Barriers between community screening for visual problems and treatments in a tertiary center

ABSTRACT OBJECTIVE To evaluate the effectiveness of mobile ophthalmic unit screenings and to investigate barriers between community care and resolution of the problem at a tertiary center. METHODS This prospective study evaluated a convenience sample from 10 municipalities in São Paulo State, Brazil. Patients were assessed in the municipality by a mobile ophthalmic unit and underwent a complete ophthalmic consultation. Patients were referred as warranted to a tertiary hospital. RESULTS The mobile ophthalmic unit screened 1,928 individuals and 714 (37%) were referred. The mean age of the referred patients was 57.12 (SD = 19.5) years with best corrected visual acuity of 0.37 (SD = 0.36) logMAR. Forty-seven (6.6%) patients were blind and 185 (26.5%) were visually impaired. Cataracts (44.7%) and pterygium (14.7%) accounted for most referrals. Of those referred, 67.1% presented to the tertiary center. The diagnosis by the mobile ophthalmic unit corresponded to the one by the tertiary center in 88.5% of the cases. There were a significantly higher number of blind and visually impaired persons among those who presented to the hospital. There was a significantly greater attendance among patients living in more distant municipalities from the reference center with a higher number of inhabitants and a greater number of ophthalmologists in the cities of origin (p < 0.05, all comparisons). Complete treatment was performed in 65.6% of patients, and loss to follow-up was the main cause of incomplete treatment in 50.7% of patients. A total of 313 cataract surgeries were performed, which reduced the number of blind patients from 20 to 2 and of visually impaired individuals from 87 to 2 (p < 0.001). CONCLUSIONS Only 37% of the patients assessed by a mobile ophthalmic unit required referral to a tertiary hospital. Among the referred patients, 67.1% presented to the hospital, and complete resolution after treatment was approximately 65.5%. There was a significant improvement in visual acuity and a reduction in the prevalence of blindness and visual impairment postoperatively.

Avaliação de aplicação única subconjuntival pré-operatória de mitomicina C em pterígio primário / Evaluation of preoperative subconjunctival single application of mitomycin C in primary pterygium

Resumo Pterígios são lesões geralmente benignas que na maioria dos casos não requer tratamento específico. É um crescimento fibrovascular sobre a córnea, geralmente a partir do lado nasal. Sua causa ainda não foi elucidada, mas parece estar relacionada à exposição aos raios ultravioleta. Quando os sintomas não são controlados com tratamento conservador, a cirurgia é indicada, porém o índice de recidiva ainda é alto, e os esforços têm sido no sentido de reduzir esse índice. A mitomicina C (MMC) é uma opção de adjuvante à cirurgia por ser um inibidor da proliferação de fibroblastos, diminuindo o risco de recorrência do pterígio. Relatamos aqui um caso que descreve cirurgia de pterígio realizada em ambos os olhos de uma mesma paciente, sendo um com MMC e outro sem ela. Os resultados e o índice de proliferação celular dos dois olhos foram comparados entre si.

Abstract Pterygia are usually benign lesions that do not require specific treatment. It is a fibrovascular growth onto the nasal side of the cornea. It`s cause has not been fully elucidated yet, but seems to be related to long -term ultraviolet ray exposure. When symptoms are not controlled with conservative treatment surgery is considered, but the recurrence rate is still high, and efforts have been made to avoid it. Mitomycin C (MMC) is a fibroblast proliferation inhibitor that can be used as adjuvant to surgery to reduce recurrence. We report here a case that describes pterygium surgery performed in both eyes of the same patient, being one with MMC and the other eye without it. Both pterygium were sent to laboratory analysis. The results and proliferation index were compared between the eyes.

A Comparative Study of Topical Mitomycin C, Cyclosporine, and Bevacizumab after Primary Pterygium Surgery

PURPOSE: To compare the recurrence rates and complications associated with instillation of topical mitomycin C, cyclosporine, and bevacizumab after primary pterygium surgery. METHODS: Between July 2013 and June 2014, we performed surgery using the bare sclera method on 132 eyes (132 patients) with primary pterygium. We randomly selected 33 eyes (33 patients) and treated them with artificial tears four times a day for three months, 29 eyes (29 patients) were treated with topical 0.02% mitomycin C four times a day for five days, 34 eyes (34 patients) were treated with topical 0.05% cyclosporine four times a day for three months, and 36 eyes (36 patients) were treated with topical 2.5% bevacizumab four times a day for three months after surgery. We prospectively determined the recurrence rates of pterygium and complications at the six-month follow-up examination. RESULTS: At six months after surgery, the recurrence rates in each group were as follows: 45.5% (15 eyes) in the control group, 10.3% (three eyes) in the mitomycin C group, 20.6% (seven eyes) in the cyclosporine group, and 41.7% (15 eyes) in the bevacizumab group (p = 0.004). No serious complications, except subconjunctival hemorrhages, were observed in any group. CONCLUSIONS: Groups receiving topical 0.02% mitomycin C and 0.05% cyclosporine after surgery showed lower recurrence rates than the control group; however, no difference in recurrence rate was observed between the control group and the group receiving topical 2.5% bevacizumab after surgery.

The role of mast cells in vascularized recurrent pterygium / O papel dos mastócitos no pterígio recidivado vascularizado

Objective: To determine and compare the mast cell count in primary and recurrent vascularized pterygium, and in normal bulbar conjunctiva. Methods: The study included 22 patients with primary pterygium (PP group) and 28 patients with vascularized recurrent pterygium (VRP group) that underwent excision via the limbal conjunctival autograft technique. Normal conjunctiva samples were collected from the superotemporal bulbar conjunctival region, just temporal to the site from which the autograft conjunctival tissue was harvested. The total number of mast cells in the pterygium (primary and recurrent) and control tissue samples was calculated microscopically using 1% toluidine blue stain under 400× magnification. Results: The mean mast cell count in primary and vascularized recurrent pterygium tissue was 7.45 ± 2.06 mm–2 and 16.11 ± 4.33 mm–2, respectively, and the difference was significant (independent samples t-test, P<0.001). The mean mast cell count in pterygium tissue was significantly higher than that in normal conjunctiva tissue in both groups (Student's t-test, P<0.001). Conclusion: An increase in the number of mast cells might play a role in the pathogenesis of recurrent pterygium. Determination of a mast cell count cut-off value could be of diagnostic significance for recurrent pterygium. .

Objetivo: Determinar e comparar o número de mastócitos em pterígio primário e recidivado vascularizado, assim como em conjuntiva bulbar normal. Métodos: O estudo incluiu 22 pacientes com pterígio primário (grupo PP) e 28 pacientes com pterígio recidivado vascularizado (grupo VRP), submetidos à exérese por meio da técnica de transplante de conjuntiva autólogo de limbo. Amostras de conjuntivas normais foram coletadas da região bulbar superotemporal, próximas do local a partir do qual o tecido autólogo de conjuntiva foi colhido. O número total de mastócitos em amostras de tecido dos pterígios (primários e recidivados) assim como dos controles foi calculado microscopicamente utilizando azul de toluidina a 1% sob magnificação de 400×. Resultados: O número de mastócitos médio no tecido pterígio primário e recidivado vascularizado foi de 7,45 ± 2,06 mm-2 e 16,11 ± 4,33 mm-2, respectivamente, e a diferença foi significativa (amostras independentes t-test, P<0,001). A contagem média de mastócitos no tecido pterígio foi significativamente mais elevada do que no tecido conjuntivo normal em ambos os grupos (teste t de Student, P<0,001). Conclusão: Um aumento no número de mastócitos pode desempenhar um papel na patogênese do pterígio recidivado. A determinação de um valor de corte na contagem de mastócitos pode ser importante para o diagnóstico de pterígio recidivado. .

Nevo de células fusiformes de Reed na conjuntiva / Spindle cell nevus of Reed in the conjunctiva

Os autores relatam um caso de nevo de Reed, lesão que apresenta aspecto histológico de malignidade, mas tem evolução benigna. Paciente de 48 anos, masculino, cor parda, apresentava pterígio nasal no olho direito, associado a uma lesão pequena e pouco pigmentada localizada na cabeça do mesmo. Realizou-se exérese de ambos, sem intercorrências, sem sinais de recidiva. O exame histopatológico revelou lesão com bordas definidas, restrita ao epitélio, constituída por células fusiformes perpendiculares à superfície, com pigmentação melânica esparsa. O diagnóstico inicial foi nevo de Spitz, mas, posteriormente, chegou-se à conclusão que se tratava do nevo de células fusiformes de Reed. O presente relato é o segundo na literatura mundial e o primeiro no Brasil.

The authors report one case of nevus of Reed, which has histological aspect of malignancy, but a benign evolution. A 48-years-old brown skin male presented nasal pterygium in right eye, associated with a small and poorly pigmented lesion located on the pterygium head. Both were excised without complications and, currently, there is no recidivation. The histopathological examination revealed one lesion with defined edges, limited to the epithelium, consisted of spindle cells perpendiculars to the surface and with sparse melanin pigmentation. The initial diagnosis was Spitz nevus, but, afterwards, we concluded that was the spindle cell nevus of Reed. This report is the second in the international literature and the first in Brazil.

Characteristics and prevalence of pterygium in small communities along the Solimões and Japurá rivers of the Brazilian Amazon Rainforest / Características e prevalência do pterígio em comunidades ribeirinhas dos Rios Solimões e Japurá localizados na Amazônia Brasileira

PURPOSE: To evaluate the prevalence and characteristics of pterygium in small communities along the Solimões and Japurá rivers, State of Amazonas, Brazil. Design: cross-sectional study. METHODS: This study was carried out on populations of the Brazilian Amazon rainforest. Data were collected by two separate ophthalmologists in three expeditions, covering 55 local communities. A total number of 1295 patients were examined, of which 659 were over 18 years old. The patients diagnosed with pterygium answered a questionnaire addressing gender, age and outdoor activity. Pterygium lesion sizes were graded as grade 1 (lesion covers until limbus), grade 2 (lesion covers cornea by 2 mm), grade 3 (lesion surrounds the pupil) and grade 4 (lesion crosses the pupil). RESULTS: Pterygium prevalence was 21.2 percent for the overall population and 41.1 percent in those over 18 years old. Patients between 40-50 years old were most affected by pterygium. Pterygium data distribution by gender showed that 57.8 percent were men. The majority of the patients diagnosed with pterygium was active outdoors (89.5 percent). Subjects affected in both eyes were 75.6 percent. Of the total population positive to pterygium the majority was grade 1 (44 percent) and 2 (48.7 percent). Most of the patients (85 percent) developed nasal pterygium. CONCLUSION: This study shows one of the highest prevalences of pterygium in the world, covering a Brazilian region never studied before.

OBJETIVO: Avaliar a prevalência e as características do pterígio em comunidades ribeirinhas dos rios Solimões e Japurá, estado do Amazonas, Brasil. MÉTODOS: Foi realizado um estudo observacional, em comunidades ribeirinhas dos rios Solimões e Japurá. Os dados foram coletados por dois avaliadores em três expedições médico oftalmológicas, num período de 9 meses, que abrangeram 55 comunidades ribeirinhas, totalizando 1295 pacientes examinados, sendo 659 maiores de 18 anos. Os portadores de pterígio foram analisados através de um questionário abrangendo sexo, idade e atividade laborativa ao sol ou não. O tamanho da lesão foi quantificado em graus. RESULTADOS: A prevalência do pterígio na população geral foi de 21.2 por cento. A prevalência entre os maiores de 18 anos foi de 41.1 por cento. A faixa etária mais acometida foi a de 41 a 50 anos. Dos portadores, 42.2 por cento eram do sexo feminino e 57.8 por cento do sexo masculino. 89.5 por cento dos pacientes acometidos pela lesão trabalhavam ao ar livre. Dos portadores, 75.6 por cento apresentavam acometimento de ambos os olhos. Dos pacientes acometidos, 48.7 por cento possuíam pterígio grau 2, 44.0 por cento apresentavam a lesão de grau 1, 5.4 por cento de grau 3 e 1.8 por cento de grau 4. Dos olhos acometidos, 85.0 por cento apresentavam somente pterígio nasal, 2.9 por cento apresentavam somente pterígio temporal e 14.5 por cento apresentavam pterígio temporal e nasal. CONCLUSÃO: Nosso estudo, nos rios Solimões e Japurá, revelou a existência de uma das maiores taxas de pterígio do mundo, em uma região que nunca havia sido avaliada.

El Pterigion ¿una Lesión Tumoral? / The Pterygium: is a tumoral lesion?

El pterigion es una alteración caracterizada por la proliferación anormal del tejido conjuntival, en algunos individuos crece a tal punto que puede afectar el eje visual. Ha sido considerada por diferentes autores como una lesión neoplásica debido a que presenta características propias de los tejidos tumorales. Se llevó a cabo una revisión sistemática de artículos científicos a partir de los cuales se respalda la propuesta hecha por Clear et al, quienes sugieren por primera vez la asociación entre la enfermedad y las neoplasias, para esto, se resaltan evidencias moleculares reportadas en los genes p53, p21 y COX-2, cuyos polimorfismos se han relacionado con la presencia de tumores, e identificados en algunos casos de pterigion.

Pterygium is an alteration characterized by the abnormal proliferation of the conjunctive tissue, in some people it can grow to the point off affecting the visual axis. It has been considered by different authors like a neoplastic injury because it has some characteristics like tumor tissues. It was carried out a systematic review of scientific articles with molecular evidences that supports the proposal showed by Clear et al, about the association between the disease and neoplasias, based on researches in the genes p53, p21 and COX-2, whose polymorphisms have been related with the presence of tumors, and also they have been identified in patients with pterygium.

Síndrome de pterigium múltiple: recurrencia en una familia / Multiple pterygium syndrome: recurrence in a family

En el presente trabajo se describe un caso de síndrome de pterigium múltiple recurrente familiar de particulares características clínicas. Esta descripción se presenta a continuación del artículo “Síndrome de Escobar: a propósito de un caso” para mostrar la heterogeneidad fenotípica y genotípica de esta entidad. El diagnóstico presuntivo se realizó en el primer hijo a los 5 días de vida y el confirmatorio a los dos meses; sobrevivió hasta los 8 meses con desnutrición, ceguera, retraso global del desarrollo y patología renal crónica. Las manifestaciones clínicas incluían fijación generalizada de articulaciones, pterigium de axila, codo y región poplítea, cifosis dorsal, desviación cubital de las manos, pie bot talo-valgo, pabellones auriculares de implantación baja y micrognatia. El diagnóstico presuntivo del segundo hijo fue ecográfico- genealógico, a las 20 semanas de gestación por síndrome de hipoquinesia fetal y fijación articular. El feto obitó a las 21 semanas de edad gestacional. La anatomía- patológica confirmó los hallazgos ecográficos, constatándose un fenotipo muy similar al de su hermano.

A recurrent and familiar case of pterygium multiple syndrome with particular clinical features is presented. This description comes after the article “Escobar syndrome: a case report” in order to show the phenotypic and genotypic heterogeneity of these cases. A preliminary diagnosis was made at 5 days of age in the first child of the couple; the definitive diagnosis was made at 2 months of age. The patient lived 8 months with malnutrition, blindness, developmental delay and chronic renal pathology. Clinical manifestations included joint contractures; elbow, armpit and popliteal region pterygium; dorsal kyphosis; cubital deviation of hands; club foot deformity; low outer ear and micrognathia. The preliminary diagnosis of the second child was ecographic, at 20 weeks of gestation by Hypokinesia fetal and joint contracture. The pregnancy was ended at 21 weeks. The anatomy pathology confirmed the ecographic findings with a phenotype very similar to the first case.

Bartsocas-Papas syndrome.

We report three sibs born to a third degree consanguineous Indian family affected with Bartsocas Papas Syndrome. All the three pregnancies were complicated by severe oligohydramnios, which is not commonly seen with Bartsocas-Papas syndrome.

Role of concanavalin A lectin in recognition of pterygium remnant after surgical excision: preliminary results of a prospective study.

BACKGROUND: Pterygium is one of the most common conjunctival diseases among ophthalmic pathologies. The frequency of recurrences is high, either after surgical treatment or after treatment combined with mitomycin C or beta-radiation therapy. AIMS: The purpose of this study was to determine whether concanavalin A (ConA) lectin bound to the pterygial surface can be used to detect recurrence or remnants of pterygium after surgical excision. MATERIALS AND METHODS: This was a prospective study on 20 patients with pterygium, divided in five stages, pre-surgery, early post-surgery (24h), late post-surgery (seven days), very late post-surgery (four weeks) and two months after the procedure. A drop of fluorescein-marked Con A (35 microg/mL) was instilled in the lower conjunctival eyelid sac and the eye was exposed to the light of a Wood's lamp for an average of five seconds. RESULTS: Out of the 20 patients, eight patients were found to have fluorescent stretch marks over the scar corresponding to residual pterygial tissue at four weeks; two months after the procedure of re-surgery we observed no fluorescent remnants. All residual pterygia were confirmed through histochemistry studies. CONCLUSION: It was possible to detect remnants of pterygium in postoperative patients and recurrences in early pre-clinical stages through the visualization of fluorescent ConA bound to the pterygial surface.

Prolapso de gordura orbitária bilateral associado a pterígio: relato de caso / Bilateral orbital fat prolapse associated with pterygium: case report

O prolapso de gordura orbitária é entidade benigna incomum que pode causar defeitos estéticos. Os autores apresentam uma paciente de 63 anos com prolapso de gordura orbitária temporal bilateral associado a pterígio medial bilateral, ressaltando aspectos clínicos e cirúrgicos. Discute-se a importância do diagnóstico clínico e de imagem, além da comprovação histopatológica da lesão.

Perfil oftalmológico dos alunos do programa alfabetização solidária em quatro municípios do Ceará / Ophthalmological profile of students to a solidary literary program in four municipalities of Ceará

Objetivo: Avaliar o perfil oftalmológico de estudantes da Alfabetização Solidária no Estado do Ceará, identificar as principais causas de baixa acuidade visual, descrever a experiência e os principais resultados obtidos. Métodos: Foram utilizados para o exame oftalmológico de mil e sete (1007) alunos do Programa Alfabetização Solidária dois refratores automatizados, dois refratores tipo Greens, duas colunas pantográficas, duas cadeiras, quatro oftalmoscópios, uma lâmpada de fenda portátil, dois tonômetros de aplanação, um oftalmoscópio indireto. Participantes: alfabetizadores treinados para medida da acuidade visual, oftalmologistas, residentes de oftalmologia, auxiliares e secretárias. Resultados: Observamos que cerca da metade dos alunos (46 por cento) tinha baixa de acuidade visual (acuidade visual menor que 0,8 em ambos os olhos), 66,33 por cento da população estudada necessitou correção óptica, destes, 37,00 por cento eram présbitas. Predominou a população na faixa de 41 a 50 anos. A maioria da população examinada era do sexo feminino (56 por cento). Trinta e nove por cento da população estudada apresentou alguma doença oftalmológica. Encontramos o pterígio e a catarata como doenças mais freqüentes. Conclusão: O programa deve ter no inicio do seu funcionamento prévio exame oftalmológico dos alunos de cada comunidade, para melhor aproveitamento do conteúdo ensinado, diminuindo desta forma a grande evasão escolar.

Conjunctival autograft transplantation for primary pterygium.

PURPOSE: To evaluate the success rate of conjunctival autograft transplantation for primary pterygium. MATERIAL AND METHOD: The results of 56 patients with primary pterygia who underwent conjunctival autograft transplantation were retrospectively reviewed. The success rate was evaluated in terms of recurrence percentage of pterygia onto the cornea. RESULTS: Of the 56 patients, 20 were men and 36 women. The mean follow-up was 16.3 +/- 8.2 months. Three (5%) eyes had recurrent pterygium within 1 year. No serious sight-threatening complications were associated with this study. CONCLUSION: Conjunctival autograft transplantation can achieve very low recurrence rates for primary pterygium and may be considered a safe procedure.

The effect of pterygium on corneal astigmatism.

OBJECTIVE: To determine the effect of pterygium on corneal astigmatism. METHOD: Two hundred and forty three eyes of 173 patients with primary pterygium were included in the present study. The extension of pterygium was measured by slit lamp and corneal astigmatism was measured by corneal topography. Correlation of the data was discussed. RESULTS: The size of pterygium extended from 0.50 mm to 8.10 mm (2.11 +/- 1.10). The diopter of corneal astigmatism ranged from 0.10 diopter to 14.60 diopter (1.86 +/- 2.39). The axis of corneal astigmatism was found in vertical axis 156 eyes (64.2%), oblique axis 36 eyes (14.8%) and horizontal axis 51 eyes (21.0%). The degree of corneal astigmatism significantly correlated with the extension of pterygium on the cornea (R Square = 0.45, p < 0.001). When the extension of pterygium exceeded 2.25 mm, there was a chance of developing corneal astigmatism of 2 diopter or more (86.21% of sensitivity and 80% of specificity). CONCLUSION: The extension of pterygium is significantly correlated with the degree of corneal astigmatism in the positive direction, with the highest percentage of with-the-rule astigmatism. Pterygium exceeding 2.25 mm of length should be considered within the limits of surgery.

Detecção de tracoma e doenças corneanas em índios da região do Alto Rio Negro / Detection of trachoma and corneal diseases in indian of the Alto Rio Negro, Amazonas, Brazil

Objetivo:Avaliar as condições oftalmológicas da população indígena do Alto Rio Negro, fronteira do Brasil com a Colômbia. Métodos: Exame oftalmológico de 179 índios habitantes do Rio Tiquié, afluente do Rio Negro, em julho de 1999. Resultado: Opacidades numulares corneanas 28,5 por cento; pterígio 12,8 por cento; tracoma 55 por cento. Do total de índios examinados 2,8 por cento apresentavam visão inferior a contar dedos a 5 metros, devido a lesões corneanas secundárias ao tracoma.

Perfil epidemiológico dos pacientes atendidos no Ambulatório de cirurgia plástica ocular da Fundaçäo Altino Ventura - Recife - PE / Epidemiological profile of Altino Ventura Fundation oculoplastic departament patients - Recife, PE

Este estudo tem como finalidade a avaliaçäo retrospectiva dos pacientes examinados no Ambulatório de Cirurgia Plástica Ocular e Vias Lacrimais no período compreendido entre janeiro e outubro de 1997. Foram avaliados dados referentes ao sexo, idade, profissäo, procedência e o segmento ocular mais afetado, procurando identificar qual a causa patológica mais frequentemente encaminhada ao serviço. Em nosso estudo o sexo predominante foi o feminino, representando 52,1 por cento dos examinados. A maioria dos pacientes atendidos se encontravam na primeira década de vida, ou seja, na faixa etária de 0-10 anos, com 22,67 por cento dos casos. Obtivemos uma idade média de 40 anos. Quanto á profissäo, as atividades domésticas foram as mais frequentes, com 32,71 por cento. Em relaçäo ao segmento mais afetado, as pálpebras foram as mais acometidas, com 57,18 por cento, sendo o entrópio, o ectrópio e triquíase as patologias palpebrais mais observadas. Recife representou 45,75 por cento da procedência dos nosso pacientes em estudo.

Multiple pterygium syndrome.

Severely involved female child with Multiple Pterygium Syndrome (Escobar) is described. She had the typical findings of the syndrome such as multiple pterygiums, characteristic facial appearance, genital anomalies. She also had bilateral optic atrophy. This is the first case described so far with optic atrophy in Multiple Pterygium Syndrome (Escobar).

Estudo do filme lacrimal em pacientes portadores de pterígeo / Precorneal film abnormalities in pterygium patients

Os autores realizaram um estudo prospectivo envolvendo 58 pacientes portadores de pterígeos unilaterais ou bilaterais. Destes, 70,7 por cento procuraram auxílio médico devido ao pterígio e os outros, por algum outro problema oftálmico. Pesquisaram nestes pacientes alteraçöes do filme lacrimal através dos testes de Schirmer I, tempo de ruptura do filme lacrimal (BUT) e Rosa Bengala, relacionando-as com a presença de pterígeo e pinguécula. Em 96,5 por cento dos pacientes foi encontrada alteraçäo do filme, näo havendo diferença significativa (p>0,05) na comparaçäo da incidência de olho seco e presença ou näo de pterígeo. Houve diferença significativa (5 por cento>p>2 por cento)na comparaçäo da incidência de olho seco e presença ou näo de pterígeo, sugerindo que o olho seco pode ser um importante fator na gênese dos sintomas do pterígeo

Efeitos do uso intra-operatório da mitomicina C na sensibilidade táctil corneana, no filme lacrimal e no epitélio córneoconjuntival de olhos operados de pterígio / Effects of the application of 0,04 por cento mitomycin C during pterygium excision on corneal sensitivy,on precorneal tear film, and corneal-conjunctival epithelium

Este estudo compara a influência do uso intra-operatório da mitomicina C a 0,04 por cento (30 casos) com controles (30 casos) na sensibilidade táctil corneana, medida com o estesiômetro de Cochet e Bonnet, no filme lacrimal avaliado pelos testes de Schirmer 1 e tempo de rompimento do filme lacrimal e no epitélio córneoconjuntival.