RCAAP Repository

Purpose:To compare the results between photorefractive keratectomy (PRK) with Custom-Q or with Wavefront-optimized (WFO) profiles in terms of asphericity and spherical aberrations, 6 months post-operative. Setting:Tertiary referral center (Centro Hospitalar e Universitário da Universidade de Coimbra, Coimbra, Portugal). Patients and Methods: Fifty-nine eyes (43 patients) were enrolled on this retrospective case series, including patients with myopia and/or astigmatism, submitted to refractive surgery with PRK (Allegretto WAVE Eye-Q Excimer Laser System, Alcon), in a Custom-Q ablation (38 eyes) or Wavefront-optimized procedure (21 eyes). We included patients with a minimum follow-up of 6 months; age over 21 years; stable refractive error for 2 years; spherical equivalent (SE) inferior to 5.50 diopters (D); percentage of altered tissue under 40% and expected final corneal curvature above 35 D. Eyes with other ophthalmological pathologies were excluded. Baseline and post-operative asphericity and optical aberrations were evaluated with Pentacam (Oculus Optikgeräte, Wetzlar, Germany). Results: The demographic and preoperative refractive data was similar between groups (all p≥0.05). Post-operative spherical equivalent in the Custom-Q and Wavefront-optimized groups was within 0.50D in 100% and 78.90% of eyes, respectively and within 0.25D in 97.06% and 73.70% of eyes, respectively. Variation of Q-value was 0.62±0.34. (range -0.07-1.24) for Custom Q group, and 0.65±0.39 (range -0.05-1.40) in the Wavefront-optimized group (p=0.82). In a multivariate linear regression model, variation of Q-value was not influenced by the ablation profile (B=0.04, p=0.49, 95%CI [-0.08,0.17]). SE was a strong predictor (B=-0.30, p<0.01, 95%CI[-0.39,-0.21]). There was a significant increase in RMS higher-order aberrations (p<0.01for both groups) and no difference between groups (p=0.53). Discussion and Conclusion: In our sample,Custom-Q ablation was not significantly different from Wavefront optimized ablation regarding post-operative asphericity. Although the increase in higher-order aberrations, both techniques were effective and safe for myopic and/or astigmatic correction up to -5.50D SE.

A ciclosporina A (CsA) é um agente imunomodulador que apresenta uma ação inibtória selectiva sobre os linfócitos células T. O CsA tópico com várias formulações tem sido usado na Oftalmologia. Este artigo tem como objetivo apresentar uma revisão da literatura científica publicada revisada por pares e ilustrar algumas aplicações da CsA na áreas das doenças da superfície ocular.

Introduction: To assess visual impairment diagnosis, management, and consequences in patients with cerebral palsy at the Cerebral Palsy Association of Coimbra. Methods:  This is a cross-sectional, descriptive study. A retrospective review of consecutive medical records was performed on 102 patients diagnosed with CP attending ophthalmology appointments between 2018 and 2019. The components of a detailed ophthalmologic evaluation, diagnostic tools, and methods to increase cooperation were recorded. We characterized cerebral palsy according to its etiology, type and resulting motor impairment. Visual function assessment included visual acuity, contrast sensitivity, stereopsis, and visual field. Ocular motility and anterior eye assessment with slit-lamp biomicroscopy results were also recorded. Performance on visual tasks such as eye hand coordination, visual spatial perception, and fix and follow were evaluated. Results: The study included 102 patients aged from 10 months to 40 years. Regarding motor dysfunction classification, tetraplegia was the most prevalent type, followed by hemiplegia and diplegia. We found 60.8% of patients to have some degree of ocular disease. Visual field restrictions were found in 29.3% of patients, ranging from 30º to 100º, including restrictions superiorly and inferiorly. Contrast sensitivity mode was 1.25%. Saccadic and pursuit movement dysfunction was found in 13.7% and 15.6% of the cases. Eye-hand coordination was impaired in 16.6% of the patients. Conclusion: Patients with cerebral palsy often present with visual disturbances. The ophthalmologist should be aware of the most frequent visual dysfunctions and how to diagnose them. Also, appropriate management to enhance visual performance can have a significant impact on social interaction, autonomy, and quality of life in these patients.

É uma honra e um enorme privilégio poder apresentar o Professor Sohan Singh Hayreh, muito justamente considerado “Uma lenda viva da Oftalmologia”. Como ficará patente para quem ler a entrevista, trata-se de alguém que desenvolveu intensa atividade médica e cirúrgica e ergueu várias vezes do zero verdadeiros laboratórios de investigação clínica.  A sua atividade foi desenvolvida em três continentes, mercê de uma enorme capacidade de mudança, sacrifício e recusa de status quo. Autor de mais de 450 artigos e 50 capítulos de livros, recebeu significativo reconhecimento e aplauso da Association for Research in Vision and Ophthalmology,  American Academy of Ophthalmology, Royal College of Ophthalmologists e International Society for Eye Research.

Ten years after uneventful laser in situ keratomileusis (LASIK), a 44-year-old man presented to the emergency de- partment after suffering blunt trauma to his left eye 1 week earlier, reporting intense glare. Although the flap was not dislocated, a central tear near the optical axis was identi- fied (Fig. 1), with several adjacent inframillimetric epithe- lial ingrowths (hyperreflective densities located between the flap and the stromal bed; Fig. 1, yellow arrowheads). The epithelial ingrowths were treated with Nd:YAG laser (48 spots, 0.3 mJ average energy). All opacities disappea- red after four weeks, with no recurrence after six months of follow-up (Fig. 2).

Introdução: A pandemia COVID-19 instalou-se em Portugal em março de 2020 e as suas consequências são ainda pouco conhecidas. Este estudo pretende avaliar o impacto da mesma sobre o tipo de diagnósticos e gravidade das situações que se apresentaram no Serviço de Urgência (SU) de Oftalmologia do Centro Hospitalar e Universitário de Coimbra (CHUC) nos primeiros meses de pandemia. Discutem-se possíveis razões para as mudanças verificadas e ambiciona-se uma melhoria da organização das equipas e sua diferenciação, caso surjam novas restrições ao funcionamento da sociedade e cuidados médicos.    Métodos: Estudo observacional retrospetivo sobre a casuística do SU de Oftalmologia do CHUC de 1 de março a 30 de junho de 2019 e 2020. Foi aplicado o teste qui-quadrado para comparação do número de visitas mensais ao SU por diagnóstico de admissão, após análise de normalidade com o teste Shapiro-Wilk, e o teste T para amostras independentes comparou o número de entradas dos dois anos. Os dados foram fornecidos pelo Serviço de Tecnologias e Sistemas de Informação do CHUC.   Resultados e Discussão: O número total de visitas ao SU de Oftalmologia do CHUC reduziu de 5709 para 3490 (-38,9%) nos meses em estudo (p< 0,05). Condições como blefaroconjuntivite (-69,7%) e conjuntivite aguda (-66,5%) foram as que maior diminuição sofreram. A patologia que sofreu proporcionalmente menor alteração foi corpo estranho na córnea (-2,7%). Por outro lado, diagnósticos como hemorragia do vítreo (+61,6%) e descolamento da retina não especificado (+37,5%) aumentaram em frequência absoluta embora não se prove o impacto da pandemia nos mesmos (p>0,05). As medidas de confinamento implementadas, o medo de infeção por COVID-19 no hospital e a diminuição de acidentes profissionais são algumas das causas apontadas.   Conclusão: Há uma clara associação entre o início da pandemia no nosso país e a redução de visitas ao SU, tendo-se verificado a diminuição de situações menos urgentes e o aumento de diagnósticos mais graves. Deve-se otimizar a resposta aos casos não urgentes de forma a não sobrecarregar o SU com condições que não requerem tratamento imediato ou presencial.

Acute macular neuroretinopathy (AMN) is a rare disease. We report a clinical case of AMN diagnosed in a 46-year-old, Caucasian female with an atypical exuberant hemorrhagic presenta- tion. She referred unilateral paracentral scotomas started 1 day before admission. Fundoscopy revealed several large, dot-and-blot and flame-shaped intraretinal hemorrhages surrounded by reddish-brown, wedge-shaped lesions pointed towards the fovea. Infrared imaging displayed petalloid dark lesions. Optical coherence tomography showed focal ellipsoid zone disruptions, areas of outer retinal hyperreflectivity and deep intraretinal hemorrhages. Fundus autofluorescence and fluorescein angiography displayed hypofluorescent areas due to intraretinal hemorrhages. One-month after presentation, the patient complained about residual scotomas. Classic reddish-brown, wedge-shaped lesions became well-demarcated and intraretinal hemorrhages almost completely resolved. Tomographic findings partially reversed but converted into outer nuclear layer thinning. Visual field examination displayed paracentral scotomas. Our patient revealed the classic AMN lesions. From our knowledge, this is the first reported AMN case with an extensive hemorrhagic presentation.

Introdução: O objetivo deste estudo é avaliar a estabilidade a longo prazo do tratamento de crosslinking (CXL) associado a queratectomia fotorefrativa (PRK) parcial com ablação com laser excimer, em doentes com queratocone, através da interpretação de parâmetros refrativos e topográficos aos 6 meses e na última avaliação disponível. Métodos: Foram incluídos 74 olhos de 71 doentes com queratocone, evidência de progresssão e/ou intolerância a lentes de contacto, nos estadios II-III de Amsler-Krumeich, submetidos ao tratamento de CXL associado a PRK parcial, com espessura estromal residual mínima de 325 μm. Os parâmetros avaliados foram a melhor acuidade visual corrigida (MAVC), a queratometria (K1, K2, K médio e K máximo), parâmetros refrativos como o valor da esfera, cilindro e o equivalente esférico (ES) e a paquimetria no ponto mais fino. Resultados: A idade média foi 32,12±9,73 anos. Reportamos os resultados aos 6 meses e os da última avaliação, entre os 12 e os 37 meses (média de 17,09±6,39 meses). Todos os parâmetros apresentaram estabilidade a longo prazo, com exceção da MAVC que melhorou em média 0,05 logMAR (0,27±0,20 logMAR aos 6 meses e 0,22±0,20 logMAR na última avaliação). Nenhum doente perdeu mais de 2 linhas na escala de Snellen e a melhoria mais acentuada verificou-se numdoente que recuperou 5 linhas. Conclusão: Os nossos resultados sugerem que a associação CXL acelerado e PRK topo-guiado leva a uma melhoria progressiva da MAVC dos 6 meses até aos 12 a 37 meses após o procedimento. Os parâmetros topográficos mantiveram-se inalterados durante este período, o que confirma a estabilização do queratocone.

Apresentamos um caso clínico de hipertensão intracraniana (HIC) numa criança com síndrome de Turner sob tratamento com hormona do crescimento (HC). Criança de 14 anos com síndrome de Turner sob terapêutica hormonal com estrogénio e hormona de crescimento (1,6 mg/dia) apresentou-se no serviço de urgência por diminuição da acuidade visual. A fundoscopia revelou edema bilateral da papila, confirmada por tomografia de coerência ótica (OCT). A tomografia computorizada e a ressonância magnética cerebrais não revelaram quaisquer alterações. A criança foi referenciada ao departamento de Neuropediatria. Realizou-se punção lombar que revelou aumento da pressão intracraniana e, desta forma, fez-se o diagnóstico de HIC. Optou-se pela suspensão da hormona do crescimento. A hipertensão intracraniana é uma entidade rara na população pediátrica. Há uma relação causal entre o HIC, o tratamento com hormona do crescimento e a síndrome de Turner. Do nosso conhecimento, é o primeiro caso em Portugal que descreve esta associação. Dado que a HIC pode levar a perda irreversível da acuidade visual, todas as crianças sob terapêutica hormonal com hormona do crescimento devem ser avaliadas de forma rotineira por oftalmologista.

Macular hemorrhage is a frequent complication of retinal macroaneurysms and represents a threat to central vision. We report the surgical use of recombinant tissue plasminogen activator (rtPA) in the treatment of macular hemorrhage. Two eyes of 2 female patients with macular hemorrhage from ruptured retinal macroaneurysms were treated with subretinal rtPA injection. Visual acuities on admission were of counting fingers (<20/400) in the 2 eyes treated. Best corrected visual acuity improved to 20/100. No major intraoperative complications were reported. Macular hemorrhage presents a low rate of spontaneous resolution and, left untreated, portends a poor prognosis. Subretinal injection of rtPA is a challenging, yet effective surgical technique, with rates of hemorrhage displacement reported between 50%-90%.

IMAGE DESCRIPTION Purtscher’s retinopathy is a rare, sight-threatening retinal disorder associated with numerous types of trauma. It has been firstly described in 1910 by Otmar Purtscher.1,2 Although the exact pathogenesis remains unclear, all clinical features suggest microembolic occlusion of the retinal precapillary arterioles.3 It frequently leads to sudden but reversible visual loss following the precipitating condition. Apart from the treatment of the underlying etiology, no therapeutic guidelines exist.4 A 25-year-old male presented to our emergency department with sudden, unilateral and painless visual loss 1 week after the surgical correction of a lumbar spine fracture due to severe lumbar trauma. Best-corrected visual acuity (BCVA) was 20/200 in the affected eye and fundoscopic examination revealed multiple cotton-wool spots, Purtscher flecken and intraretinal hemorrhages with peripapillary distribution (A). Fundus autofluorescence displayed several hypofluorescent areas (B). Optical coherence tomography showed hyperreflective inner retinal layers and subretinal fluid. Full examination of the fellow eye was unremarkable. The patient started a course of high-dose oral steroids, followed by a slow tapering. After 1 month, BCVA was 20/25 and fundoscopy revealed a complete resolution of the retinal findings. Optical coherence tomography displayed mild inner retinal atrophy and focal extrafoveal ellipsoid zone disruption with complete reabsorption of subretinal fluid.

Doente do sexo masculino, 52 anos de idade, caucasia- no, diagnosticado com polineuropatia amiloidótica familiar (PAF) desde 1993, submetido a transplante hepático em 1997. Recorre a consulta de oftalmologia por hipovisão OD com vários anos de evolução. No exame oftalmológico, a melhor acuidade visual corrigida era de percepção luminosa (sem projeção) no OD, e 20/320 no OE. A biomicroscopia é rica em achados característicos de paramiloidose ocular em ambos os olhos, revelando uma pupila de bordos crena- dos, com um aspeto típico em roda dentada, e com depósitos amilóides esbranquiçados no seu bordo (aspeto em destaque na imagem representativa do OD). A PIO era de 40 mmHg ODE, apresentando o nervo óptico uma escavação glauco- matosa, com uma relação cup/disc de 0.9 no OD e de 0.7 no OE, compatível com um glaucoma secundário que o estudo diagnóstico complementar (incluindo OCT e CV) confirmou. Concomitantemente, foram identificadas discretas opacidades vítreas bilaterais, mais pronunciadas à direita. O doente foi medicado com terapêutica hipotensora máxima e orientado para consulta de glaucoma, tendo sido submetido a cirurgia no OD (implante de válvula de Ahmed).

Valsalva retinopathy is a rare, specific retinal disorder characterized by preretinal hemorrhage caused by raised intrathoracic or intraabdominal pressure. It was firstly described by Duane in 1972.1 Patients present with sudden visual impairment, usually occurring in otherwise healthy eyes. The condition is triggered by Valsalva maneuvers including weight lifting, vomiting, coughing, constipation, blowing musical instruments, strenuous physical activities, vigorous sexual intercourse and labor. The prognosis is usually good with progressive spontaneous resolution. A 35-year-old healthy female presented with sudden onset of unilateral myodesopia referred to the right eye. Symptoms started 24 hours prior, following an intense CrossFit training session. She had no history of previous ophthalmologic disorders. Best-corrected visual acuity was 20/20 bilaterally. Anterior segment slit-lamp examination and intraocular pressure were unremarkable. Fundoscopy of the affected eye revealed a well-circumscribed, round and bright red, preretinal hemorrhage causing an elevated hemorrhagic posterior hyaloid detachment, nasal to the optic disc. The lesion had several disc areas of diameter and a horizontal, upper fluid level with gravitated blood corpuscles inferiorly. Additional small, preretinal and intraretinal hemorrhages were scattered through the macula and peripheral retina. Complete blood work, which included coagulation tests, was regular. A conservative approach was assumed. Three months later, visual acuity remained stable with complete resolution of retinal findings.

No summary/description provided

No summary/description provided

Conjunctivochalasis is a chronic conjunctival condition often underdiagnosed. The hallmark is loose, redundant conjunctival folds classically located in the inferior conjunctiva. It is often bilateral and the prevalence rates increase dramatically in the elderly. The exact pathogenesis remains unknown. Conjunctivochalasis has been strongly correlated with aging and concomitant dry eye disease. The currently recognised pathophysiology is associated with mechanical friction, tear film instability, delayed tear clearance, and ocular surface inflammation. Not all cases of conjunctivochalasis are symptomatic or clinically significant. Depending on the severity, it can lead to a spectrum of symptoms, ranging from exacerbation of a dry eye disease in mild forms, to the interference with physiological tear outflow in moderate forms, or even to exposure complications in rare severe cases. The diagnosis of conjunctivochalasis is clinical and mainly supported on a thorough history of symptoms and biomicroscopic findings. No specific treatment is required for the asymptomatic cases. When the disease is symptomatic, the therapeutic approach starts with the medical treatment. For refractory cases, an arsenal of surgical interventions is currently available as a second-line approach.

Tubulointerstitial Nephritis and Uveitis (TINU) syndrome is characterized by bilateral anterior uveitis and idiopathic tubulointerstitial nephritis. A 37-year-old female with bilateral anterior uveitis, malaise and fever was evaluated at the Ophthalmology Emergency department. Laboratory investigation revealed an elevated C-re- active protein, a raised erythrocyte sedimentation ratio and a sub-nephrotic proteinuria. Patient was then referred for Nephrology assessment and a renal biopsy showed diffuse tubulointerstitialnephritis. TINU syndrome was assumed. Bilateral anterior uveitis resolved after one week of topi- cal steroid therapy. This case highlights an under recognized syndrome, occurring in young patients with asymp- tomatic mild renal disease and chronic or recurrent anterior uveitis. It is important to be aware of this clinical entity since a prompt diagnosis and appropriate treatment can avoid poor renal and visual outcomes.