Case-control study of subconjunctival triamcinolone acetonide injection vs intravenous methylprednisolone pulse in the treatment of endothelial corneal allograft rejection.

PURPOSE: To assess the safety and effectiveness of treating corneal endothelial rejection with a subconjunctival injection of 20 mg triamcinolone acetonide in combination with topical application of 1% prednisolone acetate, as compared to treatment with an intravenous pulse of 500 mg methylprednisolone in combination with topical application of 1% prednisolone acetate. METHODS: A case-controlled study including a literature review was performed. Patients who presented with an initial episode of corneal endothelial rejection were treated with subconjunctival injection of 20 mg triamcinolone in combination with topically applied 1% prednisolone and were retrospectively matched for age and diagnosis to patients who received a single intravenous injection of 500 mg methylprednisolone in combination with topical 1% prednisolone. Patients were analysed regarding reversion of the rejection episode, intraocular pressure, and visual acuity after 1 year. RESULTS: Overall, the triamcinolone group had a better outcome regarding reversion of corneal transplant rejection (P=0.025), with 15 of 16 patients in the triamcinolone group having clear grafts, compared to only 10 of 16 patients in the methylprednisolone group. Intraocular pressure (IOP) was increased in both groups at day 30 (P=0.002), although there was no statistically significant difference in IOP between the groups (P=0.433). Visual acuity improved in both groups after 1 year (P=0.049), although slightly more improvement was observed in the triamcinolone group (P=0.002). CONCLUSIONS: The results observed in this case-controlled study suggest that the use of subconjunctival triamcinolone acetonide may benefit patients with corneal transplant rejection.

Demand incidence of retinal detachment in Brazil.

AIM: To evaluate the epidemiological characteristics of retinal detachment in a defined urban population in the Southeast of Brazil. METHODS: A retrospective study of patients consulted at the Department of Ophthalmology, State University of Campinas, São Paulo, Brazil, with retinal detachment between June 1, 2003 and July 31, 2004. Data were entered into the Statistical Package for the Social Sciences (version 10.0). RESULTS: There were a total population of 3 389 294 in the 42 cities of Campinas catchment area. A total of 313 patients fitted the inclusion criteria. The overall demand incidence of retinal detachment was 9.2:100,000. The number of males peaked in the 50-79 age group, whereas that of the females peaked in the 60 to 80+ age group. The ages ranged from 4 months to 84 years (mean 49.3). The female-to-male ratio was 1:2.1. Nontraumatic phakic detachments had the highest demand incidence of 7.1:100,000. The demand incidence of nontraumatic aphakic detachments was very low at 0.09:100,000. Almost one third of all patients seeking treatment presented inoperable cases of retinal detachments. CONCLUSIONS: This is the first study of demand incidence of retinal detachment in Latin Americans. The age-specific demand incidence increases with age. Nontraumatic phakic detachments were the most common type of detachment. The incidence of the traumatic types of detachment was higher in males than that in females. Such data are important to plan and implement vitreoretinal services taking into account the population likely to be served.

[Reasons for cataract surgery cancellation]. / Suspensão de cirurgia de catarata e suas causas.

To study the reasons for cancelling cataract surgeries, and to suggest actions to improve the efficiency of patient care. A cross-sectional study was carried out in a university hospital's ophthalmology clinic of the state of São Paulo, Brazil. Two hundred subjects were randomly selected. The mean age was 68+/- 11.4 years old. The reasons for cancelling surgery were: unpropitious clinical condition (23.1%); tight schedule (35.9%); and patient non-attendance (41%). Most of the reasons related to social issues and the hospital's administrative aspects.

Are routine preoperative medical tests needed with cataract surgery?

OBJECTIVE: The objective of this study was to investigate whether routine medical testing before cataract surgery reduces the rate of complications during the perioperative period in adults. METHODS: The study was carried out in an academic medical center in Brazil, between 10 February 2000 and 10 January 2001. The scheduled cataract operations were randomly assigned to one of two groups: 1) to be preceded by routine testing (the "routine-testing group") or 2) not to be preceded by routine medical testing (the "selective-testing group"). If the patient was assigned to the selective-testing group, it was requested that no preoperative testing be performed unless the patient presented with a new or worsening medical problem that would warrant medical evaluation with testing. In the case of patients assigned to the routine-testing group, three tests were requested: a 12-lead electrocardiogram, a complete blood count, and measurements of serum glucose. RESULTS: The sample of 1,025 patients scheduled to undergo cataract surgery was comprised of 512 assigned to the routine-testing group and of 513 assigned to the selective-testing group. The two groups had similar proportions of operations canceled and not subsequently rescheduled, 2% in each group. The cumulative rate of medical events was similar in the two groups, 9.6% in the routine-testing group and 9.7% in the selective-testing group (P = 0.923). The types of medical events were also similar in both groups. DISCUSSION: The results of this study suggest that routine medical testing before cataract surgery does not reduce the rate of complications during the perioperative period. The results also suggest it would be more efficient not to request routine preoperative tests unless indicated by patient history or physical examination.

Influence of temperature and humidity on laser in situ keratomileusis outcomes.

PURPOSE: The influence of ambient factors on the results of refractive surgery is not well-known. This study evaluated the influence of temperature and humidity on laser in situ keratomileusis (LASIK) outcomes. METHODS: Two hundred thirty-seven patients who underwent LASIK at the Clivan Instituto de Oftalmologia in Salvador--Bahia--Brazil, between May 1999 and March 2000, were evaluated. A total of 156 (65.8%) patients were female. Mean age was 30.3 +/- 7.6 years. Refractive errors: 197 patients (83.12%) had compound myopic astigmatism, 17 patients (7.17%) had myopia, 11 patients (4.64%) had compound hyperopic astigmatism, and 12 patients (5.07%) had other. Results at 15 and 60 days after LASIK were compared according to different levels of temperature and humidity in the operating room during the procedure. RESULTS: Patients whose spherical equivalent refraction varied between -0.50 to +0.50 D at 15 days after LASIK had surgery performed when the temperature was 25.1 +/- 1.4 degrees C and humidity was 45.1 +/- 4.2%; for the others, temperature was 24.7 +/- 1.5 degrees C (P = .12) and humidity was 43.0 +/- 4.0% (P = .002). The linear regression coefficient showed that lower temperature levels were associated with lower spherical equivalent refractions at 60 days after LASIK (r2 = .14; P = .03) but not at 15 days after LASIK (P = .98). The evaluation of humidity indicated an influence at 15 days after LASIK (r2 = .44; P = .04), as well as at 60 days (r2 = .45; P = .0002). CONCLUSION: Operating room environment may influence LASIK outcomes; humidity may be more significant than temperature.

Chronic dacryocystitis in American mucocutaneous leishmaniasis.

PURPOSE: This study describes lacrimal tract involvement and surgical outcome in patients with mucocutaneous leishmaniasis. METHODS: Four patients, ages 20 to 75 years, had nasal lesions resulting from mucocutaneous leishmaniasis and sought treatment for chronic dacryocystitis. Each patient had had lacrimal symptoms since childhood or early adulthood, concomitantly with the development of upper airway lesions. Dacryocystography showed nasolacrimal duct stenosis in all cases on the affected side. Three patients underwent dacryocystorhinostomy (one bilaterally), and one patient had bilateral dacryocystectomy. RESULTS: Two patients had surgical fistula closure soon after surgery. A sequential endoscopic operation for remotion of a synechia between the fistula and the middle turbinate was successful in one of these patients. Histopathologic analysis of lacrimal sacs and nasal mucous membranes close to the anastomotic site revealed chronic nonspecific inflammatory process and negative immunohistochemistry for Leishmania. CONCLUSIONS: Dacryocystitis may result from nasal mucocutaneous leishmaniasis. The surgical outcome was unsatisfactory in one of the four patients.

Cataract surgery: expectations of patients assisted during a community project in São Paulo, state of São Paulo, Brazil.

OBJECTIVE: To identify social characteristics and expectations of individuals seen during a community project for the treatment of senile cataracts. Expected results from their eye surgery and its consequences to their quality of life were studied as well. METHODOLOGY: Cataract patients (visual acuity equal to or lower than 0.2 in the more superior eye) aged 50 years or over, were surveyed by means of interviews held during their visit at the Cataract Project in São Paulo city, State of São Paulo, Brazil, in 1999. RESULTS: The sample was composed of 331 subjects of low socioeconomic level ranging in age from 50 to 97 years (average = 71.8 years). Expectation of total recovery from the cataract condition by means of surgery was declared by 80.0% of the respondents, with no significant differences between male and female subjects (P < 0.1723). Hope to resume manual activities was expressed by 59.8%. CONCLUSION: A predominance of expectations of resuming normal activity and achieving a better quality of life after cataract surgery were identified.

[Cataract surgery: or why are there some patients excluded]. / Cirurgia de catarata: o porquê dos excluídos.

Cataracts are the main cause of blindness in the world, although they can be treated with relatively simple and inexpensive surgery. This study was carried out in 1997 and 1998 in five cities in the state of São Paulo, Brazil, to identify the reasons for persons not having cataract surgery. The population studied were patients seen at a community project for the rehabilitation of cataract-caused blindness, Projeto Zona Livre de Catarata (the Cataract-free-Zone Project). A questionnaire was used to interview 776 individuals with cataracts who sought assistance at the project and who had a visual acuity of 20/100 or less in the better eye. Six hundred and eighty-three patients had previously sought ophthalmic care, most frequently (27%) at public health services. The main reasons for subjects not having had cataract surgery were financial (69% of respondents) and the feeling of "still having good eyesight" (69% of respondents). Among patients who said they were afraid of surgery, the main reason was concern about being left blind. All the subjects whom the project deemed suitable for surgery agreed to undergo the procedure. Apparently, there is a gap between searching for ophthalmic services and the surgical resolution of cataracts. The predominant reasons for not having surgery were financial and logistical. There is a need to facilitate access to cataract surgery by decentralizing social services and by developing community projects to prevent cataract-caused blindness.

Corneal topography in asymptomatic family members of a patient with pellucid marginal degeneration.

PURPOSE: To report corneal topographic patterns in asymptomatic family members of a patient with pellucid marginal degeneration. METHODS: Computer-assisted corneal topography was used to study the corneas of five family members of a patient with pellucid marginal degeneration. RESULTS: In all five asymptomatic family members, corneal biomicroscopy was normal. Corneal topography, however, showed various abnormalities in different members of this family, particularly a topographic pattern suggesting keratoconus in one family member and a topographic pattern suggesting pellucid marginal degeneration in another family member. CONCLUSION: This study reinforces the hypothesis that corneal ectatic disorders may represent different manifestations of a clinical spectrum.

Characteristics of a pediatric low-vision population.

BACKGROUND: Assessment of the causes of childhood blindness is important to develop preventive and therapeutic strategies that can reduce the incidence of visual impairment. METHODS: A retrospective survey of the clinical records of 395 consecutive children younger than 14 years of age who were attended by the Low Vision Service of State University of Campinas (UNICAMP) was conducted. Data on the age distribution, the causes of low vision, the types of low vision aids prescribed, the follow up of their use, and improvement in visual acuity were obtained. RESULTS: Congenital bilateral toxoplasmic macular scars, optic atrophy, and congenital cataracts were the major causes of low vision in this population. The optical aid most frequently prescribed was a telescope. The improvement of visual acuity with the use of aids was highly significant.

Needling versus medical treatment in encapsulated blebs. A randomized, prospective study.

OBJECTIVE: The purpose of the study is to compare the efficacy and safety of transconjunctival needling and medical treatment in eyes with encapsulated blebs. DESIGN: A randomized, prospective study. PARTICIPANTS: Two hundred eighty-two eyes that underwent a guarded filtration procedure between January 1994 and January 1996 at the Glaucoma Service of University of Campinas. INTERVENTION: Encapsulated blebs developed in 25 (8.9%) of 282 eyes and were randomized to either needling (n = 14) or medical treatment with aqueous humor suppressants (n = 11). If one treatment failed to maintain intraocular pressures (IOPs) below 20 mmHg, the other treatment was initiated. If both methods failed, surgical revision or further glaucoma surgery was performed. Complete success was defined as IOP less than 20 mmHg after one treatment method. Qualified success was defined when IOPs less than 20 mmHg were obtained with both treatment methods, whereas failure was defined when IOP greater than 20 mmHg or when further surgery was indicated. MAIN OUTCOME MEASURES: Intraocular pressure, vision, and number of antiglaucoma medications. RESULTS: After a mean follow-up of 9.6 months, medical treatment alone was successful in ten patients (90.9%), whereas needling alone was successful in one patient (7.1%) (P = 0.00003). In the needling group, 92.9% of the eyes required aqueous humor suppressants, and 57.1% were considered qualified successes at the last follow-up (mean = 10.1 months). At the last follow-up examination, there was no statistically significant difference between the mean number of medications in both groups (P = 0.797). Further glaucoma surgery was performed in five patients (35.7%) undergoing needling and one patient (9.1%) receiving medical treatment (P = 0.162). CONCLUSIONS: Medical treatment with digital pressure should be used as the initial treatment in eyes with encapsulated blebs. Needling procedures or surgical revision, methods that are more invasive and potentially associated with severe complications, should be limited to the small percentage of eyes that do not respond to medical treatment.

Ocular health myths among a hospital staff.

In order to evaluate their common beliefs in the field of ocular health, an exploratory survey was carried out among 122 professionals belonging to different ranks and specialty areas of the University of Campinas Clinical Hospital (UNICAMP-CH), São Paulo, Brazil. The non-structured questionnaire used asked about common ophthalmologic problems as well as the presence of popular myths about ocular health, such as: 'cure' of visual problems by the use of glasses; reading under insufficient lighting or watching TV too much close to the apparatus is harmful; consequences from the intensive use of the eyes; or special food being needed for better vision. The results indicated the existence of various misconceptions, even among health professionals, such as: belief in the cure of refractive problems by the use of glasses (40.0%); or damage to vision due to insufficient lighting, watching TV too much close to the apparatus or from the intensive use of the eyes (86.7%). Among the professionals performing activities within the ophthalmology department, 62.5% admitted believing in visual damage as a result of conditions such as those mentioned above and 37.5% stated that reading in a moving vehicle is detrimental to vision. From these data, one is entitled to conclude that misconceptions continue to be present, even among professionals in the health area; this indicates that educational programs in ocular health should be provided, especially for individuals working within a hospital ophthalmological service.

[Perforating eye injuries in children]. / Ferimento perfurante de globo ocular na infância.

The author studied 140 cases of perforating eye injury in children up to 15 years old admitted at the Clinic Hospital of the Medical College of the University of São Paulo (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo) from January 1989 to December 1993. These cases represent 24.71% of the total of the perforating eye injuries seen during this period, showing a ratio of 76.42% of males, a ratio of 2/1 in the group from 0 to 6 years old, 7/1 in the group from 7 to 11 years old and a ratio of 3/1 in the group from 12 to 15 years old. The most common perforating eye injuries were due to sharp objects (54.71%), contusion (20%), explosions (7.85%) and flying objects (5.71%). The relation between the severity of the injury and the prognosis is emphasized. Safety precautions should be effective in order to reduce frequence and morbidity of these perforating ocular injuries.

[Perforating eye injuries caused by motor vehicle accidents: cases assisted during the year 1994]. / Ferimentos perfurantes do globo ocular por acidentes automobilísticos: casos atendidos durante o ano de 1994.

A prospective study of 32 patients with perforating eye injuries caused by motor vehicle accidents, 24.32% of the 131 cases of perforating injuries admitted at the University of São Paulo Medical School Hospital from January to december, 1994 was performed. Most of the accidents occurred at night (68.75%), and in urban areas (65.63%). There were more male victims (65.63%), mostly under 25 years of age (53.13%). None of the victims were using seat belts and those in the front seats were more vulnerable. Safety precautions should be effectively in use in order to reduce frequency and morbidity of these injuries.

Therapeutic use of contact lenses in alkali burns of the cornea.

Rabbit eyes submitted to alkali burns (in 1 N NaOH, 7 mm, for 2 min) were evaluated as to the effect of contact lenses on the corneal reepithelialization. Forty eyes were used, divided into two groups: 3 weeks and those observed for 5 weeks. In each group, 10 eyes received a contact lens while 10 served as controls. From the daily evaluation of the corneal surface as well as the microscopic examinations at the end of the two periods of observation, we concluded that hydrophilic contact lenses provide a beneficial effect on alkali burns of the cornea, reducing the incidence of epithelial defects to statistically significant levels.