Abstract: Purpose: To determine the clinical characteristics and seasonal distribution of patients admitted to the ocular emergency department of a tertiary ophthalmology care center. Methods: The study cohort includes 27,120 patients who were admitted to ocular emergency room between November 2013 and November 2014. The age, sex, reason for admission, diagnosis, and complete ocular examination reports were recorded for each patient. X-ray and ultrasonographic examinations were performed if necessary. Results: The mean patient age was 32.83 ± 17.62 years (range, 0-95). The number of males was nearly two times the number of females, with 18,808 (69.4%) males and 8312 (30.6%) females. The diagnoses included viral conjunctivitis (7,859 patients; 29.0%), corneal foreign body (5,286 patients; 19.5%), bacterial conjunctivitis (3,892 patients; 14.4%), corneal abrasions (2,306 patients; 8.5%), and allergic conjunctivitis (1,433 patients; 5.3%) (Table 1). Other frequent diagnoses included subconjunctival hemorrhage, photo keratopathy, chemical eye injury, and penetrating and blunt eye injuries. Allergic conjunctivitis, ocular trauma, and corneal foreign body were more frequent in spring, whereas keratitis and chemical eye injury were more common in winter (chi-square test). The most common reasons for emergency room admission, in order of frequency, were viral conjunctivitis, corneal foreign body, bacterial conjunctivitis, and corneal abrasions. Conclusion: This study is the first long-term prospective study to evaluate the seasonal distribution and diagnosis of all adult and pediatric patients admitted to the emergency room for ocular conditions. The frequency of ophthalmological conditions seen in the emergency room may vary according to the season.

Abstract: Purpose: We aimed to evaluate the visual quality performance of scleral contact lenses in patients with keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism, and their impact on quality of life. Methods: We included 40 patients (58 eyes) with keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism who were examined between October 2014 and June 2017 and fitted with scleral contact lenses in this study. Before fitting scleral contact lenses, we noted refraction, uncorrected distance visual acuity, spectacle-corrected distance visual acuity, uncorrected contrast sensitivity, and spectacle-corrected contrast sensitivity. We performed corneal topography on and applied a questionnaire that included the National Eye Institute Visual Functioning Questionnaire to all participants. We recorded corrected contrast sensitivity and corrected distance visual acuity on the third month after fitting scleral contact lenses and requested that subjects repeat the National Eye Institute Visual Functioning Questionnaire. Results: The mean age of patients was 28.12 ± 13.19 years. Mean logMAR uncorrected distance visual acuity, spectacle-corrected distance visual acuity, and corrected distance visual acuity with scleral contact lenses were 0.91 ± 0.21 (0.40-1.80), 0.57 ± 0.12 (0.10-1.80), and 0.16 ± 0.02 (0.00-1.30), respectively. We observed significantly higher corrected distance visual acuity with scleral contact lenses compared with uncorrected distance visual acuity and spectacle-corrected distance visual acuity (p<0.05). Mean uncorrected contrast sensitivity, spectacle-corrected contrast sensitivity and CCS with scleral contact lenses were 0.97 ± 0.12 (0.30-1.65), 1.16 ± 0.51 (0.30-1.80), and 1.51 ± 0.25 (0.90-1.80), respectively. Significantly higher contrast sensitivity levels were recorded with scleral contact lenses compared with those recorded with uncorrected contrast sensitivity and spectacle-corrected contrast sensitivity (p<0.05). We found the National Eye Institute Visual Functioning Questionnaire overall score for patients with scleral contact lens treatment to be significantly higher compared with that for patients with uncorrected sight (p<0.05). Conclusion: Scleral contact lenses are an effective alternative visual correction method for keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism. A significant increase in visual acuity and contrast sensitivity can be obtained with scleral contact lenses in patients with irregular corneas.

Abstract: Purpose: To evaluate the effect of air pollution on the ocular surface of patients with Sjogren’s syndrome. Methods: We investigated the ocular surfaces of thirty patients with Sjogren’s syndrome and thirty healthy volunteers (control group) living in the Metropolitan Area of Buenos Aires. We used nitrogen dioxide as an indicator of exposure to air pollution. An ocular symptoms questionnaire was answered by all subjects, who also underwent a complete ocular surface ophthalmic examination-including an Ocular Surface Disease Index questionnaire, biomicroscopy, tear breakup time, Schirmer 1 test, corneal and conjunctival vital staining with fluorescein and lissamine green, tear lysozyme concentration, and impression cytology. Results: In almost all ocular surface test findings, we found a positive and significant correlation between higher levels of exposure to air pollution and higher levels of ocular surface damage in both the control group and Sjogren’s syndrome patients. In Sjogren’s syndrome patients, the Ocular Surface Disease Index questionnaire, tear breakup time, vital staining and impression cytology showed a significant correlation between high levels of air pollution and ocular surface disease. In the control group, the Ocular Surface Disease Index questionnaire, tear breakup time, and impression cytology showed a significant correlation between high levels of air pollution and ocular surface disease. Conclusions: Here we demonstrated that in patients with dry eye syndrome associated with Sjogren, abnormalities of the ocular surface and eye irritation related to air pollution are more severe than those in the control group. We believe that measuring air quality should be not only an integral part of the evaluation of ocular surface disease but also a therapeutic consideration.

Abstract: Purpose: We aimed to evaluate the safety of single intravitreal injection of each of two concentrations of 0.1 ml of sunitinib (1 and 10 mg/ml), 0.1 ml of a drug-free dispersion containing solid lipid nanoparticles, and 0.1 ml of a drug-free dispersion containing polymeric nanocapsules for analyzing the possible toxic effects using electrophysiology and histology in albino rabbit retina. Methods: We conducted an experimental controlled study of 20 eyes of albino rabbits. Intravitreal injections of each specific agent were applied to one eye per rabbit in each 5-rabbit group, while the contralateral eyes received no treatment and were used as controls. Results: We noted no electroretinographic changes in the sunitinib (1 and 10 mg/ml) or in solid lipid nanoparticles groups. However, we observed significant abnormalities in ocular morphology and in the electroretinogram in the nanocapsules group. At the histological level, only the nanocapsules group demonstrated abnormal changes, including severe edema and cytoplasmic vacuole formation. Conclusions: While nanocapsules intravitreal injections indicated retinal toxic effects, sunitinib and solid lipid nanoparticles intravitreal injections were not toxic to the retina. Our results suggest that a sunitinib preparation with solid lipid nanoparticles for controlled release may offer a significant therapeutic approach for vasoproliferative ocular disease.

Abstract: Nature has always provided an unlimited source of biologically-active compounds. Since the beginning of mankind, humans have sought resources in fauna and flora to treat eye diseases. However, it was only after the Industrial Revolution that extracts of plants and substances of animal origin could be used safely, as has been determined by controlled interventional studies. Two major challenges faced by ocular pharmacology are the following: developing drugs that are able to reduce blindness due to glaucoma; and controlling the pain associated with eye surgery. The search for a drug that effectively lowers intraocular pressure and controls the progression of glaucoma has led to the development of various ocular hypotensive agents, such as physostigmine from the Physostigma venenosum plant. The anesthetic properties of cocaine, extracted from Erythroxylon coca, finally enabled surgical procedures in the eye. Several new natural compounds have been investigated in an attempt to identify substances with the potential to provide additional benefits to eye tissue and vision. Emerging evidence of anti-inflammatory, wound-healing, antimicrobial, antioxidant, antitumor, and antiangiogenic properties attributed to plant extracts and animal tissues has encouraged more investment in research in this area. Despite technological advances in synthesizing drugs, the pharmaceutical industry still seeks new active compounds from natural sources as well as from revisiting already-established naturally derived compounds. Although a large number of naturally-occurring compounds is known, this review article focuses on the bioactive substances with scientifically-proven benefits for ocular tissues.

Abstract: PURPOSE Malignant lesions of the eyelid are the most common eye cancers. Although rarely lethal, late diagnosis can lead to serious visual morbidity. Definitive diagnosis of neoplastic lesions is pathological. Indications and types of eyelid lesions in a single high-volume ophthalmic reference center in Sao Paulo, Brazil, were analyzed. METHODS The surgical pathological reports of patients who underwent eye removal procedures between January 2000 and December 2012 were retrieved from the electronic database of the Ophthalmology Department and retrospectively reviewed. Data regarding the final anatomopathological diagnosis, sex, and age were analyzed via the χ2 test with Yates' correction. RESULTS Of the 1,113 eyelid tumors resected over the 13-year study period, 324 (29%) lesions were malignant. The most prevalent lesions were basal cell, squamous cell, and sebaceous gland carcinomas. The median ages of patients (females, n=165, 51%; males, n=159, 49%) with a diagnosis of basal cell, squamous cell, and sebaceous gland carcinomas were 65, 75, and 70 years, respectively. CONCLUSION This is the largest retrospective cohort analysis of eyelid tumors in a Latin American population. These findings are in agreement with those from large centers in other countries and regions.

Abstract: Purpose: To evaluate the effect of superior blepharoplasty on the tear film using the corneal topographer Keratograph 5M. Methods: A prospective study was performed of 27 eyes of 14 patients with superior dermatochalasis who underwent superior blepharoplasty between May and June 2016. Conservative upper eyelid blepharoplasty was performed by an en bloc resection of anterior lamellar tissue that included skin, subcutaneous tissue, and the orbicularis oculi muscle. All the eyes were imaged using the noninvasive tear breakup time tools of the Keratograph 5M. The following parameters were recorded in each patient before and 6 weeks after surgery: first noninvasive Keratograph 5M tear breakup time (the time at which the first breakup of tears occurs) and average noninvasive Keratograph 5M tear breakup time (the average time of all breakup incidents). The exclusion criteria were ophthalmological pathology, previous eyelid surgery, use of eye drops, systemic pathology, and medication that interferes with lacrimal tears. Results: The mean age of the patients was 65.1 years (range, 51-84); 86% were female. Student’s t-test was used to compare the values of first and average noninvasive Keratograph 5M tear breakup times before and after surgery. The values for first noninvasive Keratograph 5M tear breakup time evaluated before and after surgery were not significantly different (9.04 and 8.71, respectively; p=0.926). The values for average noninvasive Keratograph 5M tear breakup time evaluated before and after surgery were also not significantly different (13.01 seconds and 13.14 seconds, respectively; p=0.835). Conclusions: The results of this pilot study suggest that upper blepharoplasty does not affect tear breakup time according to the objective evaluation of breakup time with the Keratograph 5M.

Abstract: Purpose: To evaluate the outcomes of dermis-fat graft procedure for orbital volume replacement in anophthalmic socket Methods: A retrospective chart review was performed studying all dermis-fat graft surgeries done at King Khlaed Eye Specialist Hospital in the last 10-year period Sixty-two anophthalmic socket carriers underwent dermis-fat graft during the study period Data were collected on characteristics of the patients, postoperative complications, cosmesis, and functional results such as the ability to hold an external prosthesis Results: Mean age of the patients included in the study was 342 ± 97 years There were 387% of patients with grade 3 anophthalmic socket, 645% of patients had an acquired anophthalmic socket, and dermis-fat graft was performed as a secondary procedure in 613% of patients Postoperative complications included lagophthalmos (226%), graft necrosis (177%), pyogenic granuloma (129%), decreased graft size (129%), malpositioned lids (32%), and volume deficiency (32%) The prosthesis was held in place in 49 patients (79%) preoperatively and in 55 patients (887%) postoperatively Conclusion: Dermis-fat graft is an excellent option for congenital or acquired as well as primary or secondary anophthalmic sockets, with or without contraction The outcomes are favorable, and complications are rare

Abstract: Purpose: This study aimed to compare the effectiveness of eye drops containing a combination of sodium hyaluronate and trehalose and sodium hyaluronate for the treatment of corneal cross-linking and epithelial healing. Methods: This study included 46 eyes of 23 keratoconus patients who underwent corneal cross-linking on both eyes. Unpreserved trehalose 30 mg/mL and sodium hyaluronate 1.5 mg/mL (Thealoz Duo®; Thea, France) were applied six times a day on one eye of each patient and unpreserved sodium hyaluronate 0.15% (Eye Still®; Teka, Inc., Istanbul) was applied on the other eye. Patients were examined daily until complete re-epithelialization. Postoperative examinations to assess the measured size of epithelial defect were performed using slit-lamp biomicroscopy. Results: The study included 23 patients (13 females and 10 males) with a mean age of 20.9 ± 10.3 years. Corneal epithelial healing time after cross-linking was 2.3 ± 1.2 days for the trehalose and sodium hyaluronate group and 3.8 ± 2.9 days for the sodium hyaluronate group (p=0.03). Conclusion: The application of eye drops containing the combination of trehalose and sodium hyaluronate resulted in faster corneal re-epithelialization following corneal cross-linking than that of eye drops containing sodium hyaluronate alone.

Abstract: Purpose: To determine the release profile of moxifloxacin encapsulated in liposomes in the aqueous humor as a controlled release system for intracameral application. Methods: Liposomes containing moxifloxacin were obtained using the lipid film hydration method and were characterized by particle size and encapsulation efficiency. Female rabbits were used for the in vivo profile release study. Liposomes containing moxifloxacin was injected into the anterior chamber of the right eye of each animal. The rabbits were divided into five groups, and a sample of aqueous humor was collected 2, 4, 8, 24, and 48 h after administration of liposomes containing moxifloxacin administration. Moxifloxacin concentrations in the aqueous humor were analyzed using high-performance liquid chromatography. Results: The average size of the liposomes containing moxifloxacin was 60.5 ± 0.72 nm with a particle size distribution of 0.307. The encapsulation efficiency of moxifloxacin in liposomes was 92.24 ± 0.24%. The results of an in vivo release study of liposomes containing moxifloxacin, showed that the maximum moxifloxacin concentration was achieved within the first 2 h after administration (5.27 ± 1.09 mg/mL) and was followed by a decrease in intracameral concentration (0.35 ± 0.05 mg/mL) until the 24 h mark. Conclusions: The in vivo experiments resulted in liposomes containing moxifloxacin that were homogenous in size and exhibited high drug encapsulation efficiency. The results indicate that liposomes containing moxifloxacin offers a satisfactory aqueous humor release profile after intracameral application.

Abstract: Purpose: To compare the efficacy of 0.03% to­pical tacrolimus in combination with oral omega (ω) 3 with different ratios of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and antioxidants as adjuvant in the treatment of keratoconjunctivitis sicca (KCS) in dogs. Methods: Forty-five dogs with KCS were evaluated monthly for 6 months. Evaluations included performance of the Schirmer tear, fluorescein, and lissamine green tests. Tear film break-up time (TBUT) was assessed. Conjunctival cytology was evaluated at the beginning, middle, and end of the study. Conjunctiva was biopsied at the beginning and end of the study. Dogs were randomly assigned to one of the three groups (n=15): Group T (topical tacrolimus 0.03%), Group TO (topical tacrolimus + ω-1.5 EPA: 1 DHA), or Group TOA (topical tacrolimus + ω-1 EPA:4.5 DHA + antioxidants). Results: There was a significant improvement in clinical signs in all groups. TBUT increased throughout treatment in all groups; this effect was most pronounced in Group TO. Cytological analysis performed at the end of the study period, showed decreased levels of lymphocytes, neutrophils, and metaplastic and squamous cells in Groups T, TO, and TOA. Histological analysis performed at the end of the study period showed decreased levels of lymphocytes and neutrophils and increased levels of goblet cells. These effects were most pronounced in Group TO. Conclusion: Oral treatment with ω-3 containing a higher proportion of EPA than DHA increased the effectiveness of topical tacrolimus 0.03% in the treatment of keratoconjunctivitis sicca in dogs.

Abstract: The diagnosis of angle-closure glaucoma secondary to iridociliary cysts is challenging and lacks compiled literature support. We present a rare case of bilateral angle-closure glaucoma associated with pseudoplateau iris due to multiple ciliary cysts and conducted a systematic review of the literature to find similar case reports published between November 2006 and November 2016. Only 19 case reports present treatment modalities, and most cases required more than one therapeutic approach for controlling the intraocular pressure. Pseudoplateau iris attributed to iridociliary cysts should be considered in the differential diagnosis of patients with narrow angles, particularly those with ocular hypertension and glaucoma, in which management is complex. In addition to gonioscopy, ultrasound biomicroscopy is considered the conclusive method for accurate diagnosis.

Abstract: Purpose: To compare the anterior segment parameters of patients with pseudoexfoliation syndrome, patients with pseudoexfoliation glaucoma, and normal subjects. Methods: This prospective, controlled, comparative study included 150 eyes of 150 patients. The patients were divided into the pseudoexfoliation syndrome group, the pseudoexfoliation glaucoma group, and the control group (50 patients in each group). Axial length, central corneal thickness, aqueous depth, anterior chamber depth, lens thickness, K1 and K2 keratometry values, and white to white distance measurements were obtained by optical biometry and compared between the groups. Results: The mean ages of the pseudoexfoliation syndrome, pseudoexfoliation glaucoma, and control patients were 62.18 ± 6.21, 61.80 ± 6.62, and 59.40 ± 6.89 years, respectively. There were no statistically significant differences between the groups in mean age or sex ratio (p>0.05). Mean central corneal thickness was statistically significantly greater, mean aqueous depth and anterior chamber depth were statistically significantly greater, and mean lens thickness was statistically significantly less in the control group than in the pseudoexfoliation syndrome and pseudoexfoliation glaucoma groups (p 0.017). Conclusions: Patients with pseudoexfoliation glaucoma and pseudoexfoliation syndrome had greater lens thickness, shallower aqueous depth and anterior chamber depth, and less central corneal thickness than normal subjects. None of the anterior segment parameters differed between patients with pseudoexfoliation syndrome and patients with pseudoexfoliation glaucoma.

Abstract: Bilateral simultaneous cataract surgery (BSCS) has gained popularity among eye surgeons in many countries. This study examines the case of a 77-year-old patient who developed bilateral Pseudomonas aeruginosa endophthalmitis following bilateral simultaneous cataract surgery. Immediate bilateral vitrectomy and intravitreal antibiotics injection were performed. Ultimately, both eyes were eviscerated due to pain refractory to treatment and no light perception.

Abstract: PURPOSE To compare 0.5 mg and 0.625 mg of bevacizumab for treating aggressive posterior retinopathy of prematurity (AP-ROP). METHODS The medical records of patients with AP-ROP who were administered intravitreal bevacizumab (IVB) as a primary treatment at a university clinic were evaluated retrospectively. Five eyes of three patients (Group 1) who received 0.625 mg/0.025 ml IVB and 10 eyes of another five patients (Group 2) who received 0.5 mg/0.02 ml IVB were evaluated. Laser photocoagulation was used as additional treatment after relapses. Anatomic results and complications were evaluated in both groups. RESULTS We evaluated 15 eyes of eight patients (four girls and four boys) with a flat demarcation line at posterior zone 2 and plus disease or stage-3 disease in this study. The mean gestational age of the three babies in Group 1 was 26 ± 1 weeks and the mean birth weight was 835.33 ± 48.01 g. The corresponding values were 25.2 ± 1.6 weeks and 724 ± 139.03 g, respectively, for the five babies in Group 2. Retinal vascularization was completed at a mean postmenstrual duration of 53.6 ± 1.5 weeks without additional treatment in the five eyes in Group 1. Laser photocoagulation for relapse was administered to five of the 10 eyes in Group 2. Retinal vascularization was completed at a mean postmenstrual duration of 47.6 ± 1.5 weeks in the remaining five eyes. None of the patients developed complications such as cataract, glaucoma, retinal tear, retinal or vitreous hemorrhage, or retinal detachment. CONCLUSION Although lower IVB doses in the treatment of AP-ROP are expected to be safer in terms of local and systemic side effects in premature infants, these patients may require additional treatment with IVB or laser photocoagulation.

Abstract: Purpose: We report a simplified Descemet's membrane endothelial keratoplasty (DMEK) technique that involves safe and effective preparation and introduction, correct orientation, and easy unfolding of the donor graft inside the recipient anterior chamber. Methods: In this retrospective study, we assessed the surgical outcomes of 26 eyes of 23 consecutive patients (mean age, 61.2 ± 11.4 yr; range, 39-82 yr) with Fuchs endothelial corneal dystrophy (n=19) or bullous keratopathy (n=7) who underwent the Samba technique, a simplified DMEK method, at the Sorocaba Ophthalmology Hospital, Sorocaba Eye Bank, Sorocaba, Brazil, between August 2011 and July 2012. Results: Of the 26 operated eyes, only two (7.7%) experienced partial graft detachment requiring rebubbling, and in those eyes, the graft was reattached successfully with one air bubble. There were no cases of primary graft failure, tissue loss, or pupillary block. All patients with good visual potential achieved a best-corrected visual acuity of 20/30 or better at 6 months, and 82.6% achieved a best-corrected visual acuity of 20/30 or better 1 month postoperatively. Conclusion: In this retrospective study, the Samba technique, a simplified DMEK procedure, was safe and effective, with an acceptably low rebubbling rate and no incidence of primary graft failure or pupillary block. Moreover, rapid and nearly complete visual recovery was achieved. This simplified DMEK technique can be adopted by corneal surgeons worldwide as a primary treatment for endothelial dysfunction with a less steep learning curve and low rate of postoperative complications.

Abstract: Purpose: To evaluate the correlation between weight reduction and visual outcome in overweight patients with idiopathic intracranial hypertension. Methods: Thirty-nine newly diagnosed, overweight (body mass index >25 kg/m2) patients with idiopathic intracranial hypertension were studied retrospectively. All patients underwent medical treatment with acetazolamide, and a weight reduction program was also offered. Patients were grouped according to their compliance with this weight reduction program into the diet-success (Group 1) and diet-failure groups (Group 2). Body mass index, papilledema, visual acuity, and perimetric mean deviation were compared at the end of the 6-month study period. Results: Groups 1 and 2 did not differ regarding the baseline mean body mass index (32.63 ± 5.61, 32.35 ± 5.06 kg/m2), visual acuity (0.080 ± 0.13, 0.130 ± 0.24 logMAR), perimetric mean deviation (-9.978 ± 0.68, -12.86 ± 8.91), or papilledema grade (2.94 ± 0.22, 2.90 ± 0.30), respectively (p>0.05). During the 6 months' follow-up, Group 1 patients, who complied with both medical and diet therapy, improved significantly in all parameters, including body mass index (p<0.001), visual acuity (p=0.001), perimetric mean deviation (p=0.016), and papilledema grade (p<0.001). Conversely, Group 2 patients, who only underwent medical therapy, improved only in papilledema grade (p<0.001). However, coincident development of optic disc pallor was observed in three patients. Further, they also had significant loss in visual acuity (p=0.047) during the study period. Conclusion: Weight reduction combined with medical treatment is associated with significantly better improvement in visual acuity, visual field, and papilledema in idiopathic intracranial hypertension patients. Compliance with an efficient diet program should be encouraged in overweight patients with idiopathic intracranial hypertension.

Abstract: Objective: To compare the efficacy of 0.03% tacrolimus eye drops diluted in two different vehicles (linseed oil and olive oil) for the treatment of keratoconjunctivitis sicca (KCS) in dogs. Methods: This study included 60 dogs. Of this group, 20 were healthy and allocated to the control group, and 40 were diagnosed with bilateral KCS and randomly allocated to either the TO (tacrolimus in olive oil) or the TL (tacrolimus in linseed oil) groups. Ophthalmic examinations, Schirmer Tear Test-1 (STT-1), Tear Film Break-up Time (TBUT) and Fluorescein Test (FT) were carried out monthly, along with cytological and histopathological examinations at the beginning and end of the study. Results: The clinical signs, corneal ulcers, Schirmer Tear Test-1 values, and Tear Film Break-up Time values improved in both groups after one month of treatment. Cytological examination at the end of the study showed decreased lymphocytes, neutrophil, metaplastic, and squamous cell counts in both groups, while the histopathological analysis showed decreases in lymphocytes and neutrophils and an increase in goblet cell density (cells/mm2). The decreases in neutrophil count were more significant (p<0.05) in the TL group for both types of examination. Conclusion: In sum, 0.03% tacrolimus eye drops diluted in olive oil and linseed oil were effective in the treatment of keratoconjunctivitis sicca. None of the evaluated parameters differed significantly between the two groups, except for neutrophil count which was significantly lower in the TL group. Thus, linseed oil may be considered as an alternative diluent for tacrolimus eye drops.

Abstract: A retrospective and analytical study was conducted by using data from the National Transplantation System on 184,575 corneal transplantations performed between January 2001 and December 2016 in order to analyze thetrends in corneal transplantation from 2001 to 2016 in Brazil. The Cochran-Armitage test, analysis of variance, and Duncan's multiple comparisons were used to verify the existence of trends, compare the mean values between regions, and verify the mean differences, respectively. A significance level of 5% was used for all tests. The analysis showed that there was a 2.4-fold increase in the number of corneal transplantations (from 6,193 [35.2 per million people (pmp)] to 14,641 [71 pmp]; p<0.001), a 50.7% increase in the efficacy of meeting the population's demand for corneal transplantation (from 35.3% to 53.2%; p<0.001), an 11-fold increase in the number of corneal transplantation centers (from 32 to 356), and a 2.5-fold increase in the number of corneal transplantation teams (from 276 to 688) in Brazil during the period studied. The waiting list for corneal transplantation decreased by 45.4% (from 23,549 [123 pmp] to 12,865 [62.4 pmp]; p<0.001), and the corneal transplantation teams performed about 19 corneal transplantations per year. The best indices were observed in the southern, midwestern, and southeastern regions, and the worst indices were in the northern and northeastern regions. Brazil has been improving its capacity to perform corneal transplantation in the past 16 years, although this improvement varies across regions. However, the population's demand for corneal transplantation is yet to be satisfactorily met, primarily due to the low number of corneal donations.

Abstract: Purpose: This report describes the use of Descemet membrane endothelial keratoplasty for the management of endothelial decompensation after multifocal intraocular lens implantation. Methods: In this retrospective study, we reviewed and assessed the surgical outcomes of 9 patients (9 eyes) who underwent Descemet membrane endothelial keratoplasty after multifocal intraocular lens implantation. Results: Corneal edema occurred due to Fuchs endothelial corneal dystrophy (n=3), pseudophakic bullous keratopathy (n=3), Descemet’s membrane detachment (n=2), and toxic anterior segment syndrome (n=1). The Descemet membrane endothelial keratoplasty surgeries were uneventful in all eyes, but rebubbling procedures were necessary in 2 eyes. One month after the surgery, all the corneas were clear. After 6 months, excluding 1 eye with amblyopia, the mean distance corrected visual acuity was 0.10 logMAR, with all eyes achieving 0.18 logMAR or better. Conclusions: This is the first report of Descemet membrane endothelial keratoplasty after multifocal intraocular lens implantation, and it suggests that good results can be achieved without multifocal intraocular lens exchange.

Abstract: Purpose: This study reports the effects of combined use of oral doxycycline and topical cyclosporine on ocular signs, symptoms, and tear film parameters in rosacea patients. Methods: Fifty-four right eyes of 54 patients were included in this study. All patients underwent full ophthalmologic examination-including best corrected visual acuity measurement, slit-lamp anterior segment and fundus examination, tear film break-up time, and Schirmer test-before treatment and six months post-treatment. Patients were divided into two treatment groups. The first group was treated with oral doxycycline 100 mg twice daily for the first month and once daily for the following two months. The second group received topical 0.05% cyclosporine emulsion drops twice daily for six months in addition to the oral doxycycline treatment regimen. All patients received preservati ve-free artificial tear drops, warm compress, eyelash cleaning, and topical corticosteroid drops three times daily for one month. Results: A significant improvement in ocular signs and symptoms was recorded for all patients in groups 1 and 2 after treatment. There was not a significant difference in terms of itching, burning, meibomian gland inspissation, corneal neovascularization, and conjunctival hyperemia score changes between groups 1 and 2. The increases in Schirmer test and break-up time scores were significantly higher in group 2 than in group 1. Conclusions: Our results support the finding that topical cyclosporine in addition to the standard regimen improves tear function, as shown by Schirmer test and break-up time scores, in ocular rosacea patients.

Abstract: Purpose: To evaluate the outcomes of the first 30 cataract surgeries performed with a new disposable, injector-free, small-pupil expansion device. Methods: This consecutive case series included 30 eyes from 29 patients who underwent cataract surgery using a new disposable small-pupil expansion device called the Canabrava Ring (AJL Ophthalmic S.A, Spain). It is the first iris expansion ring produced with indents that do not align with each other in the superior and inferior regions, resulting in a small vertical length (0.4 mm) that minimizes the risk of endothelial contact. All eyes had poorly dilated pupils of less than 5 mm preoperatively. Fifteen eyes had significant infective or traumatic pathologies preoperatively. Vertical and horizontal pupil diameters were evaluated preoperatively, intraoperatively, and 1 month postoperatively. Results: The mean patient age was 64 ± 11.8 (standard deviation) years. The Canabrava Ring remained engaged throughout all surgeries, except one. All pupils were intraoperatively expanded to a diameter of 6.3 mm. Although preexisting pathology on the innervation of the pupils, the mean pupil diameter returns to a close preoperative size after 1 month surgery. The mean pupil diameters postoperatively and preoperatively were 4.41 and 3.77 mm, respectively (p<0.05). Postoperative complications occurred in eight eyes (one toxoplasmosis reactivation, one retinal detachment, one posterior capsule rupture, one posterior capsule opacification, and four posterior synechiae). These complications occurred in eyes with preexisting traumatic or infective pathologies or synechiae. Conclusion: The Canabrava Ring is effective for expanding and maintaining expansion of small pupils in cataract surgery. The increase in postoperative pupil diameter is clinically diminutive and can most likely be attributed to preexisting pathologies affecting pupil innervation. Further large-scale studies are required to support the present findings.

Abstract: PURPOSE Donated corneas are classified as tectonic if there are defects within any layers of the cornea which would prevent a satisfactory visual outcome after transplantation. This study aimed to evaluate whether some tectonic corneas have sufficient endothelial characteristics to allow their use in posterior lamellar keratoplasty, and explored their reclassification for use in this sight-improving procedure. METHODS A retrospective review of all corneal tissues preserved by the Sorocaba Eye Bank from January to April of 2014 was performed. All donated corneas classified as tectonic were included. Endothelial tissue was defined as healthy and viable for posterior lamellar keratoplasty if endothelial cell density was ≥2000 cells/mm2. Additional parameters analyzed included Descemet folds and stretch marks, loss of endothelial cells, corneal endothelial polymegathism/ pleomorphism, pseudo-guttata, and reflectivity. RESULTS During the study period, 2,847 corneas were preserved, of which 423 (14.85%) were classified as tectonic. Of these, 87 (20.56%) were reported as having endothelial viability and were included in the posterior lamellar keratoplasty group. Average corneal endothelial cell density of this group was 2,471 SD ± 256 cells/mm2 (range 2012-2967 cells/mm2). CONCLUSION A significant number of corneas classified as tectonic showed endothelial viability and were included in the posterior lamellar keratoplasty group (20.56%). Despite stromal and/or epithelial alterations, these corneas could have been potentially distributed for posterior lamellar transplantation to improve vision, thus reducing the corneal transplantation waiting period. This study highlights how corneal tissue reclassification could increase the potential amount of corneal tissue available for optical transplantation.

Abstract: This content is licensed under a Creative Commons Attributions 4.0 International License. Technological progress in fields such as health care has led to solutions for many problems that were thought in the past to be unsolvable. With progress in artificial intelligence, in the future diagnostic equipment will likely be autonomous and operate with minimal human talent. Thus it seems likely that exams, once performed by doctors, such as refractometry or screening of glaucoma, cataracts, and retinopathies, will be performed by machines operated by technicians. The advantages of technological development in ophthalmology include easier access to ocular checkups, contributing to the universalization of ophthalmologic exams and early detection of eye diseases. This is expected to increase the demand for generalist ophthalmologists who can accurately interpret the clinic significance of exam results as well as the demand for subspecialists who can treat complex cases using specialized techniques(1). In the past 20 years, the number of medical schools in Brazil has tripled. However, the number of vacancies in residences programs for specialized teaching has not kept up with this increase; the best-structured university services have been reduced and, in some cases, the number of residents has been reduced due to budget constraints. As newly-graduated doctors in Brazil are allowed to work clinically, many young professionals excluded from specialty opportunities in ophthalmology end up pursuing non-accredited services (not prepared for teaching). Therefore, a significant number of doctors with limited theoretical training enter the ocular health field annually. They generally work out of large urban centers where there is a great volume of appointments or in clinics performing initial exams, and thus refer cases of eye diseases to subspecialists. Putting the two above-described realities together, we can predict that less technically-prepared professionals will be excluded from the market due to technological advances, resulting in ocular exams with lower costs and better precision. Such doctors could in the future be come technicians who operate the diagnostic machines. While the future of ophthalmology has a valorization bias with large medical corporations buying and consolidating clinics, the future of ophthalmologists appears bleak. Doctors will progressively leave positions as autonomous professionals to become employees of large health companies where they do not even know their bosses. Such technological changes may be inevitable. Nevertheless, strategies can be created to improve teaching in ophthalmology and reduce the lost value of doctors’ work. One solution is to increase the number of vacancies in well-structured residence programs without endangering the quality of teaching. As there is no foresight of better financing for public health, which would favor more clinical and surgical appointments and allow a natural increase in the quantity of residencies available for medical students, a non-conventional approach is needed through thinking out of the box. Thus, we should consider the ideas of professors Rubens Belfort Jr. and Marcos Avila of creating vacancies for clinical ophthalmologists and eliminating the medical residencies in hospital environments, which are important actions to create the “ophthalmologists that Brazil needs.” Technology, teaching, and the future of ophthalmology and the ophthalmologist A Tecnologia, o ensino e o futuro da oftalmologia e do oftalmologista

Abstract: We report a case of central corneal perforation treated with an autologous lamellar scleral graft and histologic findings obtained after a subsequent penetrating keratoplasty. A corneal perforation within a large Pseudomonas ulcer in a 55-year-old male rigid gas permeable contact lens wearer was sealed by a lamellar scleral graft from the same eye, followed by an uneventful penetrating keratoplasty 6 months later. Histology of the excised button revealed that the well-apposed graft, which maintained the irregular arrangement of the scleral collagen fibers, was embedded in the corneal stroma over the deep blood vessels and a rupture in Descemet's membrane. The clinical and histologic findings showed that autologous lamellar scleral grafts can be successfully used for the emergency treatment of corneal perforation when a corneal transplant is not available. The distinctive scleral structure revealed by histology and the inadequate graft transparency indicate that visual rehabilitation of eyes with a central corneal perforation can be achieved only by a subsequent optic penetrating keratoplasty.

Abstract: PURPOSE To evaluate microstructural differences between corneas with and without Kayser-Fleischer rings in age-matched subjects with Wilson's disease with neurological symptoms, using confocal laser scanning microscopy. METHODS The study included 12 subjects with Wilson's disease with neurological symptoms. Twelve corneas presented clinically with classic Kayser-Fleischer rings, visible on slit lamp examination; the other 12 served as controls. The subjects underwent a comprehensive clinical examination. Microstructural analysis using confocal laser scanning microscopy evaluated increased corneal thickness, decreased number of cells, increased debris or specific deposits, and unusual microstructures. RESULTS Clinically, the subjects with Kayser-Fleischer rings had similar corneal findings and normal intraocular pressure; two had typical sunflower cataracts and decreased visual acuity. The control eyes all presented normal visual acuity, intraocular pressure, and corneal appearance. The microstructural analysis demonstrated similar findings in all the affected corneas. Compared with the control corneas, there were fewer keratocytes in the anterior stroma (17.380 vs. 22.380/mm3). Round, "hollow" dark areas were observed between the keratocytes; these were universal and similar in appearance in all affected corneas and all cornea layers. In the peripheral posterior stroma, there were dust-like, bright, granular deposits that tended to increase in number and density toward Descemet's membrane, masking the peripheral endothelium. The control corneas presented a normal microstructure apart from dust-like granular deposits in the periphery. CONCLUSIONS In vivo confocal microscopy is a useful tool for evaluating the corneal microstructure when a Kayser-Fleischer ring is clinically present. The ring consists of granular, bright particles that increase in density toward Descemet's membrane, and is associated with a decreased number of keratocytes and peculiar dark, round areas in all stromal layers, probably a sign of corneal damage. When the ring is not visible in subjects with Wilson's disease, changes to the corneal microstructure are insignificant.

Abstract: Purpose: To investigate the potential effects of chronic exposure to a nasal decongestant and its excipients on ocular tissues using an experimental rat model. Methods: Sixty adult male Wistar rats were randomized into six groups. The first two groups were control (serum physiologic) and Otrivine® groups. The remaining four groups received the Otrivine excipients xylometazoline, benzalkonium chloride, sorbitol, and ethylene diamine tetra acetic acid. Medications were applied into both nostrils twice a day for 8 weeks. Before the rats were sacrificed, epithelial staining, the Schirmer test, and intraocular pressure measurements were performed under ketamine/xylasine anesthesia (50 and 5 mg/kg, respectively). Results: Epithelial defects and dry eye were common findings in all study groups. Cataracts developed in two cases clinically. Histopathological evaluation revealed many different pathological alterations in all parts of the ocular tissues such as corneal edema, polypoid proliferation and hyalinization of the vessel wall, cystic formation of the lens, retinal nerve fiber layer degeneration, and corpora amylacea formation of the lacrimal gland. Conclusions: Prolonged usage of the nasal decongestant xylometazoline and its excipients may cause ophthalmic problems such as dry eyes, corneal edema, cataracts, retinal nerve fiber layer, and vascular damage in rats. Although these results were obtained from experimental animals, ophthalmologists should keep in mind the potential ophthalmic adverse effects of this medicine and/or its excipients and exercise caution with drugs containing xylometazoline, ethylene diamine tetra acetic acid, benzalkonium chloride and sorbitol for patients with underlying ocular problems.

Abstract: Purpose: To evaluate the response to sub-Tenon’s triamcinolone injection in patients with uveitis. Methods: We studied 28 eyes with macular edema associated with controlled uveitis. We administered sub-Tenon’s injection of triamcinolone and followed the patients for 180 days to analyze the positive effects (improvement of macular edema and visual acuity) and monitor the possible adverse effects. This prospective study was conducted at the Department of Ophthalmology, Hospital de Clinicas de Porto Alegre, Brazil. Results: We observed improvement in macular edema in 86% of patients. The mean central macular thickness at each time point of assessment was 432.22, 298.80, 286.37, 267.49, 253.87, and 253.49 mm at baseline (before sub-Tenon’s injection of triamcinolone), 15 days after the procedure, at 30 days, at 60 days, at 90 days, and at 180 days, respectively. The mean reduction in retinal thickness was 30.8%, 33.7%, 38.11%, 41.2%, and 41.35% at 15, 30, 60, 90, and 180 days of follow-up, respectively. Visual acuity also improved in 85.7% of patients, with a mean improvement of 1.36, 1.93, 2.23, 2.26, and 2.30 lines gained on the Early Treatment Diabetic Retinopathy Study chart at 15, 30, 60, 90, and 180 days of follow-up, respectively. No statistically significant increases in intraocular pressure and conjunctival abnormalities were caused by the procedure, and no other adverse effects were observed. Overall, the results of this study were similar to those described in the literature. Conclusions: Sub-Tenon’s injection of triamcinolone provides reduced macular thickness and improvement in visual acuity with no significant adverse effects and is therefore an effective and safe procedure for the treatment of sequelae of uveitis.

Abstract: The Nobel Prize is the world's foremost honor for scientific advances in medicine and other areas. Founded by Alfred Nobel, the prizes have been awarded annually since 1901. We reviewed the literature on persons who have won or competed for this prize in subjects related to vision and ophthalmology. The topics were divided into vision physiology, diagnostic and therapeutic methods, disease mechanism, and miscellaneous categories. Allvar Gullstrand is the only ophthalmologist to win a Nobel Prize; he is also the only one to receive it for work in ophthalmology. Other ophthalmologists that have been nominated were Hjalmar Schiotz (tonometer), Karl Koller (topical anesthesia), and Jules Gonin (retinal detachment). Other scientists have won the prize for eye-related research: Ragnar Granit, Haldan Hartline and George Wald (chemistry and physiology of vision), and David Hubel and Torsten Wiesel (processing in the visual system). Peter Medawar is the only person born in Brazil to have won the Nobel Prize.