Myrna Serapião dos Santos

Amniotic membrane transplantation for partial and total limbal stem cell deficiency secondary to chemical burn.

PURPOSE To evaluate the surgical outcome of preserved amniotic membrane transplantation (AMT) for ocular surface reconstruction in chemical burn with limbal stem cell deficiency. DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS Twenty eyes of 20 consecutive patients with limbal stem cell deficiency secondary to ocular chemical injury. INTERVENTION AMT with or without adjunctive limbal transplantation using limbal tissue from either the healthy contralateral eye (CLAU) or a living related donor (lr-CLAL). MAIN OUTCOME MEASURES Reconstruction of corneal epithelium (clear appearance without epithelial defect, normal fluorescein permeability and the absence of conjunctiva-derived goblet cells on impression cytology), decrease in corneal vascularization and improvement in visual acuity. RESULTS With a mean follow-up time of 19 months (range, 8-27 months), satisfactory ocular surface reconstruction was obtained in 15 eyes (75%), with reduced inflammation and vascularization of the ocular surface and a mean epithelialization time of 3.3 weeks. Success was observed in all cases of partial limbal stem cell deficiency (PLD) and in 68.75% (11 eyes) of cases of total limbal stem cell deficiency (TLD). Surgical failure was observed in five severe cases (31.25%). A significant visual improvement was observed in all cases after surgery, except for 2 eyes that maintained preoperative visual acuity. CONCLUSIONS AMT seems to be an efficient adjunct for ocular surface reconstruction in chemical burns with PLD. When performed in conjunction with limbal stem cell transplantation, it is also effective in most cases of TLD.

Transplantation of Conjunctival Epithelial Cells Cultivated Ex Vivo in Patients With Total Limbal Stem Cell Deficiency

Purpose: To report the outcomes of transplantation of autologous conjunctival epithelial cells cultivated ex vivo (EVCAU) in patients with total limbal stem cell deficiency (LSCD). Methods: EVCAU were cultivated on denuded human amniotic membrane and transplanted in 12 eyes of 10 patients with total LSCD. We evaluated the improvement in the defined clinical parameters of LSCD (loss of corneal epithelial transparency, superficial corneal neovascularization and epithelial irregularity/recurrent epithelial breakdown), vision acuity, impression cytology, immunocytochemical analysis (CK3/CK19), and the appearance of a regular hexagonal basal layer of cells on corneal confocal microscopy. Histologic and immunohistochemical features were studied in 3 corneal buttons of patients submitted to penetrating keratoplasty after EVCAU. Results: Cultivated conjunctival epithelium formed 4 to 5 layers with the formation of basement membrane–like structures. Immunocytochemical analysis showed positivity for CK3, CK19, MUC5AC, Ki-67, P63, and ABCG2. The improvement of the clinical parameters for this treatment in our cohort was 10 of 12 (83.3%) in a mean follow-up time of 18.5 months (range, 15–26 months), and these eyes showed an improvement in impression cytology, immunocytochemistry, and in vivo confocal analysis. Corneal buttons showed a well-formed epithelium with 5 to 6 layers, with rare cells periodic acid–Schiff+, and positivity for CK3, CK19, P63, connexin 43, and MUC5AC. Conclusion: We demonstrated the preliminary results of transplantation of EVCAU for corneal surface reconstruction in cases with total LSCD. Future studies are needed to further assess the long-term efficacy of this procedure.

Systematic review and meta-analysis of randomised clinical trials on topical treatments for vernal keratoconjunctivitis.

Aims: The aim of this study was to assess the efficacy of currently available topical drugs for vernal keratoconjunctivitis (VKC) through a meta-analysis of randomised clinical trials (RCTs). Methods: Twenty-seven RCTs (n = 2184 eyes) that had evaluated the efficacy of topical drugs for the treatment of VKC were selected according to the set criteria; 10 of these trials were suitable for statistical analysis and were enrolled in the meta-analysis. Articles published up to December 2005 were identified from the following data sources: Medline, Embase, Lilacs, the Cochrane Controlled Trials Register, and references from relevant articles. Articles in any language published with an English abstract, were screened, and those selected for inclusion were written in English, French, German, Italian, Portuguese or Spanish. The quality of the trials was assessed by the Delphi list. Statistical analysis was performed using STATA® software. Results: A significant improvement in all signs and symptoms, except photophobia, was observed after topical treatment for active VKC, independent of the type of treatment. Comparison of the efficacy of different drugs was not possible due to a lack of standardised criteria among studies. Conclusion: The currently available topical drugs are effective in treating acute phases of VKC. However, there is a lack of evidence to support the recommendation of one specific type of medication for treating this disorder. There is a need for standard criteria to assess diagnosis and therapy based on severity. There is also a need for RCTs assessing long-term effects of single drugs to control the disease and to prevent complications.

Diagnosis of epithelial ingrowth after penetrating keratoplasty with confocal microscopy.

Purpose: To report confocal microscopy use in the clinical diagnosis of epithelial ingrowth after penetrating keratoplasty (PKP). Methods: A 36-year-old female patient with keratoconus developed a well-delimited posterior hazy membrane covering the inferior two thirds of the cornea 3 months after an uneventful PKP. A posterior corneal line was present resembling an endothelial graft rejection line, but with no keratic precipitates or corneal edema. Ocular hypertension was not observed. Confocal microscopy was performed to elucidate the diagnosis. Results: Confocal microscopy showed epithelium and stroma with normal findings. Two distinct cellular types were presented at the endothelium layer. Enlarged endothelial cells were observed in the superior part of the cornea up to the leading edge of the hazy membrane. In the middle and inferior part of the graft, the cells were larger, with polygonal shape and easily recognizable hyperreflective nuclei, suggestive of epithelial cells. With these confocal microscopy findings, the patient was promptly submitted to another PKP. Histologic analysis confirmed the diagnosis of epithelial ingrowth. Conclusion: Confocal microscopy imaging technique seems to be a useful tool in the early diagnosis of epithelial ingrowth after PKP.

Transplante de membrana amniótica em casos agudos graves de queimadura ocular química e síndrome de Stevens-Johnson

OBJETIVO: Investigar o potencial terapeutico do transplante de membrana amniotica nos casos agudos graves de queimadura ocular quimica e sindrome de Stevens-Johnson. METODOS: Foram analisados retrospectivamente os prontuarios de oito pacientes, com um total de dez olhos, submetidos a transplante de membrana amniotica para tratamento de queimadura ocular quimica e sindrome de Stevens-Johnson na fase aguda entre janeiro de 1999 e maio de 2008 no Departamento de Oftalmologia da UNIFESP. Dados referentes a sexo, idade, grau da queimadura, etiologia, olho acometido, achados oftalmologicos, extensao da membrana amniotica, operacoes adicionais, tempo em dias entre a lesao e a cirurgia, acuidade visual antes e depois da cirurgia, defeito epitelial em dias, complicacoes e tempo de seguimento em meses foram coletados. RESULTADOS: A idade media dos pacientes foi de 35,7 ± 23,04 anos, dos quais seis eram homens e dois eram mulheres. Tres pacientes (quatro olhos) apresentaram sindrome de Stevens-Johnson e cinco pacientes (seis olhos) apresentaram queimadura ocular quimica. O defeito epitelial foi cicatrizado em media de 27,8 ± 4,7 dias (variando de 20 a 35 dias). Todos os pacientes evoluiram com deficiencia limbica em seguimento medio de 7,8 ± 2,8 meses (variando entre cinco e doze meses) e quatro olhos desenvolveram simblefaro. CONCLUSOES: Os resultados sugerem que o transplante de membrana amniotica representa um aditivo que pode ser realizado nos casos agudos graves de queimadura ocular quimica e sindrome de Stevens-Johnson com a finalidade de promover a epitelizacao e suprimir a inflamacao e suas consequencias, se comparado a outros trabalhos que trataram casos semelhantes com terapia medicamentosa somente. Por outro lado, nao e capaz de evitar a deficiencia limbica nesses casos, que futuramente necessitarao de transplante de celulas-tronco do limbo ou outras cirurgias para correcao da superficie ocular.

Lente de contato escleral na reabilitação ocular de pacientes com síndrome de Stevens-Johnson

PURPOSE To evaluate the efficacy of scleral contact lenses use on the management of ocular sequelae from Stevens-Johnson syndrome patients. METHODS In a retrospective study, patients who suffered sequelae of Stevens-Johnson syndrome and started the use of scleral contact lenses were followed. Patients were submitted to an evaluation of symptoms through a questionnaire; ophthalmologic exam (visual acuity measurement, biomicroscopy, ocular surface staining with fluorescein drops, Schirmer test). RESULTS Ten eyes of seven patients were analyzed. Visual acuity varied from hand movements to 20/25. All patients presented some degree of corneal opacity and slight symblepharon. In patients whose adaptation to scleral contact lenses was successful (90%), they all refered improvement of symptoms and sight. As for the biomicroscopic findings it was observed an improvement of conjunctival hyperemia and keratitis and a reduction of the mucous secretion in 90% the cases. CONCLUSIONS A successful adaptation to scleral contact lenses was feasible on most patients, with relief of symptoms and better visual acuity, probably due to regularization of the surface. Scleral contact lenses represent an important and accessible alternative to reduce the limitations inferred by the damages from Stevens-Johnson syndrome.

Assessment of surgical outcomes of limbal transplantation using simple limbal epithelial transplantation technique in patients with total unilateral limbal deficiency.

This study aimed to evaluate the effectiveness of the novel simple limbal epithelial transplantation (SLET) technique, which reduces the risk of iatrogenic limbal stem cell deficiency in the donor eye. Four patients with total unilateral limbal stem cell deficiency received a limbal graft, measuring 4 mm × 2 mm, from the contralateral healthy eye in a single surgical procedure. The graft was divided into 10-20 pieces and distributed on the corneal surface. At 6-month follow-up, a completely avascular corneal epithelial surface was obtained in two patients, and there was improvement in visual acuity in one patient. The limbal grafts did not adhere to the cornea in one patient. No serious complications related to the surgery were observed in this study.

Antigenic response to CT-P13 and infliximab originator in inflammatory bowel disease patients shows similar epitope recognition

To test the cross‐immunogenicity of anti‐CT‐P13 IBD patients’ sera to CT‐P13/infliximab originator and the comparative antigenicity evoked by CT‐P13/infliximab originator sera.

Topical tacrolimus for the treatment of severe allergic keratoconjunctivitis in children

Purpose: Administration of eye drops containing antihistamines or sodium cromoglycate and its derivatives for the treatment of allergic keratoconjunctivitis is often insufficient and usually requires the addition of corticosteroids. However, the risk of complications, such as glaucoma and cataract, limits the use of corticosteroids to short courses, resulting in inadequate long-term treatment response. Immunosuppressive drugs have been considered as a valid alternative to steroids for atopic keratoconjunctivitis and vernal keratoconjunctivitis. This study aimed to evaluate the use of topical tacrolimus (TCL) in improving the clinical signs of severe allergic keratoconjuctivitis in children. Methods: Patients with severe allergic keratoconjunctivitis associated with corneal epitheliopathy, gelatinous limbal infiltrates, and/or papillary reaction, along with a history of recurrences and resistance to conventional topical anti-allergy agents, were included in this open clinical trial. Patients were treated with 0.03% TCL ointment for ocular use. A severity score ranging from 0 to 9, with 9 being the highest and 0 being the lowest, was assigned based on signs observed on biomicroscopy prior to and following TCL treatment. Results: Analyses included 66 eyes of 33 patients. After a mean follow-up period of 13 months (range, 12-29 months), TCL treatment significantly decreased the mean symptom score severity for the right (from 5.56 ± 1.18 to 2.76 ± 1.5; p<0.001) and left (from 5.94 ± 1.16 to 2.86 ± 1.64; p<0.001). Conclusion: Topical TCL was effective and significantly improved the clinical signs of allergic keratoconjuctivitis in children. Thus, it is a potential new option for severe and challenging cases of ocular allergy.

Femtosecond assisted intrastromal corneal ring (ISCR) implantation for the treatment of corneal ectasia

PURPOSE To assess the outcomes of intrastromal corneal ring (ISCR) implantation for the treatment of corneal ectasia. METHODS Thirty-five consecutive patients with secondary corneal ectasia treated with keraring intrastromal corneal ring segment implantation aided by intralaser femtosecond technique (K-ICRS-FS) were evaluated. Visual acuity (logMAR), refraction and astigmatism vector analysis were measured preoperatively and 3 months postoperatively using vector analysis as described by some authors. RESULTS Visual acuity improved from 0.40 ± 0.20 to 0.25 ± 0.13 logMAR (p=0.0002), with reduction of the spherical equivalent from -5.41 ± 4.78 D to -2.83 ± 3.29 D (P=0.0002). Mean astigmatism reduction was 3.92 ± 2.52 D. K maximum decreased from 51.65 ± 5.83 D preoperatively to 48.58 ± 5.54 D (p=0.001) 3 months after the surgery and K minimum decreased from 45.92 ± 4.64 D to 43.96 ± 5.06 D (p=0.0041). There were no intraoperative or postoperative complications. CONCLUSION Intrastromal corneal ring implantation with the use of a femtosecond laser was a safe procedure, with low risk of complications and significant improvement on visual acuity and topographic data in this seeting of patients with secondary corneal ectasia.