Ruth Miyuki Santo

A review of guidelines for cross-cultural adaptation of questionnaires could not bring out a consensus.

OBJECTIVES The aim of cross-cultural adaptation (CCA) of a questionnaire is to achieve equivalence between the original and adapted questionnaire. Here, we aimed to review the state of the art in CCA methods. STUDY DESIGN AND SETTING We reviewed cross-disciplinary bibliographic databases for articles on methods and guidelines for CCA of questionnaires. Articles were first selected by their abstract and title, and then, we retrieved full-text English articles. References of selected articles were searched for additional relevant studies. RESULTS We identified 31 guidelines and found no consensus in CCA methods. Most methods included use of committees, focus groups, and back translations. Evidence for the best methods is lacking, although clues indicate that back translation may not be mandatory. CONCLUSION Several methods are available for CCA of questionnaires. According to experts only, most would achieve comparable results, and choosing one is a matter of preference and logistic. More evidence is needed to support recommendations. Adaptation and validation of a questionnaire are two different processes that should be distinguished and undertaken with care.

Clinical treatment of dry eye using 0.03% tacrolimus eye drops.

Purpose: To report the clinical outcome of the treatment of dry eyes using 0.03% tacrolimus eye drops (olive oil + tacrolimus 0.03%) (Ophthalmos, Sao Paulo, Brazil). Methods: Sixteen eyes of 8 patients with Sjögren syndrome dry eyes (age, 51.13 ± 9.45 years) were enrolled in this study (prospective noncontrolled interventional case series). Patients were instructed to use topical 0.03% tacrolimus eye drops twice a day (every 12 hours) in the lower conjunctival sac. Schirmer I test, break-up time, corneal fluorescein, and rose bengal staining score were performed in all patients 1 day before, and 14, 28, and 90 days after treatment with 0.03% tacrolimus eye drops. Results: The average fluorescein staining and rose bengal staining scores improved statistically significantly after 14 days of treatment and improved even more after 28 and 90 days. The average Schirmer I test did not improve statistically significantly after 28 days of treatment, although we did observe a significant improvement after 90 days of treatment with 0.03% tacrolimus eye drops. The average break-up time did not improve statistically after 14 days of treatment, although we observed a significant improvement after 28 and 90 days of treatment with 0.03% tacrolimus eye drops. Conclusions: Topical 0.03% tacrolimus eye drops successfully improved tear stability and ocular surface status in patients with dry eyes.

Oral azithromycin for treatment of posterior blepharitis.

Purpose: To evaluate the effects of oral azithromycin in patients with posterior blepharitis. Methods: Twenty-six eyes of 13 patients with posterior blepharitis diagnosed by a qualified ophthalmologist were enrolled in this study. Patients were instructed to use oral azithromycin 500 mg per day for 3 days in 3 cycles with 7-day intervals. Subjective clinical outcomes were graded and scored 1 day before and 30 days after the end of the treatment (53 days after initiating the treatment) based on severity scores of: (1) eyelid debris; (2) eyelid telangiectasia; (3) swelling of the eyelid margin; (4) redness of the eyelid margin; and (5) ocular mucus secretion. For the assessment of global efficacy, patients were asked by the investigator to rate the subjective symptoms (eyelid itching, ocular itching, eyelid hyperemia, ocular hyperemia, ocular mucus secretion, photophobia, foreign body sensation, and dry eye sensation) on a scale of 0 (no symptoms) to 5 (severe symptoms). Break-up time, Schirmer I test, corneal fluorescein staining score, and rose bengal staining score were also performed in all patients. Results: All clinical outcomes scoring showed statistically significant improvement after oral azithromycin, except for eyelid swelling. Average subjective symptom grading improved statistically after treatment with oral azithromycin, except for eyelid hyperemia, photophobia, and foreign body sensation. Average tear film break-up time values showed statistically significant improvement after the treatment with oral azithromycin. No statistically significant improvement was observed on average values of Schirmer I test, corneal fluorescein staining score, and rose bengal staining score. Conclusions: The combination of multiple clinical parameters shown in this study supports the clinical efficacy of pulsed oral azithromycin therapy for the management of posterior blepharitis.

Corneal topography in asymptomatic family members of a patient with pellucid marginal degeneration.

PURPOSE To report corneal topographic patterns in asymptomatic family members of a patient with pellucid marginal degeneration. METHODS Computer-assisted corneal topography was used to study the corneas of five family members of a patient with pellucid marginal degeneration. RESULTS In all five asymptomatic family members, corneal biomicroscopy was normal. Corneal topography, however, showed various abnormalities in different members of this family, particularly a topographic pattern suggesting keratoconus in one family member and a topographic pattern suggesting pellucid marginal degeneration in another family member. CONCLUSION This study reinforces the hypothesis that corneal ectatic disorders may represent different manifestations of a clinical spectrum.

Treatment of Sjögren's syndrome dry eye using 0.03% tacrolimus eye drop: Prospective double-blind randomized study.

OBJECTIVE To describe the clinical efficacy of the treatment of Sjögrens syndrome dry eye using 0.03% tacrolimus eye drop. DESIGN Prospective double-blind randomized study. SETTING Institutional outpatient clinic. PARTICIPANTS Forty-eight eyes of twenty-four patients with dry eye related to Sjögren syndrome were enrolled in this study. The patients were randomized in 2 groups: tacrolimus (n=14) and vehicle (n=10) group. INTERVENTION The tacrolimus group received a vial containing tacrolimus 0.03% (almond oil as vehicle) and the other group received the almond oil vehicle. All patients were instructed to use the eye drops every 12h in the lower conjunctival sac. MAIN OUTCOME MEASURES Schirmer I test, break-up-time (BUT), corneal fluorescein and Rose Bengal staining scores were evaluated in all patients one day before the treatment (baseline), 7, 14, 28 and 90 days after treatment with the eye drops. RESULTS The average fluorescein and Rose Bengal scores improved statistically after 7 days of treatment and even more after 90 days. The average Schirmer I and BUT values were unchanged after 7, 14 and 21 days but did show an improvement relative to baseline after 28 days of treatment. Schirmer I, BUT, fluorescein and Rose Bengal did not show any statistical significance in the vehicle group. CONCLUSION Topical 0.03% tacrolimus eye drop improved tear stability and ocular surface status in cases of inflammatory or SS-related dry eye. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01850979.

Chronic dacryocystitis in American mucocutaneous leishmaniasis.

Purpose This study describes lacrimal tract involvement and surgical outcome in patients with mucocutaneous leishmaniasis. Methods Four patients, ages 20 to 75 years, had nasal lesions resulting from mucocutaneous leishmaniasis and sought treatment for chronic dacryocystitis. Each patient had had lacrimal symptoms since childhood or early adulthood, concomitantly with the development of upper airway lesions. Dacryocystography showed nasolacrimal duct stenosis in all cases on the affected side. Three patients underwent dacryocystorhinostomy (one bilaterally), and one patient had bilateral dacryocystectomy. Results Two patients had surgical fistula closure soon after surgery. A sequential endoscopic operation for remotion of a synechia between the fistula and the middle turbinate was successful in one of these patients. Histopathologic analysis of lacrimal sacs and nasal mucous membranes close to the anastomotic site revealed chronic nonspecific inflammatory process and negative immunohistochemistry for Leishmania. Conclusions Dacryocystitis may result from nasal mucocutaneous leishmaniasis. The surgical outcome was unsatisfactory in one of the four patients.

Two-Year Outcome of Partial Lacrimal Punctal Occlusion in the Management of Dry Eye Related to Sjögren Syndrome

Purpose: To analyze the influence of thermal partial punctal occlusion on the ocular surface of dry eye related to Sjögren syndrome. Material and Methods: Thirty-seven eyes of 19 patients (3 male and 16 female; 49.11 ± 14.33 years old) with keratoconjunctivitis sicca were enrolled in this study. Superior and inferior partial occlusion were performed in both eyes under topical anesthesia using thermal cautery with a sterile tip to obtain lacrimal punctum smaller than 0.5 mm. Schirmer I, break-up-time, diameter of lacrimal puncta, corneal fluorescein, and rose Bengal staining scores were analyzed before and after 24 weeks and after 24 months of the procedure. All measurements were performed under controlled climate. Results: The average lacrimal punctum diameter before the procedure was 0.65 ± 0.134 mm. All lacrimal puncta were successfully reduced to less than 0.5 mm after 4 weeks of the procedure. The average Schirmer I test values improved statistically after 24 weeks and maintained stable after 24 months. Average break-up-time, rose Bengal, and fluorescein staining score values improved statistically after 24 weeks and improved even more after 24 months. Average Schirmer I test, break-up-time, rose Bengal, and fluorescein staining scores showed significant improvement (p < 0.0001) after 24 months of partial thermal punctal occlusion. Conclusion: Our study showed that reducing the punctum diameter to 0.5 mm can improve vital staining scores, break-up-time, and Schirmer I test in dry eye related to Sjögren syndrome.

Severe bilateral necrotising retinitis caused by Toxoplasma gondii in a patient with systemic lupus erythematosus and diabetes mellitus

Ocular toxoplasmosis may be remarkably atypical in situations of evident immunosuppression such as acquired immunodeficiency syndrome, malignancy, and use of chronic immunosuppressive drug therapy.1 Aggressive forms in immunocompetent hosts are very rare.2,3 We present a case of severe, bilateral necrotising retinitis by Toxoplasma gondii initially misdiagnosed as an acute retinal necrosis (ARN) syndrome, in a patient with systemic lupus erythematosus (SLE) and diabetes mellitus type 2, who was taking medium dose prednisone. A 47 year old woman reported a 3 month history of rapid visual loss in the right eye followed by a decrease in her left eye vision 2 months later. Twenty days before the onset of ocular symptoms the patient had a seizure. Her medical history showed a SLE,4 with an active lupus central nervous system disease controlled with prednisone (0.5 mg/kg/day), and type 2 diabetes mellitus. At her first visit to our service, visual acuity was hand movements in both eyes. Slit lamp examination showed 3+ aqueous cells and flare, and 2+ anterior vitreous cells in both eyes. The fundus showed a 2+ vitreous haze and almost 360° creamy white necrotising retinitis extending from the ora serrata to the posterior pole, including the macula in both eyes (Fig 1A and B). Thumbprint patches at the border between necrotic and scanty normal retina could be observed, and also diffuse vascular attenuation. Figure 1 (A) Fundus appearance of …

Enhancing the cross-cultural adaptation and validation process: linguistic and psychometric testing of the Brazilian–Portuguese version of a self-report measure for dry eye

OBJECTIVES To provide a reliable, validated, and culturally adapted instrument that may be used in monitoring dry eye in Brazilian patients and to discuss the strategies for the enhancement of the cross-cultural adaptation and validation process of a self-report measure for dry eye. METHODS The cross-cultural adaptation process (CCAP) of the original Ocular Surface Disease Index (OSDI) into Brazilian-Portuguese was conducted using a 9-step guideline. The synthesis of translations was tested twice, for face and content validity, by different subjects (focus groups and cognitive interviews). The expert committee contributed on several steps, and back translations were based on the final rather than the prefinal version. For validation, the adapted version was applied in a prospective longitudinal study to 101 patients from the Dry Eye Clinic at the General Hospital of the University of São Paulo, Brazil. Simultaneously to the OSDI, patients answered the short form-36 health survey (SF-36) and the 25-item visual function questionnaire (VFQ-25) and underwent clinical evaluation. Internal consistency, test-retest reliability, and measure validity were assessed. RESULTS Cronbachs alpha value of the cross-culturally adapted Brazilian-Portuguese version of the OSDI was 0.905, and the intraclass correlation coefficient was 0.801. There was a statistically significant difference between OSDI scores in patients with dry eye (41.15 ± 27.40) and without dry eye (17.88 ± 17.09). There was a negative association between OSDI and VFQ-25 total score (P < 0.01) and between the OSDI and five SF-36 domains. OSDI scores correlated positively with lissamine green and fluorescein staining scores (P < 0.001) and negatively with Schirmer test I and tear break-up time values (P < 0.001). CONCLUSION Although most of the reviewed guidelines on CCAP involve well-defined steps (translation, synthesis/reconciliation, back translation, expert committee review, pretesting), the proposed methodological steps have not been applied in a uniform way. The translation and adaptation process requires skill, knowledge, experience, and a considerable investment of time to maximize the attainment of semantic, idiomatic, experiential, and conceptual equivalence between the source and target questionnaires. A well-established guideline resulted in a culturally adapted Brazilian-Portuguese version of the OSDI, tested and validated on a sample of Brazilian population, and proved to be a valid and reliable instrument for assessing patients with dry eye syndrome in Brazil.

Criptococose palpebral: relato de caso

Relata-se o caso de uma paciente portadora de sindrome da imunodeficiencia adquirida empiricamente tratada com esquema triplice para tuberculose miliar. Durante a evolucao clinica a paciente cursou com lesoes comprometendo a palpebra e conjuntiva tarsal a direita. A hipotese diagnostica inicial foi de tuberculose ocular com comprometimento conjuntival e palpebral. A biopsia da lesao conjuntival mostrou presenca do Criptococcus neoformans. Apos o inicio do tratamento especifico com anfotericina B, a paciente apresentou melhora das lesoes cutâneas.