therapeutic keratoplasty and the possible association of previous eye surgery factor for the development of these infections. Characteristics of histopathological examination have been approached differently from other studies that mostly specify only the microbiological examination. The difficulty in preoperative clinical diagnosis was highlighted, which may have contributed to the evolution of the cases studied for surgical treatment.

Correlação clínico-patológica em ceratites fúngicas e uma possível evidência de infecção oportunista: relato de dois casos / Clinicopathological correlation in fungal keratitis and a possible evidence of opportunistic infection: a report of two cases

RESUMO Os autores relatam dois casos de ceratite fúngica, que apresentam em comum no exame histopatológico: a ausência de epitélio, sem ulceração e a integridade da camada de Bowman com a presença de formas fúngicas no seu interior. São sugeridos prováveis mecanismos de recidiva das ceratites fúngicas, ressaltando uma possível "via externa não usual", por meio da penetração do fungo através da camada de Bowman íntegra. A existência desta infecção oportunista não está relatada na literatura oftalmológica e são necessárias mais evidências para que seja considerada como tal.

ABSTRACT The authors describe two cases of fungal keratitis which, upon histopathological examination, are found to have in common the absence of epithelium, without ulceration and the lack of integrity of the Bowman's layer with the presence of fungal forms in their interior. Through them the authors suggest probable mechanisms of recurrence of fungal keratitis, highlighting the possible existence of an "unusual external route" that would occur by the fungus penetration through the full Bowman layer. Although these findings appear not yet reported or recovered in the ophthalmic literature, the authors suggest that they could be possible opportunistic infection signals which, however, require more evidence to be considered as such.

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

ABSTRACT Infectious keratitis is rare following laser vision correction. We present a case of aggressive fungal keratitis caused by Aspergillus flavus, following laser in situ keratomileusis (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.

RESUMO Ceratites infecciosas são raras após a correção da visão a laser. Apresentamos um relato de caso de uma ceratite fúngica agressivo por Aspergillus flavus, após ceratomileuse 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.

Reflexões sobre a ceratite fúngica por meio dos achados de exames histopatológicos / Reflections on mycotic keratitis based on findings from histopathologically examined specimens

OBJETIVO: Estudo de botões corneanos por meio do exame histopatológico para verificar as alterações ocorridas nos tecidos corneanos numa infecção fúngica e tirar desses achados orientações para o diagnóstico e o tratamento. MÉTODOS: Trabalho retrospectivo, realizado num Banco de Olhos (BOO) entre janeiro de 2006 e junho de 2011, usando dados de prontuários a partir das informações enviadas pelos cirurgiões e sendo examinado material recebido de ceratoplastia penetrante com o exame de 38 peças de 35 pacientes, sendo processadas e feitas de uma a três colorações de acordo com as dificuldades diagnósticas. RESULTADOS: Os pacientes eram na maioria homens, 57% (n=35), a faixa etária acima de 60 anos a mais numerosa com 1/3 dos pacientes. Os casos de ceratite fúngica correspondiam à média de 6,4% (n=597) do material recebido no BOO e 1,65% (n=2310) dos transplantes ocorrido com o material fornecido nos últimos 5 anos. Pelas informações dos cirurgiões 39,5% (n=38) dos casos deviam-se a perfuração corneana. Usando as datas dos transplantes foi feita uma Tábua de Observação. Em 11 (n=38) casos, a córnea procedia de transplante anterior. As formas leveduriformes nos tecidos corneanos eram de 63% (n=38). Em 50% (n=38) dos casos o infiltrado inflamatório era pequeno ou inexistente. A camada de Descemet estava íntegra em 13% (n=38), enquanto eram encontrados fungos na superfície corneana de 45% (n=38) dos casos. CONCLUSÃO: A coleta do material poderá ser feita com sucesso mesmo depois de instalado o tratamento, entretanto, nas úlceras de córnea deve ser feito preferentemente a coleta de material com espátula para exame laboratorial e a microscopia confocal in vivo. A predominância das leveduras poderá ser devido a alterações morfológicas do fungo sofridas no tecido corneano. A penetração intraocular é facilitada por alterações da Camada de Descemet e pela própria capacidade do fungo de penetrar nos tecidos justificando o tratamento sistêmico desde o início.

PURPOSE: The study of fungal invasion and pathogenicity in corneal tissue observed through the histopathological examination of specimens obtained through penetrating keratoplasty ('PKP') of samples obtained from an Eye Bank ('EB'), with the aim of applying findings in diagnosis and treatment of the condition METHODS: Retrospective non-comparative case studies on samples collected between January 2006 and June 2011 based on identification data comprised of scant historical information sent by surgeons and material obtained through PKP, consisting of 38 samples from 35 patients. Processing involved special stains for fungi in order to detect the presence thereof, with one to three colourations being performed in accordance with diagnostic difficulty in relation to each sample. RESULTS: Patients were predominantly male (20 compared to 15 females), and the most represented age group was 60+ years of age (1/3 of the patients). Mycotic keratitis was detected in 6.4% (n= 597) of cases referred to the EB and in 1.65% (n= 2310) of transplants using corneal material provided by the EB over the last five years. According to historical information provided by surgeons, 39.5% (n= 38) of cases were due to perforation of the cornea. A statistical table was prepared using transplant data. 11 specimens (n= 38) were due to an anterior corneal graft. Yeasts were present in 63% (n= 38), and 50% (n= 38) of corneal tissue had mild or non-existing inflammation. 13% (n= 38) had whole Descemet layers, while 45% (n= 38) presented fungi on the corneal surface. CONCLUSION: Corneal grasping and confocal microscopy may be performed successfully after treatment has been initiated, although in corneal ulcers samples should ideally be collected with a spatula for laboratory testing in vivo. The high prevalence of yeasts in the samples we looked at may be due to morphologic changes in corneal tissue of fungal origin. Intraocular penetration of the fungi is facilitated by changes to the Descemet layer, and assisted by the fungi's own properties. Therefore systemic treatment is justified from the outset.

Lower Energy to Make a Corneal Flap with a 60 kHz Femtosecond Laser Reduces Flap Inflammation and Corneal Stromal Cell Death But Weakens Flap Adhesion

PURPOSE: To compare corneal flaps created in rabbits with a 60 kHz femtosecond (FS) laser using different levels of raster energy and to measure early inflammation, corneal stromal cell death, and late postoperative adhesion strength. METHODS: Sixty rabbits were divided into three groups of 20 each. A flap 110 micrometer thick and 9.0 mm in diameter was made in one eye of each rabbit at raster energies of 0.7 microJ, 1.1 microJ, and 2.4 microJ. Histopathological evaluation for inflammation and apoptosis using terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining was performed at 4 and 24 hours after flap creation. The adhesion strength of the flaps was measured with a tension meter at 1 and 3 months. RESULTS: Twenty four hours after flap creation, the 2.4 microJ group had more inflammatory and CD11b-positive cells than the 0.7 and 1.1 microJ groups. The number of TUNEL-positive cells increased with raster energy at 4 and 24 hours. The grams of force (gf) needed to detach the flaps at 3 months was significantly higher in 2.4 microJ group (170 gf) than in 0.7 microJ group (97.5 gf) and 1.1 microJ group (100 gf, p = 0.03). CONCLUSIONS: Using raster energy lower than 1.1 microJ to make a flap with a 60 kHz FS laser decreases inflammatory cell infiltration and corneal stromal cell death in the central cornea but may result in a weaker flap than using higher raster energy (2.4 microJ).

Lower Energy to Make a Corneal Flap with a 60 kHz Femtosecond Laser Reduces Flap Inflammation and Corneal Stromal Cell Death But Weakens Flap Adhesion

PURPOSE: To compare corneal flaps created in rabbits with a 60 kHz femtosecond (FS) laser using different levels of raster energy and to measure early inflammation, corneal stromal cell death, and late postoperative adhesion strength. METHODS: Sixty rabbits were divided into three groups of 20 each. A flap 110 micrometer thick and 9.0 mm in diameter was made in one eye of each rabbit at raster energies of 0.7 microJ, 1.1 microJ, and 2.4 microJ. Histopathological evaluation for inflammation and apoptosis using terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining was performed at 4 and 24 hours after flap creation. The adhesion strength of the flaps was measured with a tension meter at 1 and 3 months. RESULTS: Twenty four hours after flap creation, the 2.4 microJ group had more inflammatory and CD11b-positive cells than the 0.7 and 1.1 microJ groups. The number of TUNEL-positive cells increased with raster energy at 4 and 24 hours. The grams of force (gf) needed to detach the flaps at 3 months was significantly higher in 2.4 microJ group (170 gf) than in 0.7 microJ group (97.5 gf) and 1.1 microJ group (100 gf, p = 0.03). CONCLUSIONS: Using raster energy lower than 1.1 microJ to make a flap with a 60 kHz FS laser decreases inflammatory cell infiltration and corneal stromal cell death in the central cornea but may result in a weaker flap than using higher raster energy (2.4 microJ).

Keratomycosis caused by Exserohilum rostratum.

We report a case of keratomycosis caused by Exserohilum rostratum. A 46-year-old farmer presented with history of pain, watery discharge and redness of the right eye for the past 2 weeks following trauma with vegetable matter. On ocular examination, a central corneal ulcer of about 8 mm with a greyish-white slough, feathery edges and diffuse corneal edema was seen in the right eye. KOH examination of corneal scrapings revealed thick, brown, branched, septate hyphae. Culture of corneal scrapings on Sabouraud dextrose agar showed velvety greenish-black colony with a black pigment on the reverse. The culture was identified as E. rostratum on the basis of microscopic morphology. The patient responded well to treatment with topical natamycin and oral itraconazole.

Effect of amniotic membrane combined with ciprofloxacin in curing the primary stages of pseudomonal keratitis

Keratitis caused by Pseudomonas aeruginosa is often resulted in severe corneal ulcers and perforation, which leads to losses of vision. Human amniotic membrane [HAM] forms the inner wall of the membranous sac which surrounds and protects the embryo during gestation. The purpose of this study was to evaluate the effectiveness of the amniotic membrane's healing in rabbits with pseudomonas keratitis. In total 14 rabbits divided in 2 groups of: 1 as Control and 2 as experimental amniotic membrane combined with ciprofloxacin. A 0.05 ml suspension of Pseudomonas aeruginosa ATCC 27853 was injected into rabbit's corneal stroma, with no interference in control group. In the second group, the amniotic membrane in pieces of 1.5 x 1.5 cm transplanted to the entire corneal surface by eight interrupted 10.0 nylon sutures. In the first day ciprofloxacin drop was injected to the second group every 30 minutes and through second to seventh days every 2 hours. The results of perforation in cornea and the amount of infiltration were registered. The results showed that amniotic membrane transplantation [AMT] + ciprofloxacin group had 0% perforation and the control group 85.6%. Average infiltrations were 5 mm in AMT + ciprofloxacin groups and 23.75 mm in control. The use of amniotic membrane with ciprofloxacin was effective in prevention of cornea perforation and controlling the process of pseudomonal keratitis remission. The improvement of inflammation rapidly happened in ciprofloxacin + AMT group.

Efeito do dinitrato de isossorbida sobre a hiperalgesia corneana induzida por lipopolissacarídeo / Isosorbide dinitrate effect on corneal hyperalgesia induced by lipopolysaccharide

OBJETIVO: Avaliar o efeito do dinitrato de isossorbida (DNI) sobre a hiperalgesia corneana e a infiltração de neutrófilos em um modelo experimental de ceratite superficial induzida pelo lipopolissacarídeo (LPS). MÉTODOS: A hiperalgesia foi estudada através da indução de uma ceratite inflamatória em ratos (n = 60), pela exposição da córnea ao LPS (LPS +). Após a exposição, os olhos foram tratados durante quatro dias, com as soluções tópicas: DNI (200 mg, 65 mg e 20 mg), prednisolona 1 por cento (PRED) ou Veículo. Olhos controles foram expostos apenas à solução salina (LPS -). Para avaliar a dor ocular, contouse o número de piscadas em 40 segundos, após instilação de uma gota de capsaicina 0,01 mM. A análise histopatológica foi realizada para avaliação da infiltração neutrofílica. RESULTADOS: Foram observadas áreas esbranquiçadas no estroma corneano dos olhos com a ceratite induzida pelo LPS, entre os dias 3 e 15 dias. Esses olhos (LPS +) apresentaram um número significativamente maior de piscadas que os LPS - (P = 0,019) à estimulação química. O tratamento tópico com o DNI reduziu o número de piscadas observadas (P = 0,010). Da mesma forma, olhos expostos ao LPS e tratados com DNI demonstraram redução significativa na infiltração neutrofílica (P = 0,0031). CONCLUSÃO: Baixas doses de DNI reduziram a hiperalgesia corneana e a infiltração neutrofílica nesse modelo de ceratite. Dessa forma, doadores de óxido nítrico, como o DNI, poderão ser úteis no futuro ao tratamento clínico de diversas condições dolorosas da superfície ocular.

PURPOSE: To analyze effects of isosorbide dinitrate (DNI) on corneal hyperalgesia and neutrophil infiltration in an experimental model of superficial keratitis induced by lipopolysaccharide (LPS). METHODS: Hyperalgesia was studied through the induction of inflammatory keratitis in rats (n=60), by corneal exposure to LPS. Following exposure, the inflamed eye was treated for four days, with one of the following solutions: topical DNI (200 λg, 65 λg and 20 λg), prednisolone 1 percent (PRED), and vehicle. Saline-exposed eyes (LPS -) underwent the same protocol. To evaluate ocular pain, the number of blinks in 40 seconds was counted, after one drop of 0.01 λM capsaicin. Histopathological analysis was performed with evaluation of neutrophil infiltration. RESULTS: White clouding areas were observed in the corneal stroma of eyes with LPS-induced keratitis, between day 3 and day 15. Eyes exposed to LPS had a significantly higher number of blinks than LPS - (P=0.019). Topical treatment of LPS-induced keratitis eyes with DNI reduced capsaicin-induced blinks (P=0.010). Similarly, eyes exposed to LPS and treated with DNI also displayed reduced neutrophil infiltration (P=0.0031). CONCLUSION: Low doses of topical NO donors, like DNI, reduce corneal hyperalgesia and neutrophil infiltration in this keratitis model. NO donors may be useful in the clinical treatment of painful conditions associated with surgical procedures of the ocular surface.

Você conhece esta síndrome? / Do you know this syndrome?

A síndrome de KID é uma displasia ectodérmica congênita rara que afeta a pele, o epitélio da córnea e o ouvido interno. Clinicamente, observam-se placas de eritroqueratodermia na face e pregas, geralmente presentes desde o nascimento, a surdez neurossensorial severa e bilateral, e a vascularização córnea associado à queratite de evolução progressiva à qual surge após as alterações cutâneas e auditivas na puberdade. Face ao quadro surdez, às infecções cutâneas, ao risco de cegueira e à degeneração maligna, o diagnóstico precoce da síndrome é fundamental, bem como o seguimento clínico periódico e o aconselhamento genético.

Keratitis-ichthyosis-deafness (KID) syndrome is a rare congenital ectodermal dysplasia affecting skin, the corneal epithelium and inner ear. Clinical signs consist of erythrokeratodermal plaques on the face and skin folds, usually present from birth, as well as severe and bilateral sensorineural hearing loss and corneal vascularization associated with slow-progressing keratitis which follows skin and hearing changes at puberty. In view of symptoms of deafness, blindness, skin infections and the risk of malignant degeneration, early diagnosis of the syndrome is essential, together with clinical follow-up and genetic counseling.

Update on pathologic diagnosis of corneal infections and inflammations

One of the most frequent types of corneal specimen that we received in our pathology laboratory is an excised corneal tissue following keratoplasty. Several of these cases are due to corneal infections or the sequelae, like corneal scar. Advances in the histological and molecular diagnosis of corneal infections and inflammations have resulted in rapid and accurate diagnosis of the infectious agent and in the overall understanding of the mechanisms in inflammatory diseases of the cornea. This review provides an update of histopathological findings in various corneal infections and inflammations

The effect of subconjunctival bevacizumab on corneal neovascularization, inflammation and re-epithelization in a rabbit model

PURPOSE: To evaluate the use of subconjunctival bevacizumab on corneal neovascularization in an experimental rabbit model for its effect on vessel extension, inflammation, and corneal epithelialization. METHODS: In this prospective, randomized, blinded, experimental study, 20 rabbits were submitted to a chemical trauma with sodium hydroxide and subsequently divided into two groups. The experimental group received a subconjunctival injection of bevacizumab (0.15 m; 3.75 mg), and the control group received an injection of 0.15 ml saline solution. After 14 days, two blinded digital photograph analyses were conducted to evaluate the inflammation/diameter of the vessels according to pre-established criteria. A histopathological analysis of the cornea evaluated the state of the epithelium and the number of polymorphonuclear cells. RESULTS: A concordance analysis using Kappa's statistic showed a satisfactory level of agreement between the two blinded digital photography analyses. The neovascular vessel length was greater in the control group (p<0.01) than in the study group. However, the histopathological examination revealed no statistically significant differences between the groups in terms of the state of the epithelium and the number of polymorphonuclear cells. CONCLUSIONS: Subconjunctival bevacizumab inhibited neovascularization in the rabbit cornea. However, this drug was not effective at reducing inflammation. The drug did not induce persistent corneal epithelial defects.

Fungal keratitis in Lattice dystrophy.

We report a case of fungal keratitis occurring in a patient with lattice dystrophy. A 57-year-old farmer presented with a corneal ulcer following probable entry of paddy husk in the right eye, of one month duration. Corneal scraping revealed pigmented fungal filaments while culture grew Alternaria alternata. Treatment with 5% natamycin eye drops and 1% atropine healed the infection in four weeks. We would like to draw attention to the fact that the cornea in lattice dystrophy is prone to frequent erosions and is a compromised epithelial barrier to invasion by microorganisms. Patients must be made aware of this fact and should seek attention at the earliest following any trivial trauma. Management of minor corneal abrasions in them should be directed at healing the epithelium with adequate lubricants and preventing infection with topical antibiotic prophylaxis.

What is central toxic keratopathy syndrome if it is not diffuse lamellar keratitis grade IV?

The Central Toxic Keratopathy [CTK] syndrome describes a rare, acute, self-limited, non-inflammatory process that yields central corneal opacification and significant hyperopic shift after refractive surgery. Despite being exceedingly rare, certain clinical features of CTK give the condition a striking resemblance to other more serious inflammatory conditions, including diffuse lamellar keratitis [DLK]. As the authors demonstrate in this article, despite the overlapping clinical features, CTK is a disease process that is distinct from DLK and, therefore, in need of distinct management interventions

Hanseníase ocular: uma abordagem histórica / Ocular leprosy: a historical approach

Houve uma acentuada queda na prevalência da hanseníase nas últimas três décadas. Contudo, a incidência não diminuiu na mesma proporção. Hoje, três anos após a última data estipulada pela Organização Mundial da Saúde para o controle da hanseníase, pacientes considerados curados ainda necessitam de cuidados especiais por causa de suas incapacidades e reações imunológicas. A literatura médica refere cegueira em 4 por cento a 11 por cento dos pacientes estudados e, mais de 20 por cento com graves problemas visuais devido a exposição da córnea, invasão bacilar e hipersensibilidade; estes mecanismos resultam em uma população de aproximadamente 1 milhão de pacientes cegos, embora a prevalência oficial não passe de 250.000 pacientes em todo o mundo. O autor destaca a necessidade de melhor tratamento e acompanhamento dos pacientes e, conclama os oftalmologistas a tornarem-se mais perceptivos e se interessarem mais pelo tratamento das complicações oculares da hanseníase.

A sharp drop in the prevalence of leprosy occurred in the last three decades. However, the incidence has not decreased at the same rate. Three years after the World Health Organization last deadline for leprosy control, patients considered healed still need special care for their incapacities and immunopathological reactions. Medical literature reffers blindness in 4 percent to 11 percent of studied patients and more than 20 percent with severe visual problems due to corneal exposure, bacillary invasion and hipersensibility. These mechanisms result in a population of nearly one million blind leprosy patients even though official prevalence accounts no more than 250,000 patients worldwide. The author calls for better patients management and follow-up and urges ophthalmologists to become more aware and interested in the treatment of the ocular complications of leprosy.

Tearful relations: oxidative stress, inflammation and eye diseases: [review] / Relações lacrimejantes: estresse oxidativo, inflamação e doenças oculares: [revisão]

Oxidative stress is caused by an imbalance between the production of reactive oxygen species and ability the biological systems' defense mechanisms necessary to eliminate the stress. It has been accepted that oxidative stress is involved in many acute and chronic diseases and even in normal aging. Recently, increased awareness of oxidative stress damage and its relation with ocular surface diseases incite researchers to discover possible mechanisms in the development of dry eye disease. This review focuses on the evaluation of the influence of oxidative stress on eye diseases emphasizing its relation with the pathogenesis of dry eye disease.

Estresse oxidativo é causado por um desequilíbrio entre a produção de espécies reativas do oxigênio e a habilidade dos mecanismos de defesa do sistema biológico necessários para eliminar este estresse. O estresse oxidativo tem sido aceito como um fator envolvido em várias doenças agudas, crônicas e até mesmo no envelhecimento fisiológico. Recentemente, o crescente conhecimento dos danos causados pelo estresse oxidativo e a sua relação com doenças da superfície ocular estimulou pesquisadores a descobrir possíveis mecanismos no desenvolvimento da doença do olho seco. Esta revisão tem como foco a avaliação da influência do estresse oxidativo nas doenças do olho e enfatiza a sua relação com a patogênese da doença do olho seco.

Acometimento ocular em pacientes com mansonelose / Ocular manifestations in mansonelliasis

OBJETIVOS: Avaliar as alterações oculares observadas em indivíduos com mansonelose residentes na área rural do município de Coari, AM, na região do médio Amazonas. MÉTODOS: Foi conduzido um estudo de corte transversal envolvendo 543 moradores residentes na área rural do município de Coari, na margem direita do rio Solimões. Todos os indivíduos foram submetidos a exame de gota espessa para pesquisa de microfilária e os indivíduos positivos foram submetidos a exame oftalmológico. Lesões oculares suspeitas foram biopsiadas e enviadas para exame histopatológico. RESULTADOS: Mansonella ozzardi foi encontrada no sangue periférico em 103 (18,9 por cento) indivíduos. Noventa e cinco pacientes com mansonelose foram examinados, observando ceratite puntata em 12 (11,7 por cento) destes, ceratite numular em um indivíduo (1 por cento) e esclerosante em outro (1 por cento). Biópsia de pele foi negativa em todos os indivíduos. Biópsia de conjuntiva e limbo foi realizada em cinco pacientes com mansonelose e biópsia de córnea em outros três pacientes. Duas biópsias de conjuntiva e limbo e uma biópsia de córnea foram enviadas para exame histopatológico, não sendo observadas microfilárias ou alterações sugestivas da presença destas nas peças estudadas. O restante das biópsias foi enviado para pesquisa de DNA do parasita por PCR, não se encontrando microfilária. CONCLUSÕES: Associação entre infecção por Mansonella ozzardi e lesões corneanas sem etiologia aparente foi verificada neste estudo, mas a ausência de achados específicos no exame histopatológico e a não identificação de microfilárias por PCR em lesões suspeitas põem em dúvida a o acometimento corneano na mansonelose. Estudos mais amplos de populações com alta prevalência de M. ozzardi e a realização de outros testes para identificação de microfilárias em tecido ocular são necessários para investigar a patogenicidade da microfilária ao tecido ocular.

PURPOSE: To evaluate eye manifestations in mansonelliasis patients from Coari, AM, rural area on the middle Amazonas River. METHODS: Cross-sectional study consisted of evaluation of 543 subjects from Coari rural area on Solimões River right margin. All subjects were submitted to blood test for microfilaria and the subjects who had a positive test also were submitted to skin biopsies and ophthalmologic examination. Histopathology and PCR research for microfilaria were done on eye biopsies of suspect lesions. RESULTS: Mansonella ozzardi was found in peripheral blood of 103 (18.9 percent) subjects. Ninety-five mansonelliasis patients were examined. Punctate keratitis was observed in 12 of them, nummular keratitis in one subject and sclerosing keratitis in another one. Skin biopsies were negative in all subjects. Conjunctival and limbal biopsies were done in five mansonelliasis patients and corneal biopsy in another three patients. Conjunctival and limbal biopsies of two patients and corneal biopsy of one patient showed no microfilaria or alterations due to its presence on histopathology. PCR showed no evidence of microfilaria in the other biopsies. CONCLUSION: Association between Mansonella ozzardi infection and corneal lesions with no evident etiology was observed in this study, but the lack of conclusive findings on histopathology and PCR make us doubt the corneal involvement in mansonelliasis. Large studies of high mansonelliasis prevalence populations and extensive employment of microfilaria identification tests in ocular tissue are needed to evaluate the microfilaria corneal pathogenicity.

Transplante terapêutico de córnea: resultados prolongados de série de casos / Long-term follow-up of a case series of therapeutic corneal transplant

OBJETIVO: Analisar os resultados dos transplantes terapêuticos realizados no tratamento de ceratites infecciosas. MÉTODOS: Foi feito estudo retrospectivo de 59 prontuários de pacientes com ceratite infecciosa submetidos a transplante terapêutico no Departamento de Oftalmologia da Santa Casa de São Paulo de janeiro de 2000 a dezembro de 2004. Foram obtidos dados de identificação do paciente (idade, sexo e raça), acuidade visual pré e pós-operatória, biomicroscopia pré e pós-operatória, ecografia, resultados de cultura e bacterioscopia. Foram incluídos apenas os pacientes com seguimento mínimo de 9 meses. Os pacientes foram divididos em cinco grupos: ceratite bacteriana, fúngica, mista, aquelas com cultura e/ou bacterioscopia negativa e herpética. RESULTADOS: A erradicação da infecção e o restabelecimento da integridade do bulbo ocular dentre as ceratites bacterianas foi de 95,2 por cento; nas fúngicas de 100 por cento; nas mistas de 25 por cento; naquelas com cultura e/ou bacterioscopia negativa de 95,2 por cento e nas herpéticas de 100 por cento. Dentre as complicações, foram encontrados 2 casos de rejeição, 6 de recidiva, 13 de aumento da pressão intra-ocular e 1 de perfuração. CONCLUSÃO: Nas ceratites infecciosas perfuradas ou com risco de perfuração que não respondem ao tratamento clínico conservador, o transplante terapêutico deve ser considerado importante alternativa para erradicação da infecção e restabelecimento da integridade do bulbo ocular.

PURPOSE: To describe the results of therapeutic penetrating keratoplasty in patients with impending perforation or perforated infectious keratitis. METHODS: Fifty-nine charts of patients with infectious keratitis who were submitted to therapeutic penetrating keratoplasty were retrospectively reviewed at the Department of Ophthalmology of the Santa Casa of São Paulo from January 2000 to December 2004. Pre- and post operative visual acuity, biomicroscopy, echography, culture and bacterioscopy were analyzed. Patients with a minimum 9-month follow-up were included and were divided into 5 groups: herpetic, bacterial, fungal, bacterial-fungal keratitis and keratitis with negative culture bacterioscopy. RESULTS: Erradication of infection and restoration of ocular integrity were obtained in 95.2 percent of all bacterial keratitis; 100 percent fungal; 25.0 percent bacterial-fungal; 95.2 percent negative culture and 100 percent of all herpetic keratitis. Complications included: 2 rejections, 6 recurrences, 13 glaucomas and 1 perforation. CONCLUSION: In infectious keratitis with perforation or impending perforation that did not respond to conservative clinical therapy, therapeutic penetrating keratoplasty must be considered an alternative to erradicate infection and restore the ocular integrity.

Fungal keratitis: a review

Keratomycosis is a vision-threatening fungal corneal infection. The dramatic increase in the number of cases over the past three decades is attributable not only to better diagnostic recognition, improved laboratory techniques and greater awareness by the ophthalmic society as a whole, but is also due to a true increase in the incidence of keratitis related to the indiscriminate use of topical broad-spectrum antibiotics, corticosteroids and immunosuppressive drugs, as well as surgical trauma. Corneal trauma has remained the main predisposing factor over the years, though in recent years HIV-positive cases and AIDS are taking the lead in certain areas. Aspergillus, Fusarium and Candida species remains the commonest 'organisms' isolated worldwide. Although the approach to this form of keratitis is similar to other types of microbial keratitis, it remains the most difficult in terms of diagnosis and management. Early recognition, prevention, prompt treatment and timely keratoplasty are crucial for a better outcome

HTLV-I e uveíte / HTLV-I and uveitis

Os autores descrevem os primeiros casos de uveíte intermediária associada ao HTVL-I ( vírus linfotrópico para a célula-T ) no Brasil. Foram examinados 10 pacientes com HTVL-I ( Elisa e Western-Blot ) sendo encontradas alteraçöes como vasculite e exsudaçäo na retina periférica em três casos (33 por cento), um caso (10 por cento) com Síndrome de Spogren primária e outro (10 por cento), ainda näo descrito, de ceratite intersticial. O objetivo do estudo foi identificar alteraçöes oculares em pacientes soropositivos para HTVL-I, alertando para uma nova etiologia a ser pesquisada nas uveítes intermediárias contribuindo para diminuiçäo do número, ainda grande, de casos idiopáticos.