Lupus retinopathy: epidemiology and risk factors.

Lupus retinopathy is a clinical manifestation of systemic lupus erythematosus in the visual system. It is generally asymptomatic; however, it can become a threatening condition. It is closely associated with the inflammatory activity and higher mortality of systemic lupus erythematosus. Lupus retinopathy has several different clinical presentations, such as lupus microangiopathy, vascular occlusion, vasculitis, hypertensive retinopathy associated with lupus nephritis, and autoimmune retinopathy. Although the prevalence and associated factors of lupus retinopathy have been well defined in some parts of the world, there are no data from Latin America, including Brazil. As lupus retinopathy is generally asymptomatic, without a routine fundoscopy, it has been probably underestimated. This review is intended to discuss the epidemiology and risk factors of lupus retinopathy.

Morphologic and molecular study on the lens anterior capsule in systemic sclerosis.

This study aimed to analyze the anterior lens capsule specimens from both eyes of a patient with systemic sclerosis and compare them to the eyes of a control patient. No significant differences between systemic sclerosis and control eyes were observed in the results from the hematoxylin-eosin and picrosirius staining. In the samples obtained from both systemic sclerosis and control eyes, there were expressions of caspase, a molecule expressed in cell death by apoptosis. Heparanase was overexpressed in the systemic sclerosis sample compared to the control sample. Therefore, the anterior lens capsule of the patient with systemic sclerosis is probably affected by the disease since it showed marked expression of heparanase 1.

Dual Scheimpflug imaging as a screening method for occludable angles-a comparison with gonioscopy.

AIM: To evaluate dual Scheimpflug analyzer (Galilei) as a screening method for the diagnostic of gonioscopically narrow anterior chamber angles (ACA). METHODS: In 40 eyes of 40 patients with different ACA range, the ACA, anterior chamber volume (ACV) and anterior chamber depth (ACD) were analyzed using the dual Scheimpflug analyzer (Galilei G6 system). Correspondence between these parameters and Shaffer's classification based on gonioscopy were studied. Receiving operator characteristic (ROC) curves and partition analysis were used to determine the efficacy of the Galilei system in screening for narrow angles. Agreement (Kappa statistics), sensitivity, and specificity for each eye, according to Galilei measures, were also assessed. RESULTS: Shaffer's grade (from 0 to 4) were significantly associated with each of the measurements (P<0.001). In screening eyes with narrow angles with the Galilei, the area under the ROC curve was largest (0.90) when ACD was used as the reference, and partition analysis demonstrated that those eyes were most adequately partitioned with an ACD of 2.86 mm with 100% sensitivity and 80% specificity. CONCLUSION: The Galilei is a secure, repeatable and noncontact screening method for narrow angles. However it does not provide sufficient information about the ACA anatomy to be considered a substitute for gonioscopy.

Anterior and Intermediate Uveitis Following Yellow Fever Vaccination with Fractional Dose: Case Reports.

Purpose: To describe two cases of anterior and intermediate uveitis following yellow fever vaccination with fractional dose. Methods: Case report. Results: Case 1: A 35 year-old healthy woman presented with unilateral anterior uveitis 10 days after the yellow fever vaccination. Testing excluded infectious and rheumatic diseases and the episode was fully recovered after a short course of topical treatment. Case 2: A 21 year-old previously healthy woman presented with blurred vision in the left eye (OS) 14 days after the yellow fever vaccination. The ophthalmic examination of the OS revealed intermediated uveitis. Testing excluded infectious and neurological diseases. After six weeks of treatment with oral prednisone, the ocular inflammation had resolved. Conclusion: Physicians should be aware of the possibility of eye inflammation following the yellow fever vaccination.

Evaluation of Corneal Parameters with Dual Scheimpflug Imaging in Patients with Systemic Sclerosis.

PURPOSE: To evaluate the cornea of systemic sclerosis (SSc) patients with Dual Scheimpflug Imaging. METHODS: Twenty consecutive SSc patients and 20 age and sex matched controls were enrolled in this cross-sectional study. Corneal measurements were acquired by dual Scheimpflug analyzer. RESULTS: SSc patients had statistically significant steeper corneas than the control group. The mean anterior curvature-average (SimK) was 44.93 ± 1.64 D (mean ± standard deviation) in SSc and 43.61 ± 0.99D in control group, p = 0.01. Posterior curvature was also steeper in SSc patients compared to controls (p = 0.02). There was no statistically significant difference regarding central average pachymetry (p = 0.07), thinnest pachymetry (p = 0.09). CONCLUSIONS: Patients with SSc present with steeper corneas than controls.

Is there an association between glaucoma and capillaroscopy in patients with systemic sclerosis?

PURPOSE: To evaluate the relationship between glaucoma diagnosis and the nailfold capillaroscopy pattern in patients with systemic sclerosis. METHODS: An observational study in a cohort of patients with SSc was conducted. Patients with at least one nailfold videocapillaroscopy and one ophthalmology examination at the same year were included. Data collected were: age, sex; type of systemic sclerosis according to the degree of skin impairment, self-reported ethnicity, disease duration, current use and dosage of systemic corticosteroid, current use and dosage of bosentan®, intraocular pressure, central corneal thickness, diagnosis of glaucoma and capillaroscopy pattern. RESULTS: Thirty-one patients with systemic sclerosis were enrolled, 23% had glaucoma. There was no statistically significant association between glaucoma diagnosis and the capillaroscopic pattern (p = 0.86). There was also no significant difference (p = 0.66) regarding intraocular pressure between patients with mild (13.9 ± 3.8 mmHg) and severe capillaroscopic pattern (14.4 ± 2.8 mmHg). The odds ratio of glaucoma for severe capillaroscopic pattern compared to mild was 1.6 (95% confidence interval: 0.3-9.5). CONCLUSION: Up to 23% of patients with SSc have glaucoma. The high prevalence of glaucoma in SSc suggests a possible systemic vascular disturbance as the cause. However, there seems to be no significant association between the capillaroscopy pattern and glaucoma in systemic sclerosis. Further research is required to improve the understanding of glaucoma in the context of systemic sclerosis.

Ophthalmic manifestations in patients with inflammatory bowel disease: A review.

Clinical manifestations of inflammatory bowel disease (IBD) are not locally restricted to the gastrointestinal tract, and a significant portion of patients have involvement of other organs and systems. The visual system is one of the most frequently affected, mainly by inflammatory disorders such as episcleritis, uveitis and scleritis. A critical review of available literature concerning ocular involvement in IBD, as it appears in PubMed, was performed. Episcleritis, the most common ocular extraintestinal manifestation (EIM), seems to be more associated with IBD activity when compared with other ocular EIMs. In IBD patients, anterior uveitis has an insidious onset, it is longstanding and bilateral, and not related to the intestinal disease activity. Systemic steroids or immunosuppressants may be necessary in severe ocular inflammation cases, and control of the underlying bowel disease is important to prevent recurrence. Our review revealed that ocular involvement is more prevalent in Crohn's disease than ulcerative colitis, in active IBD, mainly in the presence of other EIMs. The ophthalmic symptoms in IBD are mainly non-specific and their relevance may not be recognized by the clinician; most ophthalmic manifestations are treatable, and resolve without sequel upon prompt treatment. A collaborative clinical care team for management of IBD that includes ophthalmologists is central for improvement of quality care for these patients, and it is also cost-effective.

Assessment of eye drop instillation technique in glaucoma patients.

PURPOSE:: To study the technique of eye drop instillation in glaucoma patients and identify independent factors that may influence their performance. METHODS:: In this cross-sectional study, 71 consecutive patients with glaucoma or ocular hypertension, self-administering topical anti-glaucoma medications for ≥6 months were evaluated. All patients instilled a tear substitute into the eye with the worst eyesight using the technique normally used at home. The following parameters were evaluated: age, number of years receiving treatment with ocular hypotensive eye drops, time spent to instill the first drop, number of drops instilled, correct location of the eye drops, contact of the bottle with the eye, closing of the eyelids or occlusion of the tear punctum, and asepsis of the hands. RESULTS:: The mean age of the patients was 66 ± 10.8 years, and patients were on ocular hypotensive drugs for 11.3 ± 7.3 (range, 2-35) years. Only 28% of the patients were able to correctly instill the eye drops (squeeze out 1 drop and instill it into the conjunctival sac without bottle tip contact). Touching the tip of the bottle to the globe or periocular tissue occurred in 62% of the patients. In 49% of the patients, the eye drops fell on the eyelids or cheek. Two or more drops were squeezed by 27% of the patients. CONCLUSIONS:: The majority of glaucoma patients were unable to correctly instill eye drops. Age was an independent factor associated with eye drop instillation performance.

Refractive and Quality of Vision Outcomes with Toric IOL Implantation in Low Astigmatism.

Purpose. To evaluate the refractive and the quality of vision outcomes of toric IOL implantation in patients with low astigmatism. Design. Prospective study of single-arm. Methods. Patients with corneal astigmatism range from 0,75 D to 1,5 D and cataract that underwent cataract surgery with toric IOL. The measurements were performed preoperatively and 6 weeks after the surgery. Patients were evaluated for visual acuity with and without correction, contrast sensitivity, static and dynamic refraction, and quality of life questionnaire. Pre- and postoperative values were compared and their variations were evaluated for linear correlation. Results. 21 eyes of 21 patients. Postoperative mean uncorrected visual acuity was 0.80 ± 0.19, and the best corrected visual acuity was 0.97 ± 0.15. p < 0.001 compared to preoperative values. The average postoperative refractive cylinder was -0.34 ± 0.39. The questionnaire's total value before and after surgery was, respectively, 43.20 ± 15.76 and 79.70 ± 10.11 (p < 0.001). The correlation coefficients between the values of the questionnaire variation and the UCVA, BCVA, and CS variation were, respectively, 0.548 (p = 0.005), 0.508 (p = 0.009), and 0.409 (p = 0.033). Conclusion. Patients with low astigmatism who underwent phacoemulsification with toric IOL implantation experienced significant decrease in refractive astigmatism and improvement in their quality of life.

Intraocular pressure in chronic users of low-dose oral corticosteroids for connective tissue disease.

OBJECTIVE: To investigate the mean intraocular pressure (IOP) of patients with connective tissue disease (CTD) on low-dose chronic systemic corticosteroid therapy and compare with control subjects. DESIGN: Cross-sectional comparative study. PARTICIPANTS: A total of 86 patients with CTD were grouped according to corticosteroid therapy. Group 1 (n = 27) was composed of patients with CTD receiving low-dose systemic corticosteroid therapy (<10 mg prednisone or its equivalent oral corticosteroid) for at least 6 months, and group 2 (n = 59) included patients with CTD without use of corticosteroid therapy. Group 3 (n = 20) was composed of healthy control subjects. METHODS: All patients underwent a complete ophthalmic evaluation by an experienced investigator and had their clinical records reviewed by another independent investigator. IOP was measured by Goldmann applanation tonometry. RESULTS: In all 3 groups, the IOPs were within the normal range. The mean IOP was 13.1 ± 2.7 mm Hg (range 8-19 mm Hg) in the CTD corticosteroid group (group 1), 13.7 ± 2.7 mm Hg (range 9-22 mm Hg) in CTD group without corticosteroid therapy (group 2), and 13.1 ± 1.6 mm Hg (range 10-16 mm Hg) in the control group (group 3). No significant differences in IOP were observed among the 3 groups (p = 0.50). CONCLUSIONS: Patients under chronic treatment with low-dose systemic corticosteroid therapy for CTD presented with IOP within the normal range, not clinically significant different from the IOP of patients with CTD without any steroid therapy or from healthy control subjects.

[The relationship between the length of ciliary processes as measured by ultrasound biomicroscopy and the duration, localization and severity of uveitis]. / A relação entre o comprimento dos processos ciliares medidos pela biomicroscopia ultra-sônica e a duração, localização e gravidade das uveítes.

PURPOSE: To determine the relationship between the length of ciliary processes as measured by ultrasound biomicroscopy and the duration, localization and severity of uveitis. METHODS: We analyzed in this prospective study, 58 individuals including patients with different stages of uveitis and normal patients (112 eyes including 18 normal), between August 2001 and August 2002, at the Cleveland Clinic Foundation, Ohio, USA. All patients were referred to ultrasound biomicroscopy by the Uveitis Department, after a complete ophthalmological examination. A 50 MHz-transducer UBM model 840 (Zeiss-Humphrey) was used under topical anesthesia and immersion technique. RESULTS: The most frequent etiology was idiophatic uveitis (27.8%). Recurrent, aggressive and diffuse uveitis lead to significant damage of the ciliary processes. The most significant loss of the ciliary processes was found in the inferior quadrant and the highest in normal patients and in the temporal quadrant. Hypotonic eyes have their ciliary processes reduced. CONCLUSIONS: Ultrasound biomicroscopy has proved to be useful in evaluating anatomical changes of ciliary processes in uveitis and in ocular hypotony, and provides a basis to, make recommendations regarding baseline screening of uveitis patients. Patients who are found to have atrophy of the ciliary processes may need a more aggressive treatment for any signs of inflammation to prevent further damage and eventual hypotony.

[Fundus changes evaluation in degenerative myopia]. / Avaliação das alterações fundoscópicas na miopia degenerativa.

PURPOSE: To evaluate the presence of fundus changes in degenerative myopia. METHODS: Forty patients with refractive error of at least -6.00 diopters were selected for ophthalmologic examination followed by posterior pole photograph and echobiometry. RESULTS: We studied 57 eyes of 37 patients with refractive error ranging from -6.25 to -28.50 diopters, with mean -14.05, and axial length ranging from 26.06 to 32.86 mm, with mean 28.01. We found a temporal crescent in 36.5% and a peripapillary one in 20% of the eyes. Choroidal vessels were seen in 35% of the eyes. Posterior pole changes were as follow: posterior staphyloma in 10.5%, Fuchs' spots in 3.5% and lacquer cracks in 1.5%. Peripheral retinal examination revealed paving stone chorioretinal atrophy in 17.5%, white without pressure in 10.5%, lattice degeneration in 5%, retinal tears in 3.5% and retinoschisis in 1.5% of the examined eyes. CONCLUSIONS: Fundus changes that lead to decreased vision are common in patients with degenerative myopia. Peripheral retinal examination is very important in these patients due to the increased risk of retinal detachment.

[Number, shape, and topography of leakage points in patients with central serous chorioretinopathy]. / Número, tipo e topografia dos pontos de vazamento em pacientes com coriorretinopatia serosa central.

PURPOSE: To evaluate the number, shape and topography of leakage points in patients with central serous chorioretinopathy (CSC). METHODS: Digital photographic files of fluorescein angiography with the diagnosis of CSC were reviewed by the author. The cases considered in remission and the examinations related to the same episode were excluded. The author filled out a form containing medical record number, initials, sex, age, date of the examination and leakage point characteristics (number, shape, and topography) of the selected cases. RESULTS: The examinations of 418 patients (455 eyes) were included, with a male:female ratio of 2.32:1. Ninety-one point fifteen percent of the patients presented the disease unilaterally and 8.85% bilaterally. The mean age was 43.04 years (range, 19-68 years). Among the 455 selected eyes, 88.35% presented typical forms of CSC while 10.11% decompensation of the retinal pigment epithelium and 1.54% with isolated retinal pigment epithelium (RPE) detachment. The evaluation of typical forms of CSC showed a leakage point with uniform dye spread (inkblot) in 88.81% and 11.19% with a smoke-stack phenomenon. Regarding the leakage points, 46.01% were located in the upper nasal quadrant, 23.27% in the upper temporal quadrant, 19.18% in the lower nasal quadrant, 11.01% in the lower temporal quadrant and 0.53% in the subfoveal area. CONCLUSIONS: In our series men were affected approximately two times more often then women, most of them with a unilateral involvement and in around the fourth decade of life. About 90% of the patients presented the typical forms, with 1 or 2 inkblot points or leakage. The superior nasal quadrant was the most affected. The isolated RPE detachment rarely occurred. Decompensation of RPE affected about 10% of the patients.

[Congenital retinal macrovessel: case report]. / Macrovaso retiniano congênito: relato de caso.

Congenital retinal macrovessel is a rare vascular anomaly in which a large vessel and its tributaries cross the macula. We describe a case of retinal macrovessel in a patient complaining of decrease in visual acuity.

[Comparative study of the density of corneal endothelial cells after phacoemulsification by the "divide and conquer" and "quick chop" techniques]. / Estudo comparativo da densidade de células endoteliais da córnea após facoemulsificação pelas técnicas de "dividir e conquistar" e "quick chop"

PURPOSE: Since one of the most implicated factors in corneal endothelial cell loss after phacoemulsification is the ultrasound time, and that the "quick chop" technique utilizes less ultrasound time, the objective of this study was to compare and analyze the reduction of the central corneal endothelial cell density between the patients submitted to the "divide and conquer" and "quick chop" techniques. METHODS: Fifty-six patients with grade 3 senile cataract were prospectively selected and submitted to endocapsular phacoemulsification by the "divide and conquer" (28 patients, group 1) and "quick chop" (28 patients, group 2) techniques. The non-contact corneal central specular microscopy performed pre- and postoperatively at one month, 3 months and 6 months, and the ultrasound time used for each surgery, were verified. RESULTS: We observed that the "divide and conquer" technique spent an average of 2.0 minutes of ultrasound time and the "quick chop", 1.1 minute; that the reduction of the central corneal endothelial cell density was significant for both techniques in the first postoperative month (16.5% in group 1 and 19.4% in group 2) and that the variations in central corneal endothelial cell density that followed, at the 3rd and 6th month were not significant. There was no statistically significant difference between the variation of the central corneal endothelial cell density that occurred with both techniques (Student's "t" test p=0.334; in the 1st postoperative month). CONCLUSIONS: We concluded that the reduction of central corneal endothelial cell density was not statistically different between the two techniques.