Weight-adjusted caffeine and ß-blocker use in novice versus senior retina surgeons: a self-controlled study of simulated performance.

BACKGROUND/OBJECTIVES: Tremor and expertise are potentially influenced variables in vitreoretinal surgery. We investigated whether surgeon experience impacts the association of microsurgical performance with caffeine and ß-blockers weight-adjusted intake. SUBJECTS/METHODS: Novice and senior surgeons (<2 and >10 practice years, respectively) were recruited in this self-controlled, cross-sectional study. A simulator's task sequence was repeated over 2 days, 30 min after the following exposures: day 1, placebo, 2.5 mg/kg caffeine, 5.0 mg/kg caffeine, and 0.6 mg/kg propranolol; and day 2, placebo, 0.2 mg/kg propranolol, 0.6 mg/kg propranolol, and 5.0 mg/kg caffeine. Outcomes were total score (0-700, worst-best), simulation time (minutes), intraocular trajectory (centimeters), and tremor-specific score (0-100, worst-best). RESULTS: We recruited 15 novices (9 men [60%], 1.33 ± 0.49 practice years) and 11 seniors (8 men [72.7%], 16.00 ± 4.24 practice years). Novices performed worse after 2.5 mg/kg caffeine and improved following 0.2 mg/kg propranolol in total score (557 vs. 617, p = 0.009), trajectory (229.86 vs. 208.07, p = 0.048), time (14.9 vs. 12.7, p = 0.048), and tremor-score (55 vs. 75, p = 0.009). Surgical performance improved with propranolol post-caffeine but remained worse than 0.2 mg/kg propranolol in total score (570 vs. 617, p = 0.014), trajectory (226.59 vs. 208.07, p = 0.033), and tremor-score (50 vs. 75, p = 0.029). Seniors' tremor-score was lower after 2.5 mg/kg caffeine compared to 0.2 mg/kg propranolol (8 vs. 37, p = 0.015). Tremor-score following propranolol post-caffeine remained inferior to 0.6 mg/kg propranolol alone (17 vs. 38, p = 0.012). CONCLUSION: While caffeine and propranolol were associated with performance changes among novices, only tremor was affected in seniors, without dexterity changes. The pharmacologic exposure impact on surgical dexterity seems to be offset by increased experience.

Campimetry and visual changes after RHZE treatment for tuberculosis.

BACKGROUND: Tuberculosis (TB) caused by Mycobacterium tuberculosis has a high prevalence in Brazil (Global tuberculosis report 2020. Geneva: World Health Organization; 2020). The ethambutol-induced optic neuropathy damage is partly reversible, making its early diagnosis essential to reduce permanent visual damage. PURPOSE: To observe alterations in the computerized campimetry, Ishihara test and visual acuity secondary to rifampicin, isoniazid, pyrimethamine, ethambutol (RHZE) treatment. METHODS: Patients undergoing treatment with RHZE at the tuberculosis service of the Federal University of São Paulo were recruited from March 2019 to December 2020. The best-corrected visual acuity (VA) measurements, Ishihara test and visual fields were performed at baseline, monthly, until 2 weeks after treatment. RESULTS: Twenty-five patients were included. The VA decreased significantly (P = 0.0129) post-treatment compared to month 1. The mean deviation (MD) did not decrease significantly (P > 0.05); the pattern standard deviation (PSD) decreased post-treatment compared to month 1 (P = 0.0371). Changes in the Ishihara test increased significantly (P < 0.0001) in the second month. CONCLUSION: The VA and PSD decreased significantly after RHZE treatment. Changes in the Ishihara test were observed in the second month. TRIAL REGISTRATION: The Research Ethics Committee of Federal University of São Paulo, Paulista School of Medicine approved the study in March 2019. CAAE 04297018.4.0000.5505.

Response to "Comment On: Acute Retinal Necrosis: Is the Current Valacyclovir Regimen Adequate?"

Acute Retinal Necrosis (ARN) is a potentially devastating form of Uveitis. Antivirals are the mainstay treatment for this syndrome. In this letter, we question the current oral Valacyclovir dosage, based on the experience we had with a recent unresponsive ARN case.

Brazilian guidelines for the treatment of outpatients with suspected or confirmed COVID-19. A joint guideline of the Brazilian Association of Emergency Medicine (ABRAMEDE), Brazilian Medical Association (AMB), Brazilian Society of Angiology and Vascular Surgery (SBACV), Brazilian Society of Geriatrics and Gerontology (SBGG), Brazilian Society of Infectious Diseases (SBI), Brazilian Society of Family and Community Medicine (SBFMC), and Brazilian Thoracic Society (SBPT)

ABSTRACT Background Several therapies have been used or proposed for the treatment of COVID-19, although their effectiveness and safety have not been properly evaluated. The purpose of this document is to provide recommendations to support decisions about the drug treatment of outpatients with COVID-19 in Brazil. Methods A panel consisting of experts from different clinical fields, representatives of the Brazilian Ministry of Health, and methodologists (37 members in total) was responsible for preparing these guidelines. A rapid guideline development method was used, based on the adoption and/or adaptation of recommendations from existing international guidelines combined with additional structured searches for primary studies and new recommendations whenever necessary (GRADE-ADOLOPMENT). The rating of quality of evidence and the drafting of recommendations followed the GRADE method. Results Ten technologies were evaluated, and 10 recommendations were prepared. Recommendations were made against the use of anticoagulants, azithromycin, budesonide, colchicine, corticosteroids, hydroxychloroquine/chloroquine alone or combined with azithromycin, ivermectin, nitazoxanide, and convalescent plasma. It was not possible to make a recommendation regarding the use of monoclonal antibodies in outpatients, as their benefit is uncertain and their cost is high, with limitations of availability and implementation. Conclusion To date, few therapies have demonstrated effectiveness in the treatment of outpatients with COVID-19. Recommendations are restricted to what should not be used, in order to provide the best treatment according to the principles of evidence-based medicine and to promote resource savings by aboiding ineffective treatments.

A MULTIFACTORIAL APPROACH FOR IMPROVING THE SURGICAL PERFORMANCE OF NOVICE VITREORETINAL SURGEONS.

PURPOSE: To quantitatively analyze and compare the novice vitreoretinal surgeons' performance after various types of external exposures. METHODS: This prospective, self-controlled, cross-sectional study included 15 vitreoretinal fellows with less than 2 years of experience. Surgical performance was assessed using the Eyesi simulator after each exposure: Day 1, placebo, 2.5, and 5 mg/kg caffeine; Day 2, placebo, 0.2, and 0.6 mg/kg propranolol; Day 3, baseline simulation, breathalyzer reading of 0.06% to 0.10% and 0.11% to 0.15% blood alcohol concentration; Day 4, baseline simulation, push-up sets with 50% and 85% repetition maximum; Day 5, 3-hour sleep deprivation. Eyesi-generated total scores were the main outcome measured (0-700, worst to best). RESULTS: Performances worsened after increasing alcohol exposure based on the total score (χ2 = 7; degrees of freedom = 2; P = 0.03). Blood alcohol concentration 0.06% to 0.10% and 0.11% to 0.15% was associated with diminished performance compared with improvements after propranolol 0.6 and 0.2 mg/kg, respectively (∆1 = -22 vs. ∆2 = +13; P = 0.02; ∆1 = -43 vs. ∆2 = +23; P = 0.01). Propranolol 0.6 mg/kg was positively associated with the total score, compared with deterioration after 2.5 mg/kg caffeine (∆1 = +7 vs. ∆2 = -13; P = 0.03). CONCLUSION: Surgical performance diminished dose dependently after alcohol. Caffeine 2.5 mg/kg was negatively associated with dexterity, and performance improved after 0.2 mg/kg propranolol. No changes occurred after short-term exercise or acute 3-hour sleep deprivation.

Orbital lymphatic vessels: immunohistochemical detection in the lacrimal gland, optic nerve, fat tissue, and extrinsic oculomotor muscles / Vasos linfáticos orbitários: identificação imunohistoquímica na glândula lacrimal, no nervo óptico, no tecido adiposo e nos músculos extrínsecos oculomotores

ABSTRACT Purpose: To identify the lymphatic vessels in orbital specimens from human cadavers using light microscopy and immunohistochemical analysis. Methods: A postmortem study included 10 orbital specimens from 10 human cadavers. The orbital specimens were obtained no later than 12 hours after death. The orbital specimens were dissected into lacrimal gland, optic nerve, fat tissue, and oculomotor muscles. The histologic criteria to qualify as a lymphatic vessel were thin-walled channels of endothelium without a well-developed basal membrane and with an erythrocyte-free, irregular lumen. The immunohistochemical criteria were irregularly shaped, thin-walled vessels with an erythrocyte-free, irregular lumen and immunopositivity for podoplanin D2-40. Results: The lacrimal gland, optic nerve, fat tissue, and extraocular muscle sections were positively stained with podoplanin D2-40. Conclusions: This study demonstrated lymphatic vessels in the human orbit, more precisely, in the lacrimal gland, dura mater of the optic nerve, adipose tissue, and extrinsic oculomotor muscles via light microscopy and immunohistochemistry.(AU)

RESUMO Objetivos: Identificar vasos linfáticos em espécimes orbitários de cadáveres humanos através de microscopia óptica e análise imunohistoquímica. Métodos: Um estudo postmortem incluiu dez espécimes orbitários provenientes de dez cadáveres humanos. Todos os espécimes orbitários foram obtidos até 12 horas após a morte com uma técnica cirúrgica de exenteração orbitária e dissecados em glândula lacrimal, nervo óptico, gordura órbitária e músculos extraoculares. Para classificar como um vaso linfático, os critérios histológicos incluíram vasos endoteliais de parede única sem membrana basal bem desenvolvida, irregulares e lúmen sem hemácias, e os critérios imunohistoquímicos incluíram vasos endoteliais de parede única, com formato irregular e lúmen sem hemácias e reagentes a podoplanina D2-40. Resultados: As lâminas histológicas de glândula lacrimal, nervo óptico, tecido adiposo e músculos extraoculares reagiram positivamente a podoplanina D2-40. Conclusão: Este estudo demonstrou vasos linfáticos na órbita humana, mais exatamente, na glândula lacrimal, no nervo óptico, na gordura orbitária e nos músculos extrínsecos extraoculares via microscopia óptica e imunohistoquímica.(AU)

Pterygium in adults from the Brazilian Amazon Region: prevalence, visual status and refractive errors.

AIMS: To determine prevalence of pterygium, its role as main cause of unilateral and bilateral visual impairment and blindness and its impact on refractive errors from adults living in a high ultraviolet exposure area in the Brazilian Amazon Region. METHODS: Cluster sampling was used in randomly selecting subjects ≥45 years of age from urban and rural areas of Parintins city. Eligible subjects were enumerated through a door-to-door household survey and invited for an eye exam including refraction. Pterygium was assessed considering location (nasal, temporal or both) and size (<3 mm or ≥3 mm reaching or not pupillary margin). RESULTS: A total of 2384 persons were enumerated and 2041 (85.6%) were examined. Prevalence of pterygium was 58.8% (95% CI 53.8% to 63.7%) and associated with male gender (OR=1.63; 95% CI 1.37 to 1.94; p=0.001), while higher education was a protective factor (OR=0.63; 95% CI 0.44 to 0.92; p=0.018). Older age and rural residence were associated with pterygium ≥3 mm reaching or not pupillary margin, while higher education was a protective factor for pterygium ≥3 mm reaching pupillary margin. Prevalence of pterygium as cause of visual impairment and blindness was 14.3% and 3.9%, respectively. Significantly higher hyperopic refractive errors were found in eyes with pterygium ≥3 mm reaching or not pupillary margin. CONCLUSIONS: Pterygium was highly prevalent and the second cause of visual impairment and blindness after provision of refractive correction. Risk factors for pterygium were male gender, advanced age, lower education and rural residency. Strategies to provide pterygium early detection and proper management should be considered by healthcare authorities in this population.

Robot-assisted tremor control for performance enhancement of retinal microsurgeons.

Pars plana vitrectomy is a challenging, minimally invasive microsurgical procedure due to its intrinsic manoeuvres and physiological limits that constrain human capability. An important human limitation is physiological hand tremor, which can significantly increase the risk of iatrogenic retinal damage resulting from unintentional manoeuvres that affect anatomical and functional surgical outcomes. The limitations imposed by normal physiological tremor are more evident and challenging during 'micron-scale' manoeuvres such as epiretinal membrane and internal limiting membrane peeling, and delicate procedures requiring coordinated bimanual surgery such as tractional retinal detachment repair. Therefore, over the previous three decades, attention has turned to robot-assisted surgical devices to overcome these challenges. Several systems have been developed to improve microsurgical accuracy by cancelling hand tremor and facilitating faster, safer and more effective microsurgeries. By markedly reducing tremor, microsurgical precision is improved to a level beyond present human capabilities. In conclusion, robotics offers potential advantages over free-hand microsurgery as it is currently performed during ophthalmic surgery and opens the door to a new class of revolutionary microsurgical modalities. The skills transfer that is beyond human capabilities to robotic technology is a logical next step in microsurgical evolution.

Intravitreal Angiostrongylus cantonensis: first case report in South America.

This study reports the first case of intravitreal angiostrongyliasis in South America treated with posterior worm removal via pars plana vitrectomy. This was a retrospective, observational case study. Data from medical charts, wide-field digital imaging, ocular ultrasound, and visual evoked potential studies were reviewed. A 20-month-old boy presented with eosinophilic meningitis and right eye exotropia. Polymerase chain reaction analysis of the cerebrospinal fluid showed a positive result for Angiostrongylus cantonensis. Fundus examination revealed a pale optic disc, subretinal tracks, vitreous opacities, peripheral tractional retinal detachment, and a dead worm in the vitreous cavity. The patient underwent pars plana vitrectomy with worm removal. This case report illustrates the first case of intravitreal angiostrongyliasis in South America, possibly related to the uncontrolled spread of an exotic invasive species of snail.

Intravitreal Angiostrongylus cantonensis: first case report in South America / Angiostrongylus cantonensis intravítreo: primeiro relato de caso na América do Sul

ABSTRACT This study reports the first case of intravitreal angiostrongyliasis in South America treated with posterior worm removal via pars plana vitrectomy. This was a retrospective, observational case study. Data from medical charts, wide-field digital imaging, ocular ultrasound, and visual evoked potential studies were reviewed. A 20-month-old boy presented with eosinophilic meningitis and right eye exotropia. Polymerase chain reaction analysis of the cerebrospinal fluid showed a positive result for Angiostrongylus cantonensis. Fundus examination revealed a pale optic disc, subretinal tracks, vitreous opacities, peripheral tractional retinal detachment, and a dead worm in the vitreous cavity. The patient underwent pars plana vitrectomy with worm removal. This case report illustrates the first case of intravitreal angiostrongyliasis in South America, possibly related to the uncontrolled spread of an exotic invasive species of snail.

RESUMO O objetivo deste estudo foi relatar o primeiro caso na América do Sul de angiostrongilíase intravítrea tratada com vitrectomia posterior via pars plana e remoção do verme. Este foi um relato de caso observacional. O prontuário médico, sistema de imagem digital de campo amplo, ultrassonografia ocular, e potenciais evocados visuais foram revistos. Um menino de 1 ano e 8 meses de idade manifestou meningite eosinofílica e exotropia olho direito. A análise de PCR do liquor foi positiva para Angiostrongylus cantonensis. O exame de fundo de olho revelou disco óptico pálido, faixas sub-retinianas, opacidades vítreas, descolamento de retina tracional periférico e um verme morto no vítreo. O paciente foi submetido a vitrectomia posterior via pars plana com a remoção do verme. Concluindo, este é o primeiro relato de caso de angiostrongilíase intravítrea na América do Sul, possivelmente relacionado com a disseminação de uma espécie de lesma exótica neste continente.

Acetylcholine chloride 1% usage for intraoperative cataract surgery miosis / Cloridrato de Acetilcolina 1% na obtenção da miose intraoperatória na cirurgia de catarata

Abstract Objective: To test the efficacy of Acetylcholine chloride use in obtaining intraoperative miosis on phacoemulsification cataract surgery. Methods: Patients with cataract diagnosis and elected for surgical phacoemulsification procedure were selected. All patients underwent conventional phacoemulsification procedure performed by a single surgeon and all patients had 0.2 ml of Acetylcholine chloride 1% irrigated in the anterior chamber at the end of the surgery. The pupillary diameter was measured immediately before the beginning of surgery, immediately before and two minutes after the use of acetylcholine chloride 1%. Results: A total of 30 eyes from 30 patients were included in the study. 18 were female, and mean age was of 69.5 years with a 7.2y standard deviation on the population study. The mean pupillary diameter immediately before the beginning of surgery was 7.5 mm with a standard deviation of 0.56 mm; the mean pupillary diameter immediately before the acetylcholine chloride 1% use (after the intraocular lens im-plantation) was 7.1 mm with a standard deviation of 0.57 mm. The mean pupillary diameter two minutes after the use of acetylcholine chloride 1% in the anterior chamber was 3.4 mm with standard deviation of 0.66 mm. The mean maximum action time of ACH chloride 1% was 64 seconds, with a standard deviation of 8 seconds. The mean intraocular pressure on the first postoperative day was 19.1 mmHg with a standard deviation of 2.45 mmHg. Conclusion: We conclude that acetylcholine chloride 1% is an important drug to obtaining intraoperative miosis in cataract surgery.

Resumo Objetivo: Demonstrar a eficácia do cloridrato de acetilcolina 1% na obtenção da miose intraoperatória na cirurgia de catarata pela técnica de facoemulsificação. Métodos: Pacientes com diagnóstico de catarata e indicação de cirurgia foram selecionados para participar do presente estudo. Todos os pacientes foram operados pela técnica de facoemulsificação convencional pelo mesmo cirurgião, todos foram submetidos à aplicação de 0,2 ml do cloridrato de acetilcolina 1% na câmara anterior ao final do procedimento cirúrgico. A medida do diâmetro pupilar foi realizada imediatamente antes do início da cirurgia, imediatamente antes do uso do cloridrato de acetilcolina 1% e após 2 minutos. Resultados: Foram estudados 30 olhos de 30 pacientes, destes, 18 eram do sexo feminino, a média de idade do estudo foi de 69,5 anos com desvio padrão de 7,2 anos. A média do diâmetro pupilar imediatamente antes do início da cirurgia foi 7,55 mm com desvio padrão de 0,56mm, a média do diâmetro pupilar imediatamente antes do uso do cloridrato de acetilcolina 1% (após implante da lente intraocular no saco capsular) foi 7,1mm com desvio padrão de 0,57mm. A média do diâmetro pupilar após 2 minutos da aplicação da acetilcolina na câmara anterior foi de 3,4 mm com desvio padrão de 0,66mm. O tempo médio de ação máxima do medicamento foi de 64 segundos, com desvio padrão de 8 segundos. A média da pressão intraocular no primeiro dia do pós-operatório foi de 19,1 mmHg com desvio padrão de 2,45mmHg. Conclusão: O estudo acima mostrou que a acetilcolina apresenta boa eficácia na obtenção de miose intraoperatória na cirurgia de facoemulsificação, permitindo uma maior facilidade na confecções das suturas corneanas ou corneo-escleral, reduzindo a incidência de sinéquias anteriores periféricas. Concluimos que o cloridrato de acetilcolina 1% é um importante medicamento na obtenção da miose intraoperatória na cirurgia de catarata.

DRESS syndrome in ophthalmic patients / Síndrome DRESS em pacientes oftalmológicos

ABSTRACT Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and potentially fatal adverse drug reaction associated with skin rash, fever, eosinophilia, and multiple organ injury. A number of pharmacological agents are known to cause DRESS syndrome such as allopurinol, anticonvulsants, vancomycin, trimethoprime-sulfamethoxazole, and pyrimethamine-sulfadiazine. Here, we describe two patients who developed DRESS syndrome during ocular treatment. The first case was being treated for late postoperative endophthalmitis with topical antibiotics, intravenous cephalothin, meropenem, and intravitreal injection of vancomycin and ceftazidime before symptoms developed. We were unable to identify the causal drug owing to the large number of medications concurrently administered. The second case presented with DRESS syndrome symptoms during ocular toxoplasmosis treatment. In this case, a clearer association with pyrimethamine-sulfadiazine was observed. As a result of the regular prescription of pharmacological agents associated with DRESS syndrome, ophthalmologists should be aware of the potentially serious complications of DRESS syndrome.

RESUMO Síndrome DRESS (drug reaction with eosinophilia and systemic symptoms) é uma reação adversa a medicamentos rara e potencialmente fatal, associada à rash cutâneo, febre, eosinofilia e lesão de múltiplos órgãos. Algumas drogas podem desencadeá-la, como: alopurinol, anticonvulsivantes, vancomicina, sulfametoxazol-trimetoprim, sulfadiazina-pirimetamina, entre outras. Descrevemos dois casos que desenvolverem DRESS síndrome durante tratamento ocular. O primeiro caso apresentou os sintomas durante tratamento para endoftalmite pós-operatória tardia com antibióticos tópicos, cefalotina e meropenem intravenosos e injeção intravítrea de vancomicina e ceftazidima; não podemos identificar a droga causadora, pois múltiplas medicações foram utilizadas. O segundo caso desenvolveu os sintomas durante tratamento clássico para toxoplasmose ocular, então a associação com sulfadiazina-pirimetamina foi mais clara. Como muitos oftalmologistas prescrevem regularmente drogas que podem desencadear a síndrome DRESS, esse diagnóstico deve ser lembrado já que pode levar a sérias complicações.

Toxoplasmose e Toxoplasma gondii / Toxoplasmosis and Toxoplasma gondii

A infecção por Toxoplasma gondii é hoje muito disseminada ao redor do mundo, especialmente no Brasil. A coletânea parte da história da descoberta desse parasita e da doença por ele causada, a toxoplasmose, e visita os diferentes aspectos relacionados ao tema. São apresentados o ciclo evolutivo, a epidemiologia, o diagnóstico, o quadro clínico e o tratamento, em uma ampla revisão sobre o assunto, provavelmente a mais completa já realizada. Somente nos anos 1970 desvendou-se o ciclo de vida desse protozoário, do qual o gato é hospedeiro definitivo. Outros animais de sangue quente, entre eles o ser humano, são hospedeiros intermediários. Muitos indivíduos infectados pelo T. gondii não apresentam sintomas, mas, quando a doença se manifesta, pode ter diferentes configurações, afetando gânglios, olhos, coração, pulmões, fígado, cérebro e meninges, ou articulações. Além de uma completa revisão, a obra também traz para o leitor o que há de mais atual no conhecimento científico acerca da toxoplasmose e do T. gondii. O livro cobre praticamente todos os campos do conhecimento sobre o agente etiológico e a doença, apresentando novos aspectos, particularmente em relação à bioquímica, à interação entre o parasita e a célula hospedeira e à resposta imunológica à infecção.