In search of disambiguation: development of eye drop bottle sleeves to aid in identification and survey among possible users. A cross-sectional study

BACKGROUND: Considerable numbers of individuals present low vision, blindness, illiteracy and other conditions that could possibly impair their identification of medications, such as eye drops. Through helping these individuals to identify their eye drops, they can achieve greater autonomy. Misidentification can be avoided through use of multisensory sleeves that can be adapted to most eye drop bottles. Correct use of eye drops is important for preventing progression of diseases like glaucoma that could potentially lead to blindness. OBJECTIVE: To develop bottle sleeves to aid in identification of eye drops and then interview a group of possible users to evaluate the acceptance of the solution. DESIGN AND SETTING: Cross-sectional survey performed at an ophthalmological clinic in São Paulo (SP), Brazil. METHODS: We describe the development of multisensory sleeves to assist in identification of eye drops. To assess the acceptance of this solution, we interviewed 18 patients who were currently using three or more types of eye drops. RESULTS: We developed four prototypes for eye drop bottle sleeves and conducted an acceptance test on them. Most of the patients who answered the survey about the sleeves were elderly. Most (95%) reported believing that the sleeves would help reduce the risk of mixing up eye drops with other medications that also dispense drops. They also believed that these would increase their autonomy in using eye drops. CONCLUSION: The solution presented was well accepted and may help increase safety in using eye drops through preventing misidentification.

In search of disambiguation: development of eye drop bottle sleeves to aid in identification and survey among possible users. A cross-sectional study.

BACKGROUND: Considerable numbers of individuals present low vision, blindness, illiteracy and other conditions that could possibly impair their identification of medications, such as eye drops. Through helping these individuals to identify their eye drops, they can achieve greater autonomy. Misidentification can be avoided through use of multisensory sleeves that can be adapted to most eye drop bottles. Correct use of eye drops is important for preventing progression of diseases like glaucoma that could potentially lead to blindness. OBJECTIVE: To develop bottle sleeves to aid in identification of eye drops and then interview a group of possible users to evaluate the acceptance of the solution. DESIGN AND SETTING: Cross-sectional survey performed at an ophthalmological clinic in São Paulo (SP), Brazil. METHODS: We describe the development of multisensory sleeves to assist in identification of eye drops. To assess the acceptance of this solution, we interviewed 18 patients who were currently using three or more types of eye drops. RESULTS: We developed four prototypes for eye drop bottle sleeves and conducted an acceptance test on them. Most of the patients who answered the survey about the sleeves were elderly. Most (95%) reported believing that the sleeves would help reduce the risk of mixing up eye drops with other medications that also dispense drops. They also believed that these would increase their autonomy in using eye drops. CONCLUSION: The solution presented was well accepted and may help increase safety in using eye drops through preventing misidentification.

Three-dimensional printing of orbital computed tomography scan images for use in ophthalmology teaching / Impressão tridimensional de imagens médicas de tomografia computadorizada para uso no ensino de oftalmologia

ABSTRACT Introduction: The use of tridimensional (3D) printing in healthcare has contributed to the development of instruments and implants. The 3D printing has also been used for teaching future professionals. In order to have a good 3D printed piece, it is necessary to have high quality images, such as the ones from Computerized Tomography (CT scan) exam, which shows the anatomy from different cuts and allows for a good image reconstruction. Purpose: To propose a protocol for creating digital files from computerized tomography images to be printed in 3D and used as didactic material in the ophthalmology field, using open-source software, InVesalius®, Blender® and Repetier-Host©. Methods: Two orbit CT scan exam images in the DICOM format were used to create the virtual file to be printed in 3D. To edit the images, the software InVesalius® (Version 3.1.1) was used to delimit and clean the structure of interest, and also to convert to STL format. The software Blender® (Version 2.80) was used to refine the image. The STL image was then sent to the Repetier-Host© (Version 2.1.3) software, which splits the image in layers and generates the instructions to print the piece in the 3D printer using the polymer polylactic acid (PLA). Results: The printed anatomical pieces printed reproduced most structures, both bone and soft structures, satisfactorily. However, there were some problems during printing, such as the loss of small bone structures, that are naturally surrounded by muscles due to the lack of support. Conclusion: Despite the difficulties faced during the production of the pieces, it was also possible to reproduce the anatomical structures adequately, which indicates that this protocol of 3D printing from medical images is viable.

RESUMO Introdução: O uso de impressão em 3-D na área da saúde tem contribuído para o desenvolvimento de instrumentos e próteses. A impressão 3-D tem sido usada para o ensino de futuros profissionais. Para se alcançar uma boa peça em 3-D, é necessário ter imagens de alta qualidade, como aquelas geradas pelo exame de Tomografia Computadorizada (TC), que mostra a anatomia sob diferentes cortes e permite uma boa reconstrução de imagem. Objetivo: Propor um protocolo para a criação de arquivos digitais a partir de imagens de tomografia computadorizada a serem impressas em 3-D e usadas como modelo de material didático oftalmológico usando software de código aberto, InVesalius®, Bender® e Repetier-Host©. Métodos: Foram utilizadas imagens em formato DICOM provenientes de dois exames de tomografia computadorizada de órbitas para a impressão tridimensional. Para manuseio das imagens, foram utilizados o InVesalius®, versão 3.1.1, para delimitar e limpar a estrutura de interesse e também para converter em formato STL. O Blender®, versão 2.80 foi usado para refinamento. A imagem em STL foi então enviada para o programa Repetier-Host, versão 2.1.3, que divide a imagem em camadas e gera as instruções para impressão da peça em ácido polilático na impressora tridimensional. Resultados: As peças anatômicas impressas reproduziram de forma satisfatória a maioria das estruturas ósseas e musculares. No entanto, houve dificuldade durante a impressão das estruturas ósseas menores, como perda de estrutura óssea pequena, que não possuíam sustentação, por serem envoltas pelo músculo. Conclusão: Apesar das dificuldades encontradas na produção dessas peças de estudo, foi possível reproduzir estruturas com fidelidade, indicando que o protocolo proposto viabiliza a impressão de imagens oriundas da tomografia computadorizada para impressão tridimensional.

Ophthalmic image acquired by ophthalmologists and by allied health personnel as part of a telemedicine strategy: a comparative study of image quality.

OBJECTIVES: This study evaluates the quality of ophthalmic images acquired by a nurse technician trained in teleophthalmology as compared with images acquired by an ophthalmologist, in order to provide a better understanding of the workforce necessary to operate remote care programs. METHODS: A cross-sectional study was performed on 2044 images obtained from 118 participants of the TeleOftalmo project, in Brazil. Fundus and slit-lamp photography were performed on site by an ophthalmologist and by a nurse technician under the supervision of a remote ophthalmologist. Image quality was then evaluated by masked ophthalmologists. Proportion of suitable images in each group was compared. RESULTS: The proportion of concordant classification regarding quality was 94.8%, with a corrected kappa agreement of 0.94. When analyzing each type of photo separately, there was no significant difference in the proportion of suitable images between on-site ophthalmologist and nurse technician with remote ophthalmologist assistance for the following: slit-lamp views of the anterior segment and anterior chamber periphery, and fundus photographs centered on the macula and on the optic disc (P = 0.825, P = 0.997, P = 0.194, and P = 0.449, respectively). For slit-lamp views of the lens, the proportion of suitable images was higher among those obtained by an ophthalmologist (99.6%) than by a technician (93.8%, P < 0.01). CONCLUSIONS: Ophthalmic photographs acquired by a trained technician consistently achieved >90% adequacy for remote reading. Compared with ophthalmologist-acquired photos, the proportion of images deemed suitable achieved a high overall agreement. These findings provide favorable evidence of the adequacy of teleophthalmological imaging by nurse technicians.

Intermittent exotropia evaluation using the propedeutics proposed by Kushner: a 25-year study / Avaliação de exotropia intermitente usando propedêutica proposta por Kushner: estudo de 25 anos

ABSTRACT Purpose: To evaluate the clinical and surgical impacts of phenomena that could occur in intermittent exotropia. Methods: The medical records of intermittent exotropia cases from 1991 to 2014 were retrospectively reviewed. All patients underwent a series of measures, including a protocol to assess monocular occlusion based on the propedeutics proposed by Kushner. Results: Outdoor sensitivity was observed in 31% of patients with an undercorrection rate of 44% vs. 18% of cases with no outdoor sensitivity. After 1 h of monocular occlusion, 41% of all patients achieved an increase in deviation with an undercorrection rate of 40%, whereas 25% did not. Conclusion: The results show the importance of complete propedeutics, since there is a higher rate of late undercorrection in cases with outdoor sensitivity and increased deviation after occlusion.

RESUMO Objetivo: Avaliar os impactos clínico e cirúrgico dos fenômenos que podem ocorrer na exotropia intermitente. Métodos: Os prontuários de casos de exotropia intermitente de 1991 a 2014 foram revisados retrospectivamente. Todos os pacientes foram submetidos a uma serie de medidas incluindo o protocolo com oclusão monocular com base na propedêutica proposta por Kushner. Resultados: Outdoor sensitivity foi observada em 31% dos pacientes com taxa de subcorreção de 44% vs. 18% dos casos sem outdoor sensitivity. Após 1 hora de oclusão monocular, 41% de todos os pacientes apresentaram um aumento no desvio com uma taxa de subcorreção 40%, enquanto 25% não. Conclusão: Os resultados demonstram a importância da propedêutica completa, uma vez que há maior taxa de subcorreção tardia nos casos de outdoor sensitivity e maior desvio após a oclusão.

Intermittent exotropia evaluation using the propedeutics proposed by Kushner: a 25-year study.

PURPOSE: To evaluate the clinical and surgical impacts of phenomena that could occur in intermittent exotropia. METHODS: The medical records of intermittent exotropia cases from 1991 to 2014 were retrospectively reviewed. All patients underwent a series of measures, including a protocol to assess monocular occlusion based on the propedeutics proposed by Kushner. RESULTS: Outdoor sensitivity was observed in 31% of patients with an undercorrection rate of 44% vs. 18% of cases with no outdoor sensitivity. After 1 h of monocular occlusion, 41% of all patients achieved an increase in deviation with an undercorrection rate of 40%, whereas 25% did not. CONCLUSION: The results show the importance of complete propedeutics, since there is a higher rate of late undercorrection in cases with outdoor sensitivity and increased deviation after occlusion.

When color helps. / Quando a cor ajuda.

OBJECTIVE: To reduce the inappropriate identification of eye drops, through the use of different colors. METHODS: A group of 34 healthy volunteers was presented to two groups of four eye drops each. All eye drops were placed in identical, unlabelled vials. In one group, all four eye drops were transparent. In the other group, each had a different color. A number was assigned to each eye drop, and the volunteer was asked to identify it by color. We measured the correct index in the identification of the eye drops of the two groups. RESULTS: The volunteers had a level of education from incomplete junior school to complete graduate course, with 16 males (48%) and 18 females (52%), age range of 21 to 87 years. The success rate in the group of colored eye drops was 88% and, in the group of transparent, 24%. CONCLUSION: The use of colorings in eye drops can help distinguishing the vials and preventing misidentification.

OBJETIVO: Reduzir a identificação errônea de colírios, por meio do uso de substâncias com cores diferentes. MÉTODOS: Um grupo de 34 voluntários saudáveis foi apresentado a dois grupos de quatro colírios cada. Todos os colírios foram colocados em frascos idênticos sem rótulo. Em um grupo de quatro colírios, todos tinham conteúdos transparentes. No outro grupo, cada um dos quatro possuía uma substância de cor diferente. A cada um foi atribuído um número, e o voluntário foi solicitado a identificá-lo por meio da cor. Medimos o índice de acerto na identificação dos colírios dos dois grupos. RESULTADOS: Os voluntários possuíam nível de formação desde Fundamental incompleto até Pós-Graduação completa, sendo 16 do sexo masculino (48%) e 18 do sexo feminino (52%), com idades variando de 21 até 87 anos. O índice de acerto no grupo de colírios coloridos foi de 88% e, no grupo de colírios transparentes, de 24%. CONCLUSÃO: O uso de colorações em colírios pode auxiliar na diferenciação entre os frascos e prevenir a identificação errônea.

Third Cranial Nerve Palsy after a Chikungunya Virus Infection.

Chikungunya fever is a disease caused by a virus from the same family as dengue and Zika. It is endemic in several parts of the world and has recently spread to Latin America. We report the case of a patient, aged 58 years, from Rio de Janeiro, Brazil, who in 2013 developed an acute bilateral third cranial nerve palsy sparing the pupil. After extensive investigation, it was diagnosed as caused by chikungunya infection. The patient was treated with pulse therapy and after 5 months of the onset of the condition, the patient showed improvement.

Avaliação de aplicação única subconjuntival pré-operatória de mitomicina C em pterígio primário / Evaluation of preoperative subconjunctival single application of mitomycin C in primary pterygium

Resumo Pterígios são lesões geralmente benignas que na maioria dos casos não requer tratamento específico. É um crescimento fibrovascular sobre a córnea, geralmente a partir do lado nasal. Sua causa ainda não foi elucidada, mas parece estar relacionada à exposição aos raios ultravioleta. Quando os sintomas não são controlados com tratamento conservador, a cirurgia é indicada, porém o índice de recidiva ainda é alto, e os esforços têm sido no sentido de reduzir esse índice. A mitomicina C (MMC) é uma opção de adjuvante à cirurgia por ser um inibidor da proliferação de fibroblastos, diminuindo o risco de recorrência do pterígio. Relatamos aqui um caso que descreve cirurgia de pterígio realizada em ambos os olhos de uma mesma paciente, sendo um com MMC e outro sem ela. Os resultados e o índice de proliferação celular dos dois olhos foram comparados entre si.

Abstract Pterygia are usually benign lesions that do not require specific treatment. It is a fibrovascular growth onto the nasal side of the cornea. It`s cause has not been fully elucidated yet, but seems to be related to long -term ultraviolet ray exposure. When symptoms are not controlled with conservative treatment surgery is considered, but the recurrence rate is still high, and efforts have been made to avoid it. Mitomycin C (MMC) is a fibroblast proliferation inhibitor that can be used as adjuvant to surgery to reduce recurrence. We report here a case that describes pterygium surgery performed in both eyes of the same patient, being one with MMC and the other eye without it. Both pterygium were sent to laboratory analysis. The results and proliferation index were compared between the eyes.

Ceratite intersticial em paciente com Síndrome de Cogan / Interstitial keratitis in patients with Cogan's Syndrome

RESUMO A Síndrome de Cogan é caracterizada pela ceratite intersticial não luética associada à vertigem, tinnitus e disacusia neurossensorial. Relatamos um caso que ilustra um modelo da intervenção multidisciplinar no diagnóstico e tratamento da doença.

ABSTRACT Cogan's syndrome is characterized by interstitial keratitis non-syphilis associated with vertigo, tinnitus and sensorineural hearing loss. We report a case that illustrates a model of multidisciplinary intervention in the diagnosis and treatment of disease.

Pterígio sob flap de LASIK / Pterygium growing below the LASIK flap region

RESUMO O pterigio é uma lesão fibrovascular da superfície ocular que pode ter um comportamento agressivo e em alguns casos ameaçar a visão. Embora não exista consenso da sua patogênese, evidências recentes sugerem que seja uma condição proliferativa relacionada com a exposição à radiação ultravioleta. Relatamos aqui um caso de pterígio que cresceu sob a região do flap de cirurgia refrativa (LASIK).

ABSTRACT Pterygium is a fibrovascular lesion of the ocular surface that can display an aggressive clinical behavior and, occasionally, threaten vision. Although there is no consensus on its pathogenesis, recent evidence suggests that it is a proliferative, rather than degenerative condition, strongly correlated with exposure to ultraviolet radiation. We report a case of pterygium that grew up bellow the flap Lasik region after the surgery.

Mitomycin C in pterygium treatment.

Pterygium is a benign lesion usually growing from the nasal side of the conjunctiva onto the cornea. Most cases of pterygium does not cause problem or requires specific treatment. The exact cause of pterygium is not clear yet, but some factors are pointed as causes, being the most important the long-term ultraviolet ray exposure. Pterygium surgery is usually considered when there are symptoms that do not respond to conservative treatment. Recurrence is the main complication of the surgery, and much has been done to avoid it. Mitomycin C (MMC) has been used as a fibroblast proliferation inhibitor during the surgery to reduce the chance of recurrence of the pterygium. This review describes the use of MMC as an adjunctive, the optimal dosage, the duration of administration of MMC and possible complications, when used during, after and before the surgery. Most studies suggest that increased exposure (dose or duration) of MMC is associated with a lower recurrence, but with higher risks of complications.