Repetibilidade do estudo tomográfico da córnea com Scheimpflug rotacional, em olhos normais, olhos com ceratocone e olhos com ceratocone operados por crosslinking / Repeatability of the tomographic study of the cornea with a rotational Scheimpflug in normal eyes, eyes with keratoconus and eyes with crosslinking for keratoconus

RESUMO Objetivo Avaliar a precisão da tomografia corneana com imagens de Scheimpflug (Pentacam® AXL, OCULUS, Wetzlar, Alemanha) nos padrões de escaneamento com 25 e 50 imagens, verificando sua repetibilidade e reprodutibilidade em olhos normais, com ceratocone e com ceratocone após crosslinking. Métodos Estudo prospectivo, transversal, misto, no qual foram incluídos os pacientes que tinham córneas normais, ou com ceratocone; e não tinham realizado cirurgias corneanas, com exceção do crosslinking. Foram excluídos os pacientes que tivessem realizado outras cirurgias, como implante de anel intracorneano ou transplante de córnea. Foram realizadas três medidas com 25 imagens e três medidas com 50 imagens em cada olho incluído no estudo. Resultados O estudo avaliou 54 olhos de 41 pacientes. Destes, dez (18,52%) olhos eram com córneas normais e sem cirurgia ocular prévia aleatoriamente selecionados de 5 pacientes; 22 (40,74%) olhos aleatoriamente selecionados de 18 pacientes com ceratocone, sem cirurgia ocular prévia; e 22 (40,74%) olhos com ceratocone de 18 pacientes operados por crosslinking. No estudo da repetibilidade, percebemos uma maior variação de valores em todos os índices nos pacientes com ceratocone comparados aos de pacientes com olhos normais, em grande parte dos parâmetros analisados. Conclusão Não houve diferença significativa entre os métodos de escaneamento por 25 e 50 imagens, sendo o escaneamento por 25 imagens mais conveniente. A presença de ceratocone teve impacto negativo na repetibilidade de ambos os tipos de exame, e foi grande a concordância entre os métodos nos três grupos estudados. O coeficiente de repetibilidade permite considerar a relevância clínica dos dados para avaliar a progressão de ceratocone.

ABSTRACT Objective To evaluate the accuracy of corneal tomography with Scheimpflug images (Pentacam® AXL, OCULUS, Wetzlar, Germany) in scanning patterns with 25 and 50 images, by analyzing their repeatability and reproducibility in normal eyes, eyes with keratoconus and with keratoconus after crosslinking. Methods Prospective, cross-sectional, mixed study including patients who had normal corneas, or who had keratoconus, who had not undergone corneal surgery, with the exception of crosslinking. Patients who had undergone surgery for intracorneal ring implantation or corneal transplantation were excluded. Three measurements were performed with 25 images and three measurements were performed with 50 images on each eye included in the study. Results The study evaluated a total of 54 eyes of 41 patients. Of these, 10 (18.52%) eyes had normal corneas, without previous eye surgery, 22 (40.74%) were eyes with keratoconus, without previous eye surgery, and 22 (40.74%) were eyes with keratoconus, with crosslinking for keratoconus. In the study of repeatability, we noticed a greater variation of values in all indices in patients with KC compared to those with normal eyes, in most of the parameters analyzed. Conclusion There is no significant difference between the scanning methods with 25 and 50 images. However, 25 scans has advantages that make it the main method suggested. The presence of keratoconus has a negative impact on the repeatability of both types of examination, and there is great agreement between the methods in the three groups studied. The high repeatability coefficient in some parameters suggests that these data should be used with care in the assessment of keratoconus progression.

Intrastromal Corneal Ring Segments Implantation and Descemet Membrane Endothelial Keratoplasty for Coexisting Keratoconus and Fuchs Endothelial Dystrophy.

PURPOSE: To report two cases of coexisting keratoconus and Fuchs endothelial dystrophy treated with intrastromal corneal ring segments (ICRS) implantation and Descemet membrane endothelial keratoplasty (DMEK). METHODS: Two patients with coexisting keratoconus and Fuchs endothelial dystrophy underwent ICRS implantation and DMEK, in a two-stage procedure. Follow-up evaluation included Scheimpflug tomography and optical coherence tomography. RESULTS: In both cases, ICRS implantation improved corneal topography and DMEK restored normal corneal thickness. Corrected distance visual acuity improved from 20/100 to 20/30 and from 20/60 to 20/25. Urrets-Zavalía syndrome was diagnosed in one case and addressed with colored contact lens fitting. CONCLUSIONS: Low vision resulting from coexisting keratoconus and Fuchs endothelial dystrophy might be addressed more selectively with posterior lamellar keratoplasty and ICRS implantation. Urrets-Zavalía syndrome must be considered a possible complication after DMEK, especially in patients with keratoconus. [J Refract Surg. 2020;36(10):703-706.].

Aplanamento corneano após DMEK associado a facoemulsificação em paciente com distrofia endotelial de Fuchs, ceratocone e catarata / Corneal flattening after simultaneous DMEK and phacoemulsification in patient with Fuchs endothelial dystrophy, keratoconus and cataract combined

Resumo Descrição de relato de caso de paciente com ceratocone (KC), Distrofia Endotelial de Fuchs (DEF) e catarata concomitantes com descompensação corneana submetido a Ceratoplastia Lamelar Posterior pela técnica Descemet's Membrane Endothelial Keratoplasty (DMEK) associado a facoemulsificação com implante de lente intraocular (LIO). Observou-se aplanamento corneano significativo no pós-operatório e acuidade visual final sem correção de 20/25 . Destaca-se a possibilidade do DMEK como alternativa à Ceratoplastia Penetrante (Penetrating Keratoplasty - PK) em casos de DEF e KC associados. Aplanamento corneano pode ocorrer neste grupo de pacientes, o que pode resultar em imprevisibilidade refracional no cálculo do poder da LIO ao se optar por facectomia combinada. Neste relato, apesar da modificação da curvatura corneana após cirurgia combinada de DMEK com facectomia, a acuidade visual final sem correção foi satisfatória, demonstrando a possibilidade de sucesso desta abordagem na coexistência de DEF, KC e Catarata. Entretanto, a possibilidade de mudança significativa na curvatura corneana deve ser considerada em pacientes com KC, edema de córnea secundário a DEF e catarata, na decisão de cirurgia simultânea ou em dois tempos.

Abstract This is a case report of a patient with concomitant Keratoconus (KC), Fuchs Endothelial Dystrophy (FED) and cataract with corneal decompensation submitted to Posterior Lamellar Corneal surgery (Descemet's Membrane Endothelial Keratoplasty - DMEK) associated with phacoemulsification with intraocular lens (IOL) implantation. Corneal flattening and uncorrected visual acuity of 20/25 was observed in the postoperative period. We reasure the viability of DMEK as an alternative to Penetrating Keratoplasty (PK) in cases of associated DEF and KC associated. Changes in corneal curvature may occur in this group of patients and lead to the possibility of refractive unpredictability in IOL calculation when performing a combined cataract surgery. Despite unexpected corneal flattening, satisfactory final visual acuity was achieved, demonstrating the possibility of success of this approach in the coexistence of the three conditions. Nonetheless, the possibility of corneal curvature changes should be considered in patients with KC and corneal decompensation due to FED in decision making, regarding simultaneous or sequential surgical approach.

[Malignant melanoma of the conjunctiva]. / Melanoma maligno conjuntival.

INTRODUCTION: Melanocytic tumors comprise a wide range of lesions. These lesions can be nevi, primary acquired melanosis with or without atypia or malignant as conjunctival melanoma. Early recognition of the clinical features allows precise diagnosis and adequate intervention, reducing the rates of metastatic disease and mortality associated with conjunctival melanoma. PURPOSE: To review clinical features, diagnosis, clinical and surgical treatment modalities of the different precursor pigmented lesions (Nevi and primary acquired melanosis) and malignant melanoma. METHODS: Literature review was performed accessing the database of MEDLINE, PUBMED, LILACS e SciELO between 1980 and 2011. The keywords used, individually or combined, were: conjunctival melanoma, primary acquired melanosis, nevi, treatment, chemotherapy, recurrence, metastasis e mortality. RESULTS: Relevant clinical information for the diagnosis of malignant melanoma and differentiation from other pigmented conjunctival lesions were accessed. Clinical and pathological features and different modalities of treatment for malignant melanoma have been reviewed. CONCLUSIONS: Patients presenting with a pigmented conjunctival lesion should be evaluated by an experienced ophthalmologist. Ocular history, family history of melanoma, and clinical features of the lesion need careful assessment and malignancy risk evaluation. Digital photo documentation should be performed. Clinical or surgical planning should be done based on the clinical suspicion. Careful histopathology analysis is required for treatment orientation and prognostic factors identification, mainly in cases of malignancy.

Melanoma maligno conjuntival / Malignant melanoma of the conjunctiva

INTRODUÇÃO: Os tumores melanocíticos conjuntivais compreendem lesões que podem variar desde lesões benignas como os nevos conjuntivais, lesões pré-cancerosas como melanose adquirida primária com atipia até o melanoma maligno conjuntival. O reconhecimento das características clinicas destas lesões e seu diagnóstico preciso permitem o tratamento adequado, contribuindo para a redução da morbidade e mortalidade associados ao melanoma de conjuntiva. OBJETIVO: Revisão das características clinicas, diagnóstico e modalidades de tratamento clínico e cirúrgico das lesões precursoras (Nevos e melanose adquirida primária) e do maligno conjuntival. MÉTODOS: Revisão de literatura através de pesquisa no banco de dados MEDLINE, PUBMED, LILACS e SciELO no período de 1980 a 2011. As palavras-chave utilizadas, individualmente ou em conjunto, foram: "conjunctival melanoma", "primary acquired melanosis", "nevi", "treatment", "chemotherapy", "recurrence", "metastasis" e "mortality". RESULTADO: Características clínicas que permitem o diagnóstico do melanoma conjuntival e sua diferenciação de outras lesões pigmentadas conjuntivais foram consideradas. O estadiamento clínico e patológico, assim como modalidades de tratamento para o melanoma maligno foram revisadas. CONCLUSÕES: Pacientes portadores de lesões pigmentadas conjuntivais devem ser avaliados por um oftalmologista especialista. A história oftalmológica, a história familiar de melanoma, e características clínicas da lesão necessitam de cuidadosa avaliação, incluindo-se a determinação do risco de malignidade. A documentação fotográfica deve ser realizada. O tratamento clínico e planejamento cirúrgico devem ser baseados na suspeita clinica. A análise histopatológica por patologista experiente é fundamental para orientação do tratamento e para identificação de fatores prognósticos, principalmente em casos de doença maligna.

INTRODUCTION: Melanocytic tumors comprise a wide range of lesions. These lesions can be nevi, primary acquired melanosis with or without atypia or malignant as conjunctival melanoma. Early recognition of the clinical features allows precise diagnosis and adequate intervention, reducing the rates of metastatic disease and mortality associated with conjunctival melanoma. PURPOSE: To review clinical features, diagnosis, clinical and surgical treatment modalities of the different precursor pigmented lesions (Nevi and primary acquired melanosis) and malignant melanoma. METHODS: Literature review was performed accessing the database of MEDLINE, PUBMED, LILACS e SciELO between 1980 and 2011. The keywords used, individually or combined, were: conjunctival melanoma, primary acquired melanosis, nevi, treatment, chemotherapy, recurrence, metastasis e mortality. RESULTS: Relevant clinical information for the diagnosis of malignant melanoma and differentiation from other pigmented conjunctival lesions were accessed. Clinical and pathological features and different modalities of treatment for malignant melanoma have been reviewed. CONCLUSIONS: Patients presenting with a pigmented conjunctival lesion should be evaluated by an experienced ophthalmologist. Ocular history, family history of melanoma, and clinical features of the lesion need careful assessment and malignancy risk evaluation. Digital photo documentation should be performed. Clinical or surgical planning should be done based on the clinical suspicion. Careful histopathology analysis is required for treatment orientation and prognostic factors identification, mainly in cases of malignancy.