Marcelo Mendes Lavezzo

Sickle cell retinopathy: diagnosis and treatment

Hemoglobinopathies are a group of inherited disorders characterized by quantitative or qualitative malformations of hemoglobin (Hb). Some of these diseases present vaso-occlusive phenomena that are responsible for high morbidity in clinical and/or ophthalmologic terms. Diagnosis of hemoglobinopathies is performed exclusively through hemoglobin electrophoresis. From the ophthalmologic perspective, the most important representative of this group of diseases is sickle cell retinopathy, which presents a wide spectrum of fundus manifestations and may even lead to irreversible vision loss if not properly diagnosed and treated. The aim of this review is to present the classification of sickle cell retinopathy and to describe current management and future perspectives for its treatment, taking into consideration the clinical management of these patients.

Vogt-Koyanagi-Harada disease: review of a rare autoimmune disease targeting antigens of melanocytes

Vogt-Koyanagi-Harada disease (VKHD) is a rare granulomatous inflammatory disease that affects pigmented structures, such as eye, inner ear, meninges, skin and hair. This disease is mainly a Th1 lymphocyte mediated aggression to melanocytes after a viral trigger in the presence of HLA-DRB1*0405 allele. The absence of ocular trauma or previous intraocular surgery sets VKHD appart from sympathetic ophthalmia, its main differential diagnosis. The disease has an acute onset of bilateral blurred vision with hyperemia preceded by flu-like symptoms. The acute uveitic stage is characterized by a diffuse choroiditis with serous retinal detachment and optic disc hyperemia and edema. Fluorescein angiography in this phase demonstrates multiple early hyperfluorescent points. After the acute uveitic stage, ocular and integumentary system pigmentary changes may appear. Ocular findings may be accompanied by lymphocytic meningitis, hearing impairment and/or tinnitus in a variable proportion of patients. Prompt diagnosis followed by early, aggressive and long-term treatment with high-dose corticosteroids is most often ensued by good visual outcomes. However, some patients may experience chronic uveal inflammation with functional eye deterioration. The current review discusses the general features of VKHD, including epidemiology, classification into categories, differential diagnosis and current therapeutic approaches.

Prevalência e localização espacial dos casos de tracoma detectados em escolares de Botucatu, São Paulo - Brasil

PURPOSE To assess the prevalence of trachoma in schoolchildren of Botucatu/ SP-Brazil and its spatial distribution. METHODS Cross-sectional study in children aged from 7 to 14 years, who attended elementary schools in Botucatu/SP in November/2005. The sample size was estimated in 2,092 children, considering the 11.2% historic prevalence of trachoma, accepting an estimation error of 10% and confidence level of 95%. The sample was random, weighted and increased by 20%, because of the possible occurrence of losses. The total number of children examined was 2,692. The diagnosis was clinical, based on WHO guidelines. For the evaluation of spatial data, the CartaLinx program (v1.2) was used, and the school demand sectors digitized according to the planning divisions of the Department of Education. The data were statistically analyzed, and the analysis of the spatial structure of events calculated using the Geode program. RESULTS The prevalence of trachoma in schoolchildren of Botucatu was 2.9% and there were cases of follicular trachoma. The exploratory spatial analysis failed to reject the null hypothesis of randomness (R= -0.45, p>0.05), with no significant demand sectors. The analysis for the Thiessen polygons also showed that the overall pattern was random (I= -0.07, p=0.49). However, local indicators pointed to a group of low-low type for a polygon to the north of the urban area. CONCLUSION The prevalence of trachoma in schoolchildren in Botucatu was 2.9%. The analysis of the spatial distribution did not reveal areas of greater clustering of cases. Although the overall pattern of the disease does not reproduce the socio-economic conditions of the population, the lower prevalence of trachoma was found in areas of lower social vulnerability.

Fundus autofluorescence as a marker of disease severity in Vogt-Koyanagi-Harada disease.

icant past medical history presented to KK Women’s and Children’s Hospital, Singapore, on 21 October 2015 complaining of fever and a ‘black dot’ in her left upper eyelid for 3 days. She just returned from Malaysia with close contact with dogs during the trip. On examination, there was left upper eyelid erythema, oedema and the presence of a dog tick at the eyelid margin (Fig. 1A). Anterior segment examination was unremarkable. A procedure was performed under informed consent with topical tetracaine anaesthesia. Thermal energy was applied using a portable monopolar cautery device to the tick’s body (Fig. 1B), facilitating en bloc removal by inducing detachment of the tick. Microscopic examination of the organism revealed that it belonged to the genus Ixodes (Fig. 1C). There were no complications, and the patient recovered uneventfully. Ocular manifestations of ticks include conjunctivitis, keratitis, uveitis as well as embedment of the organism in the meibomian gland orifice presenting as a mass, oedema and erythema at the eyelid margin. Early removal of tick from its host is crucial as the risk of disease transmission increases significantly after 24 hr of attachment. Therefore, an efficient method of tick removal is crucial to avoid vector transmission of infectious diseases and localized inflammation and infection. There had been several methods of tick removal described in the literature. However, none of these methods is superior in terms of safety and efficacy profile (Fig. 1D). Many chemicals have been studied for tick removal. Compounds such as deodorized kerosene resulted in voluntary detachment in approximately 25% of the ticks that were treated (Knight et al. 1962). However, the use of chemical compounds can pose potential danger of toxicity to the ocular tissues. Chemical eradication of the organism may also precipitate regurgitation by the tick and transmission of infectious agents to its host (Flicek 2007). The use of forceps for direct mechanical tick removal could result in retained mouthparts in ocular tissues as well as fragmentation of its body which would then require further excision, complicating the removal process (Flicek 2007). Blepharoplasty incision allowing for an en bloc excision of the organism has been described (Love et al. 2001). However, this procedure is more invasive with a risk of ocular tissue loss and disruption of the ocular architecture. Tick removal using portable monopolar diathermy is a novel technique to the best of our knowledge. It is simple to perform, requiring only a few sequential thermal burns to the tick body to induce its detachment. This avoids trauma to the surrounding ocular tissues and need for excision. However, this technique might be more suitable for less tenacious ticks with shallow bites. Monopolar cautery for tick removal may be a superior and relative safe novel technique for en bloc removal of tick with minimal trauma to the surrounding ocular tissues.

Hemorragia submembrana limitante interna em paciente após Valsalva: relato de caso

To report a case of a patient with Valsalva retinopathy that developed sub-internal limiting membrane hemorrhage, underwent pars plana vitrectomy and had visual acuity improvement after that. A 35-year-old healthy patient presented with sudden and painless vision loss of her right eye, after coughing. During the ophthalmologic evaluation, she had a pre-macular hemorrhage and no other abnormalities. Initially, we chose for expectant management, but the hemorrhage did not clear totally. Thus, pars plana vitrectomy associated with internal limiting membrane peeling was indicated, with considerable improvement of her visual acuity, without perioperative complications or significant findings in the optical coherence tomography, autofluorescence and multifocal electroretinogram. In this case, sub-internal limiting membrane hemorrhage treatment with vitreoretinal surgery was relatively useful, with visual acuity improvement and resolution of sub-internal limiting membrane hemorrhage.

Vitreorretinopatia exsudativa familiar simulando doença de Coats: relato de caso

We report the case of a seven year-old male patient, born at term without any perinatal complications, referred to the Retina/Vitreous Service for diagnostic elucidation. He had a history of progressive visual acuity loss on his left eye that started four years ago. On examination, he had decreased corneal diameter and corectopia of the right eye (OD), without any noteworthy findings on the biomicroscopy of the left eye (OS). The fundus of the OD revealed total retinal detachment, and the OS initially showed peripheral retinal vascular abnormalities and retinal exudation, associated with retinal vitreous traction on the temporal sector. The CT and MRI of the brain/orbits showed no abnormalities, except for findings suggestive of an old retinal detachment on the OD, confirmed by ultrasonography, which also showed microphthalmia of the OD. The diagnosis of familial exudative vitreoretinopathy, a rare disease of autosomal dominant inheritance and related to consanguineous marriages, that can initially simulate Coats disease, was proposed. The patient was treated with diode laser photocoagulation in the temporal periphery of the OS, with improvement in the areas of vitreoretinal traction.

Perfluoroctano em cavidade orbitária após vitrectomia posterior e sutura de perfurante ocular: relato de caso

A case of a perfluoro-n-octane leakage into the orbital cavity after corneoscleral suture, scleral buckling and pars plana vitrectomy in an eye with perforating injury after trauma is reported for the first time. A previously healthy 39-year-old man was sent for ophthalmic evaluation one day after suffering a penetrating ocular trauma in his right eye while hammering a nail. On the initial evaluation, the patient presented sudden reduction of visual acuity on his right eye with a perforating corneoscleral injury, intraocular foreign body and retinal detachment. The patient was submitted to corneoscleral suture, pars plana vitrectomy with perfluoro-n-octane administration to flatten the retina and scleral buckling, when it was found transfixation of the globe by the intraocular foreign body. Postoperatively, computed tomography scans of the orbit were ordered due to proptosis, which showed the presence of hyperdense images, suggesting leakage of perfluoro-n-octane into the orbital cavity. Thus, in cases of perforating eye injury, one should be suspicious about the possibility of intraocular foreign body, as well as possible occurrence of transfixation of the globe when scheduling the surgery.

Evaluation of Pupillary Diameter in Preschool Children

Few quantitative data exist on pupil diameter, particularly in children. In this article we describe an analysis of pupil diameter and pupil area in normal preschool children during attentive gaze (AG) and spontaneous gaze (SG) using digital imaging. The pupil diameter and pupil area of 200 preschool children aged 4 to 6 years were evaluated. The images were recorded with a digital camera, transferred to a computer, processed by movie software and submitted to the Invert filter of Adobe Photoshop® software. Three consecutive measures of pupil diameter and pupil area were taken for both eyes during AG and SG. Arithmetic means of each parameter were calculated and data were expressed in millimeters. Mean pupil diameter was similar for both eyes, presenting values of 4.9 mm during AG and 4.1 mm during SG. Mean pupil area was also similar for both eyes, presenting values of 15.6 mm2 and 9.1 mm2 during AG and SG, respectively. There were no differences between boys and girls. However, 6-year-old children showed lower pupil diameter and area under both evaluation conditions.

Progressão atípica de perda visual em paciente com glaucoma primário de ângulo aberto

Dolichoectasia of the internal carotid artery (ICA) is a rare condition that may be associated with neuro-ophthalmic manifestations, such as loss of visual acuity and visual field resulting from compression of the optic nerve (ON). The aim is to report a 67-year-old male patient with primary open-angle glaucoma (POAG) with atypical evolution, asymmetry of cupping and increased pallor of the rim of the left ON, due to compressive optic neuropathy by the dolichoectatic segment. The diagnosis was based on clinical history, appearance of the ON and neuroimaging.Dolichoectasia of the internal carotid artery (ICA) is a rare condition that may be associated with neuro-ophthalmic manifestations, such as loss of visual acuity and visual field resulting from compression of the optic nerve (ON). The aim is to report a 67-year-old male patient with primary open-angle glaucoma (POAG) with atypical evolution, asymmetry of cupping and increased pallor of the rim of the left ON, due to compressive optic neuropathy by the dolichoectatic segment. The diagnosis was based on clinical history, appearance of the ON and neuroimaging.

Hipertensão venosa episcleral idiopática unilateral em mulher jovem

O objetivo e relatar o caso de uma paciente de 33 anos, que veio ao Pronto Socorro de Oftalmologia apresentando queixa de reducao da acuidade visual a esquerda, de carater insidioso e progressivo, ha dois anos. Ao exame oftalmologico, apresentava ingurgitamento dos vasos da conjuntiva bulbar, pressao intraocular muito elevada e nervo optico com escavacao total a esquerda. Foi submetida a campimetria computadorizada 24:2 WW e SITA-SWAP do olho direito, ambas com resultados dentro da normalidade. As tomografias de crânio e orbitas, bem como ultrassonografia com doppler do globo ocular, arterias oftalmicas e veias supraorbitarias nao apresentavam anormalidades. Diante disso, aventou-se a hipotese diagnostica de hipertensao venosa episcleral idiopatica, um diagnostico de exclusao, visto que patologias intracranianas e intraorbitarias haviam sido excluidas. Paciente foi tratada clinicamente com colirios hipotensores, com reducao importante da pressao intraocular a esquerda, porem nao o suficiente, evoluindo para trabeculectomia.