Primeiros casos de rejeição em transplante penetrante após vacina contra COVID-19 / First cases of penetrating corneal transplant rejection after COVID-19 vaccines

RESUMO Este artigo descreve dois casos de reação imunológica de rejeição de transplante penetrante após a aplicação de dois tipos de vacina contra a COVID-19 - CoronaVac (Sinopharm/Butantan) e MRNA BNT162&2 (Pfizer-BioNTech) - com intervalo de 1 e 10 dias, respectivamente. A rejeição se manifestou com hiperemia, edema corneano e embaçamento da visão, que responderam rapidamente ao uso de corticoide tópico e subconjuntival. Até onde sabemos, este é o primeiro relato de rejeição de transplante penetrante de córnea pós-vacina anti-COVID-19. Recomendamos, presentemente, como prevenção, colírio de prednisolona a 1% 4 dias antes e durante 2 semanas após receber qualquer tipo de vacina para a COVID-19.

ABSTRACT This paper describes two cases of allograft corneal transplant rejection after the application of two types of COVID-19 vaccines - Coronavac (Sinopharm/Butantan) and MRNA BNT162&2 (Pfizer-BioNTech) vaccines - with an interval of 1 to 10 days, respectively. The rejection manifested in the form of corneal edema, hyperemia and blurred vision, which responded rapidly to the use of topical and subconjunctival corticosteroid. As far as we know, this is the first published report of immunological rejection of penetrating corneal transplant after COVID-19 vaccination. As a preventative measure, we now recommend the use of 1% prednisolone eye drop 4 days before and during 2 weeks after having received any type of COVID-19 vaccine.

Retinosquise peripapilar e descolamento seroso de retina neuro-sensorial após esclerectomia profunda não penetrante / Peripapillary retinoschisis and serous detachment of neurosensory retina after a non-penetrating deep sclerectomy

Resumo Relato de caso de um paciente de 46 anos com glaucoma juvenil de controle clínico insatisfatório, portador de retinosquise peripapilar que, após ser submetido à esclerectomia profunda não penetrante, evoluiu com descolamento seroso da retina neuro-sensorial. A associação entre retinosquise peripapilar e o descolamento seroso pós cirurgia filtrante é de ocorrência rara, tendo sido descrito apenas um caso na literatura. A partir deste relato temos por objetivo, além de enfatizar a raridade da associação, mostrar a importância de investigar retinosquise peripapilar em pacientes glaucomatosos, em especial se associada a camada de fibras nervosas, e a importância da explanação adequada aos pacientes de um possível descolamento seroso de retina no pós-operatório de cirurgia filtrante.

Abstract Case report of a 46-year-old patient with unsatisfactory clinical controlled juvenile glaucoma and peripapillary retinoschisis who, after being submitted to non-penetrating deep sclerectomy, evolved with serous detachment of the neurosensory retina. The association between peripapillary retinoschisis and serous detachment after filtering surgery is rare and only one case has been described in the literature. The purpose of this report is, besides to emphasize the rarity of the association, to show the importance of investigating peripapillary retinoschisis in glaucomatous patients, especially if associated with retinal nerve fiber layer, and the importance of adequate explanation to patients of possible serous detachment of retina in the postoperative of filtering surgery.

Outcome of phacoemulsification and intraocular lens implantion in eyes with pseudoexfoliation and weak zonules.

PURPOSE: To evaluate the results of phacoemulsification and intraocular lens (IOL) implantation in eyes with pseudoexfoliation (PEX) and zonular weakness. METHODS: Two hundred and ninety-five patients (295 eyes) were recruited. This study is a retrospective case review of 143 PEX eyes with preoperative (Group 1) and intraoperative (Group 2) signs of zonular weakness, 76 PEX eyes (Group 3) and 76 non-PEX eyes without zonular weakness (Group 4) undergoing phacoemulsification and IOL implantation performed by single surgeon from year 1988 to 2010. Outcome measures included frequency of postoperative pseudophakodonesis, anterior capsule contraction and IOL decentration/dislocation. Postoperative vision, intraocular pressure (IOP) and glaucoma medication requirements were also assessed. A subanalysis on identical postoperative outcomes of capsular tension ring (CTR) implantation was performed. Comparisons were made for 52 PEX eyes with zonular weakness receiving nonsutured CTR implantation (Group A), 91 PEX eyes with zonular weakness not receiving CTR implantation (Group B) and 142 PEX eyes without zonular weakness (Group C). RESULTS: Mean follow-up was 4.08 ± 0.48 years and maximum was 8.3 years. Both Groups 1 and 2 showed higher incidence of complications than Groups 3 and 4 (p < 0.01). Vision, IOP and glaucoma medication requirements were similar postoperatively for all four groups. Groups A and B had a significantly higher proportion of postoperative complications than Group C (p < 0.01). There was no significant difference in risk of developing these complications between Groups A and B (p = 0.64). CONCLUSION: Postoperative complication rates are higher in PEX eyes with preoperative and/or intraoperative signs of zonular weakness undergoing phacoemulsification. Nonsutured CTR implantation does not prevent IOL and capsular complications postoperatively.

Initial Experience With the New Ahmed Glaucoma Valve Model M4: Short-term Results.

PURPOSE: To evaluate the clinical outcomes of the new Ahmed glaucoma valve (AGV) model M4. The device consists of a porous polyethylene shell designed for improved tissue integration and reduced encapsulation of the plate for better intraocular pressure (IOP) control. METHODS: Medical records of patients with an AGV M4 implantation between December 1, 2012 and December 31, 2013 were reviewed. The main outcome measure was surgical failure, defined as either (1) IOP<5 mm Hg or >21 mm Hg and/or <20% reduction of IOP at last follow-up visit, (2) a reoperation for glaucoma, and/or (3) loss of light perception. RESULTS: Seventy-five eyes of 73 patients were included. Postoperative IOP at all follow-up visits significantly decreased from a baseline IOP of 31.2 mm Hg (P<0.01). However, IOP increased significantly at 3 months (20.4 mm Hg), 6 months (19.3 mm Hg), and 12 months (20.3 mm Hg) compared with 1 month (13.8 mm Hg) postoperatively (P<0.05). At 6 months and 1 year, the cumulative probability of failure was 32% and 72%, respectively. CONCLUSIONS: The AGV M4 effectively reduced IOP in the first postoperative month, but IOP steadily increased thereafter. Consequently, failure rates were high after 1 year of follow-up.

Outcomes of Sequential Glaucoma Drainage Implants in Refractory Glaucoma.

PURPOSE: To describe the outcomes of eyes that have undergone a second glaucoma drainage implant (GDI) surgery. METHODS: A retrospective review of eyes that underwent a second GDI surgery from 2006 to 2013 was conducted. Primary outcome measures included intraocular pressure (IOP) reduction and success rates. Secondary outcome measures included glaucoma medication use, visual acuity, and number of reoperations. Success was defined as 6 ≤ IOP ≤ 21 with at least 20% IOP reduction, and no increase in the number of glaucoma medications from baseline at 3 months of follow-up or more. RESULTS: Sixty-five eyes (63 patients) had a mean follow-up of 22.4 ± 19.9 months. The most frequently placed second GDIs were an Ahmed FP7 (49%) or a Baerveldt 250 (26%) in the inferotemporal (46%) or inferonasal (35%) quadrant. At 3-year follow-up, IOP was reduced from 25.8 ± 7.7 to 17.4 ± 9.9 mm Hg (P = 0.004) and the number of glaucoma medications decreased from 3.6 ± 1.2 to 2.5 ± 1.4 (P = 0.01) compared with baseline. The median time to failure was 24.7 ± 5.8 months. There was no significant difference in failure rates for type of sequential GDI (P = 0.80) or plate location (P = 0.34). There was no significant difference in visual acuity between baseline and 3-year follow-up (P = 1.0). The most common postoperative complication was corneal edema (n = 9, 14%). CONCLUSIONS: Most eyes undergoing a second GDI achieve adequate IOP control with fewer antiglaucoma medications. Failure rates were similar regardless of quadrant selection or GDI type.

Segmental Analysis of Macular Layers in Patients With Unilateral Primary Open-Angle Glaucoma.

PURPOSE: To measure the thicknesses of the inner layers of the macula in both eyes of patients with unilateral primary open-angle glaucoma (POAG) and compare them with normal control eyes. METHODS: This prospective, cross-sectional pilot study enrolled patients with unilateral POAG, who had visual field defect in only 1 eye, and controls with a normal eye examination. Horizontal and vertical B-scan images centered on the fovea were obtained using spectral domain optical coherence. Semiautomatic delineation and segmentation of the inner layers of the retina were performed to evaluate macular retinal nerve fiber layer (mRNFL), ganglion cell complex (GCC) and ganglion cell-inner plexiform layer (GC-IPL) thicknesses. Mean, superior, inferior, nasal, and temporal inner macular layer thicknesses were compared between affected eyes, fellow eyes without visual field defect, and control eyes. RESULTS: Nineteen patients with unilateral POAG and 14 normal control eyes were enrolled. In the affected POAG eyes, thinning of the mRNFL, GCC, and GC-IPL layers on horizontal and vertical scans were significant when compared with controls (P<0.05), particularly on vertical scans (P<0.001). The mean regional macular GCC and GC-IPL were most severely thinned in the inferior and temporal perifoveal regions. The unaffected eye of patients with unilateral POAG showed significant thinning of the mRNFL only in the vertical scan when compared with normal controls (P<0.05). CONCLUSIONS: Spectral domain optical coherence tomography detected significant thinning of the mRNFL, GCC, and GC-IPL in the affected eyes of patients with unilateral POAG. Fellow eyes showed early structural changes only in the vertical mRNFL scans when compared with normal controls.

Flicker defined form, standard perimetry and Heidelberg retinal tomography: Structure-function relationships.

OBJECTIVE: To compare flicker defined form (FDF) perimetry using the Heidelberg edge perimeter (HEP) with standard automated perimetry (SAP) on the Humphrey visual field (HVF) analyzer and to compare their relationship to structural measurements acquired with the Heidelberg retina tomograph. DESIGN: Prospective, observational study. PARTICIPANTS: Thirty-one glaucomatous eyes with varying severity and 13 normal control eyes were included in this analysis. METHODS: All subjects underwent FDF testing on the HEP using the 24-2 protocol by the adaptive staircase thresholding algorithm standard strategy and SAP on the HVF analyzer 750 II using the SITA-Standard 24-2 test. Heidelberg retina tomography (HRT) testing was obtained for each patient. Spearman correlation coefficient, mean deviation (MD), and pattern standard deviation measurements by both machines were compared. RESULTS: FDF and SAP MD were significantly correlated (r = 0.81, p < 0.001). FDF and SAP MD were significantly correlated with HRT cup/disc ratio (FDF MD: p < 0.001; SAP MD: p = 0.003), disc area (FDF MD: p = 0.005; SAP MD: p = 0.059), rim volume (FDF MD: p < 0.001; SAP MD: p < 0.001), and retinal nerve fibre layer (FDF MD: p < 0.001; SAP MD: p < 0.001). CONCLUSIONS: This pilot study shows that the MD parameter of FDF correlated with SAP results. FDF and SAP had significant correlations with HRT parameters in glaucomatous and healthy eyes. The potential utility of FDF in the clinical management of glaucoma requires further investigation.

Is There a Need for New Surgical Procedures for Glaucoma? Yes!

The only method to slow or stop progressive damage caused by glaucoma, the leading cause of irreversible blindness, definitively shown to be effective, is lowering intraocular pressure, though there is also evidence that stabilizing the pressure may be beneficial. Performing surgery on the eye has proven effective in some cases, using various techniques, though with variable frequencies of success (stabilization of the disease) and various frequencies and severities of complications. Surgery offers the great advantage of longer duration of action than medicinal treatments presently available, and, also, of lessening the need of the patient to be faithful using suggested medications. There is a need to develop surgical procedures which will be effective in 1) lowering or stabilizing intraocular pressure in a way most likely to prevent glaucomatous deterioration, 2) causing the fewest and least severe problems, and 3) being the most economical. Recent efforts in this regard are promising, but not yet proven superior to well-performed trabeculectomy, itself an evolving procedure.

Tube shunt coverage with gamma-irradiated cornea allograft (VisionGraft).

PURPOSE: To investigate the clinical outcomes of tube shunt coverage using sterile gamma-irradiated cornea allograft. PATIENTS AND METHODS: The Wills Eye Hospital Glaucoma Research Center retrospectively reviewed the medical records of 165 patients who underwent glaucoma tube shunt procedures using sterile gamma-irradiated cornea allograft (VisionGraft) between December 2012 and November 2013. Demographic characteristics, type of tube shunt, and position were noted. Complications were recorded at 1 day; 1 week; 1, 3, 6, and 12 months; and on the final postoperative visit. RESULTS: One hundred and sixty-nine eyes of 165 patients were included. The mean follow-up time was 4.8±3.5 (ranging from 1 to 16) months. There was no evidence of immunological reaction, infection, or exposure in 166 eyes (98.2%). Three eyes (1.8%) experienced graft or tube exposure within the first 3 postoperative months. Two of the cases had underlying diseases: bullous pemphigoid and chronic allergic conjunctivitis. CONCLUSION: Coverage of tube shunts using gamma-irradiated cornea allograft had a low exposure rate and was well tolerated. The graft can be stored long term at room temperature and has an excellent postoperative cosmetic appearance.

Telefone celular: domínio ou incógnita médica? / Mobile phone: physician’s awareness or unfamiliarity

Introdução: A abrangência do uso do telefone celular suscita indagações e debates sobre possíveis efeitos aos seres humanos. O conhecimento adequado dos seus riscos à saúde poderia guiar políticas de saúde pública. O objetivo desta pesquisa é apresentar uma revisão dos trabalhos publicados nas últimas décadas sobre o tema e cotejá-los com o nível de conhecimento de alunos de medicina sobre a evolução do assunto. Metodologia: O trabalho foi dividido em duas etapas: a) pesquisa via internet, http://www.pubmed.gov, usando a palavra-chave: mobile phones; b) questionário, realizado por sorteio, de 30 alunos de cada ano letivo do curso de Medicina da FMABC de 2002 (n=180), avaliando a possibilidade de o aluno possuir um aparelho celular móvel e seu nível de conhecimento sobre artigos relacionados ao tema. Resultados: a) Os artigos incluídos (127) foram agrupados segundo as variáveis: “temas” e “categoria de risco”; b) da enquete, 95,93% dos alunos referiram possuir telefone celular, enquanto apenas 32% possuíam conhecimento adequado sobre os riscos da saúde. Discussão: Apesar de a maioria dos estudantes possuir o aparelho, apenas uma minoria detinha um conhecimento mais apurado sobre o assunto. A tendência deste pouco conhecimento dos alunos não segue os padrões de evidências (temas e categorias de risco) encontrados pela pesquisa na internet. Conclusão: O nível de conhecimento sobre temas lidos pelos alunos diverge daqueles obtidos na rede mundial de computadores, sugerindo a atualização de profissionais da saúde a campos ainda incógnitos e ilustrando um novo conteúdo literário àqueles responsáveis pela orientação da saúde pública.

Introduction: The widespread use of mobile phones arise questions and debates about the potential effects that mobile phones may have on human beings. These effects could pose important challenges to the public health authorities. The objective of this paper is to review, classify and compare theexisting literature to the knowledge of medical students on the subject. Methodology: The research was divided in two phases: a) internet research at http://www.pubmed.gov, usingthe keyword: “mobile phone”; b) a survey with 30, randomly chosen, FMABC students from each of the school years (n=180), assessing whether the students had a mobile phone and the student’s knowledge on subjects relatedto the theme. Results: a) The researched literature - 127 articles - was classified according to the variables: “specificsubject” and “risk category”; b) the research with students demonstrated that 95.3% of students own a mobile phone, whereas only 32% of students had knowledge on the subject. Discussion: Although most of the students own a mobile phone, few of them had any knowledge on the effectsthat mobile phones may have in human beings. Actually, the patterns on the knowledge of the students about thesubject differed from those on the literature. Conclusion: This article presents an updated review of the literature on the subject, that is relevant for public health authorities, and points out the fact that health professionals must get updated on the subject in order to fully understand the challenges the mobile phones may pose