Early-Phase Perceptions of COVID-19's Impact on Ophthalmology Practice Patterns: A Survey from the Pan-American Association of Ophthalmology.

Purpose: The COVID-19 pandemic affected medical practice worldwide due to interventions to prevent spreading. Its effect on ophthalmology practices in Latin America has not yet been explored. We aimed to assess the perceptions about the pandemic from countries' ophthalmological national and subspecialty retina societies affiliated to the Pan-American Association of Ophthalmology (PAAO). Patients and Methods: A survey-based study of leaders of national ophthalmological and retinal societies was conducted. The survey was sent by email to 30 societies, from which 20 responded (12 countries, 66.6% response rate). It included closed- and open-ended questions about (1) operational capacity and precautions, (2) telemedicine and virtual care, (3) procedures, and (4) post-pandemic considerations. Results: There was a marked decline in ophthalmology patient visits (80-95%) and elective surgeries (90%) during 2020 compared to before the pandemic. Precautions like temperature checks, mask usage, and social distancing were widely implemented while personal protective equipment (PPE) availability varied. Telemedicine use was limited due to lack of experience with it. Reopening plans focused on maintaining precautions and gradually resuming activities. Economic and security concerns were raised, and adherence to guidelines was emphasized. Respondents acknowledged the need to adapt to a "new normal". Long duration drugs, fewer imaging studies, and shorter wait times were preferred; however, availability of long duration drugs was limited. Conclusion: The pandemic impacted ophthalmology in Latin America, with reduced patient visits, procedures, and surgeries. Delayed treatment and complications were likely the result of the pandemic.

Actualización sobre factores de riesgo asociados a daño corneal post Cross-Linking / Update on risk factors associated with corneal damage post Cross-Linking

El Cross-Linking corneal es un procedimiento utilizado en oftalmología principalmente para el tratamiento del queratocono, la ectasia corneal más frecuente. A pesar de su baja tasa de complicaciones, no es una técnica exenta de ellas. Entre las principales complicaciones se encuentran el haze y el melting corneal, ambas poseen una fisiopatología que no está totalmente esclarecida. Se realizó una revisión bibliográfica sobre la asociación entre el uso de quinolonas y el daño corneal frente a la exposición de luz UV. También se plantearon factores inherentes al paciente que se han relacionado al aumento de complicaciones. Se determinó que la radiación UV produce daños en aquellos tejidos sometidos previamente a tratamiento con quinolonas siendo de suma importancia la correcta anamnesis para seleccionar a los candidatos al procedimiento. (AU)

Corneal Cross-Linking is a procedure used in ophthalmology mainly for the treatment of keratoconus, the most frequent corneal ectasia. Despite its low complication rate, it is not an exempt technique. Among the main complications are haze and corneal melting, both have a pathophysiology that is not fully clarified. A bibliographic review of the association between the use of quinolones and corneal damage versus UV light exposure was performed. Inherent patient factors that have been related to increased complications were also raised. It was determined that UV radiation causes damage to these tissues, sometimes prior to quinolone treatment, with the correction of the anamnesis being of utmost importance to select the candidates for the procedure.

Relationship Between Legal Blindness and Depression.

The higher prevalence rates of depression in visually-impaired individuals than the general population indicates that the condition per se increases the risk of depression. A person that is aware of the progressive loss of visual acuteness may have feelings of insecurity, anxiety, loss of independence and changes in social functioning, leading to depression. Several studies assessing the association between depressive symptoms and severity of vision loss have yielded inconsistent results. Some do not show any association, whereas others reported that depression severity is higher in those with substantial vision loss. The general aim of this manuscript was to determine the prevalence of depression in patients diagnosed with legal blindness in the Eye Care Service at the Hospital Córdoba between June 2016 and June 2017. The study sample consisted of 41 patients. The level of depression was assessed using the Zung scale and the degree of dependence in daily life activities was defined using the Barthel index. Data was anonymized for inclusion in a computer database and statistical confidentiality was protected. Data was analyzed using InfoStat statistical software. The results revealed a relation between legal blindness, degrees of dependency and depressive symptoms in patients of the Eye Care Service of the Hospital Córdoba. It is very important for health professionals to be trained to detect early signs and symptoms of depression and have the necessary tools for such an approach.

Phototoxic Effect of Topical Fluoroquinolones Administered Before Corneal Crosslinking in a Murine Model.

PURPOSE: Corneal crosslinking by UV light (UV-CXL) has become a popular treatment for keratoconus and corneal ectasia. Fluoroquinolones (FQs), commonly administered topically before UV-CXL, are known to be phototoxic to the skin and lens. The purpose of this study was to investigate phototoxic effects of topical FQ treatment on murine corneas before UV-CXL, in which the corneal epithelium was kept intact. METHODS: Murine corneas were treated with various antibiotics with or without riboflavin before UV-CXL. At 24 h, the animals were sacrificed, and the corneas were analyzed for histologic evidence of inflammation and apoptosis and for expression of apoptosis markers BAX and caspases 3 and 9 and for expression of matrix metalloproteinase 9 (MMP-9). Spectrofluorometric analysis was performed. RESULTS: Corneas treated with topical FQ with or without riboflavin before UV-CXL showed mild corneal stromal inflammation, apoptosis by both terminal deoxynucleotidyl transferase dUTP nick end labeling staining and increased expression of BAX gene and caspases 3 and 9 by densitometric analysis. Untreated corneas, corneas treated with azithromycin before UV-CXL, and corneas undergoing UV-CXL without any antibiotic or riboflavin pretreatment showed normal histology, no staining for apoptosis, and no increased production of apoptosis markers by polymerase chain reaction. CONCLUSIONS: The phototoxic effects of FQs on the cornea may lead surgeons to consider another antibiotic class for prophylaxis against infectious keratitis in UV-CXL. These effects, along with the known cytotoxic effects of FQs independent of UV radiation, may contribute to some of the complications of corneal UV-CXL. Dosage studies may be warranted.

Progression of choroidal metastasis of ovarian serous cystoadenocarcinoma after intravitreal bevacizumab treatment.

A 57-year-old woman presented to her ophthalmologist because of rapid deterioration in vision. Dilated funduscopic examination of the right eye showed an elevated, yellow-orange choroidal mass temporal to the fovea; a complete retinal detachment was present in the left eye. The patient was referred to an oncologist. Computerized tomography of the brain, thorax, abdomen, and pelvis were obtained. They revealed an 11-mm mass in the right parietal lobe, a 30-mm mass in the left temporal lobe, 23-mm mass in the right kidney, and multiple nodules in both lungs. Supported by published experience with intravitreal bevacizumab for choroidal metastasis, the patient was injected into the vitreous through the pars plana of the left eye. The tumor mass did not show signs of regression and the visual acuity was unchanged. The patient suffered from end-state complications tumor metastasis and expired one month after the invitreal injection.

Multiple apocrine hidrocystomas of the eyelids.

A 52-year-old man presented with a 5-year history of multiple bilateral apocrine hidrocystomas of the eyelids. For the past 3 years, the patient had developed a mechanical ectropion of the right inferior eyelid secondary to progressive enlargement of the lesions. Different therapeutic options were discussed with the patient. Surgical excision of all lesions was performed under local anesthesia. There was no recurrence after 15 months of follow-up.

Aggressive pterygium growth and corneal scarring after hyperopic photorefractive keratectomy.

PURPOSE: To describe a patient who noticed a corneal growth and accompanying rapid decrease in visual acuity soon after undergoing hyperopic photorefractive keratectomy (PRK). METHOD: Interventional case report. RESULTS: A healthy 47-year-old white woman presented with a corneal growth after undergoing PRK. Visual acuity became progressively worse over 2 years. The growth transected the visual axis, measuring 180 µm centrally and 310 µm nasally. She underwent excisional biopsy, application of mitomycin C on the limbus and adjacent corneal tissue, and grafting with cryopreserved multilayer amniotic membrane. The pathologist reported findings consistent with pterygium. The patient initially experienced improvement in uncorrected visual acuity but then became noncompliant with topical steroids. The central anterior stroma became opacified to the extent of obscuring iris details. Best-corrected visual acuity at the last follow-up was 20/30. CONCLUSIONS: Because ultraviolet exposure is a risk factor for development and growth of pterygium, 1 possible explanation for this patient's findings is the effect of the excimer laser (which has a wavelength in the ultraviolet spectrum) on a previously insignificant corneal growth and/or the corneal limbal stem cells. Patients with corneal lesions suggestive of pterygia may be at increased risk for rapid lesion growth and aggressive corneal scarring after photorefractive keratectomy with a large ablation zone.

Wavefront-guided refractive surgery after multifocal lens implantation.

PURPOSE OF REVIEW: To examine whether wavefront-guided refractive surgery has a role in correcting ametropia after implantation of multifocal intraocular lenses (IOLs). RECENT FINDINGS: This review begins with an oversight of various multifocal IOLs to help understand how a wavefront might return from the IOL and be captured by an aberrometer. The accuracy of the wavefront may be compromised in eyes with multifocal IOLs by the fact that such lenses provide simultaneous vision--that is, a simultaneous projection of in-focus and out-of-focus images of an object on the retina--and hence returning wavefronts theoretically could be captured in a similar manner by an aberrometer. However, in isolated small series, reproducible wavefront refractions--in which the manifest refraction closely approximates the wavefront refraction and good results after refractive surgery--are attained in eyes with diffractive multifocal IOLs. SUMMARY: Small studies suggest that it is possible to perform wavefront-guided excimer light amplification by stimulated emission of radiation (LASER) to correct ametropia following multifocal lens implantation. Larger studies with longer follow-up are needed to determine whether eyes with multifocal lenses derive an added benefit from wavefront-guided refractive surgery over conventional surgery. These studies may help determine whether some IOLs are better suited for subsequent refractive surgery. The age of the patient may affect the outcome of refractive surgery after multifocal IOL implantation.

Secretory Leukoprotease Inhibitor: A Native Antimicrobial Protein in the Innate Immune Response in a Rat Model of S. aureus Keratitis.

Purpose. To describe the presence of secretory leukocyte protease inhibitor (SLPI), a cationic peptide with antimicrobial and antiprotease activity in the innate immune reaction in a rat model of Staphylococcus aureus keratitis. Methods. Forty female Lewis rats were divided into 2 groups: the infectious keratitis and the epithelial defect groups. Eyes were processed for immunohistochemical studies for SLPI, interleukin-1, interleukin-6, tumor necrosis factor-alpha, and matrix metalloproteinase-8. Results. Immunohistochemical studies confirmed high levels of SLPI, IL-1, IL-6, TNF-alpha, and MMP-8 expression in eyes with S. aureus keratitis and with epithelial defects, in contrast to undetectable SLPI expression in the normal control corneas. Conclusions. To our knowledge, this paper is the first to demonstrate the presence of SLPI with increased amounts of proinflammatory cytokines in inflamed and infected corneas.

Acute rhegmatogenous retinal detachment immediately following laser in situ keratomileusis.

We report a case of acute rhegmatogenous retinal detachment (RRD) after laser in situ keratomileusis (LASIK) surgery in a highly myopic patient. Fourteen hours postoperatively, the uncorrected visual acuity was counting fingers in the left eye. Slitlamp examination revealed significant anterior chamber reaction with fibrin-like material. Fundus examination revealed 2 inferior retinal horseshoe tears associated with an RD. Preoperative fundus examination with scleral depression may detect predisposing retinal lesions in highly myopic patients. Further study is required to evaluate the relationship between LASIK, acute postoperative RRD, and predisposing factors.

Secretory leukocyte protease inhibitor is an inducible antimicrobial peptide expressed in Staphylococcus aureus endophthalmitis.

PURPOSE: To describe the presence of secretory leukocyte protease inhibitor (SLPI), a cationic peptide with antimicrobial and antiprotease activity, in the innate ocular immune reaction in a rat model of Staphylococcus aureus endophthalmitis. METHODS: Seventy-five female Lewis rats were divided into three groups: the endophthalmitis group received an intravitreal injection of 65 colony-forming units of viable S. aureus, the vehicle-injected group received balanced sterile saline solution (BSS), and the control group was not injected. Eyes were enucleated at 24 and 48 hours and processed for immunohistochemical staining and Western blot studies for SLPI. RESULTS: In S. aureus endophthalmitis eyes, there was strong immunostaining for SLPI in the retina and vitreous with associated neutrophilic infiltrates. At 48 hours, corneas also stained for SLPI. Western blots confirmed increased SLPI expression in all infected eyes. By immunohistochemical assays, SLPI was absent in the BSS and control eyes. The causative pathogen was identified in all samples from the endophthalmitis group by traditional culture methods. CONCLUSIONS: To our knowledge, this report is the first to demonstrate the presence of SLPI in the inflamed cornea, vitreous, and retina tissues of rat eyes with S. aureus endophthalmitis, suggesting that SLPI has an active role in the innate immunity of the eye. Release of SLPI by inflammatory cells in the anterior and posterior segments may contribute to the host defense response against infectious endophthalmitis.

Complete bilateral vitreous detachment after LASIK retreatment.

We describe a case of a 47-year-old woman who underwent bilateral laser in situ keratomileusis (LASIK) for the correction of myopia and astigmatism. Two months later a residual refractive error was present in both eyes. LASIK retreatment was decided and performed the following day. Twenty-four hours after the procedure, the patient reported myodesopsia in both eyes. Funduscopic examination revealed a complete bilateral posterior vitreous detachment confirmed by kinetic ultrasound. Visual disturbance in both eyes continued to be present after 10 months of follow-up. Sudden changes in intraocular pressure related to suction ring use might be the cause of posterior vitreous detachment in this patient.

Disinfection capacity of PuriLens contact lens cleaning unit against Acanthamoeba.

PURPOSE: The PuriLens contact lens system is indicated for cleaning and disinfection of soft (hydrophilic) contact lenses by means of subsonic agitation to remove lens deposits and microorganisms, and ultraviolet irradiation of the storage solution for disinfection. The capacity of the PuriLens system to disinfect storage solutions contaminated with known concentrations of Staphylococcus aureus, Pseudomonas aeruginosa, and Acanthamoeba species was evaluated. METHODS: An in vitro assessment of the antibacterial and antiparasitic efficacy of the PuriLens system was performed. Separated batches of the storage solution for the cleansing system were contaminated with stock strains of S. aureus and P. aeruginosa. A comparison of the microbiologic content was made between the solution before and after the cycle. RESULTS: The PuriLens system effectively eradicated S. aureus and P. aeruginosa organisms after a 15-minute cycle. However, viable cysts of acanthamoeba were recovered in the solution after the 15-minute cycle. CONCLUSIONS: The PuriLens system is highly efficient in protecting against contamination with common bacterial ocular pathogens. Acanthamoeba cysts, however, can survive in the solution or contact lens bath undergoing integrated subsonic debridement and indirect ultraviolet light disinfection. Use of chemical disinfecting solutions that contain agents such as chlorhexidine or other cationic antiseptics may be advisable in conjunction with use of the PuriLens device, especially in high-risk settings.

Effect of topical fluoroquinolones on the expression of matrix metalloproteinases in the cornea.

BACKGROUND: Matrix metalloproteinases play an important role in extracellular matrix deposition and degradation. Based on previous clinical observations of corneal perforations during topical fluoroquinolone treatment, we decided to evaluate the comparative effects of various fluoroquinolone eye drops on the expression of matrix metalloproteinases (MMPs) in cornea. METHODS: Eighty female Lewis rats were divided into two experimental groups: intact and wounded corneal epithelium. Uniform corneal epithelial defects were created in the right eye with application of 75% alcohol in the center of the tissue for 6 seconds. The treatment groups were tested as follows: 1) Tear drops: carboxymethylcellulose sodium 0.5 % (Refresh, Allergan); 2) Ciprofloxacin 0.3% (Ciloxan, Alcon); 3) Ofloxacin 0.3%(Ocuflox, Allergan); 4) Levofloxacin 0.5%(Quixin, Santen). Eye drops were administered 6 times a day for 48 hours. Rats were sacrificed at 48 hours. Immunohistochemical analysis and zymography were conducted using antibodies specific to MMPs-1, 2, 8 and 9. RESULTS: MMP-1, MMP-2, MMP-8 and MMP-9 expression were detected at 48 hrs in undebrided corneal epithelium groups treated with the topical fluoroquinolones. No statistical difference was observed in quantitative expression of MMPs among ciprofloxacin 0.3%, ofloxacin 0.3%, levofloxacin 0.5%. When the artificial tear group and the fluoroquinolone groups with corneal epithelial defect were compared, increased expression of MMPs was observed as a result of the wound healing process. However, the fluoroquinolone treated group exhibited high statistically significantly levels of MMPs expression. CONCLUSIONS: Our study provides preliminary evidence that topical application of fluoroquinolone drugs can induce the expression of MMP-1, MMP-2, MMP-8 and MMP-9 in the undebrided corneal epithelium compared to artificial tear eye drops.

Effects of topical nonsteroidal antiinflammatory drugs on the expression of matrix metalloproteinases in the cornea.

PURPOSE: To assess the effects of nonsteroidal antiinflammatory drug (NSAID) eyedrops on the expression of matrix metalloproteinases in corneal tissue. SETTING: Ocular Microbiology and Immunology Laboratory, Refractive Surgery Research Laboratory, The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA. METHODS: Seventy rats were divided into 2 groups: intact and debrided epithelium. Uniform central corneal epithelial defects were created in the right eye of the debrided corneal group. Each group was divided into 4 subgroups, each receiving 1 of the following eyedrops or artificial tears: The 3 NSAIDs were diclofenac sodium 0.1% (Falcon or Voltaren) and preservative-free ketorolac 0.5% (Acular PF). The artificial tears were carboxymethylcellulose sodium 0.5% (Refresh Plus PF). The eyedrops were administered 4 times a day for 1 week. The rats were killed on days 2 and 7. The corneas were excised and processed for immunohistochemical staining, Western blot assay, and zymography studies to determine the localization of the production of the following matrix metalloproteinases (MMPs): MMP-1, MMP-2, MMP-8, and MMP-9. RESULTS: Matrix metalloproteinase-1, MMP-8, and MMP-2 were detected in rat corneas at 48 hours in the debrided and intact epithelium groups treated with NSAID eyedrops. The MMP-1 and MMP-8 expression levels were higher in intact corneas in the diclofenac sodium groups than in the ketorolac and artificial tears groups. The expression was localized mostly in the epithelial cells and occasionally in keratocytes. CONCLUSION: This study provides preliminary evidence that topical application of some NSAIDs can induce the early expression of MMP-1, MMP-2, and MMP-8 in the cornea, suggesting that MMPs play a role in the corneal cytotoxicity of certain NSAIDs.

[Submacular surgery in ocular toxocariasis: a clinic-pathologic correlation]. / Cirugía submacular en toxocariasis intraocular: una correlación clínico-patológica.

PURPOSE: To present a clinico-pathologic report on ocular toxocariasis in a nine-year-old boy with a submacular fibravascular membrane who underwent submacular surgery. MATERIALS AND METHODS: A nine-year-old boy affected by chronic ocular toxocariasis in his right eye was treated. Fundus examination disclosed multiple vitreous strands attached to the retina in the inferonasal quadrant and a submacular membrane with a surrounding exudative macular detachment. Vitrectomy surgery with submacular membrane removal was performed. RESULTS: Visual acuity improved from hand motion to 20/400 after two months of follow-up. The pathological findings revealed a fibrovascular scar without parasitic remnants in the serial section of the tissue. CONCLUSION: In this case of ocular toxocariasis, submacular surgery turned out to be a good alternative treatment to improve the patient's visual acuity. Through this kind of surgery it could be possible not only to treat vitreoretinal complications of the disease but also to excise submacular membranes and reattach the retina in the macular area.