Maria de Lourdes Veronese Rodrigues

Tear film and ocular surface alterations in chronic users of antiglaucoma medications

PURPOSE Tear film can be altered by chronic medications that may disrupt the equilibrium responsible for the functioning of the lacrimal gland and ocular surface. The purpose of this study was to determine if antiglaucomatous chronic treatment induced alterations in the tear film and ocular surface. METHODS After informed consent, 21 patients using antiglaucomatous eye drops for more than 8 months and 20 age- and sex-matched volunteers without eye and systemic medications (control group) were enrolled. The data of ocular discomfort, fluorescein and lisamine green staining, tear film break-up time and Schirmer test were collected and compared by Students t test. The impression cytology data were graded and compared by chi-square test. RESULTS Patients chronically using antiglaucomatous medications presented with significant higher fluorescein staining (p=0.003), lisamine green staining (p=0.02) and lower TFBUT (p=0.001). The other compared parameters, including impression cytology were similar between the treated and control group (p>0.05). CONCLUSIONS The present study shows that the tear film and the ocular surface are altered in patients under antiglaucomatous medications. In common, all medications were preserved with benzalkonium chloride. Efforts to minimize the adverse effects of chronic use of antiglaucomatous drugs must be addressed.

Subnutrição e hipovitaminose A em pacientes com AIDS

Anthropometric measurements and biochemical determinations were performed on HIV-infected individuals and on patients with AIDS from the Ribeirao Preto region, SP, Brazil, in order to evaluate their nutritional and vitamin A status. Plasma retinol was measured by HPLC, and hepatic vitamin A stores were evaluated by the Relative Dose Response (RDR) test. Patients with AIDS presented significant undernutrition, with more marked alterations in the body fat compartment and a relative preservation of the parameters related to muscle mass (pattern of malnutrition predominantly of the marasmus type). Plasma retinol values below 1.05µmol/L were observed in 25% of the patients with AIDS and in 17.3% of HIV-infected patients and RDR values indicating low body stores of vitamin A were detected in 28% of the subjects. There was no correlation between serum retinol levels and CD4 lymphocyte counts, clinical diagnosis of AIDS, low BMI or AFI. On the other hand, hypovitaminosis A status was associated with low BMI.

Immunohistochemical expression of HLA-DR in the conjunctiva of patients under topical prostaglandin analogs treatment.

PurposeSubclinical inflammation may be observed in patients using topical antiglaucomatous drugs. The objective of this study was to investigate inflammation in conjunctiva of glaucoma patients using prostaglandin analogs, by the detection of an immunogenetic marker (HLA-DR) and compare the effect of 3 different drugs: latanoprost, bimatoprost, and travoprost in the induction of this inflammation. Subjects and MethodsThirty-three patients with primary open-angle glaucoma were evaluated without and with prostaglandin analogs topical therapy. Imprints of conjunctival cells were obtained, fixed on glass slides, and prepared for immunohistochemical analysis. ResultsBefore the use of prostaglandin analogs, 4 of the 33 patients evaluated presented expression of HLA-DR in the conjunctiva (mild). After 1 month on prostaglandin analog treatment, all but 1 patient presented HLA-DR staining. HLA-DR expression of these 32 patients was scored as mild (19 patients), medium (11 patients), or intense (2 patients). The differences were statistically significant both when the presence and the increased expression of HLA-DR were considered (P<0.001). When the 3 different groups were analyzed (latanoprost, bimatoprost, and travoprost) no statistically significant difference was found (P=0.27). ConclusionsThe use of prostaglandin analogs eye drops provokes a subclinical inflammatory reaction, observed by HLA-DR expression, even after a short period of treatment, independently of the class of the prostaglandin analogs used.

Tumor necrosis factor region polymorphisms are associated with AIDS and with cytomegalovirus retinitis.

Background:The tumor necrosis factor (TNF) gene is located within the highly polymorphic major histocompatibility complex region, exhibiting the -308 GA promoter region polymorphism and six microsatellites (TNFa–f) spanning the region nearby the TNF locus. Objective:In the present study, we evaluated the frequency of -308 GA and TNFa-e polymorphisms and respective haplotypes (in chromosomal sequence: TNFd-TNFe-308GA-TNFc-TNFa-TNFb), in 222 patients with AIDS, 52 of whom exhibited cytomegalovirus retinitis, and in 202 healthy HIV-negative individuals. Method:TNF microsatellite and single nucleotide polymorphism typings were performed by PCR followed by polyacrylamide gel electrophoresis. Results:The TNF-308A allele and the 4-3-G-2-7-1 haplotype were associated with susceptibility to AIDS, whereas the TNFb4 allele and the 3-3-G-1-11-4 haplotype were associated with protection against AIDS development. The TNFc2 allele and the 4-1-G-2-2-1 haplotype, which contains the TNFc2 allele, were associated with cytomegalovirus retinitis. Conclusion:This study highlights that polymorphic sites spanning the region nearby the TNF locus are associated with AIDS per se and with cytomegalovirus retinitis in AIDS patients.

Perfil clínico e epidemiológico das urgências oculares em pronto-socorro de referência

OBJETIVOS: Avaliar aspectos epidemiologicos dos traumas oculares num pronto-socorro de referencia. METODOS: O estudo teve dois grupos distintos de individuos: no primeiro (A) composto por vitimas de trauma ocular, em que 1.483 pacientes atendidos consecutivamente ao longo de 2003 tiveram os dados epidemiologicos analisados, e o segundo (B), em que 133 pacientes tiveram aspectos clinicos e fatores de risco e de protecao analisados consecutivamente por meio de questionario padrao, de 17 de maio a 28 de junho de 2004. RESULTADOS: No levantamento A, a maioria dos pacientes era do sexo masculino (1.314 ou 89%). Os traumas por corpos estranhos (CE) da superficie ocular foram os mais comuns, respondendo por 863 (58%) casos. O levantamento B mostrou que a protecao ocular foi usada em apenas 17% (22) dos pacientes. Os acidentes geralmente ocorreram no local de trabalho 70% (93), e o domicilio foi o segundo local de maior frequencia (22%). Ainda no levantamento B, 34% dos entrevistados tinham acidentes oculares previos. CONCLUSOES: O perfil dos pacientes vitimas de trauma ocular no presente estudo observou a maior ocorrencia entre homens e de acidentes por corpos estranhos. O uso de protecao ocular ainda e incipiente e, por outro lado, a recorrencia de trauma e consideravel. Uma estrategia continua junto a populacao, de forma preventiva e educativa com especial atencao ao ambiente de trabalho e domestico, e necessaria para reduzir a ocorrencia de trauma ocular.

Bevacizumab-loaded polyurethane subconjunctival implants: effects on experimental glaucoma filtration surgery.

PURPOSE Vascular endothelial growth factor (VEGF) may contribute to the scarring process resulting from glaucoma filtration surgery, since this cytokine may stimulate fibroblast proliferation. The aim of this study was to describe a new bevacizumab-loaded polyurethane implant (BPUI) and to evaluate its effectiveness as a new drug delivery system of anti-VEGF antibody in a rabbit model of glaucoma filtration surgery. METHODS An aqueous dispersion of polyurethane was obtained via the conventional process. Bevacizumab (1.5 mg) was then incorporated into the dispersion and was subsequently dried to form the polymeric films. Films with dimensions of 3×3×1 mm that either did (group BPUI, n=10) or did not contain bevacizumab (group PUI, n=10) were implanted in the subconjunctival space, at the surgical site in 1 eye of each rabbit. The in vitro bevacizumab release was evaluated using size-exclusion high-performance liquid chromatography (HPLC), and the in vivo effects of the drug were investigated in a rabbit experimental trabeculectomy model by examining the bleb characteristics and collagen accumulation, and by performing immunohistological analyses of VEGF expression. RESULTS HPLC showed that only 10% of the bevacizumab in the implants had been released by postoperative day 5. In vivo studies demonstrated that the drug had no adverse effects; however, no significant differences in either the bleb area score or the collagen deposit intensity between the group PUI and the group that BPUI were observed. Moreover, the group BPUI presented a significantly lower proportion of VEGF-expressing fibroblasts than group PUI (0.17±0.03 vs. 0.35±0.05 cells/field, P=0.005). CONCLUSIONS This study demonstrated that bevacizumab release from the BPUIs only occurred for a short time probably from the surface of the films. Nevertheless, they were well tolerated in rabbit eyes and reduced the number of VEGF-expressing fibroblasts.

HLA profile in patients with AIDS and tuberculosis

Studies carried out in various populations have reported an association between some HLA specificities and susceptibility to tuberculosis. We investigated the class I and class II HLA profile in Brazilian patients of various ethnic backgrounds who had AIDS and tuberculosis. Twenty-two adult patients with AIDS and tuberculosis (Group I), 103 patients with AIDS without tuberculosis (Group II) and 423 healthy individuals not infected with HIV (Group III) were evaluated. Diagnosis of HIV infection was made by ELISA, confirmed by a gelatin particle agglutination test. Diagnosis of tuberculosis was made based on clinical/radiological presentation and direct bacilloscopy or clinical specimen cultures. Class I antigens were typed by microlymphotoxicity. Class II alleles were characterized by the polymerase chain reaction (PCR). Differences in frequency of HLA specificities between groups were found in the following antigens/alleles: Group I x Group II: HLA-A31 - p=0.026; HLA-B41 - p= 0.037; HLA-DRB1*10 - p=0.037; HLA-DQB1*5 - p=0.009. Group I x Group III (control): HLA-A31 - p = 0.000008; odds ratio (OR)=31.75; HLA-B41 - p=0.003; HLA-DQB1*5 - p=0.02. HLA-A31 and HLA-B41 antigens and the HLA-DRB1*10 and HLA-DQB1*05 alleles were over-represented in patients with AIDS and tuberculosis (Group I), suggesting that these HLA molecules are associated with susceptibility to tuberculosis in Brazilian patients with AIDS.

Effect of curriculum reform on graduating student performance

With the aim of evaluating the efficacy of a new curriculum implemented in the Faculty of Medicine of Ribeirão Preto (University of São Paulo, Brazil), a yearly objective assessment of both cognitive and practical skills of undergraduate (sixth year) students was performed. All graduating student underwent a multiple-choice questions (MCQs) test and groups of 18–20 students were randomly assigned to OSCEs for either clinical (real and standardized patients) or procedure (manikins) skills. The average MCQs score for the students graduating in the new curriculum (63.1, sd = 8.9, n = 261) was significantly higher (p < 0.001) than for the previous curriculum (55.3, sd = 8.1, n = 222). Results for practical exams showed that the new curriculum was associated with significantly improved performance in five out of the six stations for procedure skills, but in only two of the 10 clinical skills stations. Final evaluation of graduating students revealed deficiencies in the local curriculum and may serve as a guide to take measures to correct them.With the aim of evaluating the efficacy of a new curriculum implemented in the Faculty of Medicine of Ribeirão Preto (University of São Paulo, Brazil), a yearly objective assessment of both cognitive and practical skills of undergraduate (sixth year) students was performed. All graduating student underwent a multiple-choice questions (MCQs) test and groups of 18-20 students were randomly assigned to OSCEs for either clinical (real and standardized patients) or procedure (manikins) skills. The average MCQs score for the students graduating in the new curriculum (63.1, SD = 8.9, n = 261) was significantly higher (p < 0.001) than for the previous curriculum (55.3, SD = 8.1, n = 222). Results for practical exams showed that the new curriculum was associated with significantly improved performance in five out of the six stations for procedure skills, but in only two of the 10 clinical skills stations. Final evaluation of graduating students revealed deficiencies in the local curriculum and may serve as a guide to take measures to correct them.

Risk factors for blindness in patients with open-angle glaucoma followed-up for at least 15 years

PURPOSE To determine the proportion of blindness and investigate the relationships between risk factors based on clinical characteristics and development of blindness in patients with primary open-angle glaucoma (POAG) treated for at least 15 years. METHODS A retrospective observational chart review was performed with 403 patients referred to a tertiary level hospital, each with a diagnosis of primary open-angle glaucoma, treated for at least 15 years. Blindness attributable to glaucoma was defined based on visual acuity and/or visual field tests. Variables considered to be possible risk factors for blindness were evaluated using odds ratio (OR), confidence interval (95% CI), and univariate and multivariate analyses. RESULTS Thirty-one patients became blind [13/53 (24.5%) - unilaterally and 18/53 (34%) - bilaterally] during the follow-up period of treatment (19.5 ± 4.6 years, range 15-31 years). Multivariate statistics with regression analysis revealed that persistency on initial therapy ≤6 months was significantly associated with blindness, both unilateral (OR: 8.4; 95% CI: 1.3-56.4) and bilateral (OR: 7.2; 95% CI: 1.3-39.6). Other potential factors such as race, age, gender or number of medications were not associated with blindness. CONCLUSION Blindness from primary open-angle glaucoma was not uncommon in this population of treated patients after the long follow-up period proposed. Persistence rates with the first therapy, as measured by a medical decision to change, were low. Persistence ≤6 months was statistically associated with the development of unilateral and bilateral blindness from glaucoma.

Perfil da demanda em um serviço de Oftalmologia de atenção primária

OBJETIVO: Para melhorar os servicos de saude e importante conhecer o perfil da demanda. Para isso, buscou-se: 1) Identificar os principais motivos de procura por atendimento oftalmologico em Unidade de Atencao Primaria; 2) Analisar as frequencias dos diagnosticos,bem como os motivos de encaminhamento de pacientes para outros servicos de Oftalmologia. METODOS: Estudo descritivo e retrospectivo de 1.010 pacientes atendidos durante o periodo de 6 meses. Parâmetros: idade e sexo do paciente, motivo da consulta,diagnostico (CID-10) e frequencia de encaminhamentos. Os dados foram obtidos atraves da analise dos prontuarios e das fichas de atendimento com os registros do CID-10. Alguns pacientes, de ambos os generos, apresentavam alteracoes anatomico-funcionais que foram agrupadas em mais de um grupo de diagnostico. RESULTADOS: Houve um predominio do sexo feminino (61,5%) e da faixa etaria de 10 a 19 anos de idade (16,7%), seguida do grupo de pacientes entre 40 a 49 anos de idade (16,5%). O principal motivo da consulta foi a baixa de acuidade visual (37,4%), seguida da revisao dos oculos (19,0%). Tambem foram frequentes a queixa de cefaleia (15,8%), prurido (10,4%), ardencia / irritacao (7,8%) e olho vermelho (7,2%).Apresentaram exame normal, 8,1% dos pacientes e entre os exames anormais a maior frequencia foi de erros refracionais (70,0%). e presbiopia (31,9%). Foram encaminhados 90 (8,9%) pacientes. O principal motivo de encaminhamento foi a necessidade de cirurgia. CONCLUSAO: O principal motivo da busca de um atendimento neste servico basico de oftalmologia foi a baixa acuidade visual que na grande maioria das vezes foi ocasionada por erro refracional e/ou presbiopia. Poucos foram os casos nao resolvidos no local do atendimento.