Roberto Pinto Coelho

Digital image processing measurement of the upper eyelid contour in graves disease and congenital blepharoptosis

OBJECTIVE This study used image processing techniques to quantify the upper eyelid contour of patients with Graves upper eyelid retraction and congenital blepharoptosis. DESIGN The study design was a cross-sectional study. PARTICIPANTS A total of 29 patients with Graves disease, 22 patients with congenital blepharoptosis, and 50 patients with no history of eye disease participated. INTERVENTION The images of the palpebral fissure of all participants were transferred to a personal computer and processed with NIH Image 1.55 software. MAIN OUTCOME MEASURES The following parameters were analyzed: the curvature of the upper eyelid contour, the position of the contour peak relative to the midline, and the ratio between the temporal and nasal upper quadrant areas of the palpebral fissure. RESULTS All upper eyelid contours could be fitted with second-degree polynomial functions. The mean temporal/nasal area ratio was 1.33 mm in patients with Graves disease, 0.92 mm in patients with blepharoptosis, and 1.04 mm in control subjects. The peak of the upper eyelid contour was found to be lateral to the midline in control subjects (1.05 mm) and in patients with Graves disease (2.09 mm). In patients with blepharoptosis, the peak was 0.69 mm medial to the midline. Overall, the distance between the midpupil and the upper eyelid margin was correlated with several factors: the degree of curvature, the position of the peak of the eyelid contour, and the temporal/nasal area ratio. CONCLUSIONS In Graves eyelid retraction, the curvature of the upper eyelid is enhanced, the peak of the contour is displaced laterally, and the temporal upper quadrant area is increased. Conversely, in congenital blepharoptosis, the eyelid is almost flat, the peak of the contour is displaced medially, and the upper quadrant area is diminished. The lateral segment of the upper eyelid is more involved than the nasal segment in both Graves upper eyelid retraction and congenital blepharoptosis.

Eyelid abnormalities in lamellar ichthyoses

PURPOSE To describe eyelid abnormalities in lamellar ichthyoses (LI). DESIGN Retrospective observational case series. PARTICIPANTS Eight patients with classic LI and two patients with congenital ichthyosiform erythroderma. METHODS Results of eyelid and corneal examinations of 10 patients with LI were reviewed and analyzed with emphasis on the relationship between eyelid ectropion and corneal damage. RESULTS All patients presented with cicatricial lagophthalmos. Of the eight patients with classic LI, five had ectropion of the four eyelids, one had only lower ectropion, and two had no degree of ectropion. Two patients with congenital ichthyosiform erythroderma had distinct eyelid abnormalities, including madarosis and eyelash retraction. Loss of vision caused by corneal damage was found in three patients with classic LI. Of these three patients, two did not have upper eyelid ectropion. CONCLUSIONS Severe corneal damage can occur in LI even if there is no upper or lower eyelid ectropion.

Pain induced by phacoemulsification without sedation using topical or peribulbar anesthesia

Purpose: To evaluate patient‐reported pain induced by phacoemulsification without sedation using topical or peribulbar anesthesia. Setting: Department of Ophthalmology, School of Medicine of Ribeirão Preto, São Paulo, Brazil. Methods: This study assessed patient‐perceived pain during phacoemulsification cataract surgery with peribulbar anesthesia (lidocaine 2%–bupivacaine 0.5% mixture) or with topical anesthesia (tetracaine drops); no patient received sedation. The same surgeon performed all surgeries using a clear corneal approach and in‐the‐bag intraocular lens implantation. Approximately 15 minutes after surgery, patients in the topical anesthesia group (n = 20) were asked to rate their pain during the procedure and patients in the peribulbar anesthesia group (n = 21), during infiltration of the anesthetic solution. Patients graded their pain using a 0‐ to 10‐point visual analog scale (0 = no pain; 10 = unbearable pain). The results in the 2 groups were compared using the nonparametric Mann‐Whitney U test. Results: The median pain score in the topical anesthesia group was 2 (range 0 to 5) and in the peribulbar anesthesia group, 3 (range 0 to 7). The mean rank in the topical anesthesia group (15.78) was significantly lower than the mean rank in the peribulbar anesthesia group (25.98) (P = .0057, Mann‐Whitney U test). Conclusion: In patients having phacoemulsification without sedation, those receiving peribulbar anesthesia reported more pain than those receiving topical anesthesia during anesthetic solution infiltration and during the procedure, respectively.

Capsulorhexis rescue after peripheral radial tear-out: Quick-pull technique

&NA; We describe a technique to rescue the continuous curvilinear capsulorhexis (CCC) in cases in which complete radial tears make it impossible to use normal traction forceps. A circumferential path and rapid movement are applied in the plane of the anterior capsule in the direction of the center pupil. This technique was used in 50 cases. In 47, the CCC could be completed; in 3, it could not and surgery was continued with low‐parameter phacoemulsification. No other intraoperative complications occurred. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of preoperative Nd:YAG laser anterior capsulotomy versus two-stage curvilinear capsulorhexis in phacoemulsification of white intumescent cataracts.

BACKGROUND AND OBJECTIVE To compare the results of preoperative Nd:YAG laser anterior capsulotomy versus two-stage continuous curvilinear capsulorhexis (CCC) in phacoemulsification of eyes with white intumescent cataracts and liquefied cortex. PATIENTS AND METHODS Twenty-three eyes with white intumescent cataract were consecutively randomized for phacoemulsification with preoperative Nd:YAG laser anterior capsulotomy (group 1, n = 11) or two-stage CCC (group 2, n = 12) procedures. Intraoperative findings and postoperative outcomes were compared using the nonparametric tests. RESULTS Postoperative visual acuity, mean surgical time, mean effective phacoemulsification time, and frequency of complications were not significantly different between the two groups (P > .05). Two cases in each group were converted to the extracapsular technique. Excluding these four patients, surgical time was shorter in group 1 (P = .017). CONCLUSION Preoperative Nd:YAG laser anterior capsulotomy is a safe technique in decompressing the capsular bag before phacoemulsification of white intumescent cataracts with liquefied cortex.

Spontaneous late in-the-bag intraocular lens dislocation after can-opener capsulotomy: case report

We report a case of a 58-year-old man presenting with a spontaneous and late in-the-bag intraocular lens dislocation to the vitreous. A previous uneventful extracapsular cataract extraction with can-opener style capsulotomy and implantation of a polymethylmethacrylate three-piece lens was performed and, two years after the surgery, the patient developed capsule contraction syndrome with a fibrotic ring formation and dislocation of the intraocular lens. Although uncommon and related mainly to continuous curvilinear capsulorhexis, capsule contraction syndrome occurs in patients undergoing extracapsular cataract surgery with can-opener style and polymethylmethacrylate lens implantation, and can be the causative factor of intraocular lens dislocation.

Comparação entre a dor provocada pela facoemulsificação com anestesia tópica e a pela infiltração peribulbar sem sedação

PURPOSE To compare pain sensation induced by phacoemulsification with topical anesthesia with that by peribulbar anesthesia, without sedation. METHODS Using a 10-level visual pain analogue scale, the pain induced by phacoemulsification with topical anesthesia (2% tetracaine drops) was measured in 20 patients. The same scale was used to measure the pain induced by peribulbar anesthesia (2% lidocaine and 0.5% bupivacaine) in 21 patients. The same surgeon performed peribulbar infiltrations and surgeries. The phacoemulsifications were done using clear corneal approach followed by in-the-bag intraocular lens implantation. Pain comparison between the two groups was performed by the non-parametrical U Mann-Whitney test. RESULTS The distribution of the pain scores of the patients who underwent cataract extraction with topical anesthesia ranged from 0 to 5 (median value = 2). The scores of the patients who underwent peribulbar infiltration ranged from 0 to 7 (median value = 3). The mean rank of the group of patients who had surgery with topical anesthesia (15.78) was significantly different from the mean rank of the patients who received peribulbar anesthesia (25.98) (p = 0.0057). CONCLUSION Without sedation, the pain induced by phacoemulsification with topical anesthesia was milder than the pain induced by peribulbar infiltration.

Clinical study of pain sensation during phacoemulsification with and without cryoanalgesia

Purpose To compare the analgesic efficacy of 2 types of anesthetic techniques—topical and topical associated with cryoanalgesia—during cataract surgery. Setting Department of Ophthalmology, University of São Paulo, Ribeirão Preto, Brazil. Design Prospective randomized study. Methods Patients with symmetrical bilateral cataract had phacoemulsification with the use of an intraocular irrigation solution at room temperature in 1 eye and a cold (4°C) solution in the contralateral eye (Group 2). The pain related to the procedure was assessed using a visual analog scale ranging from 0 to 100, with 0 representing no pain and 100 the worst pain. In addition, endothelial cell loss, the change in corneal thickness, and visual acuity were evaluated 30 days ± 2 (SD) after each surgery. The surgery duration, total irrigation volume, phacoemulsification time, and ultrasound power used were analyzed. Results The study enrolled 25 patients (50 eyes). There was no statistically significant difference in the mean pain score between Group 1 (26.0 ± 3.7) and Group 2 (21.3 ± 3.6) (P = .2016, paired t test). No significant difference was found in the mean corneal endothelial cell loss (Group 1: 10.0% ± 0.4%; Group 2: 9.9% ± 0.3%; P = .7576), corneal thickness increase (Group 1: 1.5 ± 1.0 &mgr;m; Group 2: 1.4 ± 0.9 &mgr;m; P = .9340), or visual acuity gain (Group 1: 0.54 ± 0.06 logMAR; Group 2: 0.55 ± 0.09 logMAR; P = .8208). Conclusion There is no difference in the intensity of pain during phacoemulsification with the use of topical anesthesia or topical anesthesia associated with cryoanalgesia. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Effect of bevel position on the corneal endothelium after phacoemulsification

PURPOSE To compare the extent of corneal endothelial (CE) cell loss changes in two groups of eyes submitted to phacoemulsification, with the conventional bevel-up tip position in one eye and with the bevel-down tip position in the fellow eye. METHODS This prospective clinical trial comprised 25 patients with bilateral cataracts subjected to lens removal by phacoemulsification with the conventional bevel-up tip position (GI) in one eye and with the bevel-down tip position (GII) in the fellow eye. The nuclei were graded clinically on the basis of hardness. The endothelial cell count (ECC) was evaluated preoperatively and 1, 3 and 6 months postoperatively. Total surgical time, effective ultrasound time and complications were also compared between the groups. Statistical analysis was performed by the Tukey Studentized Range test, with repeated measures for the selected periods. For the other parameters a paired t test was used. Data are presented as mean ± SD, with the level of significance set at p≤0.05. RESULTS The mean effective ultrasound time was 8.08 ± 6.75 seconds in group I and 7.00 ± 5.75 seconds in GII (P=0.1792) and total surgical time was 10.01 ± 2.46 minutes in GI and 9.86 ± 2.17 minutes in GII (p=0.6267), respectively. The paired t test revealed no statistical differences between the groups. Complications were also similar between the groups. Mean endothelial cell count loss was 6.9% in GI and 2.8% in GII at one month; 6.9% in GI and 3.6% in GII at three months and 11.9% in GI and 7.6% in GII at six months postoperatively. Comparison of endothelial cell count (ECC) showed a statistically significant difference between the groups during the postoperative period. CONCLUSION The conventional bevel-up tip position has a negative effect on corneal endothelial cells compared with the bevel-down position. Since the results of other surgical parameters were similar, the bevel-down tip position should be considered as an option in non-complicated phacoemulsification.

Preoperative Nd:YAG laser anterior capsulotomy in white intumescent cataracts: report of 11 cases

Creating a continuous curvilinear capsulorhexis in eyes with white intumescent cataracts is a challenge due to the high risk of extension of capsular tears to the lens periphery. Several approaches have been described to avoid this complication and preoperative Nd:YAG laser anterior capsulotomy has been little reported as an optional technique. Eleven patients with white intumescent cataracts were submitted to preoperative Nd:YAG laser anterior capsulotomy. All patients had some degree of cortex falling in anterior chamber after laser application. No patient developed later complications. Thus, preoperative Nd:YAG laser anterior capsulotomy represents a safe and easy option for white intumescent cataracts.