Evaluation of ocular involvement in patients with Hansen's disease.

Hansen's disease (HD) belongs to the group of neglected diseases and can cause physical deformities and disabilities, in addition to leading to social discrimination. Ocular involvement in HD is estimated at 70-75% worldwide. About 10-50% suffer from severe ocular symptoms and loss of vision occurs in approximately 5% of cases. Ocular changes may persist or worsen even after patients are considered cured and it is necessary to better understand these conditions in order to determine the need for additional public policies. The objective of this study was to identify the prevalence of ocular involvement in patients with HD at two specialist referral centers for treatment of the disease. A cross-sectional study was conducted with ophthalmological evaluations of patients with HD from June 2017 to June 2018. Diagnostic ocular findings, corrected visual acuity, and refractive error were described. Findings were correlated with patients' clinical and epidemiological variables. A total of 86 patients were evaluated, with a mean age of 50.1 years, predominantly males (59.3%), and with multibacillary HD (92%). The prevalence of ophthalmologic changes was 100% and the most common were dysfunction of the Meibomian glands (89.5%) and dry eye syndrome (81.4%). Cataracts were observed in 22 patients (25.6%), but best corrected visual acuity was normal or near normal in 84 patients (97.7%) and there were no cases of bilateral blindness. Patients with some degree of physical disability had more ophthalmological alterations, involving both the ocular adnexa (p = 0.03) and the ocular globe (p = 0.04). Ocular involvement is common in patients with Hansen's disease, reinforcing the importance of ophthalmologic examination in the evaluation and follow-up of these patients.

Epithelial basement membrane injury and regeneration modulates corneal fibrosis after pseudomonas corneal ulcers in rabbits.

The purpose of this study was to investigate whether myofibroblast-related fibrosis (scarring) after microbial keratitis was modulated by the epithelial basement membrane (EBM) injury and regeneration. Rabbits were infected with Pseudomonas aeruginosa after epithelial scrape injury and the resultant severe keratitis was treated with topical tobramycin. Corneas were analyzed from one to four months after keratitis with slit lamp photos, immunohistochemistry for alpha-smooth muscle actin (α-SMA) and monocyte lineage marker CD11b, and transmission electron microscopy. At one month after keratitis, corneas had no detectible EBM lamina lucida or lamina densa, and the central stroma was packed with myofibroblasts that in some eyes extended to the posterior corneal surface with damage to Descemet's membrane and the endothelium. At one month, a nest of stromal cells in the midst of the SMA + myofibroblasts in the stroma that were CD11b+ may be fibrocyte precursors to myofibroblasts. At two to four months after keratitis, the EBM fully-regenerated and myofibroblasts disappeared from the anterior 60-90% of the stroma of all corneas, except for one four-month post-keratitis cornea where anterior myofibroblasts were still present in one localized pocket in the cornea. The organization of the stromal extracellular matrix also became less disorganized from two to four months after keratitis but remained abnormal compared to controls at the last time point. Myofibroblasts persisted in the posterior 10%-20% of posterior stroma even at four months after keratitis in the central cornea where Descemet's membrane and the endothelium were damaged. This study suggests that the EBM has a critical role in modulating myofibroblast development and fibrosis after keratitis-similar to the role of EBM in fibrosis after photorefractive keratectomy. Damage to EBM likely allows epithelium-derived transforming growth factor beta (TGFß) to penetrate the stroma and drive development and persistence of myofibroblasts. Eventual repair of EBM leads to myofibroblast apoptosis when the cells are deprived of requisite TGFß to maintain viability. The endothelium and Descemet's membrane may serve a similar function modulating TGFß penetration into the posterior stroma-with the source of TGFß likely being the aqueous humor.

[Ocular leprosy: a historical approach]. / Hanseníase ocular: uma abordagem histórica.

A sharp drop in the prevalence of leprosy occurred in the last three decades. However, the incidence has not decreased at the same rate. Three years after the World Health Organization last deadline for leprosy control, patients considered healed still need special care for their incapacities and immunopathological reactions. Medical literature reffers blindness in 4% to 11% of studied patients and more than 20% with severe visual problems due to corneal exposure, bacillary invasion and hipersensibility. These mechanisms result in a population of nearly one million blind leprosy patients even though official prevalence accounts no more than 250,000 patients worldwide. The author calls for better patients management and follow-up and urges ophthalmologists to become more aware and interested in the treatment of the ocular complications of leprosy.

Hanseníase ocular: uma abordagem histórica / Ocular leprosy: a historical approach

Houve uma acentuada queda na prevalência da hanseníase nas últimas três décadas. Contudo, a incidência não diminuiu na mesma proporção. Hoje, três anos após a última data estipulada pela Organização Mundial da Saúde para o controle da hanseníase, pacientes considerados curados ainda necessitam de cuidados especiais por causa de suas incapacidades e reações imunológicas. A literatura médica refere cegueira em 4 por cento a 11 por cento dos pacientes estudados e, mais de 20 por cento com graves problemas visuais devido a exposição da córnea, invasão bacilar e hipersensibilidade; estes mecanismos resultam em uma população de aproximadamente 1 milhão de pacientes cegos, embora a prevalência oficial não passe de 250.000 pacientes em todo o mundo. O autor destaca a necessidade de melhor tratamento e acompanhamento dos pacientes e, conclama os oftalmologistas a tornarem-se mais perceptivos e se interessarem mais pelo tratamento das complicações oculares da hanseníase.

A sharp drop in the prevalence of leprosy occurred in the last three decades. However, the incidence has not decreased at the same rate. Three years after the World Health Organization last deadline for leprosy control, patients considered healed still need special care for their incapacities and immunopathological reactions. Medical literature reffers blindness in 4 percent to 11 percent of studied patients and more than 20 percent with severe visual problems due to corneal exposure, bacillary invasion and hipersensibility. These mechanisms result in a population of nearly one million blind leprosy patients even though official prevalence accounts no more than 250,000 patients worldwide. The author calls for better patients management and follow-up and urges ophthalmologists to become more aware and interested in the treatment of the ocular complications of leprosy.

[Long-term follow-up of a case series of therapeutic corneal transplant]. / Transplante terapêutico de córnea: resultados prolongados de série de casos.

PURPOSE: To describe the results of therapeutic penetrating keratoplasty in patients with impending perforation or perforated infectious keratitis. METHODS: Fifty-nine charts of patients with infectious keratitis who were submitted to therapeutic penetrating keratoplasty were retrospectively reviewed at the Department of Ophthalmology of the Santa Casa of São Paulo from January 2000 to December 2004. Pre- and post operative visual acuity, biomicroscopy, echography, culture and bacterioscopy were analyzed. Patients with a minimum 9-month follow-up were included and were divided into 5 groups: herpetic, bacterial, fungal, bacterial-fungal keratitis and keratitis with negative culture bacterioscopy. RESULTS: Eradication of infection and restoration of ocular integrity were obtained in 95.2% of all bacterial keratitis; 100% fungal; 25.0% bacterial-fungal; 95.2% negative culture and 100% of all herpetic keratitis. Complications included: 2 rejections, 6 recurrences, 13 glaucomas and 1 perforation. CONCLUSION: In infectious keratitis with perforation or impending perforation that did not respond to conservative clinical therapy, therapeutic penetrating keratoplasty must be considered an alternative to eradicate infection and restore the ocular integrity.

Transplante terapêutico de córnea: resultados prolongados de série de casos / Long-term follow-up of a case series of therapeutic corneal transplant

OBJETIVO: Analisar os resultados dos transplantes terapêuticos realizados no tratamento de ceratites infecciosas. MÉTODOS: Foi feito estudo retrospectivo de 59 prontuários de pacientes com ceratite infecciosa submetidos a transplante terapêutico no Departamento de Oftalmologia da Santa Casa de São Paulo de janeiro de 2000 a dezembro de 2004. Foram obtidos dados de identificação do paciente (idade, sexo e raça), acuidade visual pré e pós-operatória, biomicroscopia pré e pós-operatória, ecografia, resultados de cultura e bacterioscopia. Foram incluídos apenas os pacientes com seguimento mínimo de 9 meses. Os pacientes foram divididos em cinco grupos: ceratite bacteriana, fúngica, mista, aquelas com cultura e/ou bacterioscopia negativa e herpética. RESULTADOS: A erradicação da infecção e o restabelecimento da integridade do bulbo ocular dentre as ceratites bacterianas foi de 95,2 por cento; nas fúngicas de 100 por cento; nas mistas de 25 por cento; naquelas com cultura e/ou bacterioscopia negativa de 95,2 por cento e nas herpéticas de 100 por cento. Dentre as complicações, foram encontrados 2 casos de rejeição, 6 de recidiva, 13 de aumento da pressão intra-ocular e 1 de perfuração. CONCLUSÃO: Nas ceratites infecciosas perfuradas ou com risco de perfuração que não respondem ao tratamento clínico conservador, o transplante terapêutico deve ser considerado importante alternativa para erradicação da infecção e restabelecimento da integridade do bulbo ocular.

PURPOSE: To describe the results of therapeutic penetrating keratoplasty in patients with impending perforation or perforated infectious keratitis. METHODS: Fifty-nine charts of patients with infectious keratitis who were submitted to therapeutic penetrating keratoplasty were retrospectively reviewed at the Department of Ophthalmology of the Santa Casa of São Paulo from January 2000 to December 2004. Pre- and post operative visual acuity, biomicroscopy, echography, culture and bacterioscopy were analyzed. Patients with a minimum 9-month follow-up were included and were divided into 5 groups: herpetic, bacterial, fungal, bacterial-fungal keratitis and keratitis with negative culture bacterioscopy. RESULTS: Erradication of infection and restoration of ocular integrity were obtained in 95.2 percent of all bacterial keratitis; 100 percent fungal; 25.0 percent bacterial-fungal; 95.2 percent negative culture and 100 percent of all herpetic keratitis. Complications included: 2 rejections, 6 recurrences, 13 glaucomas and 1 perforation. CONCLUSION: In infectious keratitis with perforation or impending perforation that did not respond to conservative clinical therapy, therapeutic penetrating keratoplasty must be considered an alternative to erradicate infection and restore the ocular integrity.

Necrotizing nocardial scleritis after combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation: a case report and review of the literature.

We report the history and clinical presentation of an 88-year-old female with Fuchs dystrophy who developed an acute anterior necrotizing scleritis in her left eye 23 months after an uncomplicated combined penetrating keratoplasty and phacoemulsification with intraocular lens implantation which progressed to slceral perforation with uveal prolapses. The patient underwent a complete systemic work-up for both autoimmune and infectious causes of scleritis. Surgical specimens of the area of scleral perforation were sent for histology and microbiologic studies. Analysis of surgical specimens revealed the presence of culture-proven Nocardia asteroides as a causative agent for the patient's scleral perforation. Results of her systemic autoimmune work-up were not conclusive. Successful treatment with tectonic scleral reinforcement with donor corneal tissue and preserved pericardium, oral and topical trimethoprim-sulfamethoxazole and topical amikacin salvaged the globe and increased vision. The patient's final best-corrected visual acuity sixteen months after her last operation remains 20/70. Prompt surgical intervention with submission of appropriate specimens for pathological diagnosis and microbiology, along with consultation with rheumatologic and infectious disease specialists, are mandatory to minimize visual loss in cases of suspected infectious necrotizing scleritis.

Corneal infiltrates after excimer laser photorefractive keratectomy and LASIK.

PURPOSE: To determine the frequency and clinical characteristics of corneal infiltrates after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) and to evaluate the efficacy of treatment. METHODS: We retrospectively reviewed the records of 8508 eyes treated with PRK or LASIK in a university-based clinic for the correction of refractive errors for 60 days postoperatively. RESULTS: Corneal infiltrates were observed in 35 (0.8%) of 4492 PRK-operated eyes and in 4 (0.1%) of 4016 LASIK-operated eyes. The mean time of diagnosis was 5.46 days. Among the 39 eyes with infiltrates, 10 (9 PRK, 1 LASIK) had culture-verified infectious keratitis. Coagulase-negative Staphylococcus was the most frequently isolated bacterium (50%), followed by S aureus (20%), Corynebacterium xerosis (10%), Streptococcus viridans (10%), and an unidentified gram-positive coccus (10%). Final visual acuity of > or = 20/30, without correction, was achieved in 79.5% of the 39 eyes. CONCLUSIONS: Corneal infiltrates occurred in 0.8% of PRK eyes and 0.1% of LASIK eyes. Bacterial smears were positive for several eyes. In all cases, prompt treatment was responsible for good visual outcome.

Eyelid changes in long-standing leprosy.

To describe eyelid changes in ocular leprosy, 74 patients (148 eyes or 296 eyelids) were examined, focusing on eyelid abnormalities. The adnexal examination included evaluation of the upper eyelid crease pattern, qualitative assessment of the orbicularis oculi muscle function, measurement of the distance between the corneal reflex and the upper eyelid margin (margin reflex distance), and slit-lamp biomicroscopy of the eyelashes and tarsal conjunctiva. Eyelash ptosis was a common finding associated with a multiple upper eyelid crease pattern and trichiasis. In the past, eyelash ptosis has probably been diagnosed as upper eyelid entropion or trichiasis, but in this series entropion was not observed. The distinction between eyelash ptosis, trichiasis, and upper eyelid entropion is important because the surgical management for each is different. Other true leprotic abnormalities of the eyelids are lagophthalmos and lower lid ectropion.

Ocular manifestations in the acute phase of leptospirosis.

OBJECTIVES: To study the ocular manifestations during the acute phase of leptospirosis and their incidence in hospitalized patients due to systemic complications, and to verify the importance of routine ophthalmologic care in these cases. METHODS: Twenty-one patients, 20 males and 1 female, with clinical and laboratory (ELISA IgM) diagnoses of leptospirosis were subjected to ophthalmologic examination. RESULTS: We observed conjunctival hyperemia in 18 patients (85.7%), increased retinal venous caliber in 12 patients (57.1%), optic disc redness in 12 patients (57.1%), subconjunctival hemorrhage in four patients (19.0%), optic disc edema in one patient (4.8%), retinal vasculitis in one patient (4.8%), retinal hemorrhage in one patient (4.8%), hard exudates in one patient (4.8%), and papillitis in one patient (4.8%). No anterior chamber reaction was found. CONCLUSIONS: We observed a high incidence of several ocular manifestations in the acute phase of leptospirosis. Despite the systemic severity and high incidence of ocular disorders in the acute phase of leptospirosis, the short-term visual outcome of these patients was good.

Mycobacterium chelonae keratitis following laser in situ keratomileusis.

Corneal infection after laser in situ keratomileusis (LASIK) is rare. However, surgical trauma or breakdown of epithelium increases the risk of surface infection. We present the case of a 45 year old woman who developed keratitis due to Mycobacterium chelonae 1 month after LASIK with the Mini-Laser Sight 2000 excimer laser. After an initial improvement following antibiotic therapy the infection progressed until it was necessary to perform penetrating keratoplasty, with a successful result.

Chorioretinitis secondary to mycobacterium tuberculosis in acquired immune deficiency syndrome.

BACKGROUND: Several opportunistic intraocular infections have been described in patients with the human immunodeficiency virus, among them infections caused by Mycobacterium tuberculosis. In most cases, the diagnosis is based on clinical findings. Recent reports have described the usefulness of polymerase chain reaction techniques in the diagnosis of bacterial infections. METHODS: The authors observed a 29-year-old woman with acquired immune deficiency syndrome in whom unilateral chorioretinitis developed. The chorioretinitis appeared after cessation of treatment for pulmonary tuberculosis. We obtained aqueous humor by paracentesis and tested it by polymerase chain reaction to detect M. tuberculosis DNA. RESULTS: The polymerase chain reaction of the aqueous humor was positive for M. tuberculosis DNA. CONCLUSION: Polymerase chain reaction was useful in identifying M. tuberculosis in aqueous from a patient with chorioretinitis, pulmonary tuberculosis, and acquired immune deficiency syndrome.

Nocardial keratitis following myopic keratomileusis.

PURPOSE/METHODS: Interface opacities were detected in a patient who underwent uncomplicated myopic keratomileusis. RESULTS AND DISCUSSION: Nocardia asteroides keratitis was confirmed by microbiologic work-up and guided the correct treatment. The eye recovered 20/60 spectacle-corrected visual acuity and had a residual stromal scar.