PAAO XI 2 - 2012

Proud to be PAN-AMERICAN

PAN-AMERICAVISION

ISSN 2219-4665Junio 2012, Vol. 11(2)

THE PAN-AMERICAN JOURNAL OF OPHTHALMOLOGY

Dantas P PEC

SCIENTIFIC PRODUCTION IN LATIN AMERICA AND CARIBBEAN IS GROWING STEADLY

Mannis MJFROM THE PRESIDENT’S DESK

Rizzo JL, Chin EK, Rashid S, Park SPark SS

EXOGENOUS ENDOPHTHALMITIS: POST-OPERATIVE VERSUS POST-INTRAVITREAL INJECTION

Lichtinger A, Orukov F, Solomon A, Yahalom C, Frucht-Peery JJTOPICAL STEROIDS IN BACTERIAL KERATITIS: A RETROSPECTIVE STUDY

Klein KS, Caregnato R, Périco E, Balestro Jr NJ

QUALIDADE DE VIDA DE PORTADORES DE CERATOCONE SUBMETIDOS AO CROSSLINKING

Orellana Rios J , Sanchez KE , Iturriaga Valenzuela H, Ried Unddurraga JMDESPRENDIMIENTO DE RETINA EN SÍNDROME DE KNIEST

Tandon A, Chawla A, Valenzuela AA

VARIABLES TO CONSIDER WHEN CONFRONTING A MICROPHTHALMOS WITH A CYST

García-Fernández M, Navarro JC

SPONTANEOUS CLOSURE AND QUICK REOPENING OF A FULL THICKNESS IDIOPATHIC MACULAR HOLE

Izquierdo NJADVOCACY: LOS TRES RENGLONES DE LA EXCELENCIA MÉDICA

PAN-AMERICA

CREATIVE LATIN MEDIA, LLC.2901 Clint Moore, P.M.B 117 Boca Raton, FL 33496

Tel.: (561) 495 4728 • Fax: (561) 865 1934E-mail: [email protected] • [email protected]

June 2012, Vol. 11(2)

Aims and scope:

Vision Pan-America (printed version ISSN 2219-4665, electronic version ISSN 2219-4673), the offi cial publi-cation of the Pan-American Asso-ciation of Ophthalmology, is a quar-terly fully peer reviewed scientifi c publication that publishes original research in Ophthalmology, includ-ing review articles on ophthalmic diseases and surgical techniques, clinical scientifi c studies, basic in-vestigation, case reports, brief com-munications and letters to the editor in four languages: Spanish, English, Portuguese and French. In addi-tion, the journal publishes critical reviews of new texts in ophthalmol-ogy deemed to be of importance to the Pan-American practitioner.

Prepress Creative Latin Media. Printed in Printer Colombiana – Colombia

Section Editor, Cataracts: Nestor Gullo, MD (La Plata, Argentina)

Section Editor, Cornea and External Disease: Allan R. Slomovic, MD (Ontario, Canada)

Section Editor, Eye Banking: Luciene Barbosa de Sousa, MD (São Paulo, Brazil)

Section Editor, Genetics: Eduardo José Gil Duarte Silva, MD (Figueira da Foz, Portugal)

Section Editor, Glaucoma: James C. Tsai, MD (New Haven, CT, USA)

Section Editor, Neurophthal-mology: Karl Golnik, MD (Cincinnati, OH, USA)

Section Editor, Oncology: Rubens N. Belfort, MD (São Paulo, Brazil)

Section Editor, Ophthalmic Plastics and Orbital Diseases: Chun Cheng Lin Yang, MD MSc (San José, Costa Rica)

Section Editor, Pathology: J. Oscar Croxatto, MD (Buenos Aires, Argentina)

Section Editor, Pediatric Ophthalmology and Strabismus: Maria Estela Arroyo Yllanes, MD (México City, México)

Section Editor, Prevention of Blindness: Fernando R. Barría von Bischhoffshausen, MD (Concepción, Chile)

Section Editor, Refractive Surgery: Luis Izquierdo Jr, MD (Lima, Peru)

Section Editor, Retina and Vitreous: Mauricio Maia, MD (São Paulo, Brazil)

Section Editor, Statistics and Epidemiology: Niro Kasahara, MD (São Paulo, Brazil)

Section Editor, Uveitis and Immunology: Lourdes Arellanes-García, MD (Mexico City, Mexico)

Section Editor

PAOF INDUSTRY SPONSORS

• Abbott Medical Optics Inc.

• Alcon Inc.

• Allergan Inc.

• Bausch & Lomb Inc.

• Carl Zeiss Meditec Inc.

• Johnson & Johnson Vision Care Latin America

• Merck & Co Inc.

• Novartis International AG.

• Santen Inc.

Director of Printed Matters CLM: Eliana Barbosa

Graphic Design CLM: Juan David Medina / Catalina Lozano O.

Databases and Distribution CLM: Ximena Ortega Bernal

[email protected]

Copyediting: Piedad Camacho and Vanessa Carmona

Prepress: Alejandro Bernal

Production Staff

Managing Editor: Teresa Bradshaw (Arlington, TX, USA)

Production Editor: Terri Grassi(Arlington, TX, USA)

Mapy Padilla(Lima, Peru)

Offi ce Staff

Alejandro Lichtinger, MD (Toronto, Ontario, Canada)

Ashley Behrens, MD (Riyadh, Saudi Arabia)

Ana Luisa Höfl ing-Lima (São Paulo, Brazil)

Bruno Fontes, MD (Rio de Janeiro, Brazil)

Carol L. Karp, MD (Miami, FL, USA)

Enrique Graue-Hernández, MD (Mexico City, Mexico)

Eugenio Maul de La Puente (Santiago, Chile)

Ivan Schwab, MD (Sacramento, CA, USA)

Maria Audina Berrocal, MD (Miami, FL, USA)

Daniel Weil, MD (Buenos Aires, Argentina)

Marian Macsai, MD (Chicago, IL, USA)

Marie Eve Legare, MD (Quebec City, Canada)

Natalio Izquierdo, MD (San Juan, Puerto Rico)

Peter Quiros, MD (Los Angeles, CA, USA)

Renato Ambrósio Jr. (Rio de Janeiro, Brazil)

Editorial Review Board

Denise de Freitas, MD (São Paulo, Brazil)

Eduardo Alfonso, MD (Miami, FL, USA)

Eduardo Arenas, MD (Bogotá, Colombia)

J. Fernando Arévalo, MD (Riyadh, Saudi Arabia)

Alfredo Sadun, MD (Los Angeles, CA, USA)

Editorial Advisory Board

Administrative Editorial Council:Mark Mannis, MD (PAAO Presi-dent, Sacramento, CA, USA.), and Nelson Marques, MBA (PAOF Chairman, São Paulo, Brazil)

Associate Editor-in-Chief: Lihteh Wu, MD (San José, Costa Rica)

Editor-in-Chief:Paulo Elias C. Dantas, MDProf. of OphthalmologyDepartment of OphthalmologySanta Casa of São Paulo, Brazil

Membership, Associations and Editorial Guidelines

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1 Delegate2 PAAO Past President3 President, Affi liated National Society4 President, Affi liated Subspecialty Society

PAAO EXECUTIVE COMMITTEE 2011-2013

PresidentMark J. Mannis, MD

President ElectAna Luisa Höfl ing-Lima, MD

Past PresidentCristián Luco, MD

Vice PresidentPeter A. Quiros, MD

Executive Vice PresidentJ. Fernando Arévalo, MD FACS

Secretary, English Language RegionJames C. Tsai, MD MBA

Associate Secretary, English Language RegionCarol L. Karp, MD

Secretary, Portuguese Lan-guage RegionPaulo E.C. Dantas, MD

Associate Secretary, Portu-guese Language RegionMauricio Maia, MD

Secretary, Spanish Lan-guage RegionLihteh Wu, MD

Associate Secretary, Spanish Language RegionJorge E. Valdez Garcí a, MD MA

Executive DirectorTeresa Bradshaw

Chairman of the BoardMr. Nelson Marques

Past ChairRubens Belfort Jr, MD PhD

Vice ChairWilliam C. de La Peña, MD

Secretary TreasurerJ. Fernando Arevalo, MD

Executive DirectorTeresa Bradshaw

PAOF BOARD

ARGENTINAEnrique S. Malbrán, Sr., MD1

Ernesto Ferrer Abad, MD1,3

Gustavo Federico Bodino, MD1

J. Ignacio Manzitti, MD1

Joaquin Alfredo Bafalluy, MD1

Juan Oscar Croxatto, MD4

Lidia López, MD4

María Celeste Mansilla, MD1

Nestor Gullo, Jr., MD4

Roberto N. Ebner, MD1

S. Fabián Lerner, MD4

BOLIVIAJosé Luis Sebastián Salas, MD3

José Vladimir Justiniano Talavera, MD1

Vania Licett García Aliaga, MD1

BRAZILBruno Machado Fontes, MD1

Eduardo Büchele Rodrigues, MD1

José Alvaro P. Gomes, MD4

Liana Maria V. de O. Ventura, MD PhD1

Luciene Barbosa de Sousa, MD4

Luciene Chaves Fernandes, MD4

Marco Antonio Rey de Faria, MD1,3

Maria Cristina Nishiwaki-Dantas, MD1

Mário Junqueira Nóbrega, MD1

Nilo Holzchuh, MD1

Paulo Augusto de Arruda Mello, MD PhD1

Rubens Belfort, Jr., MD PhD2

CANADAAllan R. Slomovic, MA MD FRCS(C)1

Paul E. Rafuse, MD PhD FACS1,3

CHILECristián Luco, MD2

Fernando Barría von Bischhoffshausen, MD1,4

Francisco José Conte Silva, MD1

Gonzalo Matus, MD1

Javier Lagos Rodríguez, MD1

Juan Verdaguer Taradella, MD2

Pedro Bravo C., MD1,4

COLOMBIAAlvaro Rodríguez González, MD2

Angela María Fernández Delgado, MD1,4

Angela María Gutiérrez Marín, MD1

Carlos Alberto Restrepo Pelaez, MD1

H. Fernando Gómez Goyeneche, MD1,3

Pedro Ivan Navarro Naranjo, MD1

COSTA RICAJavier A. Montero Alpizar, MD1

Joaquín Martínez Arguedas, MD3

Lihteh Wu, MD4

Teo Evans, MD1

CUBACaridad Chiang Rodríguez, MD1

Carlos Alberto Perea Ruiz, MD1

Marcelino Rio Torres, MD3

Reinaldo Ríos Caso, MD1

DOMINICAN REPUBLICJoaquin Lora Hernández, MD1

Miguel Angel López Pimentel, MD1

Miriam Cortina, MD3

ECUADORGregorio Gabela, MD1,4

Patricio Flor Arteaga, MD1

Ximena Velasteguí Camorali, MD3

EL SALVADORCarlos Eduardo Alas Gudiel, MD1

Jaime Ricardo Avila Guerra, MD3

Rodrigo Antonio Quesada Larez, MD1

GUATEMALAPaulina Castejón, MD1

Rudy Oliver Gutiérrez Díaz, MD1,3

HAITIFrantz Large, MD3

HONDURASDoris Alvarado de Jaúregui, MD1,3

Sergio Rolando Zúñiga Castillo, MD1

MEXICOCecilio Francisco Velasco Barona, MD4

Enrique L. Graue Wiechers, MD2

Humberto Ruiz Orozco, MD1,3

José Luis Tovilla Canales, MD4

Lourdes Arellanes, MD4

María Estela Arroyo Yllanes, MD4

Raul Macedo Cué, MD1

NICARAGUASylvia Bravo Mendiola, MD1,3

PANAMABenjamín F. Boyd, MD2

Félix Emilio Ruiz Díaz, MD1,3

Miguel Fco. Wong Tang, MD1

PARAGUAYCirila Espinola de Ruiz Díaz, MD1,3

Miriam R. Cano, MD1

PERUDino Fernando Natteri Marmol, MD1

Francisco Contreras Campos, MD2

Juan Carlos Corbera Gonzalo, MD1

Juan Fernando Mendiola Solari, MD1

Miguel Guzmán Ahumada, MD3

Rocío Ardito Vega, MD1

PORTUGALEduardo José Gil Duarte Silva, MD PhD1

Maria Manuela Pires Carmona, MD1,3

PUERTO RICOIan Piovanetti Pérez, MD1,3

María Hortencia Berrocal, MD1

SPAINCarlos Cortés Valdés, MD1

Luis Fernández Vega Sanz, MD3

Miguel A. Zato Gómez de Liaño, MD PhD1

URUGUAYAlicia Martínez de Pacheco, MD1

María del Rosario Varallo, MD1

Miguel Zylberglajt Cordones, MD1,3

USAAlice R. McPherson, MD2

Andrew G. Lee, MD1

Anthony C. Arnold, MD1

Arun D. Singh, MD4

Bradley Dean Fouraker, MD1

Bradley R. Straatsma, MD JD2

Carl D. Regillo, MD1

Charles M. Zacks, MD1

David K. Coats, MD1

Eduardo C. Alfonso, MD1

George A. Williams, MD1

J. Bronwyn Bateman, MD2

James P. McCulley, MD1

John A. Irvine, MD1

Nelson R. Sabates, MD1

Paul R. Lichter, MD2

Richard K. Parrish, II, MD1

Richard L. Abbott, MD2Robert B. Bhisitkul, MD PhD1

Robert C. Drews, MD2

Robert Ritch, MD1

Ruth D. Williams, MD3

Stephanie Jones Marioneaux, MD1

Stuart R. Seiff, MD1

VENEZUELAClaudia Luz Pabón Bejarano, MD1

Luis Felipe Rivero Caret, MD1

María Angélica Cortez Bernal, MD1

Morayma Coromoto Acevedo Sorondo, MD3

Oscar Vicente Beaujón Balbi, MD1

WEST INDIESDonovan Calder, BSc MBBS FRCS3

Terrence Allan, BSc MBBS FRCS1

PAAO BOARD OF DIRECTORS 2011-2013

PAN-AMERICA 35PAN-AMERICA

EDITORIAL

EditorialPaulo E.C. Dantas, MDEditor-in-Chief

Scientific production in Latin America and the Caribbean is growing steadly

There are many institutions responsible for the burden of measuring the scientific pro-duction around the world. Among them, Web of Science (WoS), Scopus and Scimago are considered main sources, along with MedLine, operated by the National Library of Medi-cine. In Latin America, SciElo, LILACS and RedALyC are reference for bibliographic collec-tion and indexation. Looking at the recent data and numbers from those sources1, it is clear that Latin America and the Caribbean displayed a tendency toward scientific productivity growth. This is terrific news, showing that we are moving in the right direction.

In the health science area, specifically in Ophthalmology, I see the positive influence of the Pan-American Association of Ophthalmology (PAAO) in this process, as a result of the incentive of hundreds of young Pan-American scientists through scholarships, fellowships, becas and travel awards offered to them along the history, as well as the continued incentive of inviting them to perform scientific presentations in Regional sponsored meetings, in the Pan-American Congress and joint meetings with international societies such as American Academy of Ophthalmology and Association for Research in Vision and Ophthalmology (the PARD – Pan-American Research Day).

I challenge you: Take a moment and remember of colleagues that now are in high aca-demic positions in prestigious medical institutions around the world. You will be surprised on how many of them were supported by the Pan-American Association of Ophthalmology in their initiation.

In conjunction with all those activities, PAAO and PAOF have proudly supported and maintained Vision Pan-America as an excellent option for publishing science for the Pan-American scientist. This issue is a living proof of that: USA, Brazil, Spain, Canada, Chile, Puerto Rico (and even Israel!) are represented here with truly captivating papers.

Rizzo et al present an extensive overview that deals with the increasing concern for post-injection endophthalmitis widespread after use of intravitreal injections of vascular en-dothelial growth factor (VEGF) antagonists.

In an out of the ordinary article, Lichtinger et al bring some data on the use of cortico-steroids in bacterial keratitis, always a controversial issue.

Looking for answers on the quality of life among patients submitted to corneal crosslink-ing therapy, Klein et al present a particularly interesting study.

Closing this issue, three well presented and documented case reports.

Really “good scientific Pan-American stuff”!

Hope you enjoy the issue!

All the best,1. Miguel S. Journals

and scientific production in

Latin America and the Ca-

ribbean: its visibility in SciE-

LO, RedALyC and SCOPUS.

Rev Interam Bibliot [online].

2011; 34(2): 187-198.

Paulo E.C. Dantas, M.D.Editor-in-Chief Vision Pan-America, The Pan-American Journal of [email protected]@me.com

36 PAN-AMERICA

Vis. Pan-Am. 2012;11(2):36-37

Message from the PresidentDr. Mark MannisPresidente, Asociación Panamericana de OftalmologíaPresident, Pan-American Association of Ophthalmology

Del escritorio del presidente

Cuando pienso en el Panamericanismo, pienso en eventos internacionales de gran calidad, camaradería sin paralelo, ciencia clínica muy sólida y el reconoci-miento creciente que Latinoamérica, incluyendo Amé-rica del Sur y Central así como El Caribe, representan la fuente de algunos de los trabajos clínicos más creativos en nuestro campo de la medicina.

Todos estamos ocupados y activos en nuestras socie-dades nacionales, actividades que nos conducen y son las más relevantes en nuestra práctica clínica diaria. Pero la participación activa en la Panamericana nos permite lle-gar más allá de nuestras fronteras y recoger lo mejor que hay en nuestra especialidad de todo el hemisferio. Como presidente de la Panamericana, he obtenido una especial perspectiva de la oftalmología en las Américas. No es necesario decir que hay una tremenda variación regional tanto en la accesibilidad como en el nivel del cuidado of-talmológico brindado a los pacientes. Esta variación no es solo entre continentes o naciones, sino existe aun regio-nalmente en muchos de nuestros países. Contamos con una oftalmología de las más altamente desarrolladas en el mundo junto a una significativa variabilidad regional en la calidad de nuestros programas de residencia y regiones en las cuales el cuidado oftalmológico permanece bastante rudimentario. Esta interesante combinación de circunstan-cias brinda de ambos a los miembros de la Panamericana sus retos y sus oportunidades.

En los últimos ocho meses, los líderes de la Paname-ricana y la PAOF han venido trabajando para mejorar el sitio web (www.paao.org) y las contribuciones que brindan a sus miembros. Nuestros comités trabajan mucho desa-rrollando programas educativos online, webinars, cursos y reuniones que lleven lo mejor de nuestra ciencia a nues-tros miembros. Algunos de estos fueron ya evidentes en el fabuloso curso regional en Cartagena a inicios de este año. El próximo año, esperamos contar con un mayor nú-mero de cursos online, webinars, la indexación de nuestra revista científica, nuevos recursos para los oftalmólogos en entrenamiento y por supuesto, una serie de eventos re-gionales e internacionales.

Vision Pan-America tiene un segundo nuevo nom-bre: La Revista Panamericana de Oftalmología. Mientras escribo este Editorial en Vision Pan-America – ahora bajo el experimentado liderazgo editorial de Paulo Dan-tas y su Junta Editorial – estoy motivado porque muy pronto tendremos una revista propia totalmente indexada que represente verdaderamente la ciencia oftalmológica latinoamericana. Los animo a todos ustedes a apoyar la revista enviando sus trabajos y convertirse en líderes activos de la PAAO. El antiguo adagio que “una marea creciente levanta todos los barcos” es muy cierto en la PAAO. El éxito de un país en nuestra región trae nuevas posibilidades a las naciones vecinas – esto es, siempre y cuando nos comuniquemos. Esto podemos hacerlo a través de la Asociación Panamericana de Oftalmología.

From the President’s Desk

When I think about Pan-Americanism, I think of high quality international meetings, unparalleled collegiality, very solid clinical science, and the emerging recog-nition that Latin America, including Central and South America as well as the Caribbean, represent the source of some of the most creative clinical work in our field of medicine.

We are all busy and active in our national societies, the activities of which drive and are most relevant to our daily clinical practices. But active participation in the Pan-American allows us to reach beyond our bor-ders and to glean the best that there is in our special-ty from all over the hemisphere. As President of the Pan-American, I have gained a unique perspective of ophthalmology in the Americas. Needless to say, there is tremendous regional variation both in the accessibili-ty to as well as the level of ophthalmic care afforded to patients. This variation is not just between continents or nations but exists even regionally in many of our countries. We boast some of the most highly develo-ped ophthalmology in the world along with significant variability in the quality of our residency training pro-grams and regions in which ophthalmic care remains


MESSAGE FROM THE PRESIDENT

fairly rudimentary. This interesting mix of circumstan-ces provides members of the Pan-American with both its challenges and its opportunities.

For the past eight months, the executive leaders-hip of the PAAO and PAOF has been working to refine the web site (www.paao.org) and the offerings that it provides to members. Our committees are hard at work developing online educational programs, webi-nars, courses, and meetings that will bring the best of our science to our members. Some of this was already evident at the wonderful regional meeting in Cartagena earlier this year. In the coming year, we hope to see a proliferation of online courses, webinars, indexation of our scientific journal, new resources for ophthalmo-logists-in-training and, of course, an array of regional and international meetings.

Vision Pan-America has a second new name: The Pan-American Journal of Ophthalmology. As I write this Editorial in Vision Pan-America—now under the expert editorial leadership of Paulo Dantas and his Editorial Board—I am encouraged that very soon, we will have a fully indexed journal of our own that truly represents Latin American ophthalmic science. I encourage all of you to support the journal with your submissions and to become active leaders in the PAAO. The old adage that “a rising tide lifts all boats” is very true in the PAAO. The success of one country in our region brings new possibilities for neighboring nations—that is, as long as we communicate. This we can do through the Pan-American Association of Ophthalmology.

Escritorio do presidente

Quando eu penso sobre Pan-Americanismo, eu penso em eventos e encontros sem paralelo e de grande qualidade internacional. Penso em ciência clínica muito sólida e do emergente reconhecimen-to da América Latina (incluindo Centro América, América do Sul e Caribe) como fonte de alguns dos mais criativos trabalhos e estudos clínicos em nosso campo de medicina.

Nós todos estamos bastante ocupados e ativos com nossos deveres para com as nossas socieda-des nacionais cujas atividades orientam e são mais relevantes para nossa prática diária. Entretanto, par-ticipação ativa na Pan-Americana permite extrapolar nossas fronteiras geográficas, recolher e selecionar o que há de melhor para nossa especialidade em todo o Hemisfério. Como Presidente da Pan-Ame-ricana eu ganhei acesso à uma perspectiva única sobre a Oftalmologia nas Américas. Desnecessário dizer que há uma tremenda variação regional, no que diz respeito à acesso e também ao nível de cuidados oftalmológicos brindados aos pacientes. Esta va-

riação não se limita apenas a continentes ou nações, mas por vezes, até mesmo regionalmente dentro de um único país. Nós nos orgulhamos de exercer a mais desenvolvida Oftalmologia existente no mundo, ao mesmo tempo em que convivemos com variações significativas na qualidade dos programas de resi-dência e regiões nas quais o cuidado Oftalmológico ainda é relativamente rudimentar. É precisamente este “mix” de circunstâncias que traz aos membros da Pan-Americana imensos desafios e grandes opor-tunidades.

Nos últimos 8 meses, a liderança executiva da PAAO e PAOF têm trabalhado para refinar o conteúdo do website (www.paao.org) e as ofertas disponíveis para seus associados. Nossos comitês estão tra-balhando arduamente no desenvolvimento de pro-gramas educacionais, webinars, cursos e encontros virtuais que veicularão o melhor de nossa ciência aos associados. Algo disso já ficou bastante evi-dente no maravilhoso Curso Regional em Cartage-na, na primeira semana de Fevereiro passado. Para o próximo ano, nós esperamos ver uma proliferação de cursos online e webinars, a indexação da nossa revista científica, novos recursos para treinamento e aperfeiçoamento de oftalmologistas e, evidente-mente, presença nos mais importantes eventos re-gionais e internacionais, coroados pelo Congresso Pan-Americano no Rio de Janeiro de 7 a 10 de Agos-to de 2013, no qual, em conjunto com o Conselho Brasileiro de Oftalmologia, esperamos a presença de cerca de 10.000 oftalmologistas.

Vision Pan-America agora tem um segundo novo nome: A Revista Pan-Americana de Oftalmologia. Enquanto escrevo este Editorial para Vision Pan-America - agora sob a competente liderança editorial do Dr. Paulo E. C. Dantas e seu Conselho Editorial - eu estou muito confiante de que, muito brevemente, teremos uma revista indexada internacionalmente, que verdadeiramente represente a ciência oftalmo-lógica Latino-Americana. Eu os encorajo a apoiar a revista com submissões de artigos e a serem mem-bros e líderes ativos da PAAO.

Dizem que “quando a maré se levanta, ela empurra todos os barcos”. Este adágio se aplica com perfeição à Pan-Americana. O sucesso de um país em nossa re-gião gera novas possibilidades para nações vizinhas, desde que tenhamos uma comunicação adequada e efetiva. Esta comunicação e a exploração correta de novas oportunidades é o que podemos fazer juntos através da Associação Pan-Americana de Oftalmologia.

Mark Mannis, MD, FACSPresidenteAssociação Pan-Americana de Oftalmologia

38 PAN-AMERICA

REVIEW / Vis. Pan-Am. 2012;11(2):38-43

Corresponding author:

Susanna S. Park, MD, PhDUniversity of California Davis Eye Center4860 Y St., Suite 2400Sacramento, CA 95817Phone: 916-734-6544; FAX: 916-734-6197E-mail: [email protected]

ABSTRACT

Endophthalmitis is a potentially vision-threa-tening complication associated with nearly every intraocular or periocular procedure, including cata-ract surgery and intravitreal injection. Post-operative endophthalmitis after cataract surgery is a familiar entity with well-established features and treatment. However, infectious endophthalmitis after intravi-treal injection is not as well understood. The current widespread use of intravitreal injections of vascular endothelial growth factor (VEGF) antagonists has raised increasing concern for post-injection endo-phthalmitis. Endophthalmitis associated with intravi-treal injections occurs with a similar low incidence as endophthalmitis associated with cataract surgery. Post-surgical and post-injection endophthalmitis ex-hibit similar clinical features, though post-injection endophthalmitis might present earlier. These entities share the most common causative organism, Sta-phylococcus epidermidis, although there is a higher incidence of more virulent and resistant organisms such as streptococcal species in post-injection en-dophthalmitis. The proportion of eyes with a culture-negative endophthalmitis has been found more com-monly after intravitreal injection, raising concerns for distinguishing infectious endophthalmitis from sterile endophthalmitis, which may be associated with anti-VEGF therapy. The Endophthalmitis Vitrec-tomy Study (EVS) guides the treatment of exogenous endophthalmitis after cataract extraction. after cata-ract extraction, while the treatment of post-injection endophthalmitis is an area of new interest with emer-ging literature to guide management.

INTRODUCTION

Endophthalmitis after any ophthalmic procedure is a potentially vision-threatening condition. Exo-

genous endophthalmitis, although rare, has been reported to occur after nearly every intraocular or periocular procedure, including cataract surgery and intravitreal injection1. Endophthalmitis after cataract surgery has been studied extensively, and there are established guidelines for treatment2. In contrast, infectious endophthalmitis after intravitreal injection has only more recently gained attention due to the increased utilization of intravitreal injections of vas-cular endothelial growth factor (VEGF) antagonists. The use of VEGF antagonists, such as ranibizumab (Lucentis®; Genentech, South San Francisco, CA) or bevacizumab (Avastin®; Genentech) for exudative age-related macular degeneration or macular edema secondary to vascular occlusion or diabetic retino-pathy has resulted in increasing interest in studying post-injection endophthalmitis and determining op-timal treatment3. This review is a comparison of the clinical features, microbial profiles, treatments, and outcomes of exogenous endophthalmitis following cataract surgery and after intravitreal injection of anti-VEGF therapy.

1. Incidence And Clinical PresentationsCataract surgery is one of the most commonly

performed surgeries in the USA, with an estimated cataract surgery rate of 2,700 operations per million per year4. Subsequently, post-operative endophthal-mitis after cataract surgery accounts for most cases of endophthalmitis seen in clinical practice. Repor-ted incidence of endophthalmitis ranges from 0.04 to 0.2% after cataract surgeries depending on the surgical technique used5. With the increasing num-bers of cataract surgeries performed nationwide, the number of cases of postoperative endophthalmitis is rising as well6.

Exogenous endophthalmitis: Post-operative versus post-intravitreal injection

From the Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, CA

Jennifer L. Rizzo, M.D.Eric K. Chin, M.D.Saadia Rashid, M.D.Susanna S. Park, M.D. PhD

Financial Disclosure: NoneProprietary and/or fi nancial interest: None of the authors have any fi nancial or commercial interest to disclose.This study was supported in part by the Research to Prevent Blindness Unrestricted Departmental Grant.

Date of submission: 30/01/2012 / Date of approval: 09/04/2012


Rizzo JL et al. Exogenous endophthalmitis

A clinical entity with growing recognition in re-cent years is infectious endophthalmitis after intra-vitreal injection. With the rapid increase in the use of intravitreal injections to administer inhibitors of vascular endothelial growth factor (VEGF) to treat exudative age-related macular degeneration (AMD) and macular edema associated with retinal vascular occlusion7, diabetic retinopathy8, and other causes9, this clinical entity is becoming more frequent. The consensus from several large studies shows that the overall rate for post-injection endophthalmitis after any type of intravitreal injection is 0.019 to 0.16% per injection, with a range of 0.019 to 0.08% for be-vacizumab and 0.02% and 0.2% for ranibizumab10.

A recent multicenter Comparison of Age-Related Macular Degeneration Treatment Trials (CATT) study showed no statistically significant difference in the incidence of endophthalmitis between bevacizumab and ranibizumab after intravitreal injection11. In this study, endophthalmitis occurred after 4 of 5508 (0.07%) injections in 586 patients receiving bevaci-zumab and after 2 of 5449 (0.04%) injections in 599 patients receiving ranibizumab (P = 0.49). Similarly, another study by Shah et al.12, also demonstrated no difference in the risk of developing endophthalmi-tis following intravitreal injection with bevacizumab when compared to ranibizumab. This retrospective case series and case control at a single center repor-ted 23 cases of presumed infectious endophthalmitis among 27,736 injections administered, for an ove-rall rate of 0.083% per injection. A rate of 0.11% was noted following intravitreal bevacizumab injection, compared to a rate of 0.066% following intravitreal ranibizumab injection (P = 0.21), a difference that was not statistically significant. These findings are important given the potential increased risk of endo-phthalmitis when using bevacizumab off-label after it is aliquoted by a compounding pharmacy.

The signs and symptoms associated with infec-tious endophthalmitis after intravitreal anti-VEGF in-jection include many clinical features that are simi-lar to infectious endophthalmitis following cataract surgery. These features include pain, conjunctival injection, vision loss, intraocular inflammation, and hypopyon. Table 1 summarizes and compares the clinical features of endophthalmitis associated with these two clinical entities. Post-cataract surgery en-dophthalmitis often presents within approximately 6 to 13 days after the procedure.1,13 Patients with post-injection endophthalmitis typically present within 6 days of the injection.14-16

2. Causatives organisms

Staphylococcus epidermidis is the most com-mon causative organism in culture-positive infec-

tious endophthalmitis after cataract surgery as well as intravitreal anti-VEGF injections. However, strep-tococcal species have been identified as causative three or more times as frequently in endophthalmitis after intravitreal injection of VEGF antagonist than af-ter cataract surgery.1,13,35

The diagnosis of endophthalmitis is made clinica-lly. Cultures of aqueous or vitreous should be obtained to determine the causative organism although the re-sults will not be available to guide the acute manage-ment of endophthalmitis. A small amount of aqueous or vitreous can be obtained in an office setting, gene-rally with a 30-gauge needle on a tuberculin syringe or 25-gauge one-inch needle, respectively. In the En-dophthalmitis Vitrectomy Study (EVS), vitreous speci-mens were more likely to yield positive cultures than aqueous specimens, with positive cultures in 50% versus 25% respectively, in eyes with endophthalmitis after cataract surgery15. Overall, 67% of either vitreous or aqueous cultures were positive in patients where culture samples were obtained by needle aspiration. If pars plana vitrectomy was performed, vitreous sam-ples from vitrectomy yielded positive cultures in 72% of cases.

If cultures are negative, diagnoses other than infectious endophthalmitis should be considered. After cataract surgery, a non-infectious inflammation could be the result of toxic anterior segment syn-drome (TASS), retained lens fragments, or surgical trauma, and patients can present as early as 24 hours from the procedure16. Among patients who present with presumed endophthalmitis after intravitreal in-jection, the diagnosis of sterile endophthalmitis” should be considered if symptoms occurred within one day following intravitreal injection, if there is absence of a hypopyon, if there is a predominant anterior segment reaction, or if a prompt clinical improvement is noted while on topical corticoste-roid therapy17. Sterile endophthalmitis has been infrequently described occurring after anti-VEGF in-travitreal injections, particularly after bevacizumab, which can present with similar signs and symptoms to bacterial endophthalmitis18,19.

Table 1: Incidence and initial clinical presentations in infectious post-cataract surgery endophthalmitis versus infectious post-intravitreal VEGF antagonist injection endophthalmitis.

*86% of subjects had vision worse than 5/200; 26% had vision of light perception (LP)

Post-cataract surgery endophthalmitis6 Post-intravitreal VEGF antagonist injection endophthalmitis11,13,14,15,17

Rate 0.04 – 0.2% per surgery 0.019 to 0.16% per injection

Time to presentation 6-13 days 1-6 days

Pain 74% Yes

Vision loss 94.3%* Yes

Injection 82.1% Yes

Intraocular infl ammation 79% Yes

Hypopyon 85% 78%

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It is important to note that patients with sterile endophthalmitis associated with anti-VEGF injec-tions can present much later following the injection, up to 15 days in some reports15.Thus, the timeline of presentation cannot solely be used to differentia-te “sterile endophthalmitis” from infectious endo-phthalmitis.

The most commonly implicated organisms in acute-onset endophthalmitis after cataract surgery are Staphylococcus epidermidis and Staphylococcus aureus, which are normal flora on the ocular surface and are presumed to infect the globe at the time of surgery20. Potential risk factors for the development of endophthalmitis include intra-operative complica-tions, relative immune compromise, application of topical lidocaine gel before povidone-iodine prepa-ration, and inferior incision location6. Measures such as povidone iodine preparation and sterile draping prior to cataract surgery have proven effective to mi-nimize the risk of endophthalmitis21,22.

While Staphylcoccal species are also the most commonly isolated organisms in endophthalmitis after intravitreal anti-VEGF injection, a study by Mc-Cannel15 demonstrated that streptococcal species play a much more significant role than in post-ca-taract endophthalmitis. In this meta-analysis of the US literature from 2005 to 2009, endophthalmitis occurred in 52 of 105,536 injections of anti-VEGF agents, for a rate of 0.049%. Of the 26 culture positi-ve cases, oral flora including streptococcus species, was isolated in 30.8% of cases, which is a three-fold increase in the frequency of streptococcal infection compared with that found after cataract surgery. It was thought that this intriguing finding was due to in-office administration protocols, such as the lack of mask usage, which may have contaminated the procedure to nasopharyngeal flora of the injector by talking, coughing, or sneezing during the procedu-re15.Other preventative measures have been propo-

sed, including the use of a bladed speculum, sterile gloves, hemisphere of injection, displacement of the conjunctiva, and topical antibiotics before or after. However, no other measures have shown to statis-tically significantly decrease rates of endophthalmi-tis13,14,15.One recent study by Wen et al25. concluded that wearing a face mask and minimizing speech by both the provider and patient decreased contamina-tion in simulated intravitreal injections.

A 2011 retrospective review by Moshfeghi et al15.demonstrated that streptococcal species played a significant role in endophthalmitis after intravitreal injections of VEGF antagonists for exudative AMD at Bascom Palmer Eye Institute from 2005 through 2010. The study examined a total of 60,322 injec-tions at a single institution, with 12 cases (11 pa-tients) developing endophthalmitis, for a rate of 0.02%. In five of the seven culture-positive cases (71%), various streptococcus species were isolated, including S. sanguinis, S. gordonii, S. intermedius, S. salivarius, and S. mitis. However, this study did not draw any conclusions as to the cause or sour-ce for the higher proportion of streptococcal cases. The authors noted that these streptococcal infections were generally associated with poorer visual outco-mes, with 4 of the 5 cases having a final visual acuity of hand motions or worse.

Another single-center retrospective review de-monstrated a disproportionately high infection rate with streptococcus species and correlated poor outcomes with these microorganisms. Shah et al13.examined 23 cases of endophthalmitis after 27,736 intravitreal injec-tions of anti-VEGF agents, from January 2009 through May 2010 at Wills Eye Institute. Seven of the 23 cases were culture-positive. The causative organisms inclu-ded Staphylococcus epidermidis in three cases, strep-tococcus species in two cases, Staphylococcus aureus in one case, and Enterococcus faecalis in one case. All seven cases returned to baseline visual acuity after treatment, with the exception of two eyes, which grew S. viridans and S. mitis, and subsequently underwent pars plana vitrectomy for retinal detachment. Table 2 summarizes the causative organisms in infectious en-dophthalmitis after cataract surgery versus intravitreal injection.

Antibiotic drops are prescribed after intravitreal injections by more than 80% of retina surgeons which may be contributing to the rise of antibiotic-resistant organisms in post-injection endophthalmi-tis26,27. The new fourth-generation fluoroquinolones fluoroqinolones are used frequently because of their excellent ocular penetration and broad-spectrum co-verage. However, patients are developing increasing resistance to these as well. In a study of 48 eyes repeatedly treated with topical fluoroquinolones pro-phylactically for monthly intravitreal anti-VEGF the-

Table 2: Causative organisms in infectious endophthalmitis after cataract surgery versus after intravitreal VEGF antagonist injection.

Post-cataract surgery endophthalmitis

Post-intravitreal VEGF antagonist injection endophthalmitis

Reference EVS1 McCannel15 Moshfeghi16 Shah13

Number of subjects 420 52 12 23

Culture positive 69% 52% 58% 30.4%

Culture negative 30.7% 48% 42% 69.6%

Staphylococcus aureus 9.9% 0% - 14.3%

Staphylococcus epidermidis 70% 65.4% 14.0% 42.9%

Streptococcus species 9% 30.8% 71% 28.6%

Enterococcus species 2.2% - - 14.3%

Gram-positive, other 3.0% 3.8% 14%* -

Gram-negative 35.9% 0% - -

*Bacillus non-anthracis; EVS = Endophthalmitis Vitrectomy Study1



rapy, Kim et al28. found that 85% of patients develo-ped flora resistant to ofloxacin and levofloxacin, 67% to gatifloxacin, and 77% to moxifloxacin29,30. These organisms may be directly inoculated or travel along needle tracks in the conjunctiva and sclera, causing infections25.

Interestingly Alabiad et al31. demonstrated that while fluoroquinolone drops are associated with a high prevalence of development of resistance in conjunctival and nares cultures, the number of intra-vitreal injections and thus the number of times the eye is exposed to the prophylactic antibiotic drops did not correlate with resistance. A high prevalence of fluoroquinolone resistance was observed in the conjunctiva whether the eye had zero intravitreal in-jections or more than 10 intravitreal injections.

3. Treatment

The treatment guidelines used for treatment of endophthalmitis after cataract surgery are often utili-zed for treatment of endophthalmitis after intravitreal injection of anti-VEGF agents. The management of endophthalmitis is primarily guided by the EVS1, a well-known multi-center, randomized clinical trial that enrolled 420 patients with post-cataract surgery or post-secondary intraocular lens implant endo-phthalmitis from February 1990 to January 1994. The EVS demonstrated three important outcomes: (1) in patients with better than light perception (LP) visual acuity, there was no difference in visual outcomes whether they received pars plana vitrectomy (PPV) or vitreous aspiration for cultures; (2) in patients with LP visual acuity or worse, visual outcome was better in the PPV group; and, (3) systemic intravenous an-tibiotics did not result in a difference in final visual acuity or media clarity.

As a result of the EVS, prompt vitreous sam-pling and treatment with intravitreal antibiotics are mainstays of treatment, with consideration of PPV guided by visual acuity32. Vancomycin is the drug of choice to treat Gram-positive endophthalmitis, and it is non-toxic to the retina at its recommended dose (Table 3)33. Conversely, aminoglycosides such as amikacin and gentamicin, have a wide spectrum of activity against both Gram-positive and Gram-ne-gative organisms34. However, other antibiotics, such as ceftazidime, that are less toxic to the retina have largely replaced these drugs to cover Gram-negative organisms in the acute management of infectious endophthalmitis35.

Some additional treatments that remain contro-versial in the management of infectious endophthal-mitis include the use of corticosteroids36,37 and IV antibiotics45. One prospective randomized control study by Albrecht et al38. found no statistical diffe-

rence whether intravitreal dexamethasone was used in presumed bacterial endophthalmitis. However, preclinical animal studies show potential benefit of intravitreal dexamethasone in minimizing tissue damage resulting from inflammation associated with treatment of pneumococcal endophthalmitis39. Intravitreal dexamethasone may also decrease the breakdown of the blood-retinal barrier and decrease the rate of elimination of antibiotics injected intravi-treally to treat infectious endophthalmitis40.

The EVS1 does have some inherent limitations that may restrict application of the results across other forms of endophthalmitis. The only systemic antibiotics evaluated were amikacin and ceftazidime in EVS, and amikacin is known to have poor ocular penetration. Additionally, the study included only post-cataract or secondary intraocular lens implant endophthalmitis and excluded patients with no light perception (NLP) vision or very dense anterior cham-ber inflammation. Therefore, in cases of endophthal-mitis occurring after intravitreal VEGF antagonist in-jections where there may be differences in infecting organisms and antibiotic resistance when compared to EVS, modifications may be needed regarding whether to use systemic antibiotics and if so, which drug2,35. The newer generation fluoroquinolones have been shown to have excellent ocular penetration and broad spectrum anti-microbial coverage38, but may not be the drug of choice among patients receiving chronic prophylactic treatment with topical fluoroquinolones41.

Currently, there is little data regarding specific re-commendations for treatment of endophthalmitis after intravitreal VEGF antagonist. Most cases are managed like acute post-operative endophthalmitis, with EVS guiding therapy. One study of three patients by Artunay et al42. suggested that early PPV was beneficial in pa-tients with progressive vision loss and worsening infla-mmation, rather than waiting for LP vision. To date, the-re have been no prospective randomized case-control studies to firmly establish these treatment modalities.

Table 3: Treatments of endophthalmitis occurring after cataract surgery versus occurring after intravitreal injection of VEGF antagonist.

TreatmentPost-cataract surgery Endophthalmitis1,2,35

Post-intravitreal VEGF antagonist injection2,35,45

Intravitreal antibiotic

Vancomycin 1 mg/0.1 mLand

Amikacin 400 µg/0.1 mLor

Ceftazidime 2.25 mg/0.1 mL

Vancomycin 1 mg/0.1 mLand

Amikacin 400 µg/0.1 mLor

Ceftazidime 2.25 mg/0.1 mL

Topical antibioticsFluoroquinolone empirically, especially if wound leak or exposed suture (Wills)

Fluoroquniolone empirically

Intravenous antibiotic No No

SteroidTopical

Consider intravitreal Dexamethasone or oral administration if severe

Topical

Pars plana vitrectomy If visual acuity HM or betterIf signifi cant infl ammation and presumed virulent organism

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Table 4: Final visual acuity at follow-up after culture positive and culture negative endophthalmitis associated with cataract surgery versus intravitreal anti-VEGF injection

Final Visual Acuity at Follow-Up

Post-cataract surgery endophthalmitis6 Post-intravitreal injection of VEGF antagonist endophthalmitis13

Number (%) patients(n = 7)

Time of follow-up (months)Number (%) patients

(n = 23)Time of follow-up (months)

20/30 or better 4 (57%) 7, 12, 14, 49 2 (9%) 3

20/40 – 20/200 0 0 9 (39%) 3

20/400 – 20/500 0 0 5 (22% 3

CF 1 (14%) 19 6 (26%) 3

HM – LP 2 (29%) 2, 22 0 0

NLP 0 0 1 (4%) 3

4. Visual outcomes

According to the EVS visual outcomes associated with post-cataract surgery endophthalmitis may be fa-vorable, with 57% achieving 20/25 or better at follow-up of variable duration 1.The remainder of patients did poorly, and resultant visual acuities were count fingers (CF) vision or worse6. Similarly, visual outcomes as-sociated with post-intravitreal injection of VEGF an-tagonist endophthalmitis were favorable with 78% of patients returning to baseline visual acuity at 6 months. A subgroup of patients that did not return to baseline vi-sual acuity either had Streptococcal infection or retinal detachment requiring vitrectomy surgery13.

A comparison of final visual acuity in both culture-negative and culture-positive endophthalmitis following cataract surgery versus intravitreal injection is sum-marized in Table 4. It is difficult to compare the final visual acuity outcomes of endophthalmitis treatment following cataract surgery versus intravitreal injection since baseline visual acuity depends on pre-operative or pre-procedural pathology (e.g. dense nuclear sclero-sis versus exudative age-related macular degeneration, respectively). Nevertheless, Table 4 shows that 57% of patients achieved 20/30 or better visual acuity following endophthalmitis in the EVS1. Although this may appear better than the 9% who were in the same visual acuity category following intravitreal injection endophthal-mitis13, it is important to note that the poorer baseline visual acuity and underlying macular pathology indica-ting intravitreal injection may explain the wider range of final visual acuity outcomes in eyes with post-injection endophthalmitis. Considering these confounding varia-bles, it is noteworthy that 65% of eyes at 3 months and 78% of eyes at 6 months returned to baseline visual acuity following intravitreal injection endophthalmitis after treatment of the endophthalmitis7,19.

In the EVS1 the outcomes after post-cataract sur-gery endophthalmitis included 20% with various ma-cular abnormalities such as epiretinal membranes, cystoid macular edema, ischemia, and pigment chan-

ges, 6% with media opacities, 6% with miscellaneous outcomes such as vein occlusion, retinal detachment, optic atrophy, and choroidal neovascularization, 6% with unknown reasons for vision loss, 3% with phthisis, and 0.7% were enucleated. Comparable data has not been compiled for endophthalmitis following anti-VEGF intravitreal injections to date.

CONCLUSION

In summary, post-cataract surgery endophthal-mitis occurs with a similar rate as endophthalmitis following anti-VEGF intravitreal injection. Presenting symptoms of pain, redness, and visual loss frequently occur with both entities, and presenting signs of con-junctival injection, anterior chamber inflammation with hypopyon, and vitritis also occur with both entities. However, patients with post-injection endophthalmi-tis may present earlier than endophthalmitis following cataract surgery. The most common pathogen asso-ciated with both entities is Staphylococcus epider-midis. However, a proportionately larger number of post-injection endophthalmitis is due to streptococcal species, which are oral flora and often associated with poorer outcomes. Considering the success of anti-VE-GF treatments and the aging population in the United States, intravitreal injections will become even more frequently utilized, and the incidence of post-injection endophthalmitis will likely increase. Given the poten-tial for a worse outcome with endophthalmitis after intravitreal anti-VEGF injection, the use of proven pro-phylactic methods to minimize risk of infection during injection, early recognition of the clinical presentation, and prompt effective treatment are imperative. While post-surgical endophthalmitis is a well-characterized entity with an established treatment protocol, post-intravitreal injection endophthalmitis requires further investigation. Differences in modes of transmission, microbial profiles, treatments, and outcomes will help establish future guidelines for treatment.



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19. Wickremasinghe SS, Michalova K, Gilhotra J, et al. Acute intraocular infl am-mation after intravitreous injections of bevacizumab for treatment of neovas-cular age-related macular degeneration. Ophthalmology 2008;115:1911-5.

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Topical Steroids in Bacterial Keratitis: A Retrospective Study

ABSTRACT

Purpose: To review the outcomes, risk factors and morbidity of bacterial keratitis treated with and without topical steroids.

Design: Retrospective cohort study.

Methods: Demographics, risk factors, culture results, ulcer characteristics, and timing to epithe-lialization, visual acuity and recurrences were recor-ded. Patients were classified into 2 groups: 1.Topical antibiotics/steroids (ASG), and 2.Antibiotics only group (AOG).

Results: Seventy-two eyes were identified. Thirty-seven were classified in the ASG and 35 in the AOG. Predisposing factors were identified in 87.5% of cases. Penetrating keratoplasty, previous surgery, contact lens wear and Herpes simplex keratitis were the most com-mon overall. Microorganisms were identified in 85.5% and 60% of ASG and AOG, respectively. Epithelialization was completed at a mean 17.62 and 16.06 days in ASG and AOG, respectively (p= 0.533). Final mean BSCVA was 1.59±1.07 and 1.64±1.21 log MAR in ASG and AOG, respectively (p= 0.864). The number of gained Snellen lines was 0.13±0.22 in ASG and 0.14±.0.24 in AOG (p= 0.860). There were no recurrences.

Conclusion: Although a non-statistical signifi-cant delay in re-epithelialization was noted in the ASG, this did not translate into a statistical difference in final BSCVA, gained Snellen lines or recurrence of infection. In this serie, adjuvant topical steroids were not associa-ted with an increase in unfavorable outcomes.

Key words: Bacterial keratitis, corneal ulcer, topical corticosteroids, treatment of corneal ulcers, treatment of bacterial keratitis.

Resumen

Objetivo: Analizar la morbilidad, factores de ries-go y resultados asociados al tratamiento de queratitis bacteriana con y sin el uso de esteroides tópicos.

Diseño: Estudio de cohortes retrospectivo.

Métodos: Se analizaron los datos demográficos, factores de riesgo, características de la úlcera, tiempo de re-epitelización, agudeza visual y recurrencias en pacientes con queratitis bacteriana. Los pacientes fue-ron clasificados en dos grupos: 1. Antibióticos/esteroi-des tópicos (ASG) y 2. Únicamente antibióticos (AOG).

Resultados: Se identificaron 72 ojos, de los cuales 37 fueron clasificados en el ASG y 35 en el AOG. Encon-tramos por lo menos un factor de riesgo en el 87.5% de los casos; siendo los más comunes la queratoplastia pe-netrante, cirugía ocular previa, uso de lente de contacto y queratitis por Herpes simplex. Los cultivos lograron iden-tificar un agente causal en el 85.5% y en el 60% del ASG y AOG, respectivamente. El epitelio cerró por completo en un promedio de 17.62 y 16.06 días en el ASG y AOG, res-pectivamente (p= 0.533). En promedio, la agudeza visual corregida al fin del estudio fue de 1.59±1.07 y 1.64±1.21 log-MAR en el ASG y AOG, respectivamente (p= 0.864). En promedio el ASG gano, 0.13±0.22 líneas en la cartilla de Snellen, mientras que el AOG ganó 0.14±.0.24 (p= 0.860). No hubo casos recurrentes.

Conclusión: Aunque la re-epitelizacion fue un poco más lenta en el ASG, la diferencia no fue estadís-ticamente significativa ni se tradujo en cambios signi-ficativos en la agudeza visual corregida, el número de líneas ganadas en la cartilla de Snellen o el número de recurrencias. En esta serie, adyuvante encontramos que el uso adyuvante de esteroides tópicos no fue asociado con resultados desfavorables.

Alejandro Lichtinger, MD1, Faik Orukov, MD2, Avi Solomon, MD3, Claudia Yahalom, MD2, Joseph Frucht-Pery, MD3


Alejandro Lichtinger, MD399 Bathurst Street, East Wing 6E 401Toronto, ON, Canada M5T 2S8Phone: 4164320075/4166035389Fax: 4166036420

Date of submission: 20/02/2012 Date of approval: 19/03/2012Proprietary interest: Dr. Alejandro Lichtinger is a consultant for Bausch & Lomb, Canada. None of the other authors have any fi nancial or commercial interests to disclose.

From Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

1. Fellow2. Instructor3. Associate Professor

Funding: None


Lichtinger A et al. Topical steroids in bacterial keratitis.

Palabras clave: Queratitis bacteriana, úlcera de córnea, corticosteroides tópicos, manejo de úlceras corneales, manejo de la queratitis bacteriana.

INTRODUCTION

Bacterial keratitis is a potential sight-threatening disease, responsible for up to 20% of the world’s blind-ness.1 Globally, more than 1 million people are visually disabled because of microbial corneal infection.2

Topical corticosteroids have an unclear role in the management of bacterial keratitis. The reasoning be-hind corticosteroids as an adjuvant in treating bacterial keratitis is the idea that they may help resolve corneal inflammation, facilitate epithelial and stromal healing and minimize corneal opacification, neovascularization, and destruction; on the other hand, steroids can po-tentiate microbial replication, promote recrudescence, slow recovery, accelerate stromal loss and increase the risk of perforation.3 Host reactions account for much of the edematous, infiltrative, and necrotizing changes seen in bacterial keratitis, which may cause progressive corneal damage.4

There is evidence that the use of topical corticos-teroids without an antibiotic has a deleterious effect on experimental models of bacterial keratitis,5-7 and that their use for other reasons before the occurrence of bac-terial keratitis more than triple the risk of subsequent complications3 including treatment failure8, progressive infection9 and perforation.9,10

A meta-analysis of retrospective studies on steroid use in bacterial keratitis from 1950 to 2000 concluded that the efficacy of topical corticosteroids is unproven.3 There are two published prospective trials on the sub-ject with no definitive evidence to support or discoura-ge their use.11-13

The goal of this study was to retrospectively eva-luate the outcomes of bacterial keratitis when treated with topical antibiotic therapy with or without adjuncti-ve topical steroids at our center in the last 5 years by examining the speed of epithelial healing, final visual acuity, gained visual acuity and recurrence rate.

METHODS

We retrospectively reviewed the electronic medical records of patients hospitalized with the diagnosis of bacterial keratitis at the Department of Ophthalmology, Hadassah-Hebrew University Medical Center in the last 5 years. All data collection for the study was made ac-cording to local legislation and in accordance with the principles of the Declaration of Helsinki.

The following data was collected for each pa-tient: age, gender, affected eye, ocular history, pre-disposing risk factors, presenting and final visual acuity (UCVA), best spectacle corrected visual acuity

(BSCVA), culture results, topical steroid use, ulcer characteristics such as size and location, healing time and recurrences. It is important to mention that at our institution all cases of moderate/severe bacte-rial keratitis are admitted and treated as in-patients, with daily follow-up thus allowing us to have daily information on the evolution of these cases.

A corneal ulcer was defined as a corneal epithelial defect associated with an underlying acute suppurative infiltrate in the stroma, and showing variable endothelial or anterior chamber reaction, diffuse bulbar and/or lim-bal injection, chemosis, discharge, lid edema, severe pain and photophobia.

Location (central or paracentral) and size of ulcer at presentation were evaluated. Ulcers were defined as small when measuring less than 4 mm2, medium bet-ween 4 and 16 mm2 and large when measuring more than 16 mm2. Only medium and large size corneal ul-cers were included in the study.

Ulcers were scraped and inoculated into blood, chocolate and Sabouraud’s dextrose agar, thioglycate broth as well as smears for Gram and Giemsa stains before treatment was initiated. Our microbiology labo-ratory analyzed all samples.

We retrospectively classified patients in 2 groups, according to the treatment received:

- Antibiotic+Steroid Group (ASG): patients with bacterial keratitis, who received adjunctive topical ste-roids (dexamethasone phosphate 0.1% drops) to the standard antibiotics regime.

- Antibiotic-only Group (AOG): patients with bacte-rial keratitis, who received standard therapy with topical antibiotics.

The criteria for topical dexamethasone phosphate 0.1% application were:

1. They should be introduced at least 48 hours after treatment with antibiotics was initiated.

2. Identification of microorganism with antibiotic sensitivity results.

3. Clinical improvement when no microorganism was identified.

Dexamethasone phosphate 0.1% was applied 2 to 6 times a day, never exceeding the topical antibiotic dosage and was usually stopped before discontinua-tion of antibiotic treatment with the exception of ulcers on penetrating keratoplasty (PKP) or when the treating physician considered it necessary to decrease scarring.

The standard topical antibiotic treatment protocol was a combination of cefazolin 5% and gentamicin 1.4% drops every hour for the first two days, to be tape-red according to clinical response down to a minimum of 4 times a day and then discontinued. Antibiotic the-

46 PAN-AMERICA


rapy was modified on the basis of cultures, antibacterial susceptibility and clinical response.

An ulcer was considered healed when the epithelial defect was closed with no staining on fluorescein dye application, and antibiotic treatment was continued at least 4 times a day for a week after the ulcer healed.

Recurrence of infection was defined as a re-appearance of abscess occurring within one week of full re-epithelialization, when the infective element was considered cleared20, while late re-infections where defined as new infections occurring more than 30 days after initial infection and more than a week after full epithelialization.

Time to complete epithelialization, final UCVA, BSCVA gained VA and recurrence rate were the study’s main outcome measures.

Two tailed T-Test and Chi-Square Test were used for statistical analysis using SPSS software version 11.0 (SPSS Inc, Chicago, Ill, USA). All reported P values are two-tailed. P < 0.05 was considered statistically significant.

Exclusion criteria included small ulcer size or marginal location, original active non-bacterial infec-tion with microbial super infection, those treated not according to protocol or that started treatment before admission, patients that were pre-treated with steroids (except cases after PKP), neurotrophic ulcers, and those associated with an autoimmune condition. We also excluded cases in which corneal scrapings were not performed, and patients who presented with cor-neal perforation or endophthalmitis.

RESULTS

Seventy-two eyes of 72 patients were found to be eligible. Thirty-seven eyes were allocated in the ASG and 35 eyes in the AOG. The demographic characte-ristics of the patients are displayed in Table 1. The mean age was 52.5 ± 22.24 (ranging from 13 to 92 years) in ASG and 59.8 ± 23.21 (from 14 to 91 years) in AOG (P = 0.178).

At presentation, the range of BCVA was similar in both groups; mean BSCVA was 2.20± 0.91 log MAR (Snellen equivalent, 0.07±0.19) and 2.14 ± 1.03 log MAR (Snellen equivalent, 0.07±0.13) in ASG and AOG respectively (P=0.801) (Table 1).

Predisposing factors were identified in 63 eyes (87.5%). PKP, previous ocular surgery and contact lens (CL) wear were the most common predisposing factors in the ASG (32.4%, 18.9% and 18.9% respectively). In the AOG, the most common predisposing factors were previous ocular surgery, PKP and Herpes simplex ke-ratitis (20%, 14.3% and 14.3% respectively). CL wear was the most common predisposing factor in young patients and PKP in the older population. No risk fac-tors were identified in 8.1% and 17.1% in ASG and AOG respectively (Table 2).

Almost 40% of ulcers in the study were large (37.8 % in ASG and 40% in AOG) and more than half of them localized centrally (56.8% in ASG and 62.9% in AOG). The size of the ulcers and their location are summarized in Table 3.

In the ASG, microorganisms were identified in 85.5% compared to 60% in the AOG. This differen-ce was expected since a positive culture or clinical improvement were criteria to start topical corticoste-roids, if culture was negative. The most common iso-lated microorganism was P. aeruginosa (31.3% in the ASG and 28.6% in the AOG) followed by Staphylo-

Table 1. Demographic data and initial visual acuity.

Legend: Antibiotic + steroid group (ASG); Antibiotic only group (AOG).

ASG AOG

No. of patients (n) 37 35

Mean age (yrs) (range) 52.5 ±22.24 59.9 ± 23.2

Gender (%) Female 59.5 50

Male 40.5 50

Eye (%) Right 27 54.3

Left 73 45.7

Visual acuity (log Mar)

≤1 17.3% 27.6%

Mean 2.20±0.91 2.14±1.03

Range 0.1 - 3.0 0.3 - 3.0


Table 2. Associated conditions and predisposing factors.

ASG AOG

PKP 32.4% 14.3%

Ocular surgery 18.9% 20%

Contact lens 18.9% 8.6%

HSK 2.7% 14.3%

Neurotrophic ulcer 2.7% 2.9%

Surface disease 5.4% 5.7%

Trauma 5.4% 8.6%

PBK 5.4% 8.6%

None 8.1% 17.1%

Table 3. Ulcer size and location.


Ulcer size ASG AOG

Medium 62.2% 60.0%

Large 37.8% 40.0%

Ulcer location

Paracentral 40.0% 35.3%

Central 60.0% 64.7%


Lichtinger A et al. Topical steroids in bacterial keratitis.

coccus species (25% and 23.8% respectively). More than one type of bacteria was found in 12.5% and 14.3% of the cultures in ASG and AOG, respectively.

Topical steroid treatment was initiated between days 3 and 16 (mean 6.88 ± 4.14 days) and applied for a mean period of 45.2 ± 29.79 days. Seventy three percent of the patients were started on topical steroid 4 times a day. Steroid therapy was gradually tapered and stopped according to the clinical picture.

Corneal epithelialization was complete between 5 and 45 days (mean 17.62±10.78 days) in ASG and 3 to 38 days (mean, 16.06±9.71 days) in AOG. The difference was not statistically significant (p = 0.533) (Table 4).

Final mean BSCVA was 1.59±1.07 log MAR (Snellen equivalent, 0.20±0.91) in ASG and 1.64±1.21 log MAR (Snellen equivalent, 0.22±0.29) in AOG (p = 0.864). The number of gained Snellen lines was 0.13±0.22 in ASG and 0.14±.0.24 in AOG; this difference was not statisti-cal significant (p = 0.860) (Table 4).

No recurrence of bacterial keratitis was noted during the study (Table 4). Late re-infections, all of them more than 30 days after initial infection and more than a week after full epithelialization were noted in five patients receiving topical steroids and only in two patients receiving exclusively antibiotic treatment (Table 5).

DISCUSSIONIn the present study, both groups were similar with

respect to age, gender, visual acuity at presentation, and ulcer characteristics such as size and location. Forty percent of the patients had large sized ulcers and 60% of them were located centrally, most of them also had poor visual acuity on admission, reflecting the high in-cidence of severe ulcers. Predisposing risk factors were identified in 87.5% of the patients. PKP, CL and previous ocular surgery being the most common risk factors in the ASG and previous ocular surgery; HSK and PKP in the AOG. Our results in this regard are similar to pre-vious published studies, in which such predisposing factors have been identified in 84% to 97% of patients with suppurative keratitis.10,14,15

PKP was the predominant risk factor in the study, es-pecially among older patients and was present in 42% of late re-infections. Bacterial keratitis after PKP is a serious complication resulting in graft failure and poor visual outcomes. Patients who have undergone PKP are at increased risk for bacterial keratitis because of graft hypoesthesia, long term use of topical corticosteroids, soft contact lens wear, persistent epithelial defects, ex-posed sutures, ocular surface disorders and lid abnor-malities.16- 21 Although there are no prospective studies demonstrating an ideal topical corticosteroid dosage for long term rejection prevention after PKP, a survey by Pri-ce et al22 on steroid usage patterns during and after low risk penetrating keratoplasty showed that 46% and 22% of surgeons would continue low dose topical steroids in-definitely for pseudophakic and phakic patients, respecti-vely, to avoid rejection, thus confirming that an important number of surgeons consider that the risks of bacterial keratitis and other complications due to chronic steroid therapy are offset by the perceived benefit of protection against immunological graft rejection.

In this retrospective study, steroid treatment was asso-ciated with a delay in re-epithelialization that was not sta-tistically significant. Two published trials on this topic have found a trend towards improved outcomes with steroids,


Table 4. Comparative outcomes.

ASG AOG

Time to full epithelialization17.62 ± 10.78

days16.06 ±9.71

days

Final mean BSCVA (Log Mar) 1.59±1.07 1.64±1.21

Gained Snellen lines 0.13±0.22 0.14±.0.24

Recurrences 0 0

Table 5 Cases with late re-infections.

+ Patient not on steroid treatment, * Second recurrence developed 47 days after the fi rst one. PA was the isolated microorganism in the second recurrence. Penetrating Keratoplasty (PKP), contact lens (Cl), pseudophakic bullous keratopathy (PBK), Pseudomona aeruginosa (PA), Streptococcus pneumoniae (Str.pnm), Staphylococcus species (Staph.sp), no growth (NG).

CaseAge (yrs) /

GenderAssociated conditions

Culture 1 Culture 2Time to re-infection

(days)

BCVA Outcome

At presentation At re-infection

1+ 86/M PKP PA Str.vrd 34 Fc50cm HM PKP

2+ 20/F Cl PA Staph. sp 30 HM HM PKP

3 70/F PBK Poly-bacterial Poly-bacterial 120 Fc30cm Fc20cm PKP

4 49/M PKP PA PA 150 HM Fc40cm PKP

5 61/F PKP Str.pnm NG 44 Fc30cm HM Failed graft

6 90/F Neg Str.pnm 54 HM HM Refuses PKP

7* 77/F Cl, PBK Staph.sp NG 51 Fc1m HM Waiting for PKP

48 PAN-AMERICA


while their results on epithelialization differ. One of the studies found a statistically significant delay on the group receiving the steroids, while this difference was not signi-ficant in the other.11,12 Moreover, we agree with Sirinvasan et al that re-epithelialization is not an optimal outcome measure when the intervention, steroids in this case, may cause a delay in healing time while still translating to better VA and reduced infiltrate/scar size.12 Although re-epithe-lialization is an important goal, we should focus on more clinically relevant outcomes such as gained Snellen lines and final VA. The other outcome measures for the present study: final mean BSCVA, number of gained Snellen lines and the number of recurrences, were similar in both groups and we did not find any statistical significant difference.

Five out of 7 cases with late re-infection were on topical steroid treatment when the re-infection occurred. This is consistent with previous studies that suggest to-pical steroid use significantly predisposes eyes with pre-existing corneal disease to ulcerative keratitis and once microbial keratitis occurs, prior corticosteroid use signi-ficantly increases the odds of antibiotic treatment failure or o ther infectious complications.3 In our series, 5 out of these 7 patients had to be treated with a PKP, one of which failed. Another patient is waiting for a graft and another one refused to have a PKP despite our recommendation. It is interesting that the 2 patients that were not on steroid treatment at the time of re-infection, had the shortest in-terval between the primary infection and the re-infection (30 and 34 days), and that the cases on steroids presen-ted much later between 44 and 150 days post infection.

In our retrospective cohort study, adjunctive topical steroid use for the treatment of bacterial keratitis did not seem to statistically affect re-epithelialization or final BSCVA and did not increase the number of recurrent in-fections; thus, at least in our patient population, steroid treatment did not appear to be associated with an increa-se in adverse effects.

Due to the limitations of our study, we could not de-monstrate any benefit or detriment of adding corticoste-roids to the antibiotic regime. Recently, a large randomized control trial (SCUT)22 concluded that there was no overall difference in 3-month BSCVA when using adjunctive cor-ticosteroid therapy, as well as no safety concerns with its use. Our findings are in accordance with these results. Another interesting finding from this study is that they found a significant positive effect in final BSCVA of corti-costeroid use in subgroups with BSCVA at baseline worse than counting fingers and in those with ulcers that were completely central, demonstrating that steroids might still be useful in some cases.

In conclusion, steroids were not associated with an increase in adverse events in our series, and although a non-statistical significant delay in re-epi-thelialization was noted, this did not translate into a significant difference in final BSCVA, gained Snellen lines or recurrence of infection.

REFERENCES1. Thylefors B, Negrel AD, Pararajasegaram R, Dadzie KY. Global data on blindness. Bull World Health Organ 1995;73(1):115-21.

2. Chirambo MC, Tielsch JM, West KP Jr, Katz J, Tizazu T, Schwab L, et al. Blindness and visual impair-ment in southern Malawi. Bull World Health Organ 1986;64(4):567-72.

3. Wilhelmus KR. Indecision about corticosteroids for bac-terial keratitis: an evidence-based update. Ophthalmology 2002;109(5):835-42.

4. Wilhelmus KR. Epidemiol-ogy of ocular infections. In: Tasman W, Jaeger EA, eds. Duane’s Foundations of Clini-cal Ophthalmology. Chap. 43. Vol. 2. 1998, Philadel-phia: Lippincott Williams & Wilkins.

5. Suie T, Taylor FW. The effect of cortisone on experi-mental pseudomonas corneal ulcers. AMA Arch Ophthal-mol 1956;56(1):53-6.

6. Ozeki T. Experimental pseudomonas keratitis in mice. The effect of corticoste-roid. Nippon Ganka Gakkai Zasshi 1974;78(10):1084-92.

7. Paschal JF, Holland GN, Sion RF, Berlin OG, Bruckner DA, Dugel PU, et al. Mycobacterium fortuitum keratitis. Clinicopathologic correlates and corticosteroid effects in an animal model. Cornea 1992;11(6):493-9.

8. Kim RY, Cooper KL, Kelly LD. Predictive factors for re-sponse to medical therapy in bacterial ulcerative keratitis. Graefes Arch Clin Exp Oph-thalmol 1996;234(12):731-8.

9. Miedziak AI, Miller MR, Rapuano CJ, Laibson PR, Cohen EJ. Risk fac-tors in microbial keratitis leading to penetrating keratoplasty. Ophthalmology 1999;106(6):1166-70.

10. Gudmundsson OG, Ormerod LD, Kenyon KR, Glynn RJ, Baker AS, Haaf J, et al. Factors infl uencing predilection and outcome in bacterial keratitis. Cornea 1989;8(2):115-21.

11. Carmichael TR, Gelfand Y, Welsh NH. Topical steroids in the treatment of central and paracentral cor-neal ulcers. Br J Ophthalmol 1990;74(9):528-31.

12. Srinivasan M, Lalitha P, Mahalakshmi R, Prajna NV,

Mascarenhas J, Chidam-baram JD, et al. Corticoste-roids for bacterial corneal ulcers. Br J Ophthalmol 2009;93(2):198-202.

13. Acharya NR, Srinivasan M, Mascarenhas J, Ra-vindran M, Rajaraman R, Zegans M, et al. The steroid controversy in bacterial keratitis. Arch Ophthalmol 2009;127(9):1231.

14. Hindman HB, Patel SB, Jun AS. Rationale for adjunc-tive topical corticosteroids in bacterial keratitis. Arch Oph-thalmol 2009;127(1):97-102.

15. Coster DJ, Badenboch PR. Host, microbial and pharmacological factors affect-ing the outcomes of supurative keratitis. Br J Ophthalmol 1987;71(2):96-101.

16. Tuberville AW, Wood TO. Corneal ulcers in corneal transplants. Curr Eye Res 1981;1(8):479-85.

17. Huang SC, Wu SC, Wu WC, Hong HL. Microbial keratitis--a late complication of penetrating keratoplasty. Trans R Soc Trop Med Hyg 2000;94(3):315-7.

18. Bates AK, Kirkness CM, Ficker LA, Steele AD, Rice NS. Microbial keratitis after penetrating keratoplasty. Eye 1990;4(Pt 1):74-8.

19. Fong LP, Ormerod LD, Kenyon KR, Foster CS. Microbial keratitis complicating penetrating keratoplasty. Ophthalmology 1988;95(9):1269-75.

20. Al-Hazzaa SA, Tabbara KF. Bacterial keratitis after penetrating keratoplasty. Ophthalmology 1988;95(11):1504-8.

21. Vajpayee RB, Boral SK, Dada T, Murthy GV, Pandey RM, Satphathy G. Risk factors for graft infection in India: a case-control study. Br J Ophthalmol 2002;86(3)261-5.

22. Price FW, Jr., Price DA, Ngakeng V, Price MO. Survey of steroid usage patterns during and after low-risk pen-etrating keratoplasty. Cornea 2009;28(8):865-70.

23. Srinivasan M, Mascar-enhas J, Rajaraman R, Ra-vindran M, Lalitha P, Glidden DV, et al. Corticosteroids for Bacterial Keratitis: The Ste-roids for Corneal Ulcer Trial (SCUT). Arch Ophthalmol 2012;130(2):143-150.


Klein KS et al. Qualidade de vida em pacientes com ceratocone apos CXL.

Qualidade de vida de portadores de ceratocone submetidos ao crosslinking do colágeno da córnea

RESUMO

Objetivo: Avaliar a qualidade de vida (QV) e de visão dos portadores de ceratocone submetidos ao crosslinking do colágeno corneano (CXL).

Métodos: Estudo transversal, realizado em uma clínica oftálmica privada no interior do Rio Grande do Sul. Foram entrevistados 70 portadores de ceratocone submetidos ao CXL. Para avaliar a qualidade de vida foi utilizado o instrumento Visual Function Questionnaire (VFQ) 25.

Resultados: As médias mostraram-se altas nos subdomínios: visão de cores, aspectos sociais, de-pendência, visão periférica, atividades de vida diária, atividades para perto, atividades para longe, saúde mental, capacidade para dirigir automóveis, visão e saúde geral. Entretanto, as dimensões da dor ocular e da saúde geral apresentaram médias baixas em relação às demais.

Conclusão: Os portadores de ceratocone subme-tidos ao CXL apresentaram escores altos em dez dos doze subdomínios avaliados, o que caracteriza boa QV visual.

Descritores: Qualidade de Vida; Ceratocone; Of-talmologia; Enfermagem; Questionário.

ABSTRACT

Purpose: To evaluate the quality of life and vision in patients with keratoconus who underwent corneal co-llagen crosslinking (CXL).

Methods: Cross-sectional study performed at a private ophthalmic clinic in the countryside of Rio Grande do Sul. 70 keratoconus patients who un-

derwent CXL were interviewed. To evaluate the qua-lity of life, the instrument Visual Function Question-naire (VFQ) 25 was used.

Results: The averages were high in the following subdomains: color vision, social aspects, dependency, peripheral vision, activities of daily living, near tasks, far tasks, mental health, ability to drive a car, vision and mental health. However, the dimensions of the ocular pain and general health presented low averages in rela-tion to the others.

Conclusion: Patients with keratoconus who un-derwent CXL presented high scores on ten of the twelve evaluated subdomains, which features good visual qua-lity of life.

Descriptors: Quality of Life; Keratoconus; Ophthalmology; Nursing; Questionnaire.

INTRODUÇÃO

No ceratocone anterior, a córnea apresenta protu-berância (como um cone) e afinamento localizados, causando distorção na visão e baixa acuidade visual.1 Trata-se de uma doença não-inflamatória e progressi-va da córnea, acometendo ambos os olhos, levando a alterações na superfície da córnea, afinamento central e astigmatismo irregular, com diferentes graus de ci-catrização. Localizado próximo ao eixo visual, superior ou inferior a ele2, afeta a entrada da luz no olho e sua chegada na retina, alterando e distorcendo a visão3

dos indivíduos acometidos. A freqüência desta doença na população geral é de aproximadamente 1 em cada 2.000 pessoas, sem predileção pelo sexo.4-8

Até 1998, nenhum tratamento conservador para o ceratocone estava disponível.9 Dependendo de seu

Quality of life in keratoconus patients submitted to corneal collagen crosslinking

Kelly Stefani Klein1, Rita Caregnato2, Eduardo Périco3, Nelson Julio Balestro Junior4

Correspondência:

Kelly S. KleinRua Padre José Junges 579, EstrelaRio Grande do Sul BrasilTel: 5551-37121131Email: [email protected]

Date of submission: 26/01/2012 Date of approval: 21/05/2012Proprietary and/or fi nancial interest: None of the authors have any fi nancial or commercial interest to disclose.

From post-graduation program of Centro Universitário UNIVATES, Lageado, Rio Grande do Sul, Brazil

1. Enfermeira, pós-graduação2. Doutora em Educação3. Professor do Curso de Graduação em Ci´ncias Biológicas4. Oftalmologista

Funding: None

50 PAN-AMERICA


estádio evolutivo, pode ser conduzido de várias ma-neiras; sendo, nos casos iniciais, prescritos óculos.5 A correção com lentes de contato é a mais utilizada, independente da fase; entretanto, elas nem sempre são eficazes na obtenção de uma boa acuidade visual, dependendo da adaptação do paciente.2,10 Os métodos atuais de tratamento, como os segmentos de anéis intra-corneais, ceratectomia fotorrefrativa e o uso de lentes de contato apenas corrigem o erro refrativo, não impedindo a progressão da doença.11 De 10 a 20% dos pacientes apresentam alguma cicatriz corneal no eixo visual , que pode levar a baixa acuidade visual, mesmo com uso de lentes de contato; alem de apresentarem intolerância ao seu uso.10 Estes parâmetros clínicos são tradicionalmente utilizados para indicar o transplante de córnea.7-8,12-13

A indução de ligações covalentes (crosslinking - CXL) do colágeno é uma técnica inovadora, que utiliza riboflavi-na (vitamina B2) associada à ação da luz ultravioleta, para promover novas ligações covalentes intra e interfibrilares do colágeno corneal. Estas novas ligações preservam e fortalecem o estroma da córnea contra a instabilidade biomecânica.3,8,14 Realizado no Brasil há aproximadamente três anos, o CXL tem como objetivo estabilizar a córnea impedindo a progressão do ceratocone.8-9

O crescente avanço tecnológico na área da saú-de, exige da enfermagem preparo científico compa-tível às suas funções; assim, é possível orientar e esclarecer portadores de diversas doenças, como o ceratocone, em relação às suas necessidades psi-cossomáticas, a fim de melhorar os aspectos rela-cionados à qualidade de vida.

A qualidade de vida pode ser definida de forma ge-nérica ou relacionada à saúde, prevalecendo o concei-to da Organização Mundial da Saúde (OMS), o qual a estabelece como a percepção do indivíduo em relação à sua vida, considerando o contexto cultural, valores, expectativas e necessidades; ou seja, ter qualidade de vida significa o indivíduo bem consigo mesmo, com a vida e pessoas com as quais convive, reagindo de for-ma satisfatória aos problemas e controlando os acon-tecimentos do cotidiano. O conceito da qualidade de vida relacionada à saúde (QVRS) inclui a capacidade funcional, aspectos físicos, sociais e econômicos, tam-bém relacionados ao processo saúde-doença.5

Avaliar a qualidade de vida em procedimentos na oftalmologia tem sua relevância, pois os questioná-rios aplicados aos pacientes com distúrbios visuais permitem, além de explorar o impacto da diminuição visual, comparar diferentes terapêuticas em relação ao risco-benefício.16)

Atuando a seis anos na área de enfermagem, par-ticipando de uma equipe multiprofissional de cirurgia oftalmológica e interagindo com pacientes acometi-dos por diferentes doenças oculares, dentre os quais

portadores de ceratocone submetidos ao CXL, surgiu a motivação de avaliar a qualidade de vida e função vi-sual destes, possibilitando um feedback e avaliação da percepção dos pacientes em relação ao procedimento.

Partindo deste contexto e sabendo que “ainda são raros, na literatura nacional e em especial na área da oftalmologia, estudos envolvendo questionários e qua-lidade de vida17, este estudo traçou como problema de pesquisa: qual a qualidade de vida e da função visual dos portadores de ceratocone submetidos ao CXL? Para tanto, definiu-se como objetivo, avaliar a qualidade de vida e de visão desses pacientes, por meio do questio-nário VFQ 25.

MÉTODOS

Estudo transversal com abordagem quantitativa, realizado em clínica oftálmica privada localizada no interior do Rio Grande do Sul, com portadores de cera-tocone submetidos ao CXL.

Dentre os diferentes instrumentos propostos na literatura para avaliar a qualidade de vida, o Visual Function Questionnaire (VFQ) 25 é um instrumento ela-borado sob o patrocínio do National Eye Institute (NEI), desenvolvido para avaliar tanto a qualidade de vida em doenças oculares quanto à função visual.

Optou-se pelo VFQ 25 para esta pesquisa por se “tratar de um questionário dirigido exclusivamente aos pacientes oftalmológicos”19, traduzido do inglês e vali-dado pelo Departamento de Oftalmologia da Universi-dade Federal de São Paulo no ano de 1996.20 Este ins-trumento tem a finalidade de avaliar a qualidade de vida e de visão em diferentes aspectos, possuindo 25 ques-tões agrupadas em 12 subdomínios (com uma ou mais questões em cada subdomínio) assim denominados: saúde em geral; visão em geral; dor ocular; atividades de perto; atividades de longe; aspectos sociais; saúde mental; atividades da vida diária; dependência; capaci-dade de dirigir; visão de cores; e visão periférica.16,19,

20 Cada questão oferece cinco possibilidades de res-posta, com pontuação variando de 0 a 100 (0, 25, 50, 75 e 100 pontos, conforme a resposta). A pontuação final atingida é então dividida pelo número de questões, obtendo-se um escore para cada paciente, cujo valor mínimo é zero e o valor máximo é 100. Quanto maior o valor alcançado, melhor a qualidade de vida e função visual do paciente.16 A versão brasileira do VFQ 25 apresenta propriedades psicométricas válidas e con-fiáveis e pode ser aplicado para mensurar a qualidade de vida.21 Para obtenção do perfil dos participantes da pesquisa, foi adicionado um cabeçalho com variáveis a serem pesquisadas como nome, idade, sexo, profissão, escolaridade, telefone e correção visual utilizada no momento (óculos ou lentes de contato).

Para a seleção da amostra, consideraram-se os seguintes critérios de inclusão: a) faixa etária igual ou



superior a 18 anos, independente do sexo; b) pacien-tes submetidos ao CXL do colágeno corneal por diag-nóstico de ceratocone entre janeiro de 2010 e maio de 2011; c) aceitar participar do estudo.

Como critério de exclusão consideraram-se indi-víduos com alterações psíquicas, neurológicas ou de locomoção, que poderiam limitar as atividades diárias e sociais e influenciar na QV. A amostra intencional foi constituída por 70 participantes, pois 11 não respon-deram ao questionário e 6 não atenderam aos critérios de inclusão. O tamanho da amostra foi determinado por meio da fórmula de seleção para o tamanho mínimo da amostra22, considerando-se um erro amostral de 5%.

Para a coleta de dados, foi realizado um levantamen-to no sistema informatizado da Clínica, para identificar os pacientes submetidos ao CXL no período estabele-cido. Posteriormente, os prontuários foram acessados para averiguar os dados de identificação e número te-lefônico para contato. Foi realizado teste-piloto com 5 pacientes, a partir do qual se avaliou a responsividade ao questionário. Após esta fase preliminar, procedeu-se a coleta dos dados e a aplicação do questionário. Por contato telefônico, foi explicado a cada paciente o ob-jetivo do estudo e realizado o convite para participar da pesquisa. Diante do aceite, o termo de consentimento livre e esclarecido (TCLE) e o questionário foram en-viados por correspondência para o endereço dos pa-cientes com um envelope pré-selado. Isso garantiu o retorno de uma via do TCLE e do questionário, assinada e preenchida respectivamente.

Este estudo foi aprovado pelo Comitê de Ética e Pesquisa do Centro Universitário UNIVATES, sob nº de Protocolo 053/11.

Para a análise estatística dos dados foi utilizada planilha do programa Excel for Windows 7. A estatística descritiva foi aplicada para a distribuição de frequência, cálculo da média e desvio-padrão.

RESULTADOS

O perfil dos 70 participantes da pesquisa é apre-sentado na Tabela 1. Observamos uma amostra consti-tuída por 57,14% (n=40) do sexo masculino; 45,71% (n=32) com ensino médio completo; 45,71% (n=32) entre 18 e 28 anos; e 62,85% (n=44) não necessita-ram de correção visual após o procedimento.

Os portadores de ceratocone submetidos ao CXL neste estudo apresentaram média de 82,1 para o escore geral, com desvio-padrão de 12,2.

De acordo com os resultados da Tabela 2, obser-vam-se em dez dos doze subdomínios avaliados esco-res acima de 75, variando entre 75,6 e 98,6. As médias mostraram-se altas nos seguintes subdomínios, em ordem decrescente: visão de cores, aspectos sociais, dependência, visão periférica, atividades de vida diária,

atividades para perto, atividades para longe, capacida-de para dirigir automóveis, visão e saúde mental. En-tretanto, as dimensões da dor ocular e da saúde geral apresentaram médias baixas em relação às demais.

No domínio físico, foram avaliados os subdomí-nios de dor e desconforto ocular, com média de 76,8 (±21,4), revelando dor fraca a moderada; a percepção de quanto esta dor ou desconforto ‘atrapalham’ nas ati-vidades cotidianas teve média de 44,2 (±40,5). Ainda no domínio físico, temos a percepção da visão de modo geral com média de 76,9 (±14,6); a visão de cores com média de 98,6 (±5,8); visão periférica com mé-dia de 90,4 (±16,1); visão para perto com média 86,3 (±20,3); visão para longe com média 84,1 (±21,2). Nesse domínio, percebe-se menor comprometimento da visão de cores, seguida da visão periférica.

No que diz respeito ao domínio psicológico, o subdomínio “saúde mental” possibilitou avaliar a fre-quência dos sentimentos negativos provenientes do problema visual; a frequência da preocupação do pa-ciente com a sua visão; a percepção do quanto estes sentimentos negativos o prejudicam, atingindo um escore médio de 75,6 (±34,7), retratando ainda, que os pacientes continuam se preocupando com a visão, através do escore médio de 41,1 (± 33,3).

O subdomínio do nível de dependência abrange o grau de dificuldade para sair de casa sozinho, o grau de valorização e confiança em si mesmo; realização de atividades cotidianas e a percepção do grau de acome-timento do problema visual em relação à necessidade e ao auxílio das outras pessoas, no qual se estimou média de 91,3 (±22,4).

Quanto ao subdomínio das atividades diárias que ava-lia a capacidade de manter a rotina, exercendo as ativida-des básicas cotidianas, obteve-se média de 89,9 (±23,2).

Variável N %

SexoMasculinoFeminino

4030

57,1442,85

Idade18-28 anos29-39 anos≥ 40 anos

média ± dp

322513

30,7 ± 9,9

45,7135,7118,57

Nível escolaridadeFundamental

MédioSuperior incompleto

Superior completo

10321711

14,2845,7124,2815,71

Correção visual (atual)Lentes de contato

ÓculosNão necessitam

19744

27,1410

62,85

Tabela 1 - Variáveis pesquisadas sobre o perfi l dos 70 portadores de ceratocone submetidos ao CXL, entre janeiro de 2010 e maio de 2011.

52 PAN-AMERICA


No subdomínio dos aspectos sociais, a média foi de 94,5 (±12,7). Este subdomínio avalia a percepção do grau de interação com amigos ou familiares, aptidão para estudar e trabalhar.

Quanto ao subdomínio da capacidade para dirigir automóveis, o escore médio foi de 93,3 (±20,9), den-tre os pacientes habilitados. O escore médio para dirigir durante o dia foi 94,7 e durante a noite 71,9, refletindo, no geral, ausência de maiores dificuldades para dirigir.

Em relação ao subdomínio da saúde geral, os pa-cientes submetidos ao CXL apresentaram escore médio de 61,8 (±20,3).

DISCUSSÃO

Na literatura nacional brasileira foram publicados estudos de qualidade de vida relacionados à catarata16, ceratoplastia penetrante23, síndrome de Stevens John-son24, cirurgia refrativa17, glaucoma25, blefaroespasmo essencial e espasmo hemifacial26, blefaroptose18 e ce-ratocone27; entretanto, dentro de nosso conhecimento e da pesquisa bibliográfica realizada, não encontramos estudo sobre qualidade de vida de portadores de cera-tocone submetidos ao CXL.

A amostra, constituída por pacientes jovens, com média de idade de 30,7 anos, com desvio-padrão de 9,9 anos; tem média semelhante à encontrada em estudo com portadores de ceratocone submetidos ao transplan-te de córnea28, no qual menciona-se média de 31 anos. Conforme relatado em outros estudos, o ceratocone, por se tratar de uma doença crônica com início na juven-tude e duração extremamente longa, gera um impacto desproporcional na qualidade de vida dos indivíduos4, interferindo no desenvolvimento e projeto de vida, tanto nos aspectos físico, psíquico, familiar e social.5

Em outra pesquisa29, o autor cita estudo internacio-nal no qual a capacidade de leitura, inserida no sub-domínio “visão para perto”, foi um dos aspectos de-terminantes de maior preocupação nos indivíduos com baixa visão. Neste estudo, realizado no interior do Rio Grande do Sul, a maioria dos portadores de ceratocone submetidos ao CXL tem nível elevado de ensino e, con-seqüentemente, atribuem maior importância à leitura, apresentando média de 81,2 (±22,8) para a questão relacionada à dificuldade na leitura de textos.

Os subdomínios da “saúde geral” e “dor ocular” mostraram pontuação média baixa em relação aos outros, apontando restrição da QV nestes aspectos. Em

Subdomínio Média±DP Média±DP de cada questão

Saúde geral 61,8 ± 20,3 61,8 ± 20,3 (1)

Visão 76,9 ± 14,6 76,9 ± 14,6 (2)

Dor ocular 60,6 ± 36,1 76,8 ± 21,4 (4)44,2 ± 40,5 (19)

Atividades para perto 86,3 ± 20,3 81,2 ± 22,8 (5)87,1 ± 21,6 (6)90,4 ± 14,9 (7)

Atividades para longe 84,1 ± 21,2 74,6 ± 23,1 (8)86,8 ± 19,8 (9)91,0 ± 16,7 (14)

Aspectos sociais 94,5 ± 12,7 95,0 ± 10,9 (11)93,9 ± 14,4 (13)

Saúde mental 75,6 ± 34,7 41,1 ± 33,3 (3)89,6 ± 21,1 (21)

88,6 ± 20,7 (22)83,2 ± 35,3 (25)

Atividades da vida diária 89,9 ± 23,2 41,1 ± 33,3 (3)89,6 ± 21,1 (21)

88,6 ± 20,7 (22)83,2 ± 35,3 (25)

Atividades da vida diária 89,9 ± 23,2 82,1 ± 23,4 (17)83,6 ± 23,6 (18)

Dependência 91,3 ± 22,4 95,4 ± 19,2 (20)90,7 ± 23,4 (23)87,9 ± 24,0 (24)

Capacidade para dirigir automóveis 83,3 ± 20,9 94,7 ± 10,3 (15c)71,9 ± 22,7 (16)

Visão de cores 98,6 ± 5,8 98,6 ± 5,8 (12)

Visão periférica 90,4 ± 16,1 90,4 ± 16,1 (10)

Escore Geral 82,1 ± 12,2

Tabela 2: Média com desvios-padrão (DP) correspondentes a cada um dos subdomínios e escore geral dos 70 pacientes analisados.



relação à saúde geral, Ferraz29 afirma que a satis-fação com a saúde envolve sentimentos, anseios e aspirações do indivíduo e reflete a maneira como ele encara a saúde, determinando seu comporta-mento em relação a ela. Este mesmo autor, mencio-na também a relação entre o aumento do desconfor-to ocular e a piora das funções relacionadas à QV, mesmo quando a doença de base está estabilizada ou sob controle. Ressalta-se, neste estudo, esco-re médio de 60,6 para o subdomínio relativo à dor ocular, com a intensidade da dor obtendo média de 76,8, significando desconforto leve, muitas vezes relacionado a processos alérgicos, conforme outros estudos.30-31

Em estudo que avaliou portadores de ceratocone submetidos ao transplante de córnea10, evidenciou-se, em alguns casos, falta de correspondência entre resul-tado clínico e acuidade visual (AV) com a satisfação e a expectativa dos pacientes, reforçando-se a importância da aplicação de instrumentos avaliadores, tanto da QV quanto da função visual.16

O VFQ 25, aplicado neste estudo, possibilitou apreciação da QV em amplo espectro de condições oculares, mostrando-se válido para analisar a QV de portadores de ceratocone submetidos ao CXL, apre-sentando pontuação média de 82,1, superior àquela encontrada em estudos brasileiros, em pacientes submetidos a transplante de córnea, onde foram ve-rificadas médias de 69,310,23 através do VF 14. Con-sidera-se que essa diferença das médias possa ser decorrente da aplicação de dois questionários distin-tos, em procedimentos diferentes e que o benefício funcional comprovado por meio do resultado clínico e da acuidade visual obtida pode não estar de acordo com a satisfação do paciente.

Este estudo permitiu avaliar, de forma comple-mentar, diferentes aspectos da satisfação e da QV re-lacionados a visão dos portadores de ceratocone após realização do CXL; por ser este um procedimento há pouco tempo realizado no Brasil, são raros os estudos avaliando a QV desses indivíduos.

A percepção da QV e função visual dos porta-dores de ceratocone submetidos ao CXL pesquisa-dos, evidenciou escores elevados em dez dos doze subdomínios do VFQ 25, caracterizando boa QV em relação aos aspectos analisados, reforçando a im-portância de se aplicar instrumentos que avaliem tanto a QV quanto à função visual, a fim de comparar diferentes tratamentos realizados.

A aplicação do instrumento apenas após o CXL torna-se um fator limitante na avaliação das mudanças na QV decorrentes do procedimento. Sugere-se a rea-lização de outras pesquisas, utilizando-se o VFQ 25 antes e após realização do CXL em portadores de ce-ratocone, proporcionando uma real comparação dos benefícios deste novo procedimento.

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7. Lamy R, Fonseca-Netto, C, Pecego MG, Pecego JGC, et al. Reticulação do colágeno corneano com radiação ul-travioleta e ribofl avina para tratamento do ceratocone: preliminares de um estudo brasileiro. Rev Bras Oftalmol. 2008; 67(5): 231-5.

8. Jankov, MR. Hafezi F, Beko M, Ignjatovic Z, djurovic B, Markovic V, Schor Pl. Corneal crosslinking for the treatment of keratoconus: preliminary results. Arq Bras Oftalmol. 2008; 71(6): 813-8.

9. Renesto AC, Sartori M, Campos M. Crosslinking and intrastromal corneal ring segment. Arq Bras Oftalmol. 2011; 74(1): 67-74.

10. Cavalcanti MTD, Mahon M, Nóbrega DAT, Remigio MCA, Pires CS. Keratoconus: visual results, complications and life quality after penetrat-ing keratoplasty performed by a resident physican. Arq Bras Oftalmol. 2004 ; 67(3): 415-8.

11. Wollensak G. Crosslink-ing treatment of progressive keratoconus: new hope. Curr Opin Ophthalmol. 2006; 17(4): 356-60.

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Silva FBD, Cunha GHA. Estudo das modifi cações ocu-lares induzidas pelo implante estromal do anel de Ferrara em portadores de ceratocone. Arq Bras Oftalmol. 2003; 66: 417-22.

13. Ambrósio-Júnior R, Cal-das DL, Silva, RS, Pimentel LN, Valbon BF. Impacto da análise do wavefront na refratometria d pacientes com ceratocone. Rev Bras Oftal-mol. 2010; 69(5): 294-300.

14. Brochetto DC, Dantas B, Schor P. Paulo. Novos conceitos em modelamento corneano. Rev Bras Oftalmol. 2010; 69(2): 132-7.

15. Soares DA, Toledo JAS, Santos LF, Lima RMB, Galdeano LE. Qualidade de vida de portadores de insufi ciência cardíaca. Acta Paul Enfermagem. 2008; 21(2): 243-8.

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26. Osaki MH, Belfort-Júnior R. Qualidade de vida e custos diretos em pacientes com blefaroespasmo essencial e espasmo hemifacial, tratados com toxina botulínica-A. Arq Bras Oftalmol. 2004; 67(2): 43-9.

27. Lima CA. Proposição e teste de um questionário de qualidade de vida em pacientes com ceratocone [dissertação]. Campinas: Fac-uldade de Ciências Médicas de Campinas; 2000.

28. Seabra FC. Transplante penetrante de córnea em ceratocone: Estudo da junção doador - receptor pela biomicroscopia ultrassônica e videoceratografi a. São Paulo, 149p. [Tese Doutorado]. De-partamento de Oftalmologia, Unifesp; 2001.

29. Ferraz EVAP. Adaptação de questionário de qualidade de vida e percepção relativa à doença, aplicado a indivíduos portadores de catarata senil [dissertação]. Campinas (SP): Faculdade de Ciências Medicas; 2005.

30. Lyra JM. Utilização da radiofrequência para trata-mento do ceratocone [tese]. Belo Horizonte: Faculdade de Medicina; 2006.

31. Botelho PBM, Marback P, Sousa LB, Campos M, Vieira LA. Ceratoconjuntivite alérgicas e complicações no segmento ocular anterior de pacientes. Arq Bras Oftalmol. 2003; 66: 25-8.

54 PAN-AMERICA

CASE REPORT / Vis. Pan-Am. 2012;11(2):54-57

ABSTRACT

We report the management of a non-traumatic rhegmatogenous retinal de-tachment in a pediatric patient in the context of a genetic syndrome associated with failure of type 2 collagen synthesis, which manifests itself in ocular, hearing, facial, bone and joint abnormalities.

We describe the clinical presentation and surgical repair technique that in-cluded lensectomy, vitrectomy, peeling of vitreoretinal proliferative membranes, giant retinal tear management and prolonged use of intraocular silicone oil. Long-term clinical follow-up was observed.

We highlight this case report as a therapeutic challenge in a deaf and high myopic child, with motor disabilities and atypical vitreoretinal disorders that have generated technical difficulties in surgical resolution. There is also little scientific references in the literature. This disease represents a clinical model of abnormal vitreoretinal interaction.

Key words: Kniest syndrome, retinal detachment, giant retinal tear, myopia.

RESUMEN

Presentamos el manejo de un desprendimiento de retina regmatógeno no traumá-tico en paciente pediátrico, en el contexto de un síndrome genético asociado a falla de síntesis de colágeno tipo 2 que se manifiesta en alteraciones oculares, auditivas, faciales y osteoarticulares.

Se describe presentación clínica del cuadro y técnica de reparación quirúrgica que consistió en lensectomía – vitrectomía – pelaje de membranas de proliferación vitreorretinal – manejo de desgarro retinal gigante – retinopexia y tamponamiento prolongado con aceite de silicona. Se efectuó seguimiento clínico a largo plazo.

Destacamos este caso por ser un desafío terapéutico en un niño sordomudo, alto miope, con discapacidad motora y que posee alteraciones vitreorretinales atípicas que generan dificultades técnicas en su resolución quirúrgica, existir una escasa literatura mundial de referencia y representar un modelo clínico de interacción vitreorretinal anómala.

Palabras clave: síndrome de Kniest, despren-dimiento de retina, desgarro retinal gigante, miopía.

INTRODUCCIÓN

El desprendimiento de retina regmatógeno (DRR) es una enfermedad grave pero poco frecuente, en la población pediátrica.

A diferencia de los adultos, existe a menudo com-promiso de la mácula, proliferación vitreorretinal, ma-yor tiempo de duración del DRR y peor agudeza visual inicial al momento de su diagnóstico1.

Algunos factores predisponentes asociados son: cirugía ocular previa, trauma, uveítis, anormalidades

Figura 1: Paciente de 14 años con síndrome de Kniest.

Rhegmatogenous retinal detachment in Kniest Syndrome: Clinical model of abnormal vitreoretinal traction in children.

Desprendimiento de retina en síndrome de Kniest: Modelo clínico de tracción vitreorretinal anormal en niños

From Fundación Oftalmológica Los Andes, Santiago, Chile. Corresponding author:

Date of submission: 14/01/2012 Date of approval: 23/02/2012

Funding: NoneProprietary and/or fi nancial interest: None of the authors have any fi nancial or commercial interest to disclose.

Jorge Orellana Rios, M.D. , Karim Esteffan Sanchez, M.D., Hernán Iturriaga Valenzuela. M.D., José Miguel Ried Undurraga. M.D.

Jorge Orellana Rios MDServicio de Oftalmología, Hospital Regional de AntofagastaAv. Argentina 1962 , Antofagasta , Chile.Fax/Telephone: 56-55-494736E-mail :[email protected]


Orellana Rios J et al. Desprendimiento de Retina en Síndrome de Kniest

del desarrollo y miopía. Estos dos últimos forman parte de las alteraciones oculares encontradas en el síndrome de Kniest2.

El síndrome artroftalmopático de Kniest forma parte del espectro de las condrodisplasias causadas por anomalías del gen COL2A1 ubicado en el brazo largo del cromosoma 12, que participa de la síntesis del colágeno tipo 2, compartiendo lugar con el sín-drome de Stickler, mayormente conocido3.

Estos pacientes tienen alteraciones clínicas y radiológicas típicas del esqueleto axial y articula-ciones periféricas, fascies con puente nasal plano, paladar hendido y déficit auditivo importante. En el examen oftalmológico presentan alta miopía, y cambios vitreorretinales consistentes en sinéresis y licuefacción vítrea, áreas de blanco sin presión y condensación del vítreo cortical con tracción retinal, preferentemente en periferia temporal junto a dege-neraciones lattices atípicas de disposición paravas-cular y radial a la ora serrata2.

A continuación, presentaremos un paciente con sín-drome de Kniest y DRR por desgarro retinal gigante que se controló por muchos años en nuestra institución.

CASO CLÍNICO

Su historia comenzó en 1993, a los 8 meses de vida, por test de rojo pupilar alterado y macroglobo bi-lateral. Se indicó examen oftalmológico completo bajo anestesia general, encontrándose córneas de diámetro normal, tonometrías oculares bajas, alteraciones pig-mentarias de la mácula y alta miopía a la esquiascopía, con discos ópticos de aspecto conservado. Se sospe-chó una genopatía y descartó glaucoma.

Volvió a control a los 4 años de edad con diag-nóstico clínico y radiológico de displasia de Kniest, operado de paladar hendido y con sordera confir-mada. Su refracción clínica era de -14.00 dioptrías esféricas en ojo derecho y de -14.50 dioptrías esfé-ricas con -2.50 D cilíndricas a 170° en ojo izquierdo. Se recetaron lentes y desde 1997 en adelante fue seguido con tonometría y fondo de ojo. Su refracción en junio de 2001 solo había aumentado ½ dioptría de miopía en cada ojo, con mayor cambio en el as-tigmatismo bilateral y al examen con lámpara de hendidura se destacaba un vítreo muy fibrilar.

En junio de 2004 se constató una agudeza visual mejor corregida de 0.25 en cada ojo, con anteojos. Su seguimiento clínico transcurrió sin novedad, has-ta que consultó de urgencia, en mayo de 2007 por pérdida de la visión de su ojo izquierdo (Figura 1).

El examen oftalmológico destacaba visión de movimiento de manos y tensión ocular de 4 mm Hg en el ojo afectado y en su ojo derecho visión corre-gida de 0.28, con presión intraocular de 15 mm Hg. En la biomicroscopía, DRR retrocristaliniano en ojo izquierdo por desgarro retinal gigante temporal infe-rior, con irido y facodonesis (Figura 2), y fondo de ojo derecho con cuerpo vítreo fibrilar y condensacio-nes vítreas periféricas, áreas de blanco sin presión retinal y degeneraciones reticulares paravasculares radiales (Figuras 3 y 4).

Se realizó lensectomía vía pars plana, con retiro total del saco capsular y zónula, vitrectomía, pelaje de membranas inmaduras de proliferación vitreorretinal con ayuda de líquido perfluorocarbonado, vitrectomía de base vítrea y cuernos del desgarro retinal gigante, endofotocoagulación de bordes retinales y aplicación

Figura 2: Biomicroscopía del ojo izquierdo: DRR retrocristaliniano, con irido y facodonesis, en posición primaria de mirada (arriba izquierda), en abeducción (arriba centro) y en aducción (arriba derecha).

56 PAN-AMERICA


Figura 3: Retinografía ojo derecho: Nótese alteración del epitelio pigmentario a temporal de la fóvea y condensación vítrea periférica temporal a esta área atípica, y que tiende a ocultar trayectos vasculares retinales.

Figura 4: Retinografía ojo derecho: Degeneración lattice paravascular radial atípica y vítreo fi brilar en síndrome de Kniest (arriba). Degeneración lattice paralela a ora serrata y condensación vítrea periférica (abajo).

de láser diodo transescleral a opérculo anterior del desgarro, iridectomía inferior amplia, recambio aire por aceite de silicona de 5000 centistokes. No se utilizó banda ni cerclaje escleral .

Al primer día postoperatorio se constata retina apli-cada, con pliegue macular, sin deslizamiento retinal de los bordes del desgarro gigante (Figura 5).

Alrededor de la tercera semana, se encuentra con presión de 26 mm Hg, por lo que se disminuye la dosis y potencia del corticoide tópico y se agregaron hipo-tensores oculares, con estabilización de presión ocular por varios meses.

Al cuarto mes de operado, se evidencia emulsifica-ción del aceite de silicona en cámara anterior, sin descom-pensación corneal y manteniendo presiones estables.

A un año de seguimiento, su agudeza visual mejor corregida del ojo izquierdo, a través de cavidad vítrea con silicona, llegaba a 0.25, pero a los 18 meses posto-peratorios destacó al examen, un alza de tensión hasta 38 mm Hg en su ojo operado, que se trató en forma médica hasta normalizar valores de presión intraocular e indicación urgente de cirugía de extracción del aceite de la cavidad vítrea y retiro de membrana epirretinal que perpetuaba pliegue y edema macular.

Actualmente y por una mayor dificultad general para acudir a sus controles oftalmológicos, se advir-tió el desarrollo de un glaucoma secundario de ángulo abierto y pérdida de visión obtenida durante los prime-ros años, en su ojo vitrectomizado.

DISCUSIÓN

El síndrome de Kniest fue descrito por primera vez por Wilhelm Kniest, médico pediatra de la Universidad de Jena-Turingia en 1954 y su diagnóstico se efectuó por los hallazgos físicos y radiológicos típicos, sin poder establecer con exactitud cuál era la alteración genética causante4.

Actualmente, el espectro clínico de las colageno-patías tipo 2 determinadas por la alteración del gen COL2A1 que incluyen, entre otras, la displasia espon-diloepifisiaria congénita, la displasia de Kniest y la ar-troftalmopatía de Stickler, son expresiones alélicas del mismo locus dominante en el cromosoma 125. El pro-greso de los estudios genéticos ha permitido explicar la variablidad clínica de estos síndromes oftalmológicos y articulares basados en un origen común6.

En el síndrome de Kniest, la fibra de colágeno tipo 2 pierde su organización fibrilar, tornándose mas del-gada e irregular, con alteración del bandeado típico, mermando las bases del sostén mecánico del cuerpo vítreo, provocando un cambio paulatino de la densidad y consistencia del gel vítreo normal del niño, y que ayu-


Orellana Rios J et al. Desprendimiento de Retina en Síndrome de Kniest

Figura 5: Retinografía ojo izquierdo: Destaca pliegue macular y retina aplicada tras aceite de silicona en cavidad vítrea.

da a un desprendimiento vítreo anormal y brusco, sin la separación lenta y progresiva del pegamento biológico que existe entre la hialoides posterior y la membrana li-mitante interna, como ocurre normalmente en la época adulta del ser humano.

Hoy podemos establecer que dentro de las cau-sas importantes de miopía patológica en niños a descartar, se encuentra los síndromes de Stickler tipo 1 y 2, de cuyo gen causante se han descrito numerosas mutaciones que explican una amplia va-riabilidad fenotípica, incluso cuadros sin asociación sistémica, solo diagnosticables por los signos oftal-mológicos atípicos al fondo de ojo, como ya había sido clasificado en sus inicios7.

El síndrome de Stickler tipo 1 y el síndrome de Kniest tienen una sobreposición clínica y radiológica considerable, por lo que en un principio pueden difi-cultar su identificación8.

Algunas diferencias clínicas que pueden orientar a uno u otro diagnóstico, es que en el síndrome de Stic-kler hay un predominio por un hábito corporal marfa-noide y articulaciones más extensibles, en cambio en el síndrome de Kniest hay una mayor frecuencia de há-bito enanoide y articulaciones algo más rígidas, como ejemplo, al pedirles empuñar una mano.

El vítreo de estos pacientes es liquefacto e ines-table y se vuelve sinerético a temprana edad. Sin em-bargo, no hay dehiscencia en la interfase vítreoretinal en concomitancia con los cambios del cuerpo vítreo, debido a que la membrana limitante interna de la retina está compuesta por fibras de colágeno tipo 4 y el me-tabolismo anormal del colágeno tipo 2 provoca solo la desestabilización del andamiaje vítreo9. Estos cambios se han descrito a partir de la primera década de la vida como vítreo membranoso o fibrilar y son evidencia de un riesgo de hasta un 50% de DRR10.

En los ojos de pacientes con síndrome de Kniest se va generando tracción vitreorretinal mayor a lo normal en zonas de adherencia vitreorretinal patológica, aso-ciadas a las degeneraciones lattices atípicas y conden-saciones del vítreo cortical periférico, que explican la génesis del desgarro retinal gigante en estos pacientes y el despegamiento parcial y aparente de la hialoides posterior a nivel macular, que permite, entre otras ra-zones, el desarrollo de membranas epirretinales y plie-gues maculares persistentes a largo plazo10.

Es importante no olvidar la necesidad de control postoperatorio estricto de estos pacientes y advertir a sus padres y/o cuidadores de las eventuales com-plicaciones a largo plazo de los tamponamientos prolongados en cavidad vítrea y evitar así la pérdida irreversible de la visión obtenida después de una compleja cirugía vítreorretinal10,11.

1. Gonzalez CR, Singh S, Yu F, Kreiger AE, Gupta A, Schwartz SD. Pediatric rhegmatoge-nous retinal detachment: clinical features and sur-gical outcomes. Retina 2008;28(6):847-52.

2. Maumenee IH, Traboulsi EI. The ocular fi ndings in Kniest dis-plasia. Am J Ophthalmol 1985;100:155-160.

3. Yokoyama T, Nakatani S, Murakami A. A case of Kniest dysplasia with retinal detachment and the mutation analysis. Am J Ophthalmol 2003;136(6):1186-8.

4. Spranger J, Winter-pacht A, Zabel B. Kniest dysplasia: Dr. W. Kniest, his patient, the molecu-lar defect. Am J Med Genet 1997;69(1):79-84.

5. Spranger J, Winter-pacht A, Zabel B. The type II collagenopathies: a spectrum of chondro-dysplasias. Eur J Pediatr 1994;153(2):56-65.

6. Donoso LA, Edwards AP, Frost AT et al. Clini-cal variability of Stickler syndrome: role of exon 2 of the collagen COL2A1 gene. Surv Ophhalmol 2003;48:191-203.

7. Parma ES, Korkko J, Hagler WS et al. Radial

perivascular retinal de-generation: a key to the clinical diagnosis of an ocular variant of Stickler syndrome with minimal or no systemic manifes-tations. Am J Ophthal-mol 2002;134:728-734.

8. Sebag J, Nguyen N. Vitreous embryology and vítreo-retinal develop-mental disorders. In: Hartnett M, ed. Pediatric Retina. Philadelphia: Lippincott Williams Wilkins, 2005;1:13-25.

9. Capone A, Trese M. Pediatric Rhegmatog-enous Retinal Detach-ment. In: Hartnett M, ed. Pediatric Retina. Philadelphia: Lippincott Williams Wilkins, 2005; 24:365-73.

10. Soheilian M, Ramezani A, Malihi M, Yaseri M, Ahmadieh H, Dehghan MH, Azarmina M, Moradian S, Peyman GA. Clinical features and surgical outcomes of pediatric rhegmatogenous retinal detachment. Retina 2009;29(4):545-51.

11. Giuliari GP, Sadako A, Chang PY, Iovieno A. A blind eye: The price of poor physi-cian patient commu-nication. Vis Pan-Am 2010;10(2):60-1.

REFERENCIAS

58 PAN-AMERICA


Variables to consider when confronting a microphthalmos with a cyst: A case report

ABSTRACT

Microphthalmos with orbital cyst is a rare and severe non-hereditary ocular developmental anomaly. Pathologically it represents a failure in the closure of the embryonic fissure at the 7-14 mm stage of gestation, resulting in a congenital microphthalmia and the formation of a colobomatous cyst in different degrees. We present a patient with this condition to emphasize the complexity in the deci-sion making process and review the various management strategies to obtain the best long term results.

KEY WORDS: microphthalmos, orbital cyst, aspiration, orbitotomy, Delle-man syndrome

RESUMEN

Microftalmos con quiste orbital es una rara y grave anomalía ocular no-hereditaria del desarrollo. Patológicamente representa una falla en el cierre de la fisura embrio-naria en la fase de 7-14 mm de gestación, resultando en una microftalmía congénita y la formación de un quiste colobomatous en diferentes grados. Presentamos a un paciente con esta condición para enfatizar la complejidad en la toma de decisiones en el proceso y revisar las diferentes estrategias de manejo para obtener los mejores resultados a largo plazo.

Palabras clave: Microftalmos, quiste orbital, aspiración, orbitotomía, síndrome de Delleman.

INTRODUCTIONThe estimated prevalence rate of congenital micro-

phthalmia is 1.8 per 10,000 births.1 When associated with colobatomous cyst, this condition is very rare. Currently, there is no agreement to the best approach for its mana-gement as this disorder can present in a variable way. We herein report a case of a patient with microphthalmos with orbital cyst and severe non-hereditary ocular developmen-tal anomaly, discussing diagnosis and management.

CASE REPORTA two-year old patient with Delleman Syndrome was

referred to our service, presenting with progressive right proptosis. She had choanal atresia and a history of facial skin tags removed, but was confirmed not to have any brain malformations. After an extensive workup with her pediatrician, CHARGE syndrome (ocular coloboma, heart defects, choanal atresia, mental retardation, and genitouri-nary and ear anomalies) had been ruled out, and she was found to have a normal karyotype. Clinical examination showed severe right amblyopia with an eso-hyoptropia and marked proptosis. There was an evident infero-temporal iris-choroid-retinal-optic nerve coloboma affecting this eye (Figure 1a). MRI confirmed a right enlarged orbit with a microphthalmic globe and 3 cm multilocular intraconal cystic mass, displacing the orbital roof (Figure 1b).

Given the severity of the microphthalmos and the extension of the orbital cyst, a surgical approach was un-dertaken with cyst aspiration and excision, including the removal of the abnormal globe. A retrocaruncular medial orbitotomy, in conjunction with a Kronlein lateral orbito-tomy, was chosen to allow for appropriate exposure of the large cystic lesion (Figure 2a). Following the removal of the cystic content and enucleation of the globe, the sig-nificantly enlarged orbital cavity was reconstructed with a 22ml silicone ocular implant wrapped in human donor

From Department of Ophthalmology, Tulane Health Science Centre, Tulane University, New Orleans, Louisiana, USA



Anika Tandon, MD1, Arthi Chawla2, Alejandra A. Valenzuela, MD3

Dr. Alejandra A. ValenzuelaAssociate Professor, Department of OphthalmologyTulane Health Science Centre1430 Tulane Avenue, SL-69New Orleans, LA, 70112, USA

Presented in part at the annual meeting of the Canadian Ophthalmic Pathology Society in Toronto, Canada, June 2009.

Proprietary and/or fi nancial interest: None of the authors have any fi nancial or commercial interest to disclose.

1. PGY-3 Ophthalmology Resident2. MS4 Medical Student3. Associate Professor of Ophthalmology

Funding: None

Figure 1a: Clinical photograph of the right eye, showing the infero-temporal iris-retina-choroid-optic nerve coloboma.

Figure 1b: Axial T-2 weighted magnetic resonance image demonstrating the enlarged right orbit with the hyperintense multi-locular cystic lesion and an abnormal right globe.


Tandon A et al. Management of a microphthalmos with a cyst.

sclera. Macroscopic evaluation of the removed speci-men showed a microphthalmic globe with an iris co-loboma at 7 o’clock and a cyst of 29x19x14.5mm infe-riorly located, adjacent to the optic nerve (Figure 2b). Histopathological analysis revealed hypoplastic iris, dysplastic retina with lack of RPE, optic nerve hypopla-sia and retrochoroidal coloboma.

DISCUSSION

Microphthalmos with orbital cyst is a relatively rare condition. It is typically unilateral, with no gender predo-minance. It develops due to failed closure of the ocular embryonic fissure during the 7mm to 20mm stage of de-velopment.2-4 Histopathological examination of the excised cyst shows an external layer of vascularized connective tis-sue with an inner lining of neuroglial cells.2,5 Progressive enlargement of the cyst is likely due to fluid production by the glial cells, though some hypothesize that glial cell pro-liferation or a connection with the subarachnoid space may contribute.2 Diagnosis is usually made in infancy. Patients may present with proptosis or lower lid swelling associa-ted with a blue-tinged mass corresponding to the cyst.5,6 Though it is often diagnosed clinically, additional studies such as an orbital ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) are highly valuable. In addition, it is crucial to determine the visual potential of the microphthalmic eye. Electrophysiologic studies may be necessary. After diagnosing microphthalmos with orbital cyst, a team effort with a pediatrician should be coordinated to rule out any associated systemic abnormalities.4-7

There is no consensus in the best management of this condition, as it varies in presentation. Observation is often recommended for mild microphthalmos and small orbital cyst.5,8 In cases of severe microphthalmos with small cyst, conservative treatment with a conformer can be used to

1. Stoll C, Alembik Y, Dott B, Roth MP. Epidemiology of Congenital Eye Malformations in 131,660 consecu-tive births. Ophthal Paeditr Genet 1992;13:179-86

2. Lieb, W., R. Rochels, U. Gronemeyer. Microphthalmos with Colobomatous Orbital Cyst: Clinical, Histological, Immunohistological, and Electronmicroscopic Findings. Br J Ophthalmol 1990 Jan;74(1):59-62

3. Mohammad, Abd El-Nasser. Microphthalmia with Huge Cyst: A Simple Technique for Excision. Orbit 2009;28(2-3):172-5

4. Moog, U., C. Die-Smulders, J. M. J. Systermans, and J. M. Cobben. Oculocerebrocutaneous Syndrome: Report of Three Additional Cases and Aetiological Considerations. Clin Genet 1997 Oct;52(4):219-25

5. Chaudhry, Imtiaz A., Yonca O. Arat, Farrukh A. Shamsi, and Milton Boniuk. Congenital Microphthalmos With Orbital Cysts. Ophthal Plast Reconstr Surg 2004 Nov;20(6):452-7

6. McLean, C. J. The Management of Orbital Cysts As-sociated with Congenital Microphthalmos and Anophthal-mos. Br J Ophthalmol 2003 Jul;87(7):860-3

7. Tucker, Susan, Barry Jones, and Richard Collin. Systemic Anomalies in 77 Patients With Congenital Anophthalmos or Microphthalmos. Eye (Lond) 1996;10 (Pt 3):310-4

8. Polito, Ennio, and Antonio Leccisotti. Colobomatous Ocular Cyst Excision with Globe Preservation. Ophthal Plast Reconstr Surg 1995 Dec;11(4):288-92

9. Kitthaweesin, K. Orbital Aspiration as Treatment of Microphthalmos with Orbital Cyst: a Case Report. J Med Assoc Thai 2002 Sep;85(9):1024-7

10. Wiwatwongwana, Damrong, and Jack Rootman. Bilateral Microphthalmos With Cyst: Excision With Orbital Free Fat Graft. Ophthal Plast Reconstr Surg 2009 May-Jun;25(3):241-3

REFERENCES

allow for orbit development.6 Advanced cases with sig-nificant cystic volume and strong cosmetic concern may require surgical management.

The appropriate timing of surgery remains controver-sial, as the colobomatous cyst can induce orbital expan-sion. Some surgeons advocate conservative therapy with delay of surgical intervention until the orbit is of adequate size.6 For microphthalmos with an enlarging cyst, aspira-tion of the cystic fluid can be considered as a less invasive approach.5,6,9 Often, however, repeat aspirations are neces-sary due to fluid re-accumulation.5,6

Surgical excision of the cystic component with pre-servation of the globe, should be reserved for those ca-ses where the degree of microphthalmos is minimal, and the cyst is large enough to jeopardize patient’s outward appearance.8 Severe cases may require a more invasive surgical approach, with removal of the abnormal globe and multilocular cyst.5 It is important to emphasize that the potentially enlarged orbital cavity will necessitate an appropriate volume deficit reconstruction for the best long term results. Frequently, volume replacement with orbital implants or dermis fat grafts can achieve cosmetic and cli-nical success.5,10

Figure 2a: Intraoperative view after a medial and lateral orbitotomy, showing the extension of the cystic lesion in an abnormal colobomatous globe.

Figure 2b: Gross appearence of the excised microphthalmic globe and collapsed colobomatous cyst.

60 PAN-AMERICA


Spontaneous closure and quick reopening of a full thickness idiopathic macular hole

From Department of Ophthalmology, Central University Hospital of Asturias, Ovie-do, Asturias and University Hospital of Santiago de Compostela, Galicia, Spain.



Miriam García-Fernández1, Joaquín Castro Navarro1

Miriam García-Fernández, MD.Department of Ophthalmology, Central University Hospital of AsturiasC/Dionisio Ridruejo, nº5, 11ºD. CP: 33007 Oviedo, Asturias (Spain)Tel:+34-629-85-38-00Email: [email protected]: None

Confl ict of interest: None

1. Retina Department, Ophthalmology. University Central - Hospital of Asturias, Spain.

ABSTRACT

Purpose: To report a quick reopening of a spon-taneously closed full thickness macular hole.

Design: Case report.

Methods: A 68-year-old patient with stage III full thickness idiopathic macular hole in one eye was fo-llowed up for thirteen months with fundus photogra-phy and optical coherence tomography (OCT).

Results: Twelve days after the first examina-tion, that detected the macular hole, OCT scans re-vealed the closure of the macular hole associated to the development of a small epiretinal membrane (ERM). One month later, the patient was admitted to the emergency unit, complaining of progressive vi-sual loss over the past three days. OCT examination showed a full-thickness macular hole, very similar to the previously closed, and a progression of the ERM. The patient was submitted to pars plana vitrectomy with internal limiting membrane peeling and remo-val of ERM. Surgical repair resulted in significant functional and anatomic outcome.

Conclusion: The reopening of a spontaneously closed macular hole is remarkably uncommon and has been reported previously in two patients. A rigo-rous follow-up is mandatory, because these macular holes can quickly reopen, as demonstrated in this case report.

Key words: macular hole, spontaneous closure, spontaneous reopening, optical coherence tomography.

RESUMEN

Propósito: describir un caso de rápida reapertu-ra tras cierre espontáneo de un agujero macular de espesor completo.

Diseño: caso clínico.

Métodos: Paciente de 69 años con agujero ma-cular de espesor completo estadío III en un ojo que es seguido durante 14 meses mediante retinografías y tomografía de coherencia óptica (OCT).

Resultados: Doce días tras la exploración ini-cial, los cortes de la OCT revelaron el cierre del agujero macular asociado al desarrollo de una pe-queña membrana epiretiniana (MER). Un mes más tarde, el paciente acudió a urgencias por disminu-ción de agudeza visual progresiva desde hacía tres días. La exploración mediante OCT mostró un agu-jero macular de espesor completo, muy similar al que previamente se había cerrado, y una progresión de la MER.

El paciente fue sometido a vitrectomía pars plana (VPP) con pelado de membrana limitante interna y remoción de MER. La cirugía resultó en buenos re-sultados anatómicos y funcionales.

Conclusión: La reapertura tras cierre espontá-neo de un agujero macular es muy infrecuente y ha sido descrita en tan solo dos casos hasta ahora. Es necesario un seguimiento estrecho, pues estos agu-jeros pueden reabrirse rápidamente, como mostra-mos en este caso.

Cierre espontáneo y rápida reapertura de un agujero macular de espesor completo idiopático

Proprietary and/or fi nancial interest: None of the authors have any fi nancial or commercial interest to disclose.


García-Fernández M & Navarro JC. Spontaneous closure of macular hole

Palabras clave: agujero macular, cierre espon-táneo, reapertura espontánea, tomografía de cohe-rencia óptica.

INTRODUCTION

Spontaneous closure of traumatic macular hole is described as a common event in peer-reviewed literature. However, the spontaneous closure of stage III and IV idiopathic macular hole has been reported in a few cases, being considered a rare event1-8 Moreover, there are only two reported cases about reopening of a spontaneously closed macular hole9,10

CASE REPORT

A 68-year-old Spanish man was referred with complaints of decreased vision and metamorphop-sia in his left eye (OS) for approximately three months. His ocular history included previous laser photocoagulation as treatment for peripheral retinal tears in the OS and vitrectomy due to retinal de-tachment in the right eye (OD) two years ago. He was submitted to cataract surgery in both eyes four years ago.

At the first visit, his best corrected visual acuity (BCVA) was 20/70 in OS and 20/25 in OD.

Anterior segment examination revealed pseu-dophakia with no further abnormalities in both eyes. Fundus photographs revealed an image of full thickness macular hole (FTMH) in OS, and a par-tial thickness macular defect (LMH) in OD. Optical Coherence Tomography (OCT) examination (Figure 1) showed a stage III FTMH in OS and a LMH in OD.

Some cystic spaces on both edges of the full-thickness hole, and a small epiretinal membrane (ERM) were noted, as well as clear irregularity of the junction of inner and outer segments of photorecep-tors (IS/OS). Twelve days later, BCVA in OS impro-ved to 20/25. OCT scans revealed a closed macular hole. A defect in the continuity of the photoreceptor layer with a small subfoveal region of hyperreflec-tivity, probably due to the regeneration of the outer retinal layers (Figure 2) was observed.

One month later, the patient was admitted to the emergency unit, complaining of progressive visual loss in the OS over the past 3 days. OCT exami-nation showed a full-thickness macular hole, very similar to the previous findings before the macular hole spontaneous closure, as well as a progression of the ERM (Figure 3a).

The left eye was submitted to pars plana vitrec-tomy with internal limiting membrane peeling, ERM

removal and 20% SF6 intraocular gas fill with patient face down positioning. Two months after vitreoreti-nal surgery, the BCVA was 20/25. Anterior segment exam was unchanged from the initial exam. Dilated fundus examination and OCT of the OS revealed clo-sure of the macular hole. OCT imaging also showed partial restoration of foveal contour, and partial re-covery of integrity at the line corresponding to the photoreceptor layer.

One year after the vitreoretinal surgery, the BCVA remained unchanged as well as OCT and fundosco-py images (Figure 3b).

DISCUSSION

It is well known that the spontaneous closure of idiopathic macular holes is less prevalent and less well understood than closure of traumatic ma-cular holes4. Several mechanisms for spontaneous closure of idiopathic macular holes have been described: a complete detachment of the posterior hyaloid, leading to a reduction in antero-posterior tractional forces7; the bridging effect of retinal tis-sue and glial cells proliferation across the hole5,8,9; and the formation of a contractile ERM, which pro-vokes shrinkage of the hole, resulting in cells pro-liferation at its base.

In this reported case, we hypothesize that, pro-bably, a vitreomacular traction started the formation

Figure 2. Cirrus OCT scan of left eye, twelve days after fi rst examination. The closure of the full-thickness macular hole, simulating a macular pseudohole, is obeserved. An epiretinal membrane is also visible.

Figure 3. Cirrus OCT scan in left eye. (a) Reopening of the previously closed full-thickness macular hole at one month follow-up. The epiretinal membrane is more evident. A disruption of the photoreceptor layer is observed. (b) Twelve months after pars plana vitrectomy, closure of the macular hole and a nearly complete restoration of foveal contour is observed.

Figure 1. Cirrus OCT scans at fi rst visit. (a) Full-thickness macular hole in left eye. (b) Lamellar macular hole in right eye. An epiretinal membrane in both eyes is obseerved.

62 PAN-AMERICA


of the FTMH, followed by a posterior vitreous deta-chment and, as the antero-posterior tractional forces released, the macular hole began to close.

A compelling point is that the inner and outer diameters of macular holes were small, and this may had contributed to the quick closure of the hole. Despite of the complete closure, the BCVA did not improve to normal values. It is likely that the dis-ruption in the photoreceptor layer had resulted in a worse BCVA.

Several factors have been described for the reopening of full thickness macular holes after vitrec-tomy: cataract extraction (although controversial), neodymium: YAG capsulotomy, tangential contrac-tion of an ERM and others. However, the pathogene-sis of spontaneous reopening is still controversial.

It has been reported that the astrocytes and myo-fibroblasts that lead to macular hole closure may be involved in the reopening of macular holes11, hypo-thesis that may occurred in this interesting case. In the case of the tangential contraction of ERM, the formation of intraretinal cysts and their later rupture, as well as fusion, seems to be the clinical evidences to support the hypotheses for the pathogenesis of spontaneous reopening and/or closure of this ma-cular hole.

Despite spontaneous closure/reopening of ma-cular holes have being already reported in the litera-ture, there are 2 distinct features of this case report: the relatively old age for the spontaneous closure; and, more relevant, the quick closure and reopening of the hole (both findings were observed in less than two months.). We postulate that, considering the absence of either surgery or inflammatory/vascular diseases during the follow-up, the tangential traction due to the progression of the epiretinal membrane associated to probable antero-posterior traction and the consequent formation of intraretinal cysts with later rupture and fusion, might have played a role in the reopening of the full thickness macular hole.

CONCLUSION

This is the third case report in peer-reviewed li-terature, which describes the reopening of a spon-taneously closed full thickness macular hole. The relatively advanced age of the patient, as well as the quick closure and reopening of the hole, are unique features of this case report.

1-Scassa C, Bruno M, Ripandelli G, Giusti C, Scarinci E, Cupo G. Spontaneous closure of bilateral full thickness macular holes without surgery: an eleven-year follow-up. Eur Rev Med Pharmacol Sci. 2011; 15:717-20.

2-Win PH, Young TA. Spontaneous macular hole closure in bilateral macular holes. Semin Ophthalmol. 2007; 22:167-9.

3.Michalewska Z, Cisiecki S, Sikorski B, Michalewski J, Kałuzny JJ, Wojtkowski M, Nawrocki J. Spontaneous closure of stage III and IV idiopathic full-thickness macular holes--a two case report. Graefes Arch Clin Exp Opthalmol. 2008; 246:99-104.

4-Schweitzer KD, García R. Spontaneous closure of a stage III idiopathic macular hole. Can J Ophthalmol. 2007; 42:127-8.

5-Milani P, Seidenari P, Carmassi L, Bottoni F. Spontaneous resolution of a full thickness idiopathic macular hole: fundus autofl uores-cence and OCT imaging.Graefes Arch Clin Exp Ophthalmol. 2007; 245:1229-31.

6-Punjabi OS, Flynn HW Jr, Legarreta JE, Gregori G, Knighton RW, Puliafi to CA. Documentation by spectral domain OCT of spontaneous closure of idiopathic macular holes. Ophthalmic Surg Lasers Imaging. 2007; 38:330-2.

7-Ishida M, Takeuchi S, Okisaka S. Optical coherence tomography images of idiopathic macular holes with spontaneous closure. Retina. 2004; 24:625-8.

8-García-Pous M, Udaondo-Mirete P, Amselem-Gómez L, Salom-Alonso D, Cervera-Taulet E, García-Delpech S, Díaz-Llopis M. Spontaneous resolution of idiopathic macular hole type IV: optical coherence tomography follow-up. Arch Soc Esp Oftalmol. 2006; 81:229-32.

9-Kokame GT, McCauley MB. Spontaneous reopening of a spontaneously closed macular hole. Am J Ophthalmol. 2002; 133:280-2.

10-Park YH, Kim SY, Lee YC. Macular hole formation, spontaneous closure, and reopening in severe hypertensive chorioretinopathy. Clin Experiment Ophthalmol. 2007; 35:586-8.

11-Funata M, Wendel RT, de la Cruz Z, Green WR. Clinicopathologic study of bilateral mac-ular holes treated with pars plana vitrectomy and gas tamponade. Retina 1992; 12:289-98.

REFERENCES

PAN-AMERICA : 63PAN-AMERICA

Advocacy

El médico sigue siendo líder en el cuidado de la sa-lud de los pacientes, especialmente en tres campos de acción. Ejerce su liderazgo en la jerarquía educacional, en el campo de la investigación y se esfuerza por mejo-rar la salud en el ambiente en que trabaja, en función de la responsabilidad social que tiene.

La educación médica fue estandarizada a comien-zos del siglo XX partiendo del modelo del reporte de Flexner. El currículo se ha enriquecido con los años. El estilo de educación ha variado en las escuelas. Los métodos de evaluación han mejorado. El caudal de co-nocimientos ha aumentado. En toda América llevamos a cabo actividades para la educación postgraduada de los profesionales. En Colombia se comienza a hablar de certificación y re-certificación. La revista Visión Pana-mericana tiene también su función educativa para los miembros de la PAAO. Por eso, esta asociación prepa-ra varios Cursos Regionales, Convenciones y Lo Mejor de la Academia en Español. Además, la nueva página web de la Asociación contendrá un caudal de materia-les educativos para beneficio de los oftalmólogos. Es menester educar tanto al público como a los gobiernos que el oftalmólogo es el médico que más sabe de enfer-medades oftálmicas y su tratamiento. De esta manera, la salud de nuestros pueblos se verá beneficiada y protegi-da en momentos que otros profesionales de la salud se quieran abrogar de nuestra profesión.

La investigación científica es fundamental para el progreso de la medicina, y la oftalmología no es la ex-cepción. Los foros para compartir esa información son de vital importancia. La revista Visión Panamericana publica estudios de todos los países iberoamericanos. Además, la PAAO otorga varios premios a jóvenes of-talmólogos que realizan sus investigaciones en los dife-rentes campos de la especialidad.

En tercera instancia, el liderazgo puede ser usado para poder defender el mejor cuidado de las enferme-dades de sus pacientes. Es necesario trabajar proactiva-mente en el diseño de las plataformas de los partidos, sugerir ideas a los legisladores y a nivel ejecutivo, en los países democráticos. Los mejores ejemplos de esta labor proactiva la he visto en Brasil.

También es importante hacer clínicas de salud fuera de la capital para ayudar en las áreas donde los servicios médicos no son accesibles y de tal forma ayudar a los gobiernos en la promoción de la salud. El mejor ejemplo de este servicio lo he visto en Argentina, donde los oftalmólogos se han unido para dar servicios de salud en las diferentes regiones de su extenso territorio.

Es menester describir el significado de las palabras cabildeo, advocacía y lobb-ying. La palabra cabildeo surge del cabildo. Entonces cabildear se usa para incluir la acción de ir al cabildo o intendencia para presentar las ideas al alcalde o intendente de una ciudad en las culturas hispánicas. Sin embargo, en el español antiguo encon-tramos la palabra advocacía, de raíces latinas, donde ad vocare, tiene el significado de recibir un llamado, una vocación que nos impulsa a la acción por una causa. De esta forma surge también en el castellano la palabra abogacía, con referencia a los profesionales que luchan e interceden por una causa en el campo de la justicia. Inte-resantemente, la palabra advocacía se usa en el portugués. Estos términos no son tra-ducciones directas de la palabra lobbying del inglés. Esta última palabra surge en los Estados Unidos, porque el presidente electo pernoctaba en un hotel lujoso de la ciudad de Washington, la noche previa a su juramentación. Entonces, aquellos potentados que querían influenciar la política pública del presidente, pagaban por hospedarse en el mismo hotel, para poder codearse con este líder en el lobby o recibidor de dicha estancia. Finalmente, opino, humildemente, que debemos rescatar el uso de la palabra advocacía, porque es más profunda en su llamado y más amplia en la acción.

En resumen: los médicos nos distinguimos por ser líderes en tres áreas: la educación, la investigación y el servicio. Si bien debemos tratar de lograr la ex-celencia en las tres áreas, cada oftalmólogo encontrará un área donde se sentirá más a gusto en su labor. Los exhorto a que reconozcan cuál es su área de mayor destreza y la desarrollen, por el bienestar de nuestros pacientes. Desarrollando su liderazgo podrán proteger mejor la salud ocular de sus pacientes. La PAAO está presta a ayudarle en las tres áreas.

Natalio J. Isquierdo,M.D.Chairman of the PAAO Professional Relations/Advocacy Committee

Email: [email protected]

Los tres renglones de la excelencia médica

REFERENCES1. Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, pp. 346.

2. Beck, Andrew H. (2004), The Flexner Report and the Standardization of Ameri-can Medical Education, JAMA: the Journal of the American Medical Association 291(17): 2139–2140.

3. Asbridge, M. 2004. Public place restrictions on smoking in Canada: assessing the role of the state, media, science and public health advocacy. Social science & Medicine 58(1):13-24.

4. Jerningan, D. H. and P. Wright. 1996. Media advocacy: lessons from community experiences. Journal of Public Health Policy 17(3): 306-330.

64 PAN-AMERICA

PAAO / Vis. Pan-Am. 2012;11(2):64

1. This award is selected by a jury, constituted by the members of the Editorial Board nominated by the Editor-in-Chief. Members selected must not present any conflict of interest nor have any participation in any study published in VPA in the current year.

§1. At the discretion of the Editor-in-Chief, other members from the Pan-American Association of Ophthalmology can be invited to compose the jury.

§2. In case of multiple authors, the prize will be awarded to the first author.

§3. The prize will be of an amount of US$1,000.00 (one thousand dollars) and a diploma of recognition.

2. The jury is sovereign in its decision and can attribute honorable mention to other papers.

5. The result will be announced in March 2013 and the prize will be presented at the upcoming PAAO meeting (the winner will be notified in advance)

6. The Editor-in-Chief can suspend the prize at any moment.

7. This regulation cannot be changed without advise of the Editorial Board.

8. Pending questions are to be resolved by the Editor-in-Chief and the Administrative Editorial Board.

2012 Pan-American Research Day

The Editor-in-Chief and the Administrative Editorial Board of Vision Pan-America, The Pan-American Journal of Ophthalmology, (VPA), the offi cial scientifi c journal of the Pan-American Association of Ophthalmology, in conjunction with the Pan-American Foundation of Ophthalmology and the Pan-American Association of Ophthalmology, are proud to announce the 2013 Editor’s Choice Award, created to recognize the best original

scientifi c paper published in our scientifi c journal during 2012.

2012 Vision Pan-America Editor’s Choice Award

The 2012 Pan-American Research Day (PARD) took place on Saturday, May 5, in Fort Lauderdale, one day before the annual ARVO meeting. The objective of this meeting is to provide a forum for Pan-American researchers in ophthalmology to present their papers. Over 100 speakers were chosen to present their ARVO-accepted abstracts at this year’s meeting. We thank Allergan International for their support of this meeting.

Two keynote lecturers were featured: Dr. Carol L. Karp, who presented Update in the Management of Ocular Surface Neoplasia and Dr. Timothy G. Murray, who presented Ocular Oncology Update 2012: Advan-ces in Retinoblastoma Management.

The Pan-American raffled five new memberships to lucky attendees. A total of 18 travel awards, sponsored by industry leaders and private foundations, were awar-ded this year. Of these awards, the Allergan Foundation presented a new award called the Arno Habicht Award for Research Sciences, in memory of Mr. Habicht, whose untimely passing last year saddened everyone.

Pan-American Research Day Awards

Arno Habicht Award for Research Sciences

* Luiz Queiroz Sampaio da Silveira, MD (Brazil)* Elaine de Paula Fiod Costa, MD (Brazil)* Hugo E. Sepúlveda Vázquez, MD (Mexico)

David and Juliana Pyott ARVO Travel Award

* Martín Alfonso Serrano Siso, MD (Venezuela)

Johnson & Johnson Research Travel Award

* Rogelio Ribes Escudero, MD (Argentina)* Roberto Damian Pacheco Pinto, MD (Brazil)* Heloisa Moraes do Nascimento, MD (Brazil)* Nicolas Crim, MD (Argentina)* Rodrigo Bolaños Jiménez, MD (Mexico)

Santen ARVO Travel Award

* Fabiana da Fonte Gonçalves, MD (Brazil)* Paula Juliana Taich, MSc (Argentina)

Allergan Latin American Research Incentive in Glaucoma

* Daniela Díaz Robles, MD (Mexico) – 1st prize* Daniel Colicchio, MD (Brazil) – 2nd pize* Alexandre Soares Castro Reis MD – 3rd prize* Tiago dos Santos Prata (Brazil) – 4th prize

Tyson Research Initiative/RRF/PAOF – Developing Country Eye Researcher Fellowship

* Vania Dania Castro Tamanaja (Peru) * Rachael S. Allen (USA)* Mandy Hong (Canada)

The Pan-American would like to thank ARVO and all of our partners who make this event such a success.

Foto 1. Left to right: Ana Luisa Hofling, PAAO President-Elect, Dra. Heloisa Moraes do Nascimento, Dr.

Mark J. Mannis, PAAO Presdient

Foto 2. Left to Right: Dr. Paulo Dantas (Brazil), Dr. Luis Izquierdo Jr.

(Peru), Dr. Jorge Valdez (Mexico), Dr. Peter Quiroz (USA), Dr. Mark Mannis (USA), Dr. Carol Karp (USA) Dr. Ana

Luisa Hofling (Brazil), Dr. Mauricio Maia (Brazil), Dr. Cristian Luco (Chi-

le), Dr. Lihteh Wu (Costa Rica)

Foto 3. Dr. Paulo E.C. Dantas, PARD Meeting Coordinator.

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Documents

PAAO XI 2 - 2012