Luis Antonio Vieira

Clinic-cytologic study of conjunctivochalasis and its relation to thyroid autoimmune diseases : Prospective cohort study

Purpose: To determine the prevalence of conjunctivochalasis in patients with immune thyroid diseases, to determine whether there is any association between the 2 diseases, and to determine cytologic study of conjunctivochalasis through the cytology impression test. Methods: A clinical prospective cohort study carried out by the External Diseases Department in the Ophthalmology Sector and the Thyroid Department in the Endocrinology Sector at Federal University of Sao Paulo (UNIFESP). The patients included were divided into 2 groups following these inclusion criteria: a control group of 25 patients without thyroid diseases, confirmed after clinical and laboratory examinations (thyroid hormones), or any other ocular diseases. The study group consisted of 31 patients with thyroid diseases, the diagnosis of which was confirmed by the Endocrinology Sector. The thyroidopathies included were autoimmune diseases but excluded nonautoimmune diseases. A protocol endorsed by the UNIFESP was followed, using clinical and ophthalmological history, biomicroscopy, and impression cytology. Results: Fifty-two percent of patients without thyroid diseases and 88% of patients with thyroid diseases presented with conjunctivochalasis. The risk ratio was 1.705 (Pr > χ2 = 0.0038), indicating that there is an association between them. For the impression cytology in inferior bulbar conjunctiva, there was an association between the result of the impression cytology and conjunctivochalasis (Pearson χ2 = 10.1190 Pr = 0.006). Conclusion: The prevalence of conjunctivochalasis in patients with autoimmune thyroid diseases was 88%. Patients with autoimmune thyroidopathy presented higher percentages of conjunctivochalasis than the control group, confirming the association between them. The cytologic study showed the highest prevalence of abnormal surface features in eyes with conjunctivochalasis.

Biologic therapy for refractory scleritis: a new treatment perspective

Scleritis is an umbrella term for a heterogeneous group of ocular diseases that can be associated with autoimmune or systemic disorders. The purpose of this article was to review the literature regarding the use of biologic drugs to treat refractory scleritis. A search of the MEDLINE, Embase, and LILACS electronic databases was conducted, and the reference lists of published articles were hand-searched. No language filters were used. This search strategy yielded no randomized trials of the use of biologic therapies to treat scleritis; only case reports and retrospective studies were retrieved. These studies suggest that monoclonal antibodies (infliximab and adalimumab) are superior to the soluble TNF receptor fusion protein etanercept for the treatment of scleritis in patients that do not respond to corticosteroids and/or to immunosuppressive treatment. Rituximab seems to be the best option for scleritis associated with vasculitis.

Análise laboratorial de ceratites fungicas em Serviço Universitário

Purpose: To present the frequency and type of identified fungi from infectious keratitis. Methods: Retrospective survey of the cases of mycotic keratitis in the period from 1995 to 1998, at the Laboratory of Ocular Microbiology of the Department of Ophthalmology of the Federal University of Sao Paulo. Description of the fungal isolations, analysis of the causative factors and relation to the number of infectious keratitis in the same period. Results/Conclusion: Mycotic keratitis was diagnosed in 61 (5.48%) of the 1,113 patients who presented ulcer of the cornea of infectious etiology, ranging from 3.4 to 9.25%, per year. Filamentous fungi were identified in 47 cases (77.04%) and yeasts in 14 (22.95%). Fusarium was the most frequent genus (50.82%), followed by Candida (22.95%) and Aspergillus (8.19%). Phaeosiaria sp, Phoma sp, Fonsecaea pedrosoi, Exserohilum rostratum, that are rare etiological fungal agents of keratitis, were also isolated.

Transplante de córnea e o conhecimento do procedimento pelos pacientes

PURPOSE: To evaluate the understanding of the patient submitted to corneal transplant regarding the type of surgery, used treatment, rejection signs and final outcome satisfaction, at Cornea and External Disease Sector of the Federal University of Sao Paulo (UNIFESP). METHODS: 42 patients submitted to corneal transplant were interviewed using a questionnaire that includes multiple variables regarding knowledge on the general procedure, postoperative treatment, rejection signs and satisfaction with the final outcome. We also collected data about the diagnosis and the transplant. The data were tabulated and analyzed. RESULTS: 67% of 42 interviewed patients did not know what a corneal transplant is, 67% did not know about rejection signs, 30% did not know the purpose of postoperative medicines and 71% were satisfied with the final outcome. CONCLUSIONS: Most of transplanted patients do not know the meaning of corneal transplant, rejections signs and the correct use of medicines but are satisfied with the final outcome.

Recomendações para o tratamento da síndrome de Sjögren

The recommendations proposed by the Sjögrens Syndrome Committee of the Brazilian Society of Rheumatology for the treatment of Sjögrens syndrome were based on a systematic review of literature in Medline (PubMed) and the Cochrane databases until October 2014 and on expert opinion in the absence of studies on the subject. 131 items classified according to Oxford & Grade were included. These recommendations were developed in order to guide the appropriate management and facilitate the access to treatment for those patients with an appropriate indication, considering the Brazilian socioeconomic context and pharmacological agents available in this country.

Manifestações destrutivas da córnea e esclera associadas a doenças do tecido conectivo: relato de 9 casos

PURPOSE: To study the clinical features, diagnosis, treatment, and outcome of nine patients with corneal and scleral involvement associated to connective tissue disease. METHODS: Description of anterior segment abnormalities observed in nine patients with connective tissue disease, five of them previously diagnosed and four with the ocular involvement being the first manifestation of the disease. All patients were evaluated at the Corneal and External Diseases outpatient clinic of the Federal University of Sao Paulo - Escola Paulista de Medicina (UNIFESP-EPM) between July/1999 to December/2000 and were submitted to a complete ophthalmologic examination, clinical evaluation and laboratory investigation. Clinical or surgical treatment was indicated according to the ocular disease evolution. RESULTS: The clinical diagnoses of the patients with anterior segment inflammatory disease were rheumatoid arthritis in seven patients (77.8%), systemic sclerosis and Wegener´s granulomatosis in each of the remaining patients (22.2%). The most frequent ocular manifestation was scleritis (66.6%), followed by peripheral ulcerative keratitis (55.5%) and dry eye syndrome (44.4%). Eighty-nine percent (89%) of the patients required immunosuppressive therapy to control the ocular inflammatory disease. Remission of the ocular symptoms were observed after 3 months of the beginning of imunossupressive therapy on average. In 55.5% of the patients a surgical approach (conjunctival resection, application of cyanoacrylate tissue adhesive, penetrating keratoplasty and scleral patch graft) was necessary. CONCLUSION: The finding of corneal and scleral involvement associated with connective tissue disease is a sign of the disease activity and usually requires imunossupressive therapy. The ophthalmologists should be aware of these conditions in order to early diagnose and apply the appropriate treatment.

Comparative study of ophthalmological and serological manifestations and the therapeutic response of patients with isolated scleritis and scleritis associated with systemic diseases

INTRODUCTION Scleritis is a rare, progressive and serious disease, the signs of which are inflammation and edema of episcleral and scleral tissues and is greatly associated with systemic rheumatoid diseases. PURPOSE To perform a prospective and comparative study between ophthalmologic manifestations, serologic findings and therapeutic response of patients with isolated scleritis and scleritis associated with systemic rheumatoid disease. METHODS Thirty-two outpatients with non-infectious scleritis were studied, from March 2006 to March 2008. The treatment was corticoid eye drops associated with anti-inflammatory agents, followed by systemic corticoids and immunosuppressive drugs if necessary, was considered successful after six months without scleritis recurrence. RESULTS Fourteen of 32 patients had scleritis associated with systemic rheumatoid disease, of which nine had rheumatoid arthritis, two systemic lupus erythematosus, one Crohns disease, one Behçets disease and one gout. There were no difference in relation to involvement and ocular complications, there was predominance of nodular anterior scleritis and scleral thinning was the most frequent complication. The scleritis associated with systemic rheumatoid disease group had 64.3% of autoantibodies, versus 27.8% among those with isolated scleritis and this difference was statistically significant. In the isolated scleritis group 16.7% used anti-inflammatory, 33.3% corticosteroids, 27.8% corticosteroids with one immunosuppressive drug, 5.5% two immunosuppressive drugs, 16.7% corticosteroids with two immunosuppressive drugs and 33.3% pulse of immunosuppressive drugs, there was remission in 88.9%. In the scleritis associated with systemic rheumatoid disease group 7.1% used anti-inflammatory, 7.1% corticosteroids, 50% corticosteroids with one immunosuppressive drug, 7.1% two immunosuppressive drugs and 22.2% pulse of immunosuppressive drugs, 100% had treatment success. CONCLUSION Prevalence of unilateral nodular scleritis was noted in both groups and higher rates of all the parameters tested were noted in the scleritis associated with systemic rheumatoid disease group. There were no differences between the groups with respect to the use of immunosuppressive drugs and therapeutic response, which was fully satisfactory in the scleritis associated with systemic rheumatoid disease group and satisfactory in the isolated scleritis group.

Management of necrotizing scleritis after pterygium surgery with rituximab

The authors present a case of necrotizing scleritis after pterygium excision successfully treated with rituximab after attempts with high doses of corticosteroids and immunosuppressive drugs. A literature review revealed case reports and a phase I/II dose-ranging randomized clinical trial using rituximab for necrotizing scleritis with or without association with autoimmune disease. This is the only case report on rituximab treatment for necrotizing scleritis after pterygium surgery. In cases with refractoriness to immunosuppressive drugs, a CD20 antibody can be used.

Effect of Topical Tacrolimus in the Treatment of Thygeson's Superficial Punctate Keratitis

PURPOSE To evaluate topical tacrolimus ointment for treating Thygesons superficial punctate keratitis (Thygeson SPK). DESIGN Retrospective interventional case series. METHODS setting: Institutional practice. PATIENT POPULATION The medical records of 14 patients (9 women; age range, 9-65 years) with Thygeson SPK were reviewed retrospectively. Diagnosis was based on the history and clinical examination. INTERVENTION Patients were treated with tacrolimus 0.03% eye ointment instilled into the lower fornix twice daily for the first 2 weeks, followed by nocturnal application. The clinical signs and symptoms were assessed after 1 month of treatment. The drug was tapered with disease improvement. MAIN OUTCOME MEASURE(S) Treatment efficacy and side effects. RESULTS All patients had bilateral disease (average duration, 6 years). All patients, except 2 who used the medication irregularly, had improved visual acuity (VA), symptoms, and signs as long as the medication was applied. Before treatment 28.57% of patients had VA between 20/30 and 20/50, with improvement after treatment to 20/25 or 20/20. Attempts to withdraw the medication resulted in recurrent disease, and, therefore, treatment was not curative during the study period. No significant local medication side effects were reported. CONCLUSION Tacrolimus eye ointment 0.03% was effective for controlling Thygeson SPK for a long period with good patient tolerance and no noticeable local or systemic side effects. During the average 6-year follow-up, treatment was not curative. Randomized studies are difficult to conduct because of the disease rarity.

AB0533 Recommendations of Brazilian Society of Rheumatology for the Treatment of SjÖGren's Syndrome

Objectives Recommendations of Brazilian Society of Rheumatology for the treatment of Sjögrens syndrome (SS) were developed to guide management of SS considering the Brazilian social and economic context. Methods It was based on specialists opinion and systematic review on MEDLINE (PubMed) and Cochrane database until October 2014, including 127 articles classified according Oxford & Grade. Results Forty-four recommendations were organized in 3 main topics: Part 1. General recommendations and patient education: The management of SS should be conducted by multidisciplinary team. Systemic treatment should be according disease severity measured by EULAR Sjögrens Syndrome Disease Activity (ESSDAI). Patients should avoid caffeine, tobacco, alcohol, toothpaste with abrasive, and mouthrinses with alcohol. Patient should be educated about preventive measures for oral health and hydration. Aerobic exercise improves fatigue and quality of life. Immunization to influenza and pneumococo are indicated. Serum levels of vitamin D should be evaluated and supplemented if it is necessary. Part 2. Symptomatic treatment of dryness: Topical treatment for dry mouth includes saliva substitutes, sugar-free candies and gums. Topical treatments for dry eye are lubricants (glucanes or carboximethylcelulose), cyclosporine 0.05%, and punctual occlusion. Topical glucocorticoids may be used for severe dry eye for short time avoiding complications. Pilocarpine and cevimeline should be used for dry mouth and for severe dry eye. N-acetylcysteine may be used for dryness symptoms, including patients showing intolerance for muscarinic agonists. Omega-3 supplementation may be used to dry eye. Part 3. Systemic treatment: Immunosupressant and/or biological therapy are not indicated to dryness treatment. Hydroxichloroquine, glucocorticoid, and immunossupressants (azathioprine, mycophenolate mofetil, cyclophosphamide, cyclosporine) should be indicated according severity of systemic involvement. Rituximab is indicated to treat systemic manifestations without improvement with immunosuppressive therapy. Abatacept and belimumab may be considered in patients not responding to rituximab and with high level of disease activity. Acknowledgements Sociedade Brasileira de Reumatologia (SBR) Disclosure of Interest None declared