Marcelo Gehlen

Secondary Sjögren's syndrome and disease activity of rheumatoid arthritis

OBJECTIVE To study the relationship of the presence of secondary SS with disease activity, duration in RA. METHODS Eighty two patients with RA were submitted to Schirmer test, minor salivary gland biopsy, questionnaire on sicca symptoms, DAS-28 4v determination. RESULTS In this population, 20 (24.3%) patients fulfilled the American-European classification criteria for secondary SS. No relation could be found between the presence of secondary SS and disease activity (p = 0.31) and RA duration (p = 0.95). CONCLUSION Appearance of Secondary SS in RA patients is independent of RA duration or activity.

Avaliação espectrofotométrica do azul de Evans na reação inflamatória da córnea: estudo experimental em coelhos

PURPOSE: To detect Evans blue in the normal cornea, attempting to determine the period of maximum concentration of the dye after intravenous injection and to study vascular permeability in an animal model of corneal inflammation induced by alkali burn, after Evans blue injection. METHODS: Fifty rabbits were divided into 3 groups. Group I (25 animals): 20 mg/kg Evans blue were injected and the animals were sacrificed after 8, 10, 12, 14 and 16 hours. The corneas were removed and the dye concentration was measured by a spectrophotometric micromethod. Group II: in 15 animals, 10 hours after injection, the corneas were centrally fragmented with number 6, 8 and 10 mm trephines. Evans blue was extracted the same way as in Group I. Group III: alkali burn was induced in the cornea of the right eyes of 10 animals, using 1 N NaOH. Five days after the procedure, the animals were sacrificed. Ten hours prior to sacrifice, Evans blue was injected. The left corneas were the control. RESULTS: In group I, mean Evans blue concentration is at 10 h: 15.28 ± 0.09 mg/mg. In group II, mean Evans blue concentrations are: 6 mm: 0.93 ± 0.01mg/mg; 8 mm: 1.20 ± 0.06 mg/mg; 10 mm: 1.32 ± 0.05 mg/mg. In group III, mean Evans blue concentrations are: right eyes (alkali burns): 23.74 ± 2.64 mg/mg and left eyes (control): 16.71 ± 2.04 mg/mg. CONCLUSIONS: This is the first time that Evans blue has been quantified in rabbits cornea. It was possible to detect the dye from 8 to 16 hours after intravenous injection. We can conclude that Evans blue detection is a good method to quantify the alteration of vascular permeability in rabbits cornea.

Tradução e validação do índice da doença da superfície ocular para a língua portuguesa

PURPOSE To develop a cross-cultural Ocular Surface Disease Index (OSDI) for the Brazilian population and analyze its validity and effectiveness. METHODS Based on the guidelines of Guillemin et al., four English teachers, an ophthalmologist, a rheumatologist, two ophthalmology residents and a native American who does not speak Portuguese were invited. The procedure followed the steps: translation into Portuguese by two English teachers; transformation of the two translations to a single version; application of this version of the questionnaire to 27 people in the ophthalmology clinic of the Evangelic University Hospital of Curitiba, asking questions and making changes for a better understanding by the patients; retranslation into English by two English teachers who lived in the USA.; assessment for a single version, and reading them by a native USA. citizen who does not speak Portuguese to assess the comprehension of the questionnaire. The validated questionnaire was administered to 22 people in the ophthalmology clinic of the Evangelic University Hospital of Curitiba to evaluate the effectiveness of inter-and intra-interviewer. RESULTS The study of intra-observer for each of the questions showed that the questions 1, 2, 3, 4, 7 and 11 have substantial agreement; that the question 8 had almost perfect agreement and questions 5, 6, 9, 10 and 12 have moderate agreement. Studying the inter-observer agreement it was found that there are two questions with almost perfect agreement (2 and 7); substantial agreement with seven questions (questions 1, 2, 4, 5, 6, 8 and 9) and three questions with moderate agreement (10, 11 and 12). CONCLUSIONS The obtained version of OSDI has good inter and intra-observer agreement and can be used in Portuguese to evaluate the quality of life of people with dry eye.

Importância da avaliação oftalmológica em recém-natos

Objective: to verify the existence of ocular diseases in the first 48 hours of life of newborns and relate it to the clinical suspicious of pediatricians. Methods: a prospective study was performed. All infants that were born between July and December of 2000 were evaluated in the nursery of Hospital Universitario Evangelico de Curitiba (HUEC). Six hundred sixty-seven newborns were evaluated through a protocol by residents and tutors of ophthalmology, regardless of pediatricians’ suspicious of ocular disorder. The examination consisted of inspection, oblique illumination, evaluation of ocular deviation and direct ophthalmoscopy (red reflex) in all patients. Results: among all examined newborns, 3.75% showed some ocular disease. The most frequent problem was corneal opacity. The ocular diseases were not noticed by pediatricians, neonatologists and parents in fifty-six per cent of the cases presenting some problem. Conclusions: this study showed that many ocular disorders presented at birth are not noticed by pediatricians (56%), which highlights the importance of ophthalmological evaluation in all newborns as a routine examination in the first 48 hours of life.

Demographic, clinical, laboratory and treatment characteristics of spondyloarthritis patients with and without acute anterior uveitis

CONTEXT AND OBJECTIVE Acute anterior uveitis is a common extra-articular manifestation in spondyloarthritis patients. The aim of this study was to compare demographic, clinical, laboratory and treatment data among spondyloarthritis patients with and without acute anterior uveitis. DESIGN AND SETTING This was a cross-sectional analytical study at the Rheumatology Outpatient Clinic of the Evangelical University Hospital, Curitiba, Brazil. METHODS Spondyloarthritis patients with without acute anterior uveitis were compared regarding demographic data, spondyloarthritis subtype, peripheral arthritis, enthesitis, disease activity, functional index, physical examination, radiological involvement, HLA-B27 and treatment. RESULTS Presence of acute anterior uveitis was not found to have any relationship with functional index, degree of radiological involvement, peripheral arthritis or enthesitis. Acute anterior uveitis showed a negative association with skin manifestations (P = 0.04) and a trend towards higher disease activity (P = 0.06). CONCLUSION In the study sample, it could not be shown that AAU had any association with the functional and radiological prognoses. The patients with spondyloarthritis with and without acute anterior uveitis did not differ clinically except for a higher proportion of ankylosing spondylitis and smaller presence of skin involvement in those with uveitis.

Olho seco e Sjögren secundário na artrite reumatóide

OBJECTIVE: To examine the prevalence of keratoconjuntivitis sicca and secondary Sjogren syndrome (SS) in patients with RA from Southern Brazil and to analyze their relationship with RA duration, activity and patients functional class. Patients with rheumatoid arthritis (RA) may have keratoconjuntivitis sicca that can be considered an extra articular manifestation of this disease. METHODS: We studied 82 RA patients for sicca symptoms, Schirmer test, DAS-28 (RA activity index) and functional class. RESULTS: There were eye sicca symptoms in 57.3%, positive Schirmer test in 41.2% and Secondary SS in 24.3%. The presence of a positive Schirmer test or the secondary SS had no relation with disease duration (p=0.65 and 0.80), RA activity (p=0,42 and 0,25) and neither with the patients functional class (p= 0.84 and 0.79). CONCLUSION: There is a high prevalence of sicca syndrome in RA patients; one fourth of them have secondary SS. Secondary SS and sicca syndrome occurrence is independent of underlying RA activity, duration and cumulative damage.

Short-term, high-dose systemic steroids and intraocular pressure

Glucocorticoids are drugs used in almost all areas of medicine because of their anti-inflammatory and immunosuppressor properties. These medications have several limiting side effects, among them increased intraocular pressure (IOP). The association of glaucoma with topical glucocorticoid use (such as eye drops and local injection therapy) is well known but less appreciated with systemic use. Glucocorticoid pulse therapy is a treatment widely used in internal medicine for life-threatening situations and requires intravenous use of very high doses of glucocorticoids (such as 1 g of methylprednisolone/day) for a short period of time (most commonly for 3–5 days, according to the disease to be treated). This treatment can avoid the complications of severe autoimmune diseases such as rheumatic, dermatological, neurological, and hematological diseases. The effects of this type of therapy on IOP are unknown. We studied IOP in 30 patients (28 women and 2 men) with a mean age of 32.0 (SD 8.3) years who underwent pulse therapy with glucocorticoids. This study was approved by the local Research Ethical Committee, and all patients gave written consent. The patients had systemic lupus erythematosus and underwent methylprednisolone pulse therapy for focal and proliferative lupus glomerulonephritis (27/30 or 90%), nervous system involvement (2/30 or 6.6%), and severe thrombocytopenia (1/30 or 3.3%). All received 1 g methylprednisolone, intravenously, for 3 days. None of them had a known previous or family history of glaucoma, history of inflammatory eye disease, or eye surgery. Before each infusion of the glucocorticoid, the IOP was measured 3 times in each eye with a Goldmann tonometer. For statistical purposes, the mean pressure in both eyes was used for comparison. All IOP measurements were done between 8:00 AM and 10:00 AM. One patient had a mean IOP of 29 mm Hg before any intervention. We found the following mean results: day 1 (before glucocorticoid use), 14.5 (SD 3.3) mm Hg; day 2 (after 1 g methylprednisolone), 15.46 (SD 4.3) mm Hg; and day 3 (after 2 g methylprednisolone), 16.08 (SD 5.2) mm Hg (Fig. 1). Although the mean values after glucocorticoid use were on the safe side, 2 patients with initial normal IOP had values over 20 on day 3. Studying the IOP difference between days 1, 2, and 3, we found a rise of 10.8%, considered not significant (p = 0.43, one-way ANOVA). We concluded that glucocorticoid pulse therapy can be considered safe from the point of view of increases in IOP for the majority of patients, even though this result must be individualized. More studies are needed to determine whether these data can be generalized to more prolonged glucocorticoid pulse therapy.

Orbital myosits in a patient with Behçet's disease

1 Rheumatology Unit, Hospital Universitário Evangélico de Curitiba, Curitiba, PR, Brazil. 2 Spondyloarthritis Outpatient Department, Rheumatology Unit, Hospital Universitário Evangélico de Curitiba, Curitiba, PR, Brazil. 3 Rheumato-Ophtalmology Unit, Hospital Universitário Evangélico de Curitiba, Curitiba, PR, Brazil. 4 Pediatric Ophthalmology and Strabismus Department, Ophtalmology Unit, Hospital Universitário Evangélico de Curitiba, Curitiba, PR,Brazil. 5 Rheumatology Unit, Hospital Universitário Evangélico de Curitiba, Curitiba, PR, Brazil. AbstrAct

Uveíte anterior na ausência de esclerite em paciente com artrite reumatóide: relato de caso

Rheumatoid arthritis is the most common collagenosis and affects almost 0.6% of Brazilian population. It is an important cause of articular deformities. The main ocular manifestation of rheumatoid arthritis is dry eyes (secondary Sjögrens syndrome), followed by scleritis, peripheral ulcerative keratitis and uveitis. The aim of this paper is to present a case of anterior uveitis in the absence of scleritis in a patient with rheumatoid arthritis, a very rare presentation in this type of patient. Female patient, 55 years old, with rheumatoid arthritis, presenting suddenly ocular pain and low vision in the right eye. Her exam showed anterior chamber reaction with hypopion, peripheral corneal keratitis and intraocular pressure of 32 mmHg. She was diagnosed with hypertensive anterior uveitis and peripheral corneal keratitis and treated with systemic and topical corticosteroids, topical antibiotic, topic and systemic ocular hypotensive and mydriatic drops. Anterior uveitis is common in rheumatological diseases, especially in those seronegative arthropathies related to HLA B27. In this paper we present a patient with rheumathoid arthritis and anterior uveitis in the absence of scleritis, a rare presentation in actual medical literature.

Catarata em corticoterapia sistêmica: prevalência e relação com tempo e dose cumulativa de glicocorticóides

PURPOSE: To study cataract prevalence in rheumatic patients who used corticosteroid chronically and to correlate it with time and total corticosteroid dose as well as with the disease that required such treatment. METHODS: We studied 27 rheumatic patients regarding cataract using slit lamp and calculated the total dose of prednisone or equivalent steroids as well as the treatment time. RESULTS: We found an 18.52% prevalence and no correlation with cumulative dose (p=0.231) or with the underlying disease. Although the time of treatment was longer in the group with cataract, no statistically significant difference could be found (p=0.694). CONCLUSION: The authors conclude that cataract is a relativelly common complication of steroid use and that further studies are needed to understand the pathophysiologic process of its formation.