Repositório RCAAP

A autofluorescência do fundo ocular (FAF) é um exame de imagem valioso em várias doenças da retina, que poderá ser subutilizado na prática clínica diária. O objectivo deste artigo é rever os princípios básicos da autofluorescência azul e realçar sua utilidade clínica. A FAF é um exame de imagem não invasivo e rápido do fundo ocular. As imagens de FAF reflectem a distribuição da lipofuscina no epitélio pigmentar da retina (RPE), permitindo uma avaliação da sua função e a detecção de zonas de atrofia. Existem vários sistemas de aquisição de FAF, resultando em diferenças qualitativas e quantitativas que devem ser consideradas aquando da interpretação das imagens. Numerosas doenças do fundo ocular apresentam alterações no sinal de autofluorescência. Algumas apresentam padrões típicos de autofluorescência que auxiliam no seu diagnóstico, nomeadamente a degeneração macular ligada à idade (AMD), doenças hereditárias da retina, coriorretinopatias inflamatórias e retinopatia pelos antimaláricos. Nos últimos anos, vários estudos têm demonstrado o papel da FAF na monitorização e no prognóstico de várias doenças, sobretudo na área da AMD. A FAF é uma modalidade de imagem útil para fins de diagnóstico, mas também para a monitorização de várias doenças retinianas. Deve-se considerar a sua incorporação na avaliação de rotina de doentes com AMD, entre outros. 

Introduction: With growing prevalence, reduced quality of life, significant socioeconomic burden and a definite impact in cataract and laser vision correction surgeries, dry eye disease (DED) is currently a hot topic in ophthalmology. In recent years, several guidelines have been carried out to standardize the diagnosis and improve treatment approach. We intend to characterize current practices in Portugal, identify opportunities for improvement and delineate strategies to address them. Material and Methods: Cross-sectional online survey designed to assess the diagnostic approach and treatment of DED and made available to ophthalmologists across the country. The survey included 5 questions on ophthalmological profile of participants, 4 questions on DED diagnosis and 3 questions on DED treatment. Statistical analysis was made using SPSS version 26. Results and Discussion: One hundred twenty two ophthalmologists answered the survey (about 10% of practitioners in Portugal). A percentage of 48% observe between 20-40 patients with DED per month. A total of 67% always examine ocular surface of laser vision correction candi- dates, whereas only 30% always do it for cataract surgery patients. The most frequently identified DED symptom is foreign body sensation. The most commonly used diagnostic methods are fluo- rescein staining and tear break up time. Regarding treatment modalities, almost 50% of participants never used lacrimal plugs and very few recommended contact lenses or autologous serum. Mild DED treatment is considered to be very effective by 80% of ophthalmologists, while in severe DED by only 0.01%. 36% believe available treatment options are ineffective in severe DED. Conclusion: DED represents a high volume of patients seen in ophthalmology clinics. Our results mimic others in Europe and the United States. Overall, diagnosis and treatment practice patterns are in agreement with the current recommendations. However, there is still room for improvement. All patient prior surgery should be examined for DED, symptoms should be considered more as part of diagnosis and follow-up, and some easily available treatment options should be considered more often. Our findings also highlight the concern with treatment in severe DED, in which more effective therapies are needed.

An 18-year-old boy presented to our emergency department with a 1-month history of a painful left eye, photophobia, and progressive blurring of vision. His past ocular history included a penetrating left globe injury, surgically repaired 1 year before. Biomicroscopy revealed a scar in the inferior cornea and a huge epithelial iris cyst, reaching the visual axis (Panel A). BCVA of the left eye was 20/320, and intraocular pressure was 20 mmHg. Further investigation, namely ultrasound biomicroscopy (Panel B), and anterior segment-OCT (not shown) supported this diagnosis. Nd: YAG laser cystotomy was performed to rupture the cyst wall and drain its fluid content. Immediate shrinkage of the cyst was seen, but additional follow-up is required to rule out the development of procedure-related complications and cyst recurrence. With the evolution of surgical techniques, posttraumatic iris cysts have become rare entities. Nevertheless, its recognition and management are mandatory for any ophthalmologist.

No summary/description provided

Vitreous cysts are a rare and mostly accidental finding. We report a case of a 4-year-old male without a relevant medical history who resorted to a routine ophthalmology consultation. On ophthalmological examination, he had a 6/10 (Snellen decimal scale) best corrected visual acuity in both eyes. Biomicroscopy showed a pigmented and rounded lesion (3 mm of larger diameter), located in the anterior vitreous of the left eye, that moved with eye movements. Besides this lesion and the shadow-effect it produced in the retina, there were no other changes in fundus examination. Associated inflammatory/infectious pathologies were excluded. At 6-month and 1-year follow-up, no new symptoms or morphological changes of the lesion were found. The etiology of vitreous cysts is diverse, requiring a thorough study and close follow-up in order to decide the most appropriate approach.

INTRODUCTION: Ocular traumas with intraocular foreign bodies (IOFB) can have serious ocular complications, such as retinal detachment and endophthalmitis that can greatly affect the visual outcome. Pars plana vitrectomy (PPV) is the most commonly used technique to remove IOFB from the posterior segment. The purpose of this study was to evaluate the management and outcomes of posterior segment IOFB in a tertiary ophthalmology center. METHODS: Patients that suffered a penetrating eye injury with IOFB retained in the posterior segment who underwent PPV for IOFB extraction between 2010 and 2020 were included and data was collected from patients’ archives. RESULTS: Thirty eight patients with mean age of 48.68 years old were included, 86.8% were males. A percentage of 59.5% came to the ophthalmology emergency at the same day of the accident, but 16.2% took 3 days or more to seek medical help. The most common complications on initial examination included traumatic cataract (52.6%), retinal lesions (34.2%) and hyphema (23.7%). Also, before IOFB extraction, 42.1 % of patients developed endophthalmitis. Systemic antibiotics was administered to 84.2% of patients and 71.1% received intravitreal antibiotics. Comparing the 15.8% of eyes that ended up developing phthisis bulbi with those who did not, the only statistically significant difference (p<0.01) was the time between first ophthalmological contact and PPV, that was superior on the phthisis bulbi group. The development of endophthalmitis was not significantly related to a delayed surgery, nor to the use of intravitreal or systemic antibiotics. CONCLUSION: Most of our patients had traumas that occurred in an agricultural setting which usually gives rise to dirty wounds and probably contaminated IOFB. This fact could possibly justify our rather high rate of 42% of endophthalmitis (which is, nonetheless, within what is described in literature). Despite the advances in systems of visualization, equipment and materials for vitreoretinal surgery, penetrating trauma with IOFB still present a very poor prognosis in terms of visual function.

As per the Information for Authors of the Journal, Short Communications do not have an abstract.

IntroductIon: An appropriate evaluation cataract degree is essential for deciding to proceed with surgery. Our purpose was to study the relationship between objective metrics for quantifying age-related nuclear cataracts with visual impairment and phacodynamics parameters. Methods: Thirty eyes (30 patients) with age-related nuclear cataract were submitted to phacoemulsification. The average lens density (0 to 100) was evaluated by using a rotating Scheimpflug system (Pentacam HR, Oculus, Wetzlar, Germany) and the nuclear opalescence (NO) score was subjectively assessed using the Lens Opacities Classification System III (LOCS III). This different parameters were correlated with preoperative corrected distance visual acuity (CDVA) and cumulative dissipated energy (CDE). Results: The preoperative CDVA was correlated with the Scheimpflug-measured lens nuclear density value (r=0.617, p<0.01). The CDE was posi-tively correlated with the Scheimpflug-derived average density variable (r=0.681 p<0.01) than with LOCS III NO (r=0.661, p<0.01). Conclusion: The Scheimpflug-measured average density was correlated with subjective lens grading and preoperative CDVA. This metric also presented the highest positive correlation with phacodynamics.

No summary/description provided

Introduction: Ocular tuberculosis (OTB) is a rare extrapulmonary form of tuberculosis (TB). Diagnosis is usually presumptive, based on local epidemiologic factors, ocular phenotype, and corroborating immunologic tests: tuberculin skin test (TST), interferon-gamma release assay (IGRA) or both. The aim of this study was to characterize patients who were treated with antitubercular therapy (ATT) for OTB or latent tuberculous infection (LTBI) at an uveitis clinic in a tertiary referral hospital. Methods: Patients seen in our uveitis clinic between 2015 and 2021 that had ATT were included and divided into OTB group and LTBI group. Clinical data was analyzed with SPSS statistics®. Results: We included 38 patients with OTB with a mean age of 53.39 years old. A percentage of 21.1% were immigrants and 2.6% were HIV+. A positive IGRA and/or a TST≥15 mm was found on 97.38%. The most prevalent form of OTB was panuveitis (36.8%), followed by posterior uveitis (21.1%), anterior uveitis (13.2%), intermediate uveitis (13.2%), retinal vasculitis (7.9%), scleritis (5.3%) and episcleritis (2.6%). ATT on 81.6% of patients was a combination of rifampin (RIF), isoniazid (INH), ethambutol and pyrazinamide for the first 2 months followed by INH+RIF. The mean duration of treatment was 8.7 months. The group of LTBI had 16 patients, 18.8% were immigrants and none was HIV+. The diagnosis of 93.75% of patients was based on a positive IGRA and/or TST≥15 mm. The majority (93.75%) were tested and treated prophylactically before starting immunosuppression.  Conclusion: TB incidence in Portugal it is still one of the highest in the European Union. Immigrants represented 24.6% of cases in 2019, which is similar to the prevalence found in our study. Conversely, 9% of TB patients in 2019 were HIV+, which is higher than what was found. Almost every patient with ocular inflammation followed in our uveitis clinic is tested for TB and the threshold to start ATT is low, but positive test results should be considered for the initiation of ATT only in the context of a strong clinical suspicion. 

Kyrieleis plaques are a rare fundoscopic sign, in which multiple yellowish-white deposits are arranged in a beaded pattern along the branches of the central retinal artery. Their presence reflects severe intraocular inflammation, typically associated with infectious posterior uveitis. Here, we describe the case of a 58-year-old man who presented to our emergency department with a right red-eye, vision loss and floaters. The ophthalmological exam revealed unilateral panuveitis with the presence of Kyrieleis plaques. Laboratory evaluation was marked by a positive Mantoux skin test and a presumptive diagnosis of ocular tuberculosis was made. The patient was treated for active disease with a 4-drug anti-tuberculosis regimen, along with topical and oral corticosteroids, which allowed for the complete resolution of vitritis, gradual fading of the plaques and total vision recovery. Due to its rarity and strong association with infectious etiologies, the presence of Kyrieleis plaques in our patient ́s eye fundus was crucial to narrow the range of possible differential diagnoses. Accurate diagnosis subsequently led to prompt and adequate treatment, with great visual outcomes.

INTRODUÇÃO: O nosso objectivo foi avaliar comparativamente a previsão de fórmulas de terceira e nova geração (Barrett Universal II, Kane e Hill-RBF 3.0) no cálculo de lentes intraocula- res (LIO) com e sem o uso de um novo ajuste de comprimento axial (CA) na previsão dos resulta- dos refrativos de olhos com baixo CA. MÉTODOS: Estudo retrospectivo que inclui olhos com CA inferior a 22,0 mm submetidos a cirurgia de catarata sem intercorrências e implante de uma LIO AcrySof SN60AT. Todos os doentes realizaram biometria óptica (Carl Zeiss IOLMaster 700) e o equivalente esférico pós-operatório para a LIO implantada foi calculado para as fórmulas SRK/T, Holladay 1, Hoffer Q, Haigis, Barrett Universal II, Kane e Hill-RBF 3.0. O ajuste do CA através do método de Cooke (CMAL) foi utilizado para as fórmulas SRK/T, Holladay 1 e Hoffer Q. Os dados foram analisados antes e após a otimização das constantes das LIOs. Os resultados incluíram o erro de previsão médio (ME) e mediano (MedE), o erro de previsão médio (MAE) e mediano absoluto (MedAE) e a proporção de olhos dentro de 0,50, 0,75 e 1,00 dioptrias (D) da previsão pré-operatória. RESULTADOS: Incluíram-se 64 olhos com CA médio de 21,54 ± 0,57 mm. Sem ajustes, a fórmula Hoffer Q foi a única com um erro de previsão miópico –0,157D ± 0,60 e a Hill-RBF 3.0 teve o menor desvio padrão para o erro de previsão 0,031D ± 0,58. Após a otimização das constantes, o erro absoluto médio verificou-se em ordem ascendente nas fórmulas de Kane 0,43D, Hill-RBF 3.0 0,43D, Barrett 0,44D, Hoffer Q 0,45D, Haigis 0,45D, Holladay 1 0,48 e SRK/T 0,53D. A fórmula de Kane, com o menor MAE, produziu um erro de previsão dentro de 0,50D, 0,75D e 1D em 71,9%, 84,4% e 90,6% dos casos, respectivamente. A utilização do CMAL não melhorou as previsões. A introdução de variáveis opcionais nas fórmulas de Kane (LT e CCT) e Barrett Universal II (LT e WTW) alteraram o erro de previsão >0,1D em menos de 30% dos casos e maioritariamente sem melhoria adicional dos resultados. CONCLUSÕES: Fórmulas recentes como a Barrett Universal II, Kane, Hill-RBF v3.0 apresentam um bom desempenho, principalmente após otimização das constantes. Sem otimização, a Hoffer Q é a única fórmula com erro de previsão miópico o que pode explicar sua popularidade neste subconjunto de doentes. O ajuste CMAL, originalmente desenvolvido para outro biómetro óptico (optical low-coherence reflectometry - OLCR), não melhorou os resultados. O uso de variáveis opcionais nas fórmulas de Kane e Barrett Universal II também não melhoraram as previsões.

Introduction: To date several genetic variants are known to play an important role in age-related macular degeneration(AMD). Variations in the genetic pool of different populations impact the disease prevalence, incidence and risk of progression. This report aims to determine the genetic contribution in the development of AMD in a Portuguese population from the Coimbra Eye Study (CES,NCT01298674,NCT02748824), and to determine the genetic risk score(GRS). Methods: Participants in the CES underwent ophthalmologic examination and imaging in baseline and 6.5-year follow-up visits. AMD staging was performed in a centralized reading center. Two genetic analyses were performed, a case-control analysis and a progression to AMD analysis. Genomic DNA was isolated from blood samples collected in the follow-up visit. Genetic sequencing was performed using the EYERISK assay under the European Eye Epidemiology Consortium (E3). Sixty-nine single nucleotide polymorphisms (SNPs) were genotyped and tested for association under an additive model with presence/absence of AMD in the follow-up visit, and with progression/no progression in the longitudinal analysis. Logistic regression analysis was performed to assess allelic odds ratio at 95% CI for each variant, adjusted for age and sex. GRS were calculated for AMD cases/controls and progressors/non-progressors.  Results: In case-control analysis samples from 237 patients and 640 controls were included. The SNPs associated to increased risk of AMD were: ARMS2 rs10490924, ARMS2/HTRA1 rs3750846,CFH rs35292876,SLC16A8 rs8135665,TGFBR1 rs1626340. The SNPs with protective effect were: CFH rs10922109, CFH rs1410996,C2/CFB/SKIV2L rs429608,CETP rs5817082,CNN2 rs10422209,CFB rs641153 and RDBP_CFB rs760070. In progression to AMD analysis (630 non-progressors and 137 progressors), identified risk-variants for progression were: ARMS2 rs10490924, ARMS2/HTRA1 rs3750846,CFH rs35292876; and protective variants were C2_CFB_SKIV2L rs429608,CFH rs10922109,CFH rs1410996,CNN2 rs10422209,CFHR5 rs10922153,SYN3/TIMP3 rs5754227,COL10A1 rs3812111. The GRS for AMD cases and controls was 1.12±1.19 and 0.65±1.12 (p<0.001), and for progressors and non-progressors was 1.19±1.18 and 0.67±1.14 (p<0.001). Conclusion: This is the first genetic study in AMD in a Portuguese population.  Similar variants were found to be associated with the presence and progression to AMD in our epidemiological study, while others were protective. The GRS was significantly different between cases and controls showing its potential when assessing risk. Genetic characterization is important to pursue in different populations to further expand the knowledge of AMD pathophysiology.

Macular atrophy (MA) is one of the late stages of age-related macular degeneration (AMD) and leads to irreversible loss of visual function. During the past years, efforts have been made towards a more detailed comprehension of the characteristics of MA, and a panel of retina specialists has recently established a new classification system to describe atrophy in the context of neovascular AMD, by the CONAN group. Furthermore, recent publications have focused on investigating the progression of MA, as well as the factors that might influence MA growth rates, particularly anti-VEGF injections.

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Introduction: This study reports type of visits realized during 2020 in Portugal, population habits, and eye complaints regarding visual health in the COVID-19 pandemic context. Material and Methods: An email invitation to an online cross-sectional survey and also performed to patients from ophthalmology clinics in Portugal from September/November 2020.  Results: Eight hundred thirty three respondents (60% females) aged more than 18 years-old, participated with valid anonymous responses. Of the total number of respondentes, 54% identified a lot of discomfort caused by increasing dry eye symptoms according to more intense digital work and lens fogging up when using masks. A percentage of 90% of the respondents used digital devices at least 3 hours on average per day, and 33% started using digital devices more than 8 hours on average per day. In addition, 44% of respondents felt that their near vision had worsened in this period. The first major symptom of presbyopia was related to difficulty reading smaller letters in packages; 90% had the first symptoms at the age of 40. The most frequent ametropia identified were astigmatism (47%) and myopia (43%). For parents, having good eyesight (79.5%) was the most valued aspect of their children's lives.  Conclusion: The findings provide an idea of the challenges during COVID-19 for eye practices. In a society highly dependent on vision, it is essential to focus on signs and symptoms that lead to ophthalmologic conditions. The excessive use of digital devices and the use of masks during this pandemic has aggravated some pointing the importance of reference to plan efficient eye care in similar situations.

Myopia is a growing global health concern, with an increasing prevalence - in 2000 1.4 billion people were mypic and it is estimated that this number will reach 4.8 billion by 2050.1 It appears that both genetic predisposition and environmental factors exhibit an association with myopia, particularly the increased exposure to screens and near activities from an early age, the digital projection under brighter classroom and a low outdoor activity.1,2 Nowadays there are no widely used methods, considered safe and effective for long-term use, to slow myopia progression. The recommendation for lifestyle and behaviour change are not enough; progressive addition spectacles have shown insignificant effect3; orthokeratology has showed certain effect on slowing axial elongation but that implies sleeping with lenses overnight which bares the risk of infective keratitis4; low-dose (0.01%) atropine proved to induce clinically significant reduction in myopia progression, however it is a minimally invasive treatment and implies a good compliance to the treatment.5 So other optical approaches for myopia control in children have been developed, including dual-focus (DF) concentric soft contact lenses (CLs)6 and multifocal spectacles with defocus segments or aspherical lenslet technology, attempting to reduce peripheral hyperopic defocus (HD), and induce myopic defocus (MD) at the central retina.7,8 Since I started my professional activity in France, at the end of 2020, I came across a large number of children and teenagers with myopia at risk of progression. At that time, in addition to treatment with low-dose atropine or orthokeratology, the prescription of new multifocal spectacles was already part of current clinical practice. So I started to prescribe this type of spectacles, intending to slow the myopia progression. The rationale is that this kind of optical devices might slow prolonged accommodation, by reducing the amount of HD.6 Recent animal studies suggest that the peripheral visual field plays a critical role in the regulation of ocular growth. It has been demonstrated that peripheral optical blur, supplants those originating from the central retina, and imposed peripheral MD, by using dual-power or multifocal lenses, oppose the stimulus for axial elongation.9,10 Therefore, the aim behind this design is to provide good central visual acuity, while inducing peripheral MD during both distance and near viewing.10 The design of DF concentric soft CLs consists in a small distance optic zone in the centre, surrounded by alternating defocusing (less negative) and distance correcting zones.6,8,11 Modest myopia control effects of 30%–50% reduction in myopia progression, compared to single vision (SV) CLs correction over two years, have been reported.11 Likewise, Lam C et al,12 showed a significantly reduction on myopia progression by 25%-31% less axial elongation, in school-children wearing defocus incorporated soft contact lenses, compared with those wearing the SV contact lenses, over 2 years. Similarly, Anstice et al,13 reported less axial myopia progression in eyes wearing DF CLs, without prejudice of visual acuity, accommodation or contrast sensitivity. MiSight (CooperVision) is a daily disposable DF soft CLs, available for prescriptions from -0.25 to -6.00D. A three-year clinical evaluation of this lens, including 144 children aged 8-12 years, showed a 59% effectiveness in slowing myopia progression.14,15 One of the available MD spectacle lens is the HOYA MiYOSMART, with Defocus Incorporated Mutliple Segment (DIMS) technology. It was launched in 2018, and developed in cooperation with The Hong Kong Polytechnic University (HKPU). It’s available for prescriptions until -10.00D sphere and -4,00D cylinder. The DIMS lens is a DF spectacle lens that comprises a central optical zone (9 mm in diameter) for correcting distance refractive error, and an annular multiple focal zone (33 mm in diameter) with a re- lative positive power of 3.50 D.16 The results of a two-year double-blind randomised trial16 conducted on children aged 8-13 years, showed that MiYOSMART spectacle lens wear slowed myopia progression in 52% of children and axial elongation in about 62%, compared with SV wearers. It also suggested that there were no rebound effects for those who stop wearing the MiYOSMART spectacle lens. Later, a three-year data17 corroborated the results, showing that the lens continued to slow myopia progression. Recently, the six-year follow-up study results were announced at the Association for Research in Vision and Ophthalmology (ARVO) 2022 conference in Denver, Colorado in the U.S., by Professor Carly Lam from the Centre for Myopia Research at the HKPU, who conducted the research.18 The findings sustained what the two and three-years results already reported16,17 - demonstrating that the MiYOSMART spectacle lens myopia control effect is sustained over time and that there was no rebound effects for those who stop wearing these lens. Essilor Stellest spectacle lenses are another option for the treatment of myopia in children. It uses a highly aspherical lenslet target (HALT) lens technology, which consists of 11 rings of aspherical lenslets. The power of lenslets on each ring has been determined to guarantee a MD, and consequently to slowdown myopia progression. Such as with MiYOSMART, Stellest is also available for prescriptions until -10.00D sphere and -4,00D cylinder. In a two-year clinical trial, the amount of myopia progression and axial length increase was significantly less in groups wearing these type of lenses, when compared with the SV spectacle lenses group.19 Finally, there is also ZEISS MyoVision,20 a spectacle lens that applies the principles of peripheral defocus management, inducing a peripheral MD. It is available for prescriptions until -10.00D sphere and -6,00D cylinder. However its effectiveness in reducing the rate of myopia progression has not yet been demonstrated.20 During the last year and a half, I was able to follow the evolution of some patients wearing MiYOSMART and Essilor Stellest, and a large part of them presented no evolution of the refractive error. Similar to what has been described, inspite of the adaptation time, it seems that the majority of the children do not have difficulties in wearing these no- vel designs.7 However, the older they are, the more difficulties they have to support the new lenses. Regarding DF soft CLs, it is not always possible to prescribe it at an early age, due to fear of its handling. Nevertheless, it is an optical alternative that I always try to present, at the time of therapeutic discussion. The emerging reports from recent studies show that optical strategies that take into account the peripheral retina, appear to produce larger decline in myopia progression than those that do not. Accordingly, dual-focus contact lenses and multifocal spectacles with defocus or aspherical lenslet technology, may be an ideal alternative option to myopia treatment, as they are minimally invasive and prevent the long-term effects of atropine, and the risk of noncompliance associated with orthokeratology. However, additional studies and longer treatment periods will be necessary to prove clinical efficacy of these lenses on myopia progression prevention.

INTRODUCTION : Tubulointerstitial nephritis and uveitis syndrome is a rare disease characterized by the occurrence of tubulointerstitial nephritis and uveitis, in the absence of other explain- able systemic disease. In this review we aim to appraise and to clarify what is acknowledged in order to elucidate the demographics, genetic predisposition, most frequent symptoms and laboratory findings, most adequate treatment and also patient’s prognosis. METHODS : A systematic review across PubMed, Web of Science and Scopus was performed, according to PRISMA guidelines, in order to identify all relevant articles regarding both tubulointerstitial nephritis and uveitis. RESULTS: We identified 240 publications, of which 176 were excluded. The average age of Tubulointerstitial nephritis and uveitis syndrome diagnosis was 30.6 years-old, with a female predominance (2:1); according to presentation symptoms, tubulointerstitial nephritis precedes uveitis more commonly and amongst uveitis cases the majority were bilateral anterior uveitis. Moreover, the most common systemic symptoms were fatigue, fever, and weight loss; blood analysis commonly presented with elevated serum creatinine, erythrocyte sedimentation rate, C-reactive protein, blood urea nitrogen level and urinalysis frequently showed proteinuria, glycosuria, and elevated urinary-β2-microglobulin. The majority (78.8%) of patients were putted on corticosteroids, with 21.9% needing an additional immunosuppressor, being mycophenolate mofetil (29.8%) and azathioprine (28.0%) the preferred ones. The mean time until relapse, which occurred in 48.3% of patients, was 89.3 days. CONCLUSION: Tubulointerstitial nephritis and uveitis syndrome is not just a pediatric syndrome, as once thought. Presentation seems to be variable, although tubulointerstitial nephritis typically presents first, with systemic symptoms such as fatigue. As clinicians becomes more aware of the disease, follow-up after the first symptoms allows for earlier diagnosis. Relatively to treatment, most patients responded to corticosteroids, and despite the relapses, the prognosis was generally favorable.

An 86-year-old woman with history of bilateral phacoemulsification (13 years prior), diabetic retinopathy sub- mitted to several treatments (pan-retinal photocoagulation, anti-VEGF intravitreal injections, and bilateral pars plana vitrectomy) and low visual acuity in the left eye (OS) due to retinal fibrosis, presented to the emergency ward with complaints of diminished visual acuity in her right eye (OD). On examination, her best-corrected visual acuity (BCVA) was hand motion in the OD and counting fingers in the OS. Fundoscopy of OD revealed a posteriorly dislocated three-piece intraocular lens (IOL) inside the capsular bag. During pars plana vitrectomy, the disposition of the IOL alongside the anterior capsule’s phimosis and Soemmering’s ring mimicked a light blue iris (Fig. 1). The IOL/capsular bag complex was removed and replaced with an aphakic iris-claw intraocular lens, improving her OD BCVA to 20/25. Lens epithelial cells are involved in the pathogenesis of anterior capsule fibrosis and posterior capsule opacification following cataract surgery.1 In 1928, Soemmering first described a ring of cortical fibers between the posterior capsule and the borders of the anterior capsule remnant, hence the name Soemmering’s ring.2,3 This finding is explained by the active proliferation of equatorial epithelial cells leading to an accumulation of new lens fibers between the equator and the anterior capsule margin/IOL optic.1,4 In contrast, the anterior epithelial cells undergo fibrous metaplasia leading to fibrosis of the anterior capsule, which leads to capsule phimosis in cases of small capsulorhexis.1