Simultaneous ocular and osseous syphilis: a case report / Sífilis com envolvimentos ocular e ósseo simultâneos: um relato de caso

ABSTRACT Syphilis is a reemerging and potentially serious disease. Owing to its ubiquity and pleomorphism, it is called "the great imitator". We report the case of a young woman with secondary syphilis who presented with bilateral acute syphilitic posterior placoid chorioretinopathy along with a syphilitic skull periostitis. A pachymeningeal enhancement was observed on magnetic resonance imaging, but we believe it was an extension of the bone process rather than a meningitis itself on the basis of the normal cerebrospinal fluid analysis results. Treatment with intravenous crystalline penicillin resulted in complete resolution of the signs, symptoms, and imaging findings. Secondary syphilis is the stage with the highest bacteremia and the highest transmissibility, presenting mainly with mucocutaneous disorders and, less frequently, with involvement of other organs. High suspicion and a pragmatic approach are essential to the diagnosis because this disease can affect several organs, as in the present case, in which the eyes, bones, and skin were affected.

RESUMO A sífilis é uma doença reemergente e potencialmente grave. Por sua onipresença e pleomorfismo, é denominada "grande imitadora". Relatamos caso de paciente jovem com sífilis secundária, que se apresentou com coriorretinopatia placóide sifilítica posterior aguda bilateral, simultaneamente a periostite craniana sifilítica. A despeito de realce paquimeníngeo observado na ressonância magnética, acreditamos que este tenha sido uma extensão do processo ósseo e não, uma meningite em si, uma vez que o exame do líquido cefalorraquidiano estava completamente normal. Tratamento com penicilina cristalina intravenosa resultou em completa resolução dos sinais, sintomas e achados de imagem. A sífilis secundária é o estágio de maior bacteremia e maior transmissibilidade da doença, apresentando-se principalmente com quadros mucocutâneos, mas também, menos frequentemente, com envolvimento de outros órgãos. Elevada suspeição e uma abordagem pragmática são necessárias para o diagnóstico, uma vez que essa doença pode afetar vários órgãos, como no caso relatado, em que foram acometidos olhos, ossos e pele.

Simultaneous ocular and osseous syphilis: a case report.

Syphilis is a reemerging and potentially serious disease. Owing to its ubiquity and pleomorphism, it is called "the great imitator". We report the case of a young woman with secondary syphilis who presented with bilateral acute syphilitic posterior placoid chorioretinopathy along with a syphilitic skull periostitis. A pachymeningeal enhancement was observed on magnetic resonance imaging, but we believe it was an extension of the bone process rather than a meningitis itself on the basis of the normal cerebrospinal fluid analysis results. Treatment with intravenous crystalline penicillin resulted in complete resolution of the signs, symptoms, and imaging findings. Secondary syphilis is the stage with the highest bacteremia and the highest transmissibility, presenting mainly with mucocutaneous disorders and, less frequently, with involvement of other organs. High suspicion and a pragmatic approach are essential to the diagnosis because this disease can affect several organs, as in the present case, in which the eyes, bones, and skin were affected.

Unnoticed metallic foreign body in the camerular angle inducing chronic uveitis / Corpo estranho metálico não notado em ângulo camerular induzindo uveíte crônica

ABSTRACT We report the case of an eight-year-old male patient with a four-month history of unilateral anterior chronic uveitis, associated with a pigmented lesion surrounded by fibrinoid material in the inferior camerular angle and with a fibrotic lesion in the extreme periphery of the inferior retina. The patient had no history of trauma or any other clinical symptoms. Although the patient was suspected of having toxocariasis, serological tests were negative. Partial symptomatic improvement was achieved using both orally and topically administered corticosteroids. In addition, a decrease in fibrinoid material around the pigmented camerular lesion revealed it to be regular and cylindric. Computed tomography of the orbits revealed a metallic foreign body in the topography of the inferior camerular angle. The patient underwent removal of the foreign body through a corneal incision and photocoagulation around the inferior retinal traction. Excellent visual and anatomical results were obtained.(AU)

RESUMO Os autores relatam o caso de paciente do sexo masculino, 8 anos de idade, com história de uveíte crônica anterior unilateral há quatro meses, associada a lesão pigmentada envolvida por material fibrinóide em ângulo camerular inferior e a lesão fibrótica em extrema periferia de retina inferior. Não havia histórico de trauma ou outros sintomas clínicos. A hipótese de toxocaríase foi afastada diante de testes sorológicos negativos. Melhoria sintomática parcial foi alcançada com administração de corticosteróide vias oral e tópica. Ademais, redução na quantidade de material fibrinóide ao redor da lesão camerular a revelou regular e cilíndrica. Foi realizada tomografia computadorizada de órbitas, permitindo a detecção de corpo estranho metálico na topografia de ângulo camerular inferior. O paciente foi submetido a remoção do corpo estranho através de incisão corneana e a fotocoagulação ao redor da tração retiniana inferior. Excelentes resultados visual e anatômico foram obtidos.(AU)

Punctate inner choroidopathy with atypical presentation / Coroidopatia interna ponteada de apresentação atípica

ABSTRACT We report a case of a young Caucasian female presenting with sudden decrease of vision in the left eye, metamorphopsia, and nasal scotoma. Past medical history revealed a diagnosis of myasthenia gravis, which was currently treated with azathioprine, pyridostigmine, and prednisone. Ophthalmological examination showed fundus with clear vitreous and yellow-white lesions that were isolated and perimacular in the right eye, multiple and confluent in the macula, and punctate in periphery in the left eye. Laboratory workup ruled out the presence of infectious and inflammatory diseases. Fundus autofluorescence disclosed hypoautoflurescence with hyperfluorescent margins corresponding to the lesions observed in both eyes and the angiogram revealed hyperfluorescence since early phases without late leakage. Spectral-domain optical coherence tomography showed areas of intermittent retinal pigment epithelium elevations and disruption of the ellipsoid zone. She was diagnosed with punctate inner choroidopathy and then treated with an increased dose of daily prednisone, which resulted in progressive improvement of her visual acuity and anatomical status.(AU)

RESUMO Relato de caso de mulher jovem, caucasiana, com súbita diminuição de acuidade visual de olho esquerdo, metamorfopsia e escotoma nasal. Apresentava diagnóstico de Miastenia gravis, em tratamento com Azatioprina, Piridostigmina e Prednisona. Fundo de olho demonstrava vítreo límpido e lesões amarelo-esbranquiçadas, perimaculares e isoladas em olho direito, múltiplas e confluentes em mácula e pontilhadas em periferia no olho esquerdo. Exames laboratoriais descartaram doenças infecciosas e inflamatórias. Auto-fluorescência revelou lesões hipoautofluorescentes com margens hiperfluorescentes correspondentes às observadas em ambos os olhos, enquanto angiofluoresceinografia mostrou hiperfluorescência desde as fases iniciais sem vazamento tardio. Tomografia de coerência óptica de domínio espectral revelou áreas de elevações intermitentes do epitélio pigmentar da retina e interrupção da zona elipsóide correspondente. Definiu-se como diagnóstico a coroidopatia interna ponteada, sendo instituído aumento na dose diária de Prednisona, com melhoria progressiva da acuidade visual e do aspecto de fundo de olho da paciente.(AU)

Punctate inner choroidopathy with atypical presentation.

We report a case of a young Caucasian female presenting with sudden decrease of vision in the left eye, metamorphopsia, and nasal scotoma. Past medical history revealed a diagnosis of myasthenia gravis, which was currently treated with azathioprine, pyridostigmine, and prednisone. Ophthalmological examination showed fundus with clear vitreous and yellow-white lesions that were isolated and perimacular in the right eye, multiple and confluent in the macula, and punctate in periphery in the left eye. Laboratory workup ruled out the presence of infectious and inflammatory diseases. Fundus autofluorescence disclosed hypoautoflurescence with hyperfluorescent margins corresponding to the lesions observed in both eyes and the angiogram revealed hyperfluorescence since early phases without late leakage. Spectral-domain optical coherence tomography showed areas of intermittent retinal pigment epithelium elevations and disruption of the ellipsoid zone. She was diagnosed with punctate inner choroidopathy and then treated with an increased dose of daily prednisone, which resulted in progressive improvement of her visual acuity and anatomical status.

Unnoticed metallic foreign body in the camerular angle inducing chronic uveitis.

We report the case of an eight-year-old male patient with a four-month history of unilateral anterior chronic uveitis, associated with a pigmented lesion surrounded by fibrinoid material in the inferior camerular angle and with a fibrotic lesion in the extreme periphery of the inferior retina. The patient had no history of trauma or any other clinical symptoms. Although the patient was suspected of having toxocariasis, serological tests were negative. Partial symptomatic improvement was achieved using both orally and topically administered corticosteroids. In addition, a decrease in fibrinoid material around the pigmented camerular lesion revealed it to be regular and cylindric. Computed tomography of the orbits revealed a metallic foreign body in the topography of the inferior camerular angle. The patient underwent removal of the foreign body through a corneal incision and photocoagulation around the inferior retinal traction. Excellent visual and anatomical results were obtained.

Cataract remains an important cause of blindness in Campinas, Brazil.

OBJECTIVE: To estimate the prevalence of blindness in the elderly population of Campinas, Brazil, and to describe the coverage and quality of cataract surgery services in the area. METHODS: A brief assessment of cataract surgery services (using the "RACSS" (Rapid Assessment of Cataract Surgical Services Method) was conducted using random cluster sampling, with a sample composed of 60 clusters of 40 people aged 50 years or older. Visual acuity (VA) was measured and the lens status observed by direct visual ophthalmoscopy. From the selected sample of 2,400 subjects, 92.67% were examined. RESULTS: Blindness (VA < 3/60 with available correction) was found in 1.98 % (2.03 % among male subjects, and 1.94 % among female subjects). The prevalence of blindness varied with age, from 0.2%, in the group from 50 to 54 years, to 7.2% in those above 80. Cataract was the main cause of blindness (40.2%) followed by suspected posterior segment disorders (18.2%), diabetic retinopathy (15.9%), and glaucoma (11.4%). The cataract surgical coverage was of 93% (VA < 3/60) and 82.18% when the criterion was VA 6/60 in the best eye. The main reasons the subjects did not receive surgical treatment were: fear of undergoing surgery, 11.1%; lack of awareness about the condition, 16.7%; waiting for maturity, 16.7%; and contraindication to surgery, 44.4%. CONCLUSION: Cataract is the major cause of blindness in Campinas. Education on eye diseases, their prevention and treatment must become part of the city's public healthcare policies.

Cataract surgery complications as a cause of visual impairment in a population aged 50 and over.

The purpose of this study was to measure the extent to which complications relating to cataract surgery are a cause of visual impairment in a population aged 50 and over from the city of Campinas, São Paulo State, Brazil. An assessment of cataract surgery services was conducted using random cluster sampling, with the sample composed of 60 clusters of 40 people aged 50 years or older. Of the selected sample of 2,400 subjects, 92.67% were examined. Of these 2,224 examined subjects, 75 (3.37%) presented bilateral visual impairment and 164 unilateral, while a total of 314 (7.06%) eyes presented visual impairment. 352 eyes had undergone cataract surgery. The causes of visual impairment after surgery were concurrent eye disease (56%), surgical complications (28.8%) and refractive errors (15.2%). Cataract surgery complications represented the 5th most important cause of visual impairment. The other main causes were cataract, posterior segment disorders, diabetic retinopathy and glaucoma. These results suggest cataract surgery complications are a major cause of visual impairment in this population. Their prevention and treatment must be part of public health care policies.

Cataract surgery complications as a cause of visual impairment in a population aged 50 and over / Complicações de facectomias como causa de baixa visual em uma população com 50 ou mais anos de idade

The purpose of this study was to measure the extent to which complications relating to cataract surgery are a cause of visual impairment in a population aged 50 and over from the city of Campinas, São Paulo State, Brazil. An assessment of cataract surgery services was conducted using random cluster sampling, with the sample composed of 60 clusters of 40 people aged 50 years or older. Of the selected sample of 2,400 subjects, 92.67 percent were examined. Of these 2,224 examined subjects, 75 (3.37 percent) presented bilateral visual impairment and 164 unilateral, while a total of 314 (7.06 percent) eyes presented visual impairment. 352 eyes had undergone cataract surgery. The causes of visual impairment after surgery were concurrent eye disease (56 percent), surgical complications (28.8 percent) and refractive errors (15.2 percent). Cataract surgery complications represented the 5th most important cause of visual impairment. The other main causes were cataract, posterior segment disorders, diabetic retinopathy and glaucoma. These results suggest cataract surgery complications are a major cause of visual impairment in this population. Their prevention and treatment must be part of public health care policies.

Objetivou-se avaliar a relevância das complicações de facectomias como causa de baixa acuidade visual na população > 50 anos em Campinas, São Paulo, Brasil. Uma avaliação dos serviços de cirurgia de catarata foi conduzida utilizando amostragem aleatória de agrupamentos populacionais, sendo composta por 60 agrupamentos de 40 pessoas > 50 anos. Na amostra de 2.400 indivíduos, 92,67 por cento foram examinados. Dos 2.224 examinados, 75 (3,37 por cento) apresentaram baixa acuidade visual bilateral, 164, unilateral. e um total de 314 (7,06 por cento) olhos apresentou baixa acuidade visual. Trezentos e cinqüenta e dois olhos tinham sido submetidos a facectomias. As causas de baixa acuidade visual pós-cirurgia foram doenças oculares concomitantes (56 por cento), complicações cirúrgicas (28,8 por cento) e erros refrativos (15,2 por cento). Complicações de cirurgias de catarata foram a quinta causa mais importante de baixa acuidade visual. Outras causas principais foram catarata, doenças oculares do segmento posterior, retinopatia diabética e glaucoma. Estes resultados sugerem que complicações de cirurgias de catarata é uma importante causa de baixa acuidade visual na população em estudo. Sua prevenção e tratamento precisam fazer parte das políticas de saúde pública.

Problem-solving capacity for vitreoretinal diseases in a university health center.

PURPOSE: To evaluate the effectiveness of the tertiary care delivered to patients with vitreoretinal diseases in a defined urban population; to substantiate the planning and allocation of resources in order to improve the tertiary eye care delivery system in a specific area. METHODS: Data were collected from consecutive first-time patients between June 1, 2003 and July 31, 2004 in the Department of Ophthalmology, State University of Campinas, São Paulo, Brazil. Problem-solving capacity values were calculated for vitreoretinal surgery and photocoagulation. Data were entered into the Statistical Package for the Social Sciences (version 10.0). RESULTS: Of the 7500 patients referred to the Department, 641 were deemed suitable for analysis. The diagnoses analyzed were retinal detachment (26.0%), diabetic retinopathy (21.0%), and vitreous hemorrhage (7.7%). The median ages were 52, 59 and 57.5, respectively. Of all patients referred for retinal detachment, 26.5% were inoperable. The values obtained for the problem-solving capacity (PSC) showed that 38.1%, 33.0% and 93.5% of those eligible for an ophthalmic intervention (for retinal detachment, vitreous hemorrhage and diabetic retinopathy) had obtained treatment. The main reason for not giving treatment was the unavailability of operating room time and photocoagulation time (87.1%). CONCLUSIONS: This was the first study of tertiary eye care service performance in Latin America. Sight-threatening conditions such as retinal detachment and diabetic retinopathy are not thoroughly covered by the health system in this area. Various ways to reduce the problem are considered. The study has provided valuable information on planning high-complexity eye services in the population in question.

Appraisal of the retention of the knowledge for ophthalmology specialists of the Brazilian Ophthalmology Council.

PURPOSE: To determine the retention of knowledge along the years after certification of physicians as ophthalmology specialists. METHODS: The physicians, former ophthalmology residents, were selected at the Department of Ophthalmology, State University of Campinas, São Paulo, Brazil, and randomly allocated to three groups of seven individuals, according to the time as specialists. Group 1 consisted of one-year specialists, group 2 of five-year specialists and group 3 of ten-year specialists. Each participant answered a test with twenty-five multiple choice randomly selected questions, based on the national certificate tests applied by the Brazilian Ophthalmology Council between 1994 and 2003. Each question scored four points. RESULTS: The mean age of groups 1, 2 and 3 was 27, 30 and 36 years, respectively. A preponderance of males was found in all groups. Group 1 achieved the highest score, average of 88, group 2 achieved 77, and group 3 achieved the lowest, average of 64 (p<0.05). CONCLUSION: Loss of knowledge retention amongst specialists of the Brazilian Ophthalmology Council, has been observed along the years after the certification.

Appraisal of the retention of the knowledge for ophthalmology specialists of the Brazilian Ophthalmology Council

OBJETIVO: Determinar a retencão de conhecimento teórico ao longo dos anos, após a aprovacão para o título de especialista em oftalmologia. MÉTODOS: Foram selecionados aleatoriamente três grupos, com sete médicos cada, entre ex-residentes do Departamento de Oftalmologia da Universidade Estadual de Campinas. Os médicos do grupo 1 tinham sido aprovados para o título de especialista em oftalmologia do Conselho Brasileiro de Oftalmologia (CBO) há um ano, os do grupo 2 há cinco anos e os do grupo 3 há dez anos. Cada oftalmologista respondeu um teste escrito composto por 25 questões escolhidas aleatoriamente entre as provas aplicadas pelo CBO entre os anos 1994 e 2003. Cada questão valeu 4 pontos de um total de 100 possíveis. RESULTADOS: A média de idade dos grupos 1, 2 e 3 foi de 27, 30 e 36 anos, respectivamente. Preponderância do sexo masculino ocorreu em todos os grupos. A média de acertos do grupo 1 foi de 88 pontos, do grupo 2 foi de 77 pontos e do grupo 3 foi de 64 pontos (p<0,05). CONCLUSÕES: Houve diminuicão significativa da retencão de conhecimento teórico ao longo dos anos, após a aprovacão para o título de especialista em oftalmologia.