Bilateral ocular deposit of chlorpromazine / Depósito ocular bilateral de clorpromazina

ABSTRACT Chlorpromazine is a medication widely used in psychiatry for the treatment of psychoses, especially schizophrenia. Since 1964, published articles have been correlating this medication with the appearance of ocular alterations. In this paper, we report the case of a 65-year-old patient with ocular effects due to long-term therapy with chlorpromazine. Biomicroscopy of both eyes presented diffuse granular brown deposits, most prominent at the deep stroma and corneal endothelium level. Also showed anterior subcapsular brown deposits with a stellate pattern in the lens. The total amount exceeds 2.000g (significant for the ocular alterations described) considering the patient's daily dosage of chlorpromazine of 300mg for ten years. After performing complete ophthalmic evaluation and discarding other causes for the ocular deposits, we diagnosed a secondary corneal deposit and cataract due to the use of chlorpromazine. This case reinforces the importance of periodic follow-up with an ophthalmologist for chlorpromazine users to trace ocular changes, heeding the exposure time and its dosage.

RESUMO A clorpromazina é uma medicação muito empregada na psiquiatria para tratamento de psicoses, especialmente em casos de esquizofrenia. Desde 1964 existem artigos publicados que correlacionam o uso dessa medicação com o aparecimento de alterações oculares. Neste trabalho, relatamos o caso de um paciente de 65 anos com efeitos oculares devido à terapia de longo prazo com clorpromazina. A biomicroscopia de ambos os olhos apresentou depósitos granulares difusos e de cor marrom, mais proeminente ao nível do estroma profundo e do endotélio da córnea, além de depósitos castanhos subcapsulares anteriores centrais em um padrão estrelado no cristalino. Considerando a dose diária de clorpromazina de 300mg por 10 anos usada pelo paciente, a quantidade total ultrapassa 2.000g (dose considerada significativa para as alterações oculares descritas). Após avaliação oftalmológica completa e descartado outras causas desses depósitos oculares, foram diagnosticados depósito corneano e catarata secundários ao uso de clorpromazina. O caso apresentado reforça a importância do acompanhamento oftalmolÓgico periÓdico de usuários de clorpromazina para o rastreio de alteraçÕes oculares, atentando-se ao tempo de exposição à droga e à posologia da mesma.

Acquired anterior staphyloma after corneal ulcer associated with the use of crack / Estafiloma anterior adquirido após úlcera de córnea associado a uso de crack

ABSTRACT We describe an unusual case of acquired anterior staphyloma in a patient addicted to crack cocaine. At the beginning of his crack cocaine abuse, he noticed redness and irritation of his eyes. Over the next 4 months, the patient also noticed the onset of decreasing visual acuity in his right eye (OD). Initially, his visual acuity was light perception in OD, and slit-lamp examination revealed a corneal infiltrate with a peripheral perforation and an iris prolapse. The patient was hospitalized to ensure compliance with the prescribed treatment and was advised to undergo therapeutic keratoplasty; however, the patient left the hospital against medical advice and was lost to follow-up for the next 6 months. He returned with complaints of photophobia and the inability to close his right eyelids. At this time, his cornea had developed an anterior staphyloma and required a sclerokeratoplasty. Following surgery, the patient was again lost to follow-up.

RESUMO Descrevemos um raro caso de estafiloma anterior adquirido em um paciente viciado em crack. No início do uso do crack, paciente observou hiperemia e irritação nos seus olhos. Durante os próximos 4 meses, evoluiu com piora progressiva da visão em seu olho direito (OD). Inicialmente, sua visão no OD era de percepção luminosa e ao exame de biomicroscopia observava-se um importante infiltrado corneano com uma perfuração periférica e hérnia de íris. O paciente foi hospitalizado para garantir seu correto tratamento e indicado ceratoplastia terapêutica; no entanto, o paciente abandou o hospital e ficou 6 meses sem acompanhamento. Após esse período, paciente retornou queixando-se de importante fotofobia e inabilidade em ocluir o OD. Neste momento, sua córnea havia desenvolvido um importante estafiloma anterior e necessitou de uma escleroceratoplastia no OD. Após a cirurgia, mais uma vez o paciente abandonou o tratamento e perdeu o seguimento pós-operatório.

The prevalence of ocular surface complaints in Brazilian patients with glaucoma or ocular hypertension / Prevalência de sintomas da doença da superfície ocular em pacientes brasileiros com glaucoma ou hipertensão ocular

PURPOSE: To examine the prevalence of ocular surface complaints in Brazilian patients with glaucoma or ocular hypertension who used topical intraocular pressure (IOP)-lowering regimens. METHODS: In this multicenter, noninterventional, single-visit study, adults with glaucoma or ocular hypertension treated with an IOP-lowering regimen were administered the 12-item ocular surface disease index (OSDI) questionnaire. Each response was scored on a 5-point scale, with 0 indicating symptom present none of the time and 4 indicating symptom present all of the time. The average of the 12 item responses for each patient was transformed to a scale from 0 to 100, with higher scores representing worse disabilities. OSDI results then were categorized as absence of OSD (scores of 0-12), mild OSD (scores of 13-22), moderate OSD (scores of 23-32), or severe OSD (scores of 33100). RESULTS: The 173 enrolled patients had a mean age of 61.2 years, were women in 65.3% of cases, and had glaucoma in 89.0% of cases and ocular hypertension in 11.0% of cases. OSDI scores for 158 patients using 1 IOP-lowering therapy indicated no OSD in 37.3% of patients (59/158), mild OSD in 20.9% (33/158), moderate OSD in 17.1% (27/158), and severe OSD in 24.7% (39/158). For the 120 patients using 1 IOP-lowering medication and having a known duration of diagnosis of glaucoma or ocular hypertension, mean OSDI scores were numerically higher (worse) for the 39 patients with a diagnosis ≥6 years long (score 25 [± 20], indicating moderate OSD) than for the 81 patients with a diagnosis lasting <6 years (score 22 [± 20], indicating mild OSD); however, no significant differences in OSDI scores by duration of diagnosis were evident in means (P=0.49), distributions (P≥0.26), or correlation (P=0.77). CONCLUSIONS: A large proportion of Brazilian patients treated with 1 IOP-lowering therapy had some ocular surface complaints.

OBJETIVO: Avaliar a prevalência de sintomas decorrentes de doença de superfície ocular (DSO) em pacientes brasileiros com glaucoma ou hipertensão ocular que utilizam tratamento ocular tópico para redução da pressão intraocular (PIO). MÉTODO: Neste estudo multicêntrico, não intervencional de uma única visita, pacientes adultos com glaucoma ou hipertensão ocular em tratamento para redução da pressão intraocular (PIO) responderam aos 12 itens do questionário "índice de doença da superfície ocular" (OSDI). Cada resposta foi pontuada numa escala de 5 pontos, com 0 (zero) indicando a ausência de sintomas e 4 indicando sintomas presentes todo o tempo. A média de respostas dos 12 itens para cada paciente foi transformada numa escala de 0 a 100, com pontuações mais elevadas representando piores deficiências. Os resultados do OSDI foram categorizados como ausência de DSO (pontuação de 0-12), DSO leve (pontuação de 13-22), DSO moderada (pontuação de 23-32) ou DSO grave (pontuação de 33-100). RESULTADOS: Os 173 pacientes incluídos apresentavam idade média de 61,2 anos, 65,3% eram mulheres (65,3%), tinham glaucoma em 89,0% dos casos e hipertensão ocular em 11,0% dos casos. As pontuações do OSDI para os 158 pacientes utilizando uma medicação para redução da PIO indicaram "DSO ausente" em 37,3% dos pacientes (59/158), "DSO leve" em 20,9% (33/158), "DSO moderada" em 17,1% (27/158) e "DSO grave" em 24,7% (39/158). Para os 120 pacientes utilizando medicação redutora da PIO e com duração conhecida do diagnóstico de glaucoma ou hipertensão ocular, a pontuação média do OSDI foi numericamente superior (pior) para 39 pacientes com diagnóstico realizado há mais de 6 anos (pontuação 25 [± 20] indicando DSO moderado) do que para 81 pacientes com o diagnóstico realizado há menos de 6 anos (pontuação 22 [± 20] indicando DSO leve); no entanto, não houve diferença estatisticamente significativa na média da pontuação OSDI na duração do diagnóstico (P=0.49), distribuição (P≥0,26), ou correlação (P=0,77). CONCLUSÃO: Uma grande proporção de pacientes brasileiros tratados com uma medicação para redução da PIO apresenta sintomas decorrentes de doença da superfície ocular (DSO).

Effects of conditioned media from human amniotic epithelial cells on corneal alkali injuries in rabbits

This study was performed to evaluate the effects of conditioned media (CM) from human amniotic epithelial cells (HAECs) on the corneal wound healing process. Eighteen rabbits (36 eyes) were used and randomly assigned to three groups according treatment: CM from HAECs (group 1), vehicle alone (group 2), and saline (group 3). Corneal alkali injuries were induced with 1 N sodium hydroxide. Each reagent used for treatment evaluation was injected into the dorsal bulbar subconjunctiva and the area of the corneal epithelial defect was measured every other day. Two animals from each group were euthanized at a time on days 3, 7, and 15, and the cornea was removed for histological examination. The sum of the epithelial defect areas measured on day 0 to day 6 as well as day 0 to day 14 in group 1 was significantly smaller than those of other groups. Histological examination revealed that the group 1 corneas had less inflammatory cell infiltration and showed more intact epithelial features compared to the other groups. These results suggest that CM from HAECs promote corneal wound healing in rabbits.

Sphingosine-1 phosphate prevents ethanol-induced corneal epithelial apoptosis.

Background: Apoptosis is a programmed cell death in multicellular organisms, found in a wide variety of conditions, including inflammatory process, everywhere in the body, including the cornea and conjunctiva. Aim: To evaluate the effect of a new topical formulation of sphingosine-1 phosphate on preventing apoptosis of the corneal epithelium. Setting: Medical University. Materials and Methods: We tested several formulations suitable for topical application. Twenty-five rabbits were distributed among five groups. Group 1 comprised the controls. In Group 2, 20% ethanol was applied topically for 20 seconds; in Group 3, 50 μM topical sphingosine-1 phosphate was applied 2 hours prior to 20% ethanol application. In Group 4, 200 μM topical sphingosine-1 phosphate was applied 2 hours before the 20% ethanol application. In Group 5, only 200 μM topical sphingosine-1 phosphate was applied. Apoptosis was evaluated using the terminal deoxynucleotidyl transferase biotin-dUTP Nick End Labeling (TUNEL) assay. Pairwise comparisons were performed using t-tests with Scheffe's correction. Data were analyzed using STATA 9.0 statistical software. Results: A suspension of sphingosine-1 phosphate in the presence of Montanox 80 was stable and could be formulated without sonication. Epithelial apoptosis was detected only in Groups 2 and 3. Conclusion: Sphingosine-1 phosphate can prevent ethanol-induced apoptosis in the corneal epithelium of rabbits.

Vortex Keratopathy in a Patient Receiving Vandetanib for Non-Small Cell Lung Cancer

We report a case of vortex keratopathy in a patient treated with vandetanib for non-small cell lung cancer (NSCLC). A 44-year-old female who underwent two cycles of chemotherapy for NSCLC complained of visual blurring in both eyes after the initiation of vandetanib, an anti-epidermal growth factor receptor (EGFR) and anti-vascular endothelial growth factor receptor 2 protein tyrosine kinase inhibitor. On ophthalmic examination, visual acuities were 20 / 20 OU and, with the exception of diffuse vortex keratopathy in both eyes, other findings were unremarkable. Vandetanib is believed to have caused vortex keratopathy in this patient. Anti-EGFR properties affecting normal corneal epithelial cell migration and wound healing or drug associated metabolite deposition, which is the case in numerous drug-associated vortex keratopathies, may be possible underlying mechanisms in the formation of this corneal complication.

Methotrimeprazine-induced Corneal Deposits and Cataract Revealed by Urine Drug Profiling Test

Two schizophrenic patients who had been taking medication for a long period presented with visual disturbance of 6-month duration. Slit-lamp examination revealed fine, discrete, and brownish deposits on the posterior cornea. In addition, bilateral star-shaped anterior subcapsular lens opacities, which were dense, dust-like granular deposits, were noted. Although we strongly suspected that the patient might have taken one of the drugs of the phenothiazine family, we were unable to obtain a history of medications other than haloperidol and risperidone, which were taken for 3 yr. We performed a drug profiling test using urine samples and detected methotrimeprazine. The patient underwent surgery for anterior subcapsular lens opacities. Visual acuity improved in both eyes, but the corneal deposits remained. We report an unusual case of methotrimeprazine-induced corneal deposits and cataract in a patient with psychosis, identified by using the urine drug profiling test.

Toxicidade ocular por derivados da 4-aminoquinolona / Ocular toxicity due to 4-aminoquinoline derivatives

A toxicidade retiniana da cloroquina tem sido extensamente estudada desde a sua primeira descrição em 1957. Esta droga é usada no tratamento de várias doenças reumatológicas e dermatológicas, com tendência atual ao uso da hidroxicloroquina a cloroquina. A dose diária da droga parece determinar o desenvolvimento da doença ocular, não devendo ultrapassar 4 mg/kg/dia. O quadro clínico é caracterizado por escotoma paracentral no campo visual associado à maculopatia em " olho de boi" . O campo visual e a tela de Amsler são os exames que podem detectar mais precocemente as alterações tóxicas retinianas. O presente texto propõe uma revisão da patogênese, quadro clínico, diagnóstico diferencial, exames complementares e tratamento. Os autores utilizaram em sua pesquisa os bancos de dados da PubMed (MEDLINE), LILACS e Biblioteca do Centro de Estudos de Oftalmologia.

Retinal toxicity of chloroquine has been extensively studied since its first description in 1957. This drug is used on a chronic basis to treat several rheumatologic and dermatologic diseases, a there is a trend to use hydroxychloroquine rather than chloroquine. The recommended dose for hydroxychloroquine is 4 mg/kg lean body weight per day. The clinical picture of chloroquine retinopathy is characterized by a paracentral visual field scotoma with associated parafoveal retinal pigment epithelium atrophy, known as 'bull's eye maculopathy. The visual field and Amsler grids are the exams that early detect toxicity retinopathy. The authors aim to review the pathogenesis, clinical features, differential diagnosis, complementary exams, and treatment. The sources of references were PubMed (MEDLINE), LILACS and Ophthalmology Library databases.

Microscopia confocal in vivo nos depósitos corneanos por amiodarona / In vivo confocal microscopy in amiodarone corneal deposits

OBJETIVO: Descrever os achados da microscopia confocal in vivo em pacientes nos diversos estágios de ceratopatia induzida por amiodarona, e correlacionar o estadiamento biomicroscópico com o estadiamento confocal. MÉTODOS: Vinte olhos de 10 pacientes (6 homens e 4 mulheres) em tratamento com amiodarona, que apresentavam ceratopatia induzida pela droga, foram selecionados para o estudo, com a microscopia confocal (MC). RESULTADOS: A média de idade foi 58 ± 6,2 anos (50-66 anos) e o tempo de uso da droga foi de 6 ± 3,2 anos (2-11 anos). Todos pacientes tinham acuidade visual com correção melhor ou igual a 20/40. A biomicroscopia evidenciou ceratopatia por amiodarona: dois pacientes no estágio 1, quatro no estágio 2 e quatro no estágio 3. Todas as córneas apresentaram inclusões intracelulares brilhantes e de alta refletividade na camada epitelial basal. A partir dos estágios 2 e 3, foram encontrados microdepósitos em todas camadas corneanas. Foram observados afilamento e aumento da tortuosidade dos nervos corneanos nos estágios 2 e 3 da ceratopatia. A contagem endotelial média foi de 2.524 ± 150,3 células/mm². CONCLUSÃO: O epitélio basal foi o mais acometido nos diferentes estágios da ceratopatia. Nos pacientes do estágio 1 a biomicroscopia, os microdepósitos subepiteliais são restritos ao epitélio superficial e basal, ao passo que nos pacientes dos estágios 2 e 3, os microdepósitos afetam todas camadas corneanas. A medida que a ceratopatia avança, os nervos corneanos ficam mais afilados e tortuosos.

PURPOSE: To describe in vivo confocal microscopy findings in patients with different stages of amiodarone-induced keratopathy, and correlate biomicroscopy stages with confocal stages. METHODS: Twenty eyes of 10 patients (6 men and 4 women), who receive treatment with amiodarone were selected for the study with confocal microscopy (MC). RESULTS: The average age was 58 ± 6.2 years (50-66 years) and time of use of the drug was 6 ± 3.2 years (2-11 years). All patients have best correct visual acuity ³ 20/40. There were two patients in stage 1, 4 patients in stage 2 and 4 in stage 3 of induced keratopathy. All corneas presented brilliant intracellular inclusions with high reflectivity in the basal epithelium layer. Patients in stage 2 and 3 have all corneal layers affected. There are thinning and increase of tortuosity of corneal nerves in patients in stage 2 and 3. The endothelial count was 2,524 ± 150,3 cell/mm². CONCLUSION: The basal epithelium was most affected in any of the keratopathy stages. In stage 1 patients only the superficial and basal epithelium are affected, while patients in stages 2 and 3 have all corneal layers affected. With the advance of keratophaty the corneal nerves became thinner and tortuous.

Indicaçäo indevida de anestésicos tópicos oculares / Improper indication of ocular topical anesthetics

O abuso de anestésicos tópicos oculares, apesar de infreqüente, é um problema potencialmente sério que pode resultar em danos corneanos e até diminuiçao ou perda permanente da visao. Com o objetivo de verificar a indicaçao indevida destas drogas nas "consultas de balcao", quatro acadêmicos de Medicina visitaram quarenta e sete farmácias de Caxias do Sul, queixando-se de sensaçao dolorosa em um dos olhos. Das farmácias consultadas, 32 por cento (15) indicaram colírios com nafazolina + berberina (Lerin) ou nafazolina + zinco (Moura Brasil), 23,5 por cento (11) anestésicos tópicos e apenas 12,7 por cento (6) recomendaram consulta com oftalmologista. Os autores revisam os danos oculares causados pelos anestésicos tópicos.

Silicone oil keratopathy

Light microscopy and electron microscopic examination were carried out on the corneal buttons of two patients who required penetrating keratoplasty for treatment of corneal complication following the intraocular injection of silicone oil to repair recurrent retinal detachments in aphakic eyes. Light microscopic examination demonstrated increased cellularity and irregularity of collagen fibers of stromal layer, defect of endothelial cell layer and endothelial degeneration. Electron microscopy examination demonstrated marked decrease in endothelial cell population density, accompanied by flattening and thinning of the remaining cells and attenuation of cell borders. There were silicone droplets in the endothelial cell layer and collagenous layer posterior to endothelial layer. These findings are well correlated to clinical manifestation and are thought to be rather due to barrier effect of silicone oil than direct toxicity.

Lesäo corneana grave produzida por anestésico tópico / Grave corneal lesion produced by topical anesthetic

Os autores apresentam o caso de um paciente que teve graves lesöes corneanas pelo uso de tetracaina tópica. Recomendam que colírios anestésicos sejam fornecidos só com receita médica