Inês Leal

Hypoxia challenge test and retinal circulation changes - a study using ocular coherence tomography angiography

Previous studies report that the response of retinal vessels to a decrease in oxygen (hypoxia) is vasodilation, thus increasing blood flow. We aimed to characterize the changes in retinal microvasculature induced by a mild hypoxia stress test in a healthy population, using ocular coherence tomography angiography (OCT‐A) technology.

Efficacy and safety of intravitreal anti-tumour necrosis factor drugs in adults with non-infectious uveitis : a systematic review

Anti‐tumour necrosis factor (TNF) drugs have been extensively used in non‐infectious uveitis (NIU), when corticosteroids or conventional immunosuppressive drugs cannot adequately control inflammation or intolerable side‐effects occur. However, systemic anti‐TNF therapies are also associated with a myriad of side‐effects. Therefore, intravitreal administration of anti‐TNF biologics has been employed to minimize patient morbidity and systemic adverse effects, while maintaining therapeutic effectivity. We undertook a systematic review to determine evidence of efficacy and safety of intravitreal administration of anti‐TNF drugs in adults with NIU. We conducted this systematic review according to the PRISMA guidelines. The protocol was registered with PROSPERO (CRD42016041946). We searched CENTRAL, MEDLINE and EMBASE, from inception to April 2017, as well as clinical trial registries and grey literature. The qualitative analysis included all studies of adult patients with a diagnosis of NIU and who received intravitreal anti‐TNF drugs with a 4‐week minimum follow‐up. A total of 4840 references were considered for title and abstract screening. Seven full texts were screened, and five studies were considered for analysis. All studies were open‐label, single‐centre, prospective, non‐randomized, interventional case series with a follow‐up between 4 and 26 weeks, employing either adalimumab in two studies and infliximab in three. Three studies showed a treatment effect of anti‐TNF intravitreal injections, while one study revealed short‐term improvement and one study revealed no efficacy of anti‐TNF intravitreal therapy. None of the studies reported ocular adverse effects but only two studies included electrophysiological assessment in the safety analysis and no study assessed systemic human anti‐drug antibodies. The available evidence is not sufficiently robust to conclude about the clinical effectivity of intravitreal anti‐TNF in NIU and so no recommendation can be made. In conclusion, intravitreal injection of anti‐TNF antibodies remains a possible treatment option to be explored through robust clinical investigation.

Use of Ocular Hypotensive Medications in Portugal: Pem Study

Purpose: There is scarcity of European data about intraocular pressure (IOP)-lowering prescribing patterns. We aimed to describe and discuss the nationwide prescription of these medications in Portugal. Materials and Methods: This was a cross-sectional study including all patients who were prescribed at least 1 IOP-lowering medication in 2015 in Portugal. All ocular hypotensive drug prescriptions were gathered from the common electronic drug prescription system used by all hospitals and clinics in Portugal. Demographic data, medications prescribed (number and formulation), physician specialty, and costs of medications were provided in an encrypted and anonymous form. Statistical analyses were performed using STATA. Results: A total of 231,634 participants (57% women) were prescribed IOP-lowering medications in 2015, representing 4.0% of the population older than 40 years of age and 2.2% of the Portuguese total population. Mean age was 72±13 years. Topical IOP-lowering therapy accounted for a total of 26 million euros (M&OV0556;) in costs, shared between patients and the national health system. General practitioners (GPs) accounted for 52% of all prescriptions. The most prescribed drugs were latanoprost (28%), timolol/dorzolamide (19%), and brimonidine (14%). Among all, 72% of patients were on monotherapy. Compared with ophthalmologists, GPs presented qualitative differences in their prescription pattern, such as a lower proportion of unit dose prescription. Conclusion: A significant percentage of the Portuguese population is currently treated with IOP-lowering medications, and the majority of them are on monotherapy. Although GPs are responsible for most prescriptions, their prescription pattern is different from that of ophthalmologists. This nationwide study revealed prescription patterns and disclosed the burden of the disease in terms of its medical management.

Sympathetic ophthalmia related to conjunctival invasive squamous-cell carcinoma

Sympathetic ophthalmia (SO) is a rare, diffuse, bilateral, and granulomatous nonnecrotizing panuveitis that may follow intraocular penetrating trauma. Our aim is to report a rare case of SO following orbital exenteration. Orbital exenteration was performed on a 48-year-old african female due to conjunctival keratinizing squamous cell carcinoma with intraocular involvement of the left eye. Five days after the uneventful procedure, the patient presented signs and symptoms compatible with SO. Key differential diagnoses were excluded, and prompt and aggressive immunosuppression was started with a favourable but slow clinical response. This case highlights the fact that SO can also be induced by a neoplasm with intraocular invasion or by aggressive nonpenetrating surgery. While the underlying pathogenesis of SO is still not fully elucidated, we hereby contribute with a novel potential mechanism leading to its development.

Relationship between intraocular pressure and anterior lamina cribrosa depth: a cross-sectional observational study in a healthy Portuguese population

Purpose To investigate the association between anterior lamina cribrosa depth (ALCD), determined with enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT), and intraocular pressure (IOP) in a healthy Portuguese population. Methods In this cross-sectional observational study conducted between January and July 2015, 2 optic nerve head (ONH)–centered EDI-OCT cross-scans were performed and ALCD was defined as the perpendicular distance between the line connecting both edges of Bruchs membrane opening and the anterior border of the lamina cribrosa at the maximum depth point. A multivariate regression model was performed to assess the association of IOP and ALCD. Results The studied population included 59 subjects (35 women) with a mean age of 61.7 ± 15.1 years. Mean vertical and horizontal maximum ALCD was 444.5 ± 92.2 μm and 427.6 ± 82.7 μm, respectively. When controlling for age and spherical equivalent, maximum vertical and horizontal ALCD were positively correlated with intraocular pressure (R2>0.20) by 8.58 μm (95% confidence interval [CI] 2.80-14.36 μm; p<0.01) and 8.25 μm (95% CI 2.71-13.78 μm; p<0.01) per mm Hg of IOP, respectively. Conclusions Our sample of healthy subjects presented a statistically significant positive correlation between IOP and ALCD when controlling for possible confounding factors. These results may trigger further studies to better elucidate the role of IOP in the morphologic and functional dynamics of the ONH.

Análise da revisão Cochrane : anti-fator de crescimento vascular endotelial na prevenção da hemorragia vítrea pós-operatória após vitrectomia por retinopatia diabética proliferativa : Cochrane Database Syst Rev. 2015;8:CD008214

Postoperative vitreous hemorrhage is a complication following vitrectomy for proliferative diabetic retinopathy, delaying visual recovery and making fundus examination and disease follow-up more difficult. Anti-vascular endothelial growth factor drugs such as bevacizumab, when injected in the vitreous cavity, reduce vascular proliferation and their use has been proposed to reduce the incidence of postoperative vitreous hemorrhage. The authors of this Cochrane systematic review evaluated all randomized controlled trials on the pre- or intraoperative use of anti-vascular endothelial growth factor to reduce postoperative vitreous hemorrhage occurrence after vitrectomy in patients with proliferative diabetic retinopathy. The results suggested that the use of intravitreal bevacizumab was effective in reducing early postoperative vitreous hemorrhage (i.e. at four weeks) occurrence, with a good safety profile. This work aims to summarize and discuss the findings and clinical implications of this Cochrane systematic review.

Retropupillary iris claw intraocular lens implantation in aphakia for dislocated intraocular lens.

Background Nowadays, dislocated intraocular lenses (IOLs) and inadequate capsular support are becoming a challenge for every ophthalmic surgeon. Explantation of dislocated IOL and iris claw IOL (ICIOL) are the techniques that have been used in our ophthalmic department. The aim of this study is to report our technique for retropupillar ICIOL. Methods This study is a retrospective case series. A total of 105 eyes with dislocated IOL from the patients at the Department of Ophthalmology in Santa Maria Hospital, a tertiary reference hospital in Lisbon, Portugal, from January 2012 until January 2016, had been analyzed. Of these 105 eyes, 66 eyes had dislocated one-piece IOL and 39 eyes had dislocated three-piece IOL. The latter underwent iris suture of the same IOL and were excluded from this study. The remaining 66 eyes with dislocated one-piece IOL underwent pars plana vitrectomy, that is, explantation of dislocated IOL through corneal incision and an implantation of retropupillary ICIOL. Operative data and postoperative outcomes included best corrected visual acuity, IOL position, intraocular pressure, pigment dispersion, clinical signs of endothelial cell loss, and anterior chamber depth. Results The mean follow-up was 23 months (range: 6–48 months). The mean preoperative best corrected visual acuity was 1.260±0.771 logMAR, and postoperative best corrected visual acuity was 0.352±0.400 logMAR units. Mean vision gain was 0.909 logMar units. The patients had the following complications: 1) retinal detachment was found in one patient, 2) corneal edema was found in three patients, 3) high intraocular pressure was observed in twelve patients, 4) subluxation of the IOL was observed in one patient, and 5) macular edema was found in three eyes. Conclusion The results demonstrate that retropupillary ICIOL is an easy and effective method for the correction of aphakia in patients not receiving capsule support. The safety of this procedure must be interpreted in the context of a surgery usually indicated in complicated cases.

Automated gonioscopy photography for iridocorneal angle grading

Purpose: The aim of this study is to assess the agreement between manual and automated gonioscopy for iridocorneal angle opening. Methods: The research is a cross-sectional observational study. Manual and automated gonioscopy were performed to consecutive patients in a glaucoma clinic. Iridocorneal angle opening grading was performed according to Shaffer’s classification. Automated gonioscopy was performed with NGS-1 automated gonioscope (NIDEK Co., Gamagori, Japan). The automated gonio-photos were graded by two independent observers. Agreement between automated and manual gonioscopy and also among raters was ascertained by Fleiss’ kappa statistic and comparison of area under curve. Results: In total, 88 eyes of 47 subjects were analysed. Mean age was 63 ± 10 years. Twenty eyes (22.7%) were excluded from grading due to poor quality images. Angle closure was detected in 23.4% with dynamic gonioscopy in comparison with 4.3% using automated image grading. The agreement for angle closure diagnosis between dynamic and automated gonioscopy was low (κ = 0.09 ± 0.10; p = 0.18). The area under curve for detecting eyes with angle closure showed poor accuracy between automated and manual methods (area under curve: 0.53 ± 0.05, 95% confidence interval: 0.44–0.62). There was modest inter-rater agreement for angle opening assessment of automated images with Fleiss’ kappa of 0.17 (95% confidence interval: 0.035–0.238). Conclusion: Manual and automated gonioscopy showed only slight agreement for the assessment of iridocorneal angle opening status. Further improvements of the NGS-1 automated gonioscopy and technique are desired for widespread use in a real-life setting.

Steroid-induced protracted severe ocular hypertension in a 14-year-old girl

Steroid-induced ocular hypertension (SIOH) is a challenging entity in paediatric age, with many being refractory to medical therapy. Literature is scarce about surgical options in these cases. A 14-year-old girl with bilateral uveitis and macular oedema had received an intravitreal and subconjunctival triamcinolone injection in the right (OD) and left (OS) eye, respectively. While the steroid was effective in resolving the oedema, intraocular pressure (IOP) increased to about 40 mm Hg OD and 34 mm Hg OS, despite being under maximal IOP-lowering therapy. An initial conservative approach was preferred due to the young patient age and given that most cases of SIOH are transient. However, progressive structural changes were documented, and bilateral sequential minimally invasive glaucoma surgery (MIGS: XEN gel stent) was taken. With a follow-up of 6 months, the patient is drug-free with IOP around 14 mm Hg. This report discusses the role and efficacy of MIGS in a paediatric case of SIOH.

The National Student Survey: validation in Portuguese medical students

Abstract The UK National Student Survey (NSS) is a sound and widely used instrument for assessing students’ academic experiences. We aimed to translate the NSS for Portuguese students and to validate the instrument in a sample of medical undergraduates. The research team translated and adapted the NSS for Portuguese students (NSS-P). The survey was administered on an online platform to 1,256 final-year students at eight Portuguese medical schools. A total of 329 medical students (69.9% female) replied to the NSS-P, a response rate of 26.2%. Confirmatory factor analysis showed that the original six-factor structure had an adequate fit to the data. Adequate internal consistency was observed for all the subscales. Medium to large correlations were found among all the subscale scores and between the subscale scores and the students’ overall satisfaction. Multiple regression showed that the scores on the Teaching, Organization and Management and Personal Development subscales significantly predicted the students’ overall satisfaction. Approximately 64% of the students reported being satisfied with the quality of their courses. Significant differences among the medical schools in their NSS-P scores were found. The NSS-P is a valid and reliable measure for assessing medical students’ perceptions of academic quality.