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- Hyperbaric Oxygen Therapy in Retinal Arterial Occlusion: Epidemiology, Clinical Approach, and Visual OutcomesPublication . Lopes, AS; Basto, R; Henriques, S; Colaço, L; Silva, F; Prieto, I; Guerreiro, FPURPOSE: To evaluate the efficacy and safety of hyperbaric oxygen therapy (HBOT) in patients with acute retinal artery occlusion (RAO). Secondarily, to analyse the epidemiology and the clinical approach. METHODS: Retrospective study of 13 patients submitted to HBOT between 2013 and 2018. The analysed parameters consisted of: systemic history, time between symptoms onset and treatment, initial approach, number of HBOT sessions, complications of HBOT and best corrected visual acuity-BCVA (of the total sample, central RAO-CRAO-group, and branch RAO-BRAO group). RESULTS: Arterial hypertension was the most prevalent systemic risk factor (53.8%). Initial therapies were 100% normobaric oxygen administration, topical and oral hypotensive medication, eye massage and aspirin. CRAO was observed in 69.2% and BRAO in 30.8% of the cases, with clinically significant visual improvement (a decrease in logMAR of 0.3) in 55.5% and 75%, respectively. Time between symptoms onset and treatment had a median of 9 hours. The median number of HBOT sessions was 7, without complications. CONCLUSIONS: HBOT provide BCVA improvement in patients with RAO, when it is performed in an early time after the symptom onset. It seems to be an effective and safe therapeutic option for a pathology that still remains without approved treatment.
- Unilateral leukemic infiltration and acute angle closure as the first sign of B-cell acute lymphoblastic leukemia relapsePublication . Silva, D; Mota, M; Bilé, A; Ramalho, M; Pinto, S; Pires, G; Teixeira, S; Prieto, IObjective: Unilateral ocular leukemic infiltration with acute angle closure is an infrequent complication of B-cell acute lymphoblastic leukemia (ALL-B). We present a clinical case of leukemic ocular infiltration as the sole manifestation of ALL-B relapse. Methods: Case description Results: A 15-year-old female with a history of acute lymphoblastic leukemia in remission for 2 years and pulmonary tuberculosis treated in the past year presented with ocular redness and decreased visual acuity in the left eye (LE) with 5 days of evolution. Visual acuity was 20/20 in the right eye (RE) and absence of light perception in the left eye (LE). Biomicroscopy of LE showed a small hypopion, anterior chamber cells 4+, vitreous cells 3+, and a large white mass in the vitreous with associated vitreous hemorrhage in organization. In LE fundoscopy, the vitreous mass occupying most of the vitreous cavity and associated hemorrhage prevented retina visualization. B-scan ultrasound showed a multilobulated mass occupying virtually the entire vitreous cavity with associated choroidal detachment. Forty-eight hours later, she developed acute angle closure of LE with an IOP of 55 mmHg. A flow cytometric analysis of the anterior chamber and vitreous showed leukemic tumor cells. The microbiologic exam and PCR for Mycobacterium tuberculosis were negative. No other signs of relapse of the disease were identified after investigation by the oncology department. Rescue treatment of the underlying disease was started, with symptomatic improvement. Conclusion: Leukemic ocular infiltration can be the only manifestation of ALL-B relapse.
- Outcomes of Trabeculectomy With and Without Mitomycin C in Pseudoexfoliative Glaucoma Compared With Mitomycin C in Primary Open Angle Glaucoma.Publication . Lopes, AS; Vaz, F; Henriques, S; Lisboa, M; Vendrell, C; Prieto, IThe aim of this study was to evaluate the outcomes of trabeculectomy with mitomycin C (MMC) in patients with Pseudoexfoliative Glaucoma (PXG) and compare the results with the outcomes of trabeculectomy without MMC in PXG and with MMC in Primary Open Angle Glaucoma (POAG). Ninety eyes (76 patients) submitted to trabeculectomy were included in a one-year retrospective study. Fifty-eight eyes with PXG were divided into group 1 (28 eyes) and group 2 (30 eyes), with and without MMC application respectively. Then, the group 1 results were compared with 32 eyes with POAG that performed trabeculectomy with MMC (group 3). Main outcome measures were intraocular pressure (IOP), number of IOP lowering medications, rate of bleb failure (encapsulation, flattening and/or vascularization) and the number of eyes submitted to surgical procedures after trabeculectomy (needling, 5-fluorouracil (5FU) or 2nd trabeculectomy). Results revealed that compared to trabeculectomy with MMC in POAG and trabeculectomy with MMC in PXG, trabeculectomy without MMC in PXG leads to higher IOP (preoperative mean ± standard deviation [SD] was 28.6 ± 5.4 mmHg in group 1, 32.2 ± 8.2 mmHg in group 2 and 26.1 ± 6.5 mmHg in group 3; and after one year was 13.9 ± 3.9 mmHg in group 1, 16.1 ± 5.9 mmHg in group 2 and 12.5 ± 4.0 mmHg in group 3); higher number of IOP lowering medications (preoperative mean ± SD was 3.1 ± 0.60 in group 1, 2.8 ± 0.81 in group 2 and 3.4 ± 0.76 in group 3; and after one year was 1.1 ± 1.1 in group 1, 1.1 ± 1.0 in group 2 and 0.33 ± 0.89 in group 3); higher prevalence of bleb failure (47% in group 1, 53% in group 2, and 18% in group 3); and increased participation in surgical procedures following trabeculectomy (47% in group 1, 57% in group 2, and 6% in group 3). We concluded that trabeculectomy without MMC in PXG had the worst surgical outcome. Thus, PXG appears to be a potential risk factor for filtration bleb failure. Therefore, it could be considered in surgical protocols of MMC application.
- Peripapillary Retinal Nerve Fiber Layer Thickness and Peripheral Microcirculation in Raynaud’s DiseasePublication . Pedrosa, C; Pina, S; Paula, F; Amaral, M; Vaz, FPurpose: Normal-tension glaucoma has been associated with systemic vascular diseases such as peripheral vasospasm. This study aims to evaluate the influence of peripheral vasospasm on the thickness of the retinal nerve fiber layer (RNFL) in Raynaud's disease (RD), and the correlation between global RNFL and peripheral microcirculation features in RD patients. Methods: Observational cross-sectional study of 18 patients (35 eyes) with a diagnosis of RD followed in our clinic, and 20 healthy controls (39 eyes). RNFL parameters were obtained using spectral domain optical coherence tomography (SD-OCT Spectralis®, Heidelberg). Global and sectorial peripapillary RNFL thickness were registered. Age, gender, refractive error, best-corrected visual acuity and intraocular pressure were determined, and slit-lamp biomicroscopy and fundus examination were performed. Nailfold videocapillaroscopy (NC) was performed in the RD group to characterize capillary morphology and blood flow. Mann-Whitney and Fisher's exact tests were used for statistical analysis. Statistical significance level was set at p<0.05 (two-sided). Results: There was no significant difference in the global RNFL between RD patients and the control group (p=0.35). The presence of avascular areas in NC was associated with a lower global RNFL thickness (p=0.026). Conclusion: The association between avascular areas in NC and the lower global RNFL thickness in RD patients suggests that systemic vasospasm severity may be related to optic nerve damage propensity. Therefore, its presence in NC may identify RD patients at risk for optic nerve head damage. A larger sample with a long-term study is needed to support the clinical and therapeutic implications of our findings.
- Digital Asthenopia: Portuguese Group of Ergophthalmology Survey.Publication . Vaz, F; Henriques, S; Silva, D; Roque, J; Lopes, AS; Mota, MINTRODUCTION: Given the increasing use of electronic devices, and the increasing number of complaints with its use, we intend to evaluate the prevalence of manifestations of dry eye and ocular fatigue in a population of individuals, who use the computer daily to perform all their professional tasks, as well as to correlate these complaints with the number of hours of digital use as well as their possible improvement with behavioural measures and use of tear drops. MATERIAL AND METHODS: A total of 77 individuals (154 eyes) were evaluated on two separate days with a 1-month interval. They completed two questionnaires: OSDI and PEG Eye Fatigue. An objective ocular surface assessment was performed: Schirmer test without anesthetic, DR-1a Dry Eye Monitor™, hyperemia evaluation, lacrimal break up, presence of keratitis and lesions in the conjunctiva, as well as near accommodation point and near convergence point. After the first evaluation, the subjects were divided into two groups: group A (< 2 hours of computer working) and group B (> 2 hours of computer working). Some environmental measures to reduce complaints and recommendation of use of artificial tears were explained to the latter. RESULTS: There was a statistically significant difference in the majority of the parameters evaluated in the group B, in relation to the morning period (group A) - tear film (p = 0.032), hyperemia (p < 0.001), BUT (p < 0.001), keratitis (p < 0.001), conjunctival lesion (p = 0.002) and accommodation point (p < 0.001). In the evaluation - one month later - there were no statistically significant differences in any of the parameters analysed in the group A, and in group B there was a decrease in most parameters at the end of that period - Schirmer test (p = 0.005), lacrimal film (p = 0.022), keratitis (p < 0.001), conjunctival lesion (p = 0.005) and fatigue score (p < 0.001). DISCUSSION: It was thus possible to show the appearance of ocular fatigue and ocular surface changes with prolonged use of computers (> 2 hours) as well as a significant improvement in symptomatology (subjective assessment) as well as of ocular surface changes (objective evaluation) with the implementation of postural measures, regular breaks and use of lubricants. This is the first study, to the best of our knowledge, of digital asthenopia in which, in addition to the subjective evaluation, the presence of ocular surface modifications (objective assessment) were evaluated and the respective improvement with the aforementioned ergophthalmological measures were evaluated. CONCLUSION: This survey highlights the increased overall level of awareness that we need to have to face the rapid and wide-scale changes driven by the emergence of digital technology and, more particularly, its impact on user's vision and posture. We concluded that the longer we use the electronic devices (more than two hours) the more severe the complaints and rates of ocular surface changes are. Environmental and ocular strategies can attenuate or even eliminate the discomfort caused by this syndrome, and increase professional performance and quality of life.
- A Rare Case of Bilateral ProptosisPublication . Serodio, J; Jonet, M; Trinidade, M; Coutinho, I; Favas, CA 65-year-old man presented with a 2-year history of severe bilateral proptosis, palpable lymphadenopathy and moderate hepatosplenomegaly. A blood test was positive for hepatitis C infection. CT showed palpebral infiltrative lesions with regional progression through the temporal and masticatory spaces to the pharynx and hypopharynx causing almost complete airway obstruction. A palpebral biopsy was consistent with low-grade Bcl-2+ extra-nodal MALT non-Hodgkin B-cell lymphoma. The patient received six cycles of rituximab-based chemotherapy with clinical remission at 9-month follow-up. Bilateral proptosis is a rare presentation of several diseases. When brain CT excludes cavernous sinus pathology, thyroid ophthalmopathy or haematological malignancy should be considered. LEARNING POINTS: Bilateral proptosis is a rare presentation with a broad differential diagnosis, and is most frequently is caused by cavernous sinus disease, thyroid ophthalmopathy or haematological malignancy.Hepatitis C may be associated with MALT lymphoma and presents mainly at non-gastric locations even with few hepatic manifestations of the infection.Long-term low-grade lymphoma may present with severe disseminated disease at diagnosis, but treatment response is generally good.
- Changes in choroidal thickness following trabeculectomy and its correlation with the decline in intraocular pressurePublication . Silva, D; Lopes, AS; Henriques, S; Lisboa, M; Pinto, S; Vaz, F; Prieto, IPURPOSE: Evaluate whether there are significant changes in choroidal thickness following trabeculectomy, and how they relate do the decline in intraocular pressure. METHODS: This was a prospective evaluation of 28 eyes who underwent Moorfields modified trabeculectomy. The choroidal thickness was measured via OCT with enhanced depth imaging, before surgery and 1 day, 1 week and 1 month after surgery. Measurements were taken at the fovea, 1000 µm temporal to the fovea and 1000 µm nasal to the fovea. The relationship between choroidal thickness and intraocular pressure was statistically evaluated. RESULTS: The mean intraocular pressure before surgery was 25.07 ± 4.64 mmHg; 8.57 ± 3.62 mmHg after 1 day; 10.36 ± 4.39 mmHg after 1 week and 13.71 ± 5.13 mmHg after 1 month. Mean choroidal thickness increased after trabeculectomy with maximal values at 1 week. The largest increase was found at the fovea, with an average before surgery of 253.54 ± 62.01 µm; 286.75 ± 64.20 µm at 1 day, 286.36 ± 63.14 µm at 1 week and 271.00 ± 60.31 µm at 1 month. Increase in choroidal thickness was significant 1 day and 1 week after surgery in the foveal (p = 0.012, p = 0.007) and temporal (p = 0.040, p = 0.000) locations and 1 week postoperatively on the nasal location (p = 0.016). None of them were significant at 1 month after surgery. Preoperative IOP and choroidal thickness were correlated at all macular locations (ρ = 0.449-0.525, p = 0.004-0.016) yet no correlation was found between increase in choroidal thickness and decline in intraocular pressure in the postoperative period. CONCLUSION: Choroidal thickness appears to increase temporarily after trabeculectomy and these changes were not correlated with the decline in intraocular pressure. Further research is required to fully understand this phenomenon.
- Melanoma da CoroideiaPublication . Coutinho, I; Teixeira, T; Simões, C; Lopes, C; Borrego, M; Fernandes, J; Cabral, J; Prieto, I; Proença, RChoroidal melanoma is the most common primary intraocular malignant tumor in adults. None of the different treatments available offers advantages of survival, resorting more and more to conservative treatments such as brachytherapy, which has been available in Portugal since 2013. In this article we review the clinical characteristics, risk factors, diagnosis, complementary exams and therapeutic options in choroidal melanoma.
- A challenged case of Vogt-Koyanagi-Harada syndrome: when dermatological manifestations came first.Publication . Coutinho, I; Pedrosa, C; Santos, C; Pina, S; Lisboa, M; Bernardo, M; Prieto, INTRODUCTION: Vogt-Koyanagi-Harada syndrome (VKHS) is an inflammatory systemic autoimmune disease principally affecting pigmented tissues in the ocular, auditory, integumentary and central nervous systems. Patients are generally women in the fourth decade of life. The prognosis is correlated mainly with the time between diagnosis and the start of treatment and number of recurrent episodes of inflammation. Most complications are mainly ocular. The purpose of this paper is to describe a clinical case of VKHS. MATERIAL AND METHODS: A child with a challenging clinical presentation in which the dermatological symptoms occurred before ocular manifestations. DISCUSSION AND CONCLUSION: VKHS is rare in children and can be a diagnostic challenge. It seemed interesting to share this case as an opportunity to expand our knowledge of the clinical spectrum of diseases and reflect about current diagnostic criteria.
- Reconstruction of delayed scleral flap melting with bovine pericardium after trabeculectomy with mitomycin C.Publication . Coutinho, I; Silva, D; Mota, M; Lisboa, M; Trancoso, V; Prieto, IAim: To present a challenging case of hypotony after trabeculectomy and its treatment. Case description: A 22-year-old woman with juvenile glaucoma underwent a conventional trabeculectomy with mitomycin C on the right eye (OD). In the immediate postoperative period, we observed a hyperfiltration bleb with hypotony refractory to conservative measures leading to hypotony maculopathy. A surgical revision with scleral flap resuture and conjunctival graft was performed with a satisfactory result and resolution of hypotony maculopathy. After two years, the patient complained of low visual acuity (VA) of the OD. During examination, we observed a fine and avascular bleb with Seidel and visualization of the underlying uveal tissue, an intraocular pressure (IOP) of 5 mmHg, and chorioretinal folds. A new revision of the trabeculectomy was performed. During the procedure, it was not possible to identify the scleral flap, so the fistula was closed with a patch of collagenous membrane derived from bovine pericardium (Tutopatch® graft). A good clinical evolution occurred. After 2 months, IOP was 15 mmHg without Seidel or changes in the fundus and VA was 20/20. After 8 months of follow-up, the IOP remains stable without further complaints. Conclusion: This case illustrates the difficulties faced in the management of a common complication of trabeculectomy and highlights some of the options available for its treatment. There are few reports of scleral melting after trabeculectomy. However, trauma and scleral necrosis associated with mitomycin are listed as the main causes. The use of a scleral patch derived from bovine pericardium allows effective suturing and closure of the aqueous leak.