Versão impressa
REVISTA BRASILEIRA DE OFTALMOLOGIA
vol. 73 - nº 5 - Setembro/Outubro 2014
SET/OUT 2014
VOLUME 73 NÚMERO 5 P. 253-316
100
95
75
25
RBO
5
0
DESDE 1942
CAPA REVISTA-JUL-AGO-2014
quinta-feira, 13 de novembro de 2014 11:34:53
253
ISSN 0034-7280
Revista
Brasileira de
(Versão impressa)
ISSN 1982-8551
(Versão eletrônica)
Oftalmologia
PUBLICAÇÃO OFICIAL:
SOCIEDADE BRASILEIRA DE OFTALMOLOGIA
SOCIEDADE BRASILEIRA DE CATARATA E IMPLANTES INTRAOCULARES
SOCIEDADE BRASILEIRA DE CIRURGIA REFRATIVA
Sociedade Brasileira
de Oftalmologia
Indexada nas bases de dados:
LILACS
Literatura Latinoamericana
em Ciências da Saúde
SciELO
Scientific Electronic
Library OnLine
WEB OF SCIENCE
www.freemedicaljournals.com
Disponível eletronicamente:
www.sboportal.org.br
Publicação bimestral
Editor Chefe
Newton Kara-Junior (SP)
Editor Executivo
Arlindo José Freire Portes (RJ)
Co-editores
André Luiz Land Curi (RJ)
Arlindo José Freire Portes (RJ)
Bruno Machado Fontes (RJ)
Carlos Eduardo Leite Arieta (SP)
Hamilton Moreira (PR)
Liana Maria Vieira de Oliveira Ventura (PE)
Marcony Rodrigues de Santhiago (RJ)
Mario Martins dos Santos Motta (RJ)
Maurício Maia (SP)
Niro Kasahara (SP)
Renato Ambrósio Jr. (RJ)
Rodrigo Jorge (SP)
Rodrigo Pessoa Cavalcanti Lira (PE)
Silvana Artioli Schellini (SP)
Walton Nosé (SP)
Corpo Editorial Internacional
Baruch D. Kuppermann - Califórnia - EUA
Christopher Rapuano - Phyladelphia - EUA
Curt Hartleben Martkin - Colina Roma - México
Daniel Grigera - Olivos - Argentina
Deepinder Kauer Dhaliwal - Pittsburg - EUA
Felipe A. A. Medeiros - Califórnia - EUA
Felix Gil Carrasco - México – México
Fernando Arevalo - Riyadh - Arábia Saudita
Francisco Rodríguez Alvira – Bogotá - Colombia
Howard Fine - Eugene - EUA
Jean Jacques De Laey - Ghent - Bélgica
Kevin M. Miller - Califórnia - EUA
Lawrence P. Chong - Califórnia - EUA
Lihteh Wu – San José - Costa Rica
Liliana Werner - Utah - EUA
Miguel Burnier Jr. - Montreal - Canadá
Pablo Cibils - Assunção - Paraguai
Patricia Mitiko Santello Akaishi – Arábia Saudita
Peter Laibson - Phyladelphia - EUA
Steve Arshinoff - Toronto - Canadá
Corpo Editorial Nacional
A. Duarte - Rio de Janeiro - RJ
Abelardo de Souza Couto - Rio de Janeiro- RJ
Abrahão da Rocha Lucena - Fortaleza - CE
Alexandre Augusto Cabral de Mello Ventura - Recife - PE
Alexandre H. Principe de Oliveira – Salvador – BA
Alexandre Seminoti Marcon – Porto Alegre - RS
Ana Carolina Cabreira Vieira – Rio de Janeiro – RJ
Ana Luisa Hofling de Lima - São Paulo - SP
André Correa de Oliveira Romano – Americana - SP
André Curi - Rio de Janeiro - RJ
André Luis Freire Portes - Rio de Janeiro - RJ
André Marcio Vieira Messias – Ribeirão Preto – SP
Andrea Kara José Senra - São Paulo – SP
Antonio Marcelo Barbante Casella - Londrina - PR
Armando Stefano Crema- Rio de Janeiro- RJ
Beatriz de Abreu Fiuza Gomes – Rio de Janeiro - RJ
Bruna Vieira Ventura - Recife - PE
Coordenação de
Aperfeiçoamento de
Pessoal
de Nível Superior
http://www.capes.gov.br
Rev Bras Oftalmol, v. 73, n. 5, p. 253 - 316, Set./Out. 2014
Bruno Diniz – Goiânia - GO
Carlos Augusto Moreira Jr.- Curitiba- PR
Carlos Gabriel Figueiredo - São José do Rio Preto - SP
Carlos Ramos de Souza Dias- São Paulo- SP
Claudio do Carmo Chaves - Manaus - AM
Cristiano Caixeta Umbelino - São Paulo - SP
Daniel Lavinsky – Porto Alegre - RS
David Leonardo Cruvinel Isaac – Goiania - GO
Diego Tebaldi Q. Barbosa - São Paulo - SP
Edmundo Frota De Almeida Sobrinho- Belém- PA
Eduardo Buchele Rodrigues – Florianópolis - SC
Eduardo Cunha de Souza – São Paulo - SP
Eduardo Damasceno - Rio de Janeiro - RJ
Eduardo Dib – Rio de Janeiro - RJ
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Eliezer Benchimol - Rio de Janeiro - RJ
Enzo Augusto Medeiros Fulco – Jundiaí - SP
Eugenio Santana de Figueiredo – Juazeiro do Norte - CE
Fábio Marquez Vaz – Ondina – BA
Felipe Almeida - Ribeirão Preto - SP
Fernando Cançado Trindade - Belo Horizonte- MG
Fernando Marcondes Penha - Florianópolis - SC
Fernando Oréfice- Belo Horizonte- MG
Fernando Roberte Zanetti – Vitória - ES
Flavio Rezende- Rio de Janeiro- RJ
Francisco de Assis Cordeiro Barbosa - Recife - PE
Frederico Valadares de Souza Pena – Rio de Janeiro - RJ
Frederico Guerra - Niterói - RJ
Giovanni N.U.I.Colombini- Rio de Janeiro- RJ
Guilherme Herzog Neto- Rio de Janeiro- RJ
Harley Biccas - Ribeirão Preto - SP
Haroldo Vieira de Moraes Jr.- Rio de Janeiro- RJ
Hélcio Bessa - Rio de Janeiro - RJ
Helena Parente Solari - Niterói - RJ
Heloisa Helena Abil Russ – Curitiba – PR
Henderson Celestino de Almeida- Belo Horizonte- MG
Hilton Arcoverde G. de Medeiros- Brasilia- DF
Homero Gusmao de Almeida- Belo Horizonte- MG
Italo Mundialino Marcon- Porto Alegre- RS
Iuuki Takasaka – Santa Isabel - SP
Ivan Maynart Tavares - São Paulo - SP
Jaco Lavinsky - Porto Alegre - RS
Jair Giampani Junior – Cuiabá - MT
Jeffersons Augusto Santana Ribeiro - Ribeirão Preto - SP
João Borges Fortes Filho- Porto Alegre- RS
João Luiz Lobo Ferreira – Florianópolis – SC
João Marcelo de Almeida G. Lyra - Maceió - AL
João Orlando Ribeiro Goncalves- Teresina- PI
Jorge Carlos Pessoa Rocha – Salvador – BA
JorgeAlberto de Oliveira - Rio de Janeiro - RJ
José Augusto Cardillo – Araraquara – SP
José Beniz Neto - Goiania - GO
José Ricardo Carvalho L. Rehder- São Paulo- SP
Laurentino Biccas Neto- Vitória- ES
Leonardo Akaishi - Brasília - DF
Leonardo Provetti Cunha - SP
Leticia Paccola - Ribeirão Preto - SP
Liana Maria V. de O. Ventura- Recife- PE
Luiz Alberto Molina - Rio de Janeiro - RJ
Manuel Augusto Pereira Vilela- Porto Alegre- RS
Marcelo Hatanaka – São Paulo – SP
Marcelo Netto - São Paulo - SP
Marcelo Palis Ventura- Niterói- RJ
Marcio Bittar Nehemy - Belo Horizonte - MG
Marco Antonio Bonini Filho - Campo Grande - MS
Marco Antonio Guarino Tanure - Belo Horizonte - MG
Marco Antonio Rey de Faria- Natal- RN
Marcos Pereira de Ávila - Goiania - GO
Maria de Lourdes Veronese Rodrigues- Ribeirão Preto- SP
Maria Rosa Bet de Moraes Silva- Botucatu- SP
Maria Vitória Moura Brasil - Rio de Janeiro - RJ
Mário Genilhu Bomfim Pereira - Rio de Janeiro - RJ
Mario Luiz Ribeiro Monteiro - São Paulo- SP
Mário Martins dos Santos Motta- Rio de Janeiro- RJ
Marlon Moraes Ibrahim – Franca - SP
Mauricio Abujamra Nascimento – Campinas - SP
Maurício Bastos Pereira - Rio de Janeiro - RJ
Maurício Dela Paolera - São Paulo - SP
Miguel Ângelo Padilha Velasco- Rio de Janeiro- RJ
Miguel Hage Amaro - Belém - PA
Milton Ruiz Alves- São Paulo- SP
Moyses Eduardo Zadjdenweber - Rio de Janeiro - RJ
Nassim da Silveira Calixto- Belo Horizonte- MG
Nelson Alexandre Sabrosa - Rio de Janeiro – RJ
Newton Kara-José - São Paulo - SP
Newton Leitão de Andrade – Fortaleza – CE
Núbia Vanessa dos Anjos Lima Henrique de Faria - Brasília-DF
Octaviano Magalhães Júnior - Atibaia - SP
Oswaldo Moura Brasil- Rio de Janeiro- RJ
Otacílio de Oliveira Maia Júnior – Salvador - BA
Patrick Frensel de Moraes Tzelikis – Brasília – DF
Paulo Augusto de Arruda Mello Filho – São Paulo – SP
Paulo Augusto de Arruda Mello- São Paulo- SP
Paulo Schor - São Paulo - SP
Pedro Carlos Carricondo – São Paulo – SP
Pedro Duraes Serracarbassa – São Paulo – SP
Priscilla de Almeida Jorge – Recife – PE
Rafael Ernane Almeida Andrade - Itabuna – BA
Raul N. G. Vianna - Niterói - RJ
Remo Susanna Jr.- São Paulo- SP
Renata Rezende - Rio de Janeiro - RJ
Renato Ambrosio Jr.- Rio de Janeiro- RJ
Renato Luiz Nahoum Curi- Niterói- RJ
Richard Yudi Hida – São Paulo – SP
Riuitiro Yamane - Niterói - RJ
Roberto Lorens Marback - Salvador - BA
Roberto Pinto Coelho – Ribeirão Preto – SP
Rodrigo França de Espíndola – São Paulo – SP
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Rubens Belfort Neto – São Paulo – SP
Rubens Camargo Siqueira- São José do Rio Preto- SP
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Walton Nose- São Paulo- SP
Wener Passarinho Cella - Plano Piloto - DF
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Revista Brasileira de Oftalmologia, ISSN 0034-7280, é uma publicação bimestral da Sociedade Brasileira de Oftalmologia
Diretoria da SBO 2013-2014
Presidente
Marcus Vinicius Abbud Safady (RJ)
Vice-presidentes
Elisabeto Ribeiro Goncalves (MG)
Fabíola Mansur de Carvalho (BA)
João Alberto Holanda de Freitas (SP)
Ricardo Lima de Almeida Neves (RJ)
Tania Mara Cunha Schaefer (PR)
Secretário Geral
André Luis Freire Portes (RJ)
1º Secretário
Sérgio Henrique S. Meirelles (RJ)
2º Secretário
Giovanni N. U. I. Colombini (RJ)
Tesoureiro
Gilberto dos Passos (RJ)
Diretor de Cursos
Arlindo José Freire Portes (RJ)
Diretor de Publicações
Newton Kara-Junior (SP)
Diretor de Biblioteca
Armando Stefano Crema (RJ)
Conselho Consultivo
Membros eleitos
Jacó Lavinsky (RS)
Paulo Augusto de Arruda Mello (SP)
Roberto Lorens Marback (BA)
Conselho Fiscal
Efetivos
Francisco Eduardo Lopes Lima (GO)
Leiria de Andrade Neto (CE)
Roberto Pedrosa Galvão (PE)
Suplentes
Eduardo Henrique Morizot Leite (RJ)
Jorge Alberto Soares de Oliveira (RJ)
Mizael Augusto Pinto (RJ)
SOCIEDADES FILIADAS À SOCIEDADE BRASILEIRA DE OFTALMOLOGIA
Associação Brasileira de Banco de Olhos e Transplante de
Córnea
Presidente: Ari de Souza Pena
Associação Maranhense de Oftalmologia
Presidente: Romero Henrique Carvalho Bertand
Associação Matogrossense de Oftalmologia
Presidente: Maurício Donatti
Associação Pan-Americana de Banco de Olhos
Presidente: Luciene Barbosa de Souza
Associação Paranaense de Oftalmologia
Presidente: Otavio Bisneto
Associação Rondoniense de Oftalmologia
Presidente: Lhano Fernandes Adorno
Associação Sul Matogrossense de Oftalmologia
Presidente: Elson Yamasato
Sociedade Alagoana de Oftalmologia
Presidente: Mário Jorge Santos
Sociedade Brasileira de Administração em Oftalmologia
Presidente: Flávio Rezende
Sociedade Brasileira de Catarata e Implantes Intraoculares
Presidente: Armando Crema
Sociedade Brasileira de Cirurgia Plástica Ocular
Presidente: Ricardo Morschbacher
Sociedade Brasileira de Cirurgia Refrativa
Presidente: Renato Ambrósio Jr.
Sociedade Brasileira de Ecografia em Oftalmologia
Presidente: Norma Allerman
Sociedade Brasileira Glaucoma
Presidente: Francisco Lima
Sociedade Capixaba de Oftalmologia
Presidente: Cesar Ronaldo Vieira Gomes
Sociedade Catarinense de Oftalmologia
Presidente: Ramon Coral Ghanem
Sociedade Cearense de Oftalmologia
Presidente: Dácio Carvalho Costa
Sociedade Goiana de Oftalmologia
Presidente: Lúcia Helena Meluzzi
Sociedade Norte-Nordeste de Oftalmologia
Presidente: Francisco de Assis Cordeiro Barbosa
Sociedade de Oftalmologia do Amazonas
Presidente: Leila Suely Gouvea José
Sociedade de Oftalmologia da Bahia
Presidente: André Hasler Príncipe de Oliveira
Sociedade de Oftalmologia do Nordeste Mineiro
Presidente: Mauro César Gobira Guimarães
Sociedade de Oftalmologia de Pernambuco
Presidente: João Pessoa de Souza Filho
Sociedade de Oftalmologia do Rio Grande do Norte
Presidente: Ricardo Maia Diniz
Sociedade de Oftalmologia do Rio Grande do Sul
Presidente: Afonso Reichel Pereira
Sociedade de Oftalmologia do Sul de Minas
Presidente: Mansur Elias Ticly Junior
Sociedade Paraense de Oftalmologia
Presidente: Lauro José Barata de Lima
Sociedade Paraibana de Oftalmologia
Presidente: Saulo Zanone Lemos Neiva
Sociedade Piauiense de Oftalmologia
Maria de Lourdes Cristina Alcântara Paz Carvalho do Nascimento
Sociedade Sergipana de Oftalmologia
Presidente: Bruno Campelo
255
Revista
Brasileira de
ISSN 0034-7280
(Versão impressa)
ISSN 1982-8551
(Versão eletrônica)
Oftalmologia
PUBLICAÇÃO OFICIAL:
SOCIEDADE BRASILEIRA DE OFTALMOLOGIA
SOCIEDADE BRASILEIRA DE CATARATA E IMPLANTES INTRAOCULARES
SOCIEDADE BRASILEIRA DE CIRURGIA REFRATIVA
Fundada em 01 de junho de 1942
CODEN: RBOFA9
Indexada nas bases de dados:
SciELO
Scientific Electronic
Library OnLine
WEB OF SCIENCE
www.freemedicaljournals.com
Disponível eletronicamente:
www.sboportal.org.br
LILACS
Literatura Latinoamericana
em Ciências da Saúde
Coordenação
de Aperfeiçoamento de
Pessoal
de Nível Superior
http://www.capes.gov.br
Publicação bimestral
Rev Bras Oftalmol, v. 73, n. 5, p. 253 - 316, Set./Out. 2014
Contents - Sumário
Editorial
257
Structure, style and writing of a scientific paper: the way in which researchers
acknowledge their peers
Estrutura, estilo e escrita de artigo científico: a maneira com que pesquisadores reconhecem
seus pares
Newton Kara-Junior
260
Social aspects of corneal transplantation in Brazil: contrast between advances in
surgical technique and limiting access to the population
Aspectos sociais do transplante de córnea no Brasil: contraste entre avanços na técnica
cirúrgica e limitação de acesso à população
Hirlana Gomes Almeida, Richard Yudi Hida
Artigos originais
262
The role of Descemet’s membrane in the pathogeny of corneal edema following
anterior segment surgery
O papel da membrana de Descemet na patogenia do edema corneano após cirurgia de
segmento anterior
Karine Feitosa Ximenes, Jailton Vieira Silva, Karla Feitosa Ximenes Vasconcelos, Fernando Queiroz Monte
269
Preemptive analgesia of nepafenac 0.1% in retinal photocoagulation
Analgesia preemptiva com nepafenaco 0,1% na fotocoagulação da retina
Emerson Fernandes de Sousa e Castro, Erika Araki Okuda, Vinícius Balbi Amatto, Hirlana Gomes Almeida,
Marina Gracia, Newton Kara-Junior
256
273
Analysis quantitative and qualitative of the tear film in patients undergoing PRK
and LASIK with femtosecond
Análise quantitativa e qualitativa do filme lacrimal nos pacientes submetidos a PRK e
LASIK com femtossegundo
Rubens Amorim Leite, Ricardo Menon Nosé , Fábio Bernardi Daga, Tatiana Adarli Fioravanti Lui, Giovana
Arlene Fioravanti Lui, Adamo Lui-Netto
279
Novel spatula and dissector for safer deep anterior lamellar keratoplasty
Uso de espátula e dissector para otimização da ceratoplastia lamelar anterior profunda
(DALK)
Gustavo Bonfadini, Eun Chul Kim, Mauro Campos, Albert S. Jun
282
Serological profile of candidates for corneal donation
Perfil sorológico de candidatos a doação de córneas
Adroaldo Lunardelli, Richard Beraldini Alvarenga, Maria Luiza Assmann, Dário Eduardo de Lima Brum,
Mirna Adolfina Barison
287
Sealing the gap between conjunctiva and Tenon’s capsule in primary pterygium
surgery
Adição do selamento entre conjuntiva e cápsula de Tenon em cirurgia de pterígio primário
Ricardo Alexandre Stock, Luan Felipe Lückmann, Gabriel Alexander Ken-Itchi Kondo, Elcio Luiz Bonamigo
291
Visual impairment, rehabilitation and International Classification of Functioning,
Disability and Health
Deficiência visual, reabilitação e Classificação Internacional de Funcionalidade,
Incapacidade e Saúde
Marissa Romano da Silva, Maria Inês Rubo de Souza Nobre, Keila Monteiro de Carvalho, Rita de Cássia Ietto
Montilha
302
Knowledge about primary open angle glaucoma among medical students
Nível de conhecimento sobre glaucoma primário de ângulo aberto entre os estudantes de
medicina
Saulo Costa Martins, Marcos Henrique Mendes, Ricardo Augusto Paletta Guedes, Vanessa Maria Paletta
Guedes, Alfredo Chaoubah
Relato de Casos
308
Central retinal artery occlusion associated with patent foramen ovale
Oclusão de artéria central da retina associada a forame oval patente
Patrícia Regina de Pinho Tavares, Mariana Rezende de Oliveira, Eduardo de Castro Miranda
Diniz , Rafael Mourão Agostini , Daniela Vieira de Aguiar
311
Adult dacryocystocele
Dacriocistocele no adulto
Silvia Helena Tavares Lorena , João Amaro Ferrari Silva
Instruções aos autores
314
Normas para publicação de artigos na RBO
EDITORIAL
257
Structure, style and writing of a scientific paper:
the way in which researchers acknowledge
their peers
Estrutura, estilo e escrita de artigo científico:
a maneira com que pesquisadores
reconhecem seus pares
T
he style of a scientific paper indicates to reviewers and readers whether the authors are familiar with the science. In
this respect, systematically reading scientific publications is excellent training for beginning researchers.
Scientific publications are documents that need to contain sufficient information for readers to understand the authors’
observations and decide whether the conclusions are justified by the data, as well as giving them the ability to repeat the
experiment.
All clinical research starts with a “doubt”, a question that cannot be answered based on the current knowledge found
in the literature. Starting from this question, the research paper is structured as follows:
1.
2.
3.
4.
Introduction – What question has been asked?
Methods – How was it studied?
Results – What has been found?
Discussion – What do these findings mean?
The Introduction should be short (three or four paragraphs) and should clearly convey the question that the authors
will try to answer with the study. For the reader to understand the relevance of the authors’ question, the paper should start
with a brief literature review to provide the context and justify the study, showing that it is needed to fill the current gaps in
knowledge. In case the subject matter has already been approached in previous publications, the new study can be justified
by showing that it can be better than the previous ones (highlighting methodological flaws, limitations in sample size, etc.).
It should be noted that publishers do not want to publish, authors do not want to cite, and readers do not want to read studies
that simply repeat what has already been done several times before.
Thus, in the Introduction, the brief literature review should start from what is already known about the subject in order
to justify the study’s objectives. Ideally, the description of existing knowledge should progressively centre on the gap that
the study intends to fill. For example, if the research question is related to the existence of emotional factors that could
influence cataract patients in their decision to undergo surgery, the Introduction should start by citing the importance of
vision and the fear of becoming blind, followed by an explanation of the social problem of cataract blindness, and the visual
benefits and risks of corrective surgery. Finally, it could point out the fact that persons with low vision may avoid cataract
surgery due to emotional reasons (fear of becoming blind due to surgical complications), thus stressing the study’s importance
as a way to identify such situations and to inform awareness campaigns (1).
All information included in the Introduction should be backed by previous studies, and references should always be
provided. Authors should avoid writing about what readers are already likely to know; instead, priority should be given to
explaining what readers do not know. This requires knowing the target audience and having an idea of the type of journal the
paper will be submitted to. Thus, in the previous example (1), if the readers are physicians, there is no need to explain what
cataract is. Finally, the Introduction should describe the study design and clearly state the study’s objective (e.g. “a prospective,
randomised, double-blind study to determine the efficacy and safety of…”). When planning a study, it can be interesting to
write the Introduction before starting data collection, so that researchers remain focused on their original goals.
The Methods section describes how the data were collected and how the study was conducted. The more the methods
are described in a detailed and objective manner, the greater the confidence of reviewers and readers on the study results.
If the methods used to answer the research question are unsound, the study results and conclusions will be limited.
If the research involves a new procedure or test, it should be described in detail so that the study can be reproduced in
the future. Standard measurement methods described in previous publications, unless considered unsound, should be used
Rev Bras Oftalmol. 2014; 73 (5): 257-9
258
Kara-Junior N
again (and the source should be mentioned) to facilitate data comparison among different papers. For example, if the study
that inspired the authors to research the visual performance of a different intraocular lens model used a certain wavefront
sensor, a measurement chart, and a visual satisfaction questionnaire, the new study should ideally use the same assessment
methods. This helps minimise the influence of other variables in the comparison of results across studies (2,3).
The Methods section should start by presenting the study design, describing the type of study, its randomisation and
blinding. The place and date where the study was conducted should also be mentioned. An explanation of how the study was
conducted should then follow: sample selection, inclusion criteria, approval by a research ethics committee, a precise
description of materials and drug dosages, a description of the treatment, and a presentation of study variables. Finally, the
statistical analysis of data should be described. Thus, while the Introduction explains “what” has been studied and “why”, the
Methods section describes “how”, “when” and “where” the study was conducted.
Authors should never believe that their methods are immune to criticism, as no study is flawless; instead, they are
expected to avoid gross errors and to highlight the study’s limitations, so that readers can judge the validity of the results
based on their own reality and needs. Ideally, the reader should first have their interest aroused by the topic presented in the
Title (in response to the research question presented by the authors) and then read the Introduction in order to understand
the study’s context and relevance. Next, the Methods section should be read carefully to make sure that the sample was
collected and the study was conducted in a way that meets the reader’s reality and requirements. For example, a study
assessing the population’s knowledge about cataract surgery in a developing country will probably not influence clinical
practice in developed countries (4).
A critical analysis of papers through careful assessment of the methodology allows readers to identify biases
(methodological errors) that might invalidate or limit the results. Readers should not simply trust that every article published
in a scientific journal is methodologically correct, even if the journal has a high impact factor (5).
The Results section should present the data obtained in the study. It should not contain the authors’ interpretations or
opinions. Tables should be used to group important data, and statistical analysis should be done to validate comparisons.
The Results section should start by characterising the population represented by the sample and, if there is more than one
study group, by determining whether they are homogeneous. Homogeneous groups indicate that the randomisation method
was adequate, because if all study subjects have the same chance of being in either group, then characteristics such as gender
and age should be equivalent, on average.This kind of information can be grouped into a table and will help assure readers that
personal characteristics did not influence the study results. For example, in the case of a study assessing the effectiveness of two
capsulorhexis techniques in intumescent cataract (6), the study sample represents the population of patients suffering from this
type of cataract, so the results are only valid for this type of patient. As regards study groups (supposing each group was
operated with a different capsulorhexis technique), if randomisation has been performed correctly, i.e., if all participants had
the same chance of being randomly assigned to either group, then personal characteristics (sex, age, axial length, etc.) should
be similar, thus indicating that individual variations probably did not influence the results.
In a study, data are represented by numbers and the results represent the meaning of those numbers; thus, results
should be described in writing, while data should be presented in tables. Paragraphs should start by describing the results
and then refer the reader to a table, indicating what can be found in it. Tables should always be self-sufficient, presenting all
the information the reader needs to understand them without the need to read the rest of the article. Whenever possible,
results should be accompanied by statistical analysis, which provides credibility to comparisons (7).
Qualitative, subjective terms such as “very”, “large”, “only”, and so on should be avoided; instead, the text should
focus on quantitative information, such as absolute numbers and percentages. It is important to cite all the data related to the
study variables and described in the Methods section, i.e. all study items listed in the Methods should appear in the Results
and be mentioned in the Discussion.
In the Discussion section, research findings should be correlated with data from the literature and their significance
should be interpreted. The Discussion should only quote relevant studies (confirming or contradicting the present study); it
is not necessary to analyse the entire literature. Data already presented in the Results should not be repeated in the
Discussion. All the findings presented in the Results should be commented in the Discussion, and only the main numbers or
percentages should be mentioned.
The Discussion should begin with a summary of the main findings, discussing possible methodological flaws. Findings
should then be compared to those of previous studies, and their clinical implications should be discussed. This is where the
strengths of the study should be emphasised, and previous studies can perhaps be criticised. In the Discussion, authors should
express their opinions.
Even if the authors believe their study will change clinical practice, its importance should not be exaggerated,
because studies in general only provide a limited contribution to any subject matter, and a subject can hardly be exhausted
in a single work. The Discussion should end with a short summary of the main findings and their implications (conclusion).
It is interesting to conclude with suggestions for future studies.
Rev Bras Oftalmol. 2014; 73 (5): 257-9
Structure, style and writing of a scientific paper: the way in which researchers acknowledge their peers
259
Scientific writing is different from spoken scientific language. It should avoid jargon and superlatives, and words
should be carefully chosen. The greatest desire of any author is to have their work read and cited by as many people as
possible. Thus, the text should be pleasant to read and easy to interpret, otherwise readers can easily lose interest in the
paper. In scientific writing, sentences should be simple and straightforward, stating what the reader needs to know in the
shortest possible way. All abbreviations should be explained at the beginning of each section (Introduction, Methods, Tables,
etc.), because readers will not necessarily read the article in the order it is presented.
In the Methods section, drugs should always be referred to by their active principle, and where trade names are used,
the laboratory’s name and the place of origin should always be mentioned.
In the Results section, numbers should, whenever possible, be followed by a percentage, thus helping readers understand
the scale of the data. In tables, calculations should be double checked, with special attention to percentages, because
depending on the approximation of decimals, they may not add up to 100%. Authors should check that all tables are
mentioned in the text, that the same terms are used in the table and the text, and that the header is self-sufficient.
Once the paper is finished, it should be read by physicians not involved in the study before being submitted for
publication; alternatively, authors should save the article for a few days and then read it again. Some authors are so
familiar with the subject matter that they may write in a way that is not clear enough for readers.
Newton Kara-Junior
Editor-Chefe da Revista Brasileira de Oftalmologia
Professor Colaborador, livre-docente e professor do Programa de Pós-graduação
da Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
R EFERENCES
1.
Marback, R.F.;TEMPORINI, E. R. ; Kara-Junior, N. . Emotional factors prior to cataract surgery. Clinics (USP. Paper version), v. 62, p. 433438, 2007.
2.
HIDA, W. T. ; MOTTA, A. P. ; et al. Estudo comparativo do desempenho visual e análise de frente de onda entre as lentes intra-oculares
multifocais difrativas Tecnis ZM900 e Acrysof Restor SN60D3. Arquivos Brasileiros de Oftalmologia (Paper version), v. 71, p. 788-792,
2008.
3.
Santhiago M ; NETTO MV ; BARRETO jr J ; et al. A contralateral eye study comparing apodized difrative and full difrative lenses:
wavefront analysis and distance and near uncorrected visual acuity. Clinics (USP. Paper version), v. 64, p. 953-60, 2009.
4.
Kara-Junior, N. ; HOLZCHUH, N. ; KARA-JOSE, N. . Popular beliefs regarding the treatment of senile cataract. Revista de Saúde Pública,
v. 36, n.3, p. 343-349, 2002.
5.
CHAMON, Wallace. Plágio e condutas inadequadas em pesquisa: onde chegamos e o que podemos fazer. Arq. Bras. Oftalmol. [online].
2013, vol.76, n.6, pp. V-VI. ISSN 0004-2749.
6.
Kara-Junior, N. ; Santhiago M ; Kawakami A ; Carricondo, P., C. ; HIDA, W. T. . Mini-rhexis for white intumescent cataracts. Clinics (USP.
Paper version), v. 64, p. 309-312, 2009.
7.
LOPES, Bernardo et al. Biostatistics: fundamental concepts and practical applications. Rev. bras.oftalmol. [online]. 2014, vol.73, n.1, pp. 1622. ISSN 0034-7280.
Rev Bras Oftalmol. 2014; 73 (5): 257-9
260
EDITORIAL
Social aspects of corneal transplantation in Brazil:
contrast between advances in surgical technique
and limiting access to the population
Aspectos sociais do transplante de córnea no Brasil:
contraste entre avanços na técnica cirúrgica e
limitação de acesso à população
T
he constant search for knowledge drives technological advances and exponentially increases the number of diagnostic
and therapeutic alternatives in ophthalmology. Not infrequently, procedures that in the recent past used to be
considered the gold standard are now proscribed.
The development of less invasive and more effective surgical techniques increases the demand for transplants.
Keratoplasty is currently a safer, more effective and successful procedure than the techniques and procedures used in the
recent past, and it can be used to treat diseases once considered inoperable(1,2). Because of this, an increasing number of
patients are now able to overcome obstacles such as fear and insecurity and undergo the procedure(3,4).
It is known that in many cases, traditional penetrating keratoplasty can be replaced by anterior or posterior
lamellar keratoplasty, in which only the damaged layers of the cornea are removed and replaced, while the healthy
ones remain intact.
Anterior lamellar keratoplasty is indicated for corneal opacities of the anterior or middle stroma, and it can be
superficial (at the level of the stroma-stroma interface, referred to as superficial anterior lamellar keratoplasty [SALK]) or
deep (at the stroma-Descemet membrane interface, referred to as deep anterior lamellar keratoplasty [DALK]). It is
indicated in diseases such as keratoconus, pellucid marginal degeneration, stromal dystrophies, and ectasia after refractive
surgery with healthy posterior layers(5,6,7). Even though the technique has a longer learning curve, it offers significant
advantages, since it does not penetrate the anterior chamber and preserves the host endothelium, thus significantly reducing
the risk of endothelial rejection(5,6,7).
Posterior lamellar keratoplasty can be used to replace the damaged endothelium without the need for large incisions
or corneal sutures; it can be performed by posterior lamellar keratoplasty (PLK), deep lamellar endothelial keratoplasty
(DLEK), Descemet’s stripping endothelial keratoplasty (DSEK), Descemet’s stripping automated endothelial keratoplasty
(DSAEK), Descemet’s membrane endothelial keratoplasty (DMEK), and Descemet’s membrane automated endothelial
keratoplasty (DMAEK). It is indicated in cases of Fuchs endothelial dystrophy, pseudophakic bullous keratopathy, and
endothelial failure after penetrating keratoplasty with healthy anterior layers(5,6,7). The main advantages of the procedure
are minimal changes in corneal topography compared to the baseline, stable refraction, a healthy endothelium, and an eye
globe less susceptible to trauma(5,6,7).
Improvements in surgical techniques, however, also depend on advances in the instruments and materials available in
the market, which are designed to produce less trauma and reduce the incidence of peri- and postoperative complications.
Using a microkeratome or excimer laser, cuts of different thicknesses and diameters can be performed both on the host and
the donor buttons(7). More recently, however, femtosecond laser, which has a greater wave length than excimer laser, has
been widely used for resection of corneal tissue as well as to create the corneal flap with a shape determined by the
surgeon(7). Furthermore, viscoelastic substances developed to maintain spaces (cohesive) or to protect intraocular tissues
(dispersive) during surgery can now perform both functions at once(8). There have also been significant improvements in
tissue processing and storage, for example by using artificial anterior chambers which allow preparation of the cornealscleral button in the same manner as with the entire eye globe(7). These advances in surgical instruments and preservation
methods of the corneal button increase the quality of transplanted tissue and therefore lead to better surgical outcomes to
patients and their families.
Rev Bras Oftalmol. 2014; 73 (5): 260-1
Social aspects of corneal transplantation in Brazil: contrast between advances in surgical technique and limiting access to the population
261
However, it should be noted that many patients with indications for corneal transplantation do not enter the transplant
waiting list and give up on visual rehabilitation. This occurs because part of the population, in particular low-income
patients, even when instructed by physicians to undergo transplantation, do not receive appropriate guidance, do not
understand such guidance, or cannot afford treatment costs(9).
This suggests that having access to ophthalmic care and receiving an indication for corneal transplantation does not
imply that patients will actually undergo definitive treatment. Therefore, improved communication is needed between the
secondary and tertiary levels of care to ensure effective registration of patients in waiting lists and adequate access to
corneal transplantation(9).
A good example of a pioneer, effective and well-organised programme, supported by the Department of Health and
the State Government, is the São Paulo State transplant programme, where the waiting list is cleared and surplus corneas
are sent to other states of the Brazilian federation, helping reduce their waiting lists(10).
In conclusion, there are currently less invasive surgical techniques that increase the benefits of transplantation and
improve the quality of life of operated patients. However, even though technological advances in the methods and materials
for corneal transplantation have contributed to increasing the safety and efficacy of the procedure, logistical obstacles and
limited access to surgical treatment still prevent these advances from being evenly available to the entire population. It is
thus necessary to ensure accessibility to a health system capable of diagnosing and treating the entire population.
Hirlana Gomes Almeida
Ph.D. Student, Medical School of the São Paulo University (USP)
Richard Yudi Hida
Head of the Cataract Unit and Technical Manager of the Santa Casa de Misericórdia Tissue Bank, São Paulo
R EFERENCES
1.
Coelho JCU, Trubian PS, Freitas ACT, Parolin MB, Schulz GJ, Martins EL. Comparação entre o custo do transplante hepático cadavérico e
o intervivos. Rev Assoc Med Bras 2005;51:158-63.
2.
Solar SP, Ovalle AR, Simian MEM, Escobar JH, Beca JPI. Tres factores que influyen en la actitud de las personas ante la donación de
órganos. Rev. Chilena de Cirugía. 2008;60(3):262-7.
3.
Temporini ER, Kara-Junior N, Kara José N, Holzchuh N. Popular beliefs regarding the treatment of senile cataract. Rev Saúde Pública.
2002;36(3):343-9.
4.
Marback R, Temporinia ER, Kara-Junior N. Emotional factors prior to cataract surgery. Clinics. 2007;62(4):433-8.
5.
Brito S, Cardoso A, Costa E, Rosa A, Quadrado MJ, Murta J. DSAEK: a espessura será realmente importante? Rev Sociedade Portuguesa
de Oftalmologia. 2012:36(3):247-56.
6.
Macedo JP, Forseto AS, Allemann N, Sousa LB. Avaliação da ceratoplastia lamelar anterior profunda em pacientes com ceratocone. Arq.
Bras. Oftalmol. 2009:72(4).
7.
Moreira H, Sousa LB, Sato EH, Faria MAR. Banco de olhos, transplante de córnea. In: Série Oftalmologia Brasileira. 3.ed. 2013.
8.
Espíndola RF, Castro EFS, Santhiago MR, Kara-Junior N. A clinical comparison between DisCoVisc and 2% hydroxypropylmethylcellulose
in phacoemulsification: a fellow eye study. Clinics. 2012;67(9):1059-62.
9.
Kara-Junior N, Mourad PCA, Espíndola RF, AbilRuss HH. Expectativas e conhecimento entre pacientes com indicação de transplante de
córnea. Rev Bras Oftalmol. 2011;70(4):230-4.
10. Associação Brasileira de Transplantes de Órgãos. Registro Brasileiro de Transplantes. Dimensionamento dos Transplantes no Brasil e em
cada estado [online journal]. Jan/Dec 2012. Available at: http://www.abto.org.br/abtov03/Upload/file/RBT/2012/RBT-dimensionamento2012.pdf.
Rev Bras Oftalmol. 2014; 73 (5): 260-1
O
262 RIGINAL
ARTICLE
The role of Descemet’s membrane in the
pathogeny of corneal edema following
anterior segment surgery
O papel da membrana de Descemet na patogenia do edema
corneano após cirurgia de segmento anterior
Karine Feitosa Ximenes1, Jailton Vieira Silva2, Karla Feitosa Ximenes Vasconcelos3, Fernando Queiroz Monte1
A BSTRACT
Objective: To find relevant factors in the pathogeny of postoperative corneal edema in post-cataract surgery and post-keratoplasty
cases, through the study of histopathological findings in order to see what can be done to avoid successive keratoplasties. Methods:
Retrospective descriptive study of histopathological findings in postoperative corneal edema cases. Tissues were obtained from penetrating
keratoplasty in the period between september 2009 and august 2013. A medical record review was conducted primarily looking for
information about previous surgeries. Results: Seventy corneal buttons were included, out of which 34 were from male patients and 36
were from female patients. The mean age was 63.1±17.20 (mean ± SD) years. Most of cases were corneal failure after keratoplasty
(71.43%). The main change found in endothelium was cellular rarefaction (58 cases), and it was also the most common histopathological
change. Changes in integrity predominated in Descemet’s membrane (53 cases), whether in the form of rupture, isolated detachment
or detachment associated with rupture. Endothelial changes associated with the absence in Descemet’s membrane integrity were
frequent. Conclusion: Descemet’s membrane detachment is a frequent histopathological finding in postoperative corneal edema cases
studied, thus it should be considered an important factor in the pathogeny of such cases. This change should be carefully researched in
the postoperative period in order to be diagnosed and treated early, possibly avoiding many keratoplasty indications.
Keywords: Descemet membrane; Corneal edema/etiology; Corneal edema/pathology; Keratoplasty
RESUMO
Objetivo: Encontrar fatores importantes na patogenia do edema corneano pós-cirúrgico, em casos de pós-facectomia e pós-ceratoplastia,
por meio do estudo dos achados histopatológicos, a fim de ver o que pode ser feito para evitar sucessivas ceratoplastias. Métodos:
Estudo retrospectivo descritivo das alterações histopatológicas de casos de edema corneano pós-cirúrgicos. Os tecidos foram provenientes de ceratoplastia penetrante no período compreendido entre setembro de 2009 e agosto de 2013. Foi realizada revisão de prontuários em busca principalmente de informações sobre cirurgias prévias. Resultados: Foram incluídos 70 botões corneanos, sendo 34 de
pacientes do sexo masculino e 36 do sexo feminino. A média das idades foi de 63,1±17,20 (média ± DP) anos. A maioria dos casos era
de falência após transplante (71,43%). A rarefação celular foi a principal alteração encontrada no endotélio (58 casos), sendo também
a alteração histopatológica mais frequente. Na membrana de Descemet, predominaram as alterações de integridade (53 casos), seja na
forma de ruptura, de descolamento isolado ou de descolamento associado à ruptura. Foi frequente a associação de alterações endoteliais
à ausência da integridade da membrana de Descemet. Conclusão: Descolamento da membrana de Descemet é um achado histopatológico
frequente nos casos de edema corneano pós-cirúrgicos estudados, devendo ser considerado um fator importante na patogenia dos
mesmos. Essa alteração deve ser procurada com atenção nos pós-operatórios, a fim de ser diagnosticada e tratada precocemente, vindo
possivelmente a evitar muitas indicações de ceratoplastia.
Descritores: Lâmina limitante posterior; Edema da córnea/etiologia; Edema da córnea/patologia; Ceratoplastia
1
Ceará State Eye Bank, Fortaleza/CE, Brazil.
Federal University of Ceará, Fortaleza/CE, Brazil.
3
General Hospital of Fortaleza, Fortaleza/CE, Brazil.
2
Work conducted at the Ceará State Eye Bank, Brazil.
The authors have no public and private financial support, or financial interest
Received for oublication 08/04/2014 - Accepted for publication 08/06/2014
Rev Bras Oftalmol. 2014; 73 (5): 262-8
The role of Descemet’s membrane in the pathogeny of corneal edema following anterior segment surgery
INTRODUCTION
C
orneal oedema is a clinical condition characterised by
increased anteroposterior corneal thickness or
diameter(1,2).It can be confined to the epithelium or part
of it, and it can also affect only the stroma. Nevertheless, in most
cases both the epithelium and the stroma are affected(2).
Wherever oedema develops, structural elements are
separated from one another. In the stroma, the keratocytes are
separated from each other and from adjacent collagen fibres;
these, in turn, also move apart from one another. Oedema is
generally associated with loss of transparency of the affected
area of the cornea(2).
The two main factors in the aetiology of corneal oedema
are endothelial dysfunction(2-4) and Descemet’s membrane defects.
Endothelial cells form a single layer of pump cells in the posterior cornea and are responsible for constantly dehydrating the
cornea. These cells decrease in number with age and are usually
incapable of regeneration(5).Ophthalmologists are well aware of
the limited regeneration capacity of the human corneal
endothelium and of the need for extreme caution to avoid injuries to this important tissue during surgical procedures(6).
Defects in Descemet’s membrane also lead to the inflow of
aqueous humour into the cornea, with subsequent stromal
oedema(5).Descemet’s membrane detachment can result from
any factor causing a rupture in Descemet’s membrane, including
surgical procedures (cataract extraction, iridectomy, cyclodialysis,
penetrating keratoplasty) and tears due to congenital glaucoma,
keratoconus, keratoglobus, or trauma(7).Large and extensive
detachments have an exuberant presentation, with corneal
oedema and marked reduction in visual acuity, and often require
surgical intervention to prevent permanent corneal
decompensation and the need for corneal transplantation(8).
Given the above, our objective was to determine the
pathogeny of postoperative corneal oedema after cataract
extraction and keratoplasty by studying histopathology findings
in Descemet’s membrane and the endothelium, in order to determine potential early measures that might prevent the need for
repeated keratoplasties. Histopathological changes may be
suggestive of what needs to be rigorously investigated during the
postoperative period in patients submitted to these procedures.
M ETHODS
A study of corneal buttons from penetrating keratoplasties
conducted between September 2009 and August 2013 and
submitted to the Eye Bank for histopathological examination
was conducted. Tissues were fixed in 10% neutral formaldehyde
and sliced by a pathologist while lying on the endothelial side,
with the cut starting from the epithelium and ending at the
endothelium. Samples were embedded in paraffin, cut into 2.5ìm thick slices, and stained with haematoxylin-eosin. Following
preparation, tissues were examined by the authors with an optical
microscope.
This was a retrospective, descriptive study of the
histopathological changes found in postoperative corneal
oedema. Because of the lack of studies to which our results
could be compared, we simply assessed the frequency of each
finding. Using this statistical method is also warranted by our
interest in studying the pathogeny of the condition and examining
263
the changes found in the sample. In further studies based on
these findings, statistical probabilities can also be calculated.
Corneal buttons presenting stromal oedema were selected.
Stromal oedema was histopathologically defined as the presence
of separation between structures such as keratocytes and collagen
fibres. Oedema was classified into five grades depending on the
degree of separation. Epithelial oedema (cell oedema, cytoplasmic
vacuoles, microcysts, and bubbles) was not considered in the
classification, despite being present in almost all cases.
Specimens with grade I (mild) oedema presented only a
slight and sparse separation between structures (Figure 1a).Cases
where the separation was more frequent and widespread were
classified as grade II (mild-moderate) oedema (Figure 1b). Grade III (moderate) oedema showed generalised swelling, but with
slight separation between structures (Figure 1c). In grade IV
(moderate-severe) oedema, the separation was wider and very
frequent (Figure 1d). Finally, specimens with grade V (severe)
oedema presented greater separation with generalised swelling
(Figure 1e). In some cases, a tissue sample presented oedema of
varying intensity in different regions. Such cases were classified
according to the predominant type of oedema or to its average
intensity.
The exclusion criteria were inflammatory reactions,
synechiae, stromal thinning, and specimens without a medical
record or with no record of prior surgery. Thus, only pure cases
of postoperative corneal oedema were included, i.e. those not
associated with secondary causes.
The medical records of selected cases were reviewed for
Figure 1a: Mild oedema (grade I) with slight, sparse separation of
stromal structures. Note the thickened Descemet’s membrane.
Figure 1b: Mild-moderate oedema (grade II) with more widespread
separation.
Rev Bras Oftalmol. 2014; 73 (5): 262-8
264
Ximenes KF, Silva JV, Vasconcelos KFX, Monte FQ
During histopathological examination, samples presenting
any degree of corneal and diagnosed with bullous keratopathy
or graft failure were investigated for changes in Descemet’s
membrane and the corneal epithelium. Changes in Descemet’s
membrane included ruptures, detachment, folds, bifurcations,
abnormal thickness, and distension. Endothelial changes included
cell rarefaction or cell abnormalities. Since this study was focused
on the pathogeny of corneal oedema, data collection was centred
on its potential causal factors. Nonetheless, factors that seemed
to be a consequence of the condition are also mentioned, in
order to present the full array of histopathological findings.
Figure 1c: Moderate oedema (grade III). The oedema is more generalised
but the separation is still mild. Microcysts can be seen in the epithelium.
R ESULTS
Seventy corneal buttons were included in this study, of
which 34 were from male patients and 36 from female patients.
Mean age was 63.1 ± 17.20 years (mean ± SD). The sample included
20 cases of bullous keratopathy following cataract extraction
and 50 cases of graft failure. The distribution of cases according
to the five grades of oedema is shown in Table 1.
The histopathological changes found in the samples are
shown in Table 2. The most common changes in Descemet’s
membrane were ruptures in 41 cases (58.57%) and detachment
in 40 cases (57.14%), followed by folds in 25 cases (35.71%). The
main change found in the endothelium was cell rarefaction, in 58
cases (82.86%). Considering all types of changes, endothelial cell
rarefaction was the most common.
Table 1
Figure 1d: Moderate-severe oedema (grade IV), with wider and very
widespread separation. A large bubble can be seen detaching part of
the epithelium.
Sample distribution according to the grade of corneal
oedema found in specimens submitted for examination
between September 2009 and August 2013.
Grade
I
II
III
IV
V
Total
Figure 1e: Severe oedema (grade V). The oedema is generalised and
the separation is much wider. Bubbles can be observed in the
epithelium.
information on the surgeon’s diagnosis, previous surgery, gender,
and age. All cases of prior cataract extraction or corneal
transplantation were recorded. Cases where the surgeon’s
diagnosis indicated bullous keratopathy following cataract
extraction or graft failure following a previous transplantation
were considered as such. In cases where the surgeon’s diagnosis
was lacking, this information was obtained in the medical record
which contained a standard form for corneal transplantation.
Cases of previous transplantation were considered as graft
failure, and cases of previous cataract extraction were considered
as bullous keratopathy.
Rev Bras Oftalmol. 2014; 73 (5): 262-8
Bullous keratopathy
following cataract
extratction (%)
5
3
4
5
3
(25)
(15)
(20)
(25)
(15)
20 (100)
Graft
failure (%)
13 (26)
8 (16)
7 (14)
14 (28)
8 (16)
50 (100)
Total (%)
18
11
11
19
11
(25.71)
(15.71)
(15.71)
(27.14)
(15.71)
70 (100)
The distribution of histopathological changes found in cases of bullous keratopathy following cataract extraction and graft
failure are shown in Table 3.Ruptures and detachment were the
predominant changes in Descemet’s membrane, both for bullous
keratopathy and graft failure. Cell rarefaction was the main
endothelial change in both groups, as well as the most frequent
histopathological change overall.
The charts below show the distribution of histopathological
changes along the five grades of corneal oedema following anterior segment surgery. Only those changes that can be considered
as causal factors are shown, namely changes to the integrity of
Descemet’s membrane (ruptures, ruptures plus detachment, and
isolated detachment) and isolated endothelial changes. Chart 1
shows that changes to the integrity of Descemet’s membrane
were the predominant finding, with detachment being very
frequent, whether or not associated with rupture (40 cases).
The role of Descemet’s membrane in the pathogeny of corneal edema following anterior segment surgery
Table 2
Corneal changes found in specimens submitted for
examination between September 2009 and August 2013.
Changes
Descemet’s
membrane
Endotheliun
Quantidade (%)
Ruptures
Detachment
Folds
Bifurcations
Thickening
Thinning
Distension
41 (58.57)
40 (57.14)
25 (35.71)
3 (4.29)
4 (5.71)
6 (8.57)
3 (4.29)
Cell rarefaction
Cellabnormalities
58 (82.86)
9 (12.86)
Percentages do not add up to 100% because some specimens contained
multiple changes.
Table 3
Comparison of changes found in cases of bullous
keratopathy following cataract extraction and graft failure
in specimens submitted for examination between
September 2009 and August 2013.
Changes
Bullous keratopathy
following cataract
extratction (%)
Graft
failure
(%)
Descemet’s Ruptures
membrane Detachment
Folds
Bifurcations
Thickening
Thinning
Distension
10 (50)
14 (70)
4 (0)
0 (0)
3 (15)
3 (15)
0 (0)
31
26
21
3
1
3
3
Endotheliun Cell rarefaction
Cellabnormalities
15 (75)
1 (5)
43 (86)
8 (16)
265
associated with rupture, with 28 cases (40%). Isolated ruptures
were found in 13 cases (18.57%), and isolated detachment was
found in 12 cases (17.14%).
Considering the distribution of changes according to the
grade of oedema (Charts 3-7), it was found that changes to the
integrity of Descemet’s membrane prevailed in all grades. A
frequent change to the integrity of Descemet’s membrane in all
grades of oedema was detachment, whether or not associated
with rupture. Isolated endothelial changes were found mainly in
grade IV oedema, with 9 cases (47.37%), followed by detachment,
found in 8 cases (42.10%).
DISCUSSION
This was a descriptive study of histopathological changes
found in Descemet’s membrane and the corneal endothelium of
patients with corneal oedema following anterior segment surgery
(keratoplasty or cataract extraction). Most cases included in the
sample were graft failures, which can be attributed to the fact
that most corneal buttons submitted to the Eye Bank for
histopathological examination come from emergency
keratoplasties, where the corneal button is routinely submitted
Chart 1
Distribution of histopathological changes
according to the grade of oedema.
(62)
(52)
(42)
(6)
(2)
(6)
(6)
Percentages do not add up to 100% because some specimens contained
multiple changes.
Table 4
Changes to the integrity of Descemet’s membrane in
cases of postoperative corneal oedema.
Changes
Ruptures
Detachment
Folds
N (%)
Chart 2
Histopathological changes found in cases of bullous
keratopathy following cataract extraction (black)
and graft failure (grey).
13 (18.57)
28 (40)
12 (17.14)
Percentages do not add up to 100% because this table only includes
changes to Descemet’s membrane, which were not found in all specimens.
Isolated endothelial changes were only found in 17 cases. The
distribution of changes in both groups was relatively similar to
the sample as a whole (Chart 2).
The frequency of changes to the integrity of Descemet’s
membrane, either in isolation or associated with other findings,
are shown in Table 4.The most common change was detachment
Rev Bras Oftalmol. 2014; 73 (5): 262-8
266
Ximenes KF, Silva JV, Vasconcelos KFX, Monte FQ
Chart 3
Chart 6
Histopathological changes found in cases of bullous
keratopathy following cataract extraction (black) and graft
failure (grey) with mild (grade I) oedema.
Histopathological changes found in cases of bullous
keratopathy following cataract extraction (black) and graft
failure (grey) with moderate-severe (grade IV) oedema.
Chart 7
Chart 4
Histopathological changes found in cases of bullous
keratopathy following cataract extraction (black) and graft
failure (grey) with severe (grade V) oedema.
Histopathological changes found in cases of bullous
keratopathy following cataract extraction (black) and graft
failure (grey) with mild-moderate (grade II) oedema.
Chart 5
Histopathological changes found in cases of bullous
keratopathy following cataract extraction (black) and graft
failure (grey) with moderate (grade III) oedema.
Rev Bras Oftalmol. 2014; 73 (5): 262-8
for examination, while samples from cataract extraction are only
occasionally submitted. Most cases of both bullous keratopathy
following cataract extraction and graft failure presented oedema
grade I and IV, according to our classification.Therefore, no
correlation was established between the diagnosis and the degree
of oedema.
The main histopathological change found both in cases of
bullous keratopathy following cataract extraction and graft
failure was endothelial cell rarefaction. Since isolated endothelial
changes were seen in only 17 of the 70 specimens (Chart 1),
endothelial changes were frequently associated with changes to
the integrity of Descemet’s membrane — either isolated
detachment, rupture, or both combined. We suggest that this
association might not be due to chance alone — instead, changes
to Descemet’s membrane could be the cause of endothelial
changes. Another explanation could be related to the way the
pieces were sliced, a factor we had no control over due to the
retrospective nature of this study. We are also aware that
endothelial cells are easily altered by fixation and staining;
therefore, it is difficult to obtain a precise image of their normal
and pathological structures through microscopic examination of
fixed, stained slides(3).Nonetheless, we underline the reliability
The role of Descemet’s membrane in the pathogeny of corneal edema following anterior segment surgery
of endothelial histopathological findings based on studies such
as William et al., who found a direct correlation between the
number of endothelial cells in histological examination and the
density of cells in specular microscopy(9).Our research, however,
did not focus on the endothelium, as these changes have already
been thoroughly studied. Instead, we focused mainly on
Descemet’s membrane, as it was altered in 53 out of the 70 cases
(Chart 1 and Table 4), and because of the potential effects of
oedema on the membrane and the possibility to institute early
and effective treatment against such changes.
Since our main objective was to study the pathogeny of
corneal oedema, we focused mainly on changes to the integrity of
Descemet’s membrane (Chart 1 and Table 4), which are mentioned
in literature as possible causes of the condition(5).Among these
changes, detachment was a frequent finding, either associated with
rupture (40% of cases) or in isolation (17.14% of cases).
Detachment was thus found in 57.14% of cases, which stresses the
importance of recognising it as a treatable cause. However, it is
still unclear whether the rupture could have strained Descemet’s
membrane to the point of detachment or whether the two events
were concurrent. Among the changes unrelated to pathogeny, the
most frequentwere folds, followed by thinning, thickening,
distension, and bifurcations (Table 2).However, it is unclear
whether these findings occurred as a consequence of oedema or
by chance. Folds were roughly twice as frequent in cases of graft
failure (42% of cases) than in bullous keratopathy following
cataract extraction (20% of cases). This might be explained by the
fact that folds tend to resolve over time on biomicroscopy, and
cases of graft failure, particularly primary failure, usually undergo
earlier transplantation.
Most studies addressing the aetiology of bullous
keratopathy or corneal oedema, however, mention endothelial
cell loss or dysfunction as the main aetiological factor(1,2,10,11).Few
sources in the literature mention Descemet’s membrane defects
as a cause of corneal oedema(5), and they usually do not make
reference to surgical trauma. Studies on changes to the integrity
of Descemet’s membrane after surgery usually focus on
membrane detachment following cataract extraction and its
treatment. Contrary to the literature, which limits the
aetiopathogenesis of bullous keratopathy and corneal oedema
mostly to endothelial changes or, on a smaller scale, solely to
changes to the integrity of Descemet’s membrane, our
histopathological study has shown that changes to Descemet’s
membrane may be associated with endothelial changes in the
pathogeny of bullous keratopathy following cataract extraction.
The suggestion that changes to the integrity of Descemet’s
membrane are probably the main pathogenic factor in cases of
bullous keratopathy following cataract extraction could also be
made for cases of graft failure. Despite the improving results of
penetrating keratoplasty, graft failure still remains a significant
problem. Common aetiologies include primary donor failure,
surgical complications, complications related to intraocular lenses,
persistent epithelial defects, rejection, infection, glaucoma, trauma, and relapse of primary corneal dystrophies(12).However,
changes to endothelial cells are cited in literature as one of the
main factors leading to corneal graft failure, as is the case for
bullous keratopathy. Bell et al.observed a low initial endothelial
cell count in sequential examinations by specular microscopy
and a continuous decrease in cell density over the firstfive
postoperative years in patients who met the criteria for late
endothelial failure and who had been subjected to repeated
keratoplasties (13).Santos et al., studying corneal specimens
267
diagnosed as grafts failures, found endothelial decompensation
as the most common histopathological finding (14).With the
exception of studies such as Aurora et al., few papers mention
Descemet’s membrane defects as part of the aetiopathogenesis
of corneal graft failure(15).
Considering Descemet’s membrane defects — which, in
our study, involved mostly detachment associated or not with
rupture — as an important factor in the pathogeny of bullous
keratopathy following cataract extraction and graft failure after
keratoplasty, this change should always be investigated in cases
of oedema occurring in the immediate postoperative period of
these procedures. Descemet’s membrane detachment is a rare
but severe complication of intraocular procedures(16).It is not
uncommon in cataract surgery, with a reported incidence of 0.5%
and 2.6% in extracapsular surgery and phacoemulsification,
respectively(17).Many approaches have been suggested for the
condition, such as observation (18), injection of C3F8 (19,20) or
SF6 (8,20,21) gas into the anterior chamber, injection of
viscoelastic (22) , transcorneal sutures (23) , and corneal
transplantation. Descemet’s membrane detachment can be
classified into two types: planar, when stromal separation is under
1 mm; and non-planar, when the separation is greater than 1
mm. Both types of can be further classified as either peripheral
or peripheral with central involvement(7).Vastine et al.suggest
that the small planar detachments should be managed with
observation, since many cases resolve spontaneously. Large planar or non-planar detachment or scrolled detachment require
surgical intervention(24).Kim et al.recommend treatment with
intracameral gas injection in cases of a detached yet intact
Descemet’s membrane(8).
In sum, as mentioned above, multiple approaches exist for
treating Descemet’s membrane detachment. There are some
alternative treatments to corneal transplantation that can lead
to complete resolution of corneal oedema and prevent the need
for transplantation. Although repositioning may take some time,
the endothelium/detached Descemet’s membrane complex may
remain relatively healthy in the anterior chamber, with corneal
transparency eventually resuming when the repositioning takes
place(21).Once again, we stress the need to thoroughly investigate
the presence of this change in cases of corneal oedema in the
immediate postoperative period of cataract extraction or corneal
transplantation, in an attempt to avoid keratoplasty through
early diagnosis and alternative therapies. We are aware that it is
not always possible to visualise Descemet’s membrane with a slit
lamp in cases of severe corneal oedema(16), and because more
sophisticated diagnostic methods are not always easily available,
we suggest considering the use of the aforementioned alternative
routine methods in cases of early corneal oedema following
traumatic anterior segment procedures in an attempt to treat
the condition before the first or successive keratoplasties.
CONCLUSION
This study used histopathology findings to demonstrate
that changes to the integrity of Descemet’s membrane, which in
this study consisted primarily of detachment associated or not
with ruptures, are frequently found in cases of corneal oedema
following anterior segment surgery, in particular cataract
extraction and corneal transplantation. The high frequency of
this finding suggests that it plays an important role in the
pathogeny of the studied cases of corneal oedema.
Rev Bras Oftalmol. 2014; 73 (5): 262-8
268
Ximenes KF, Silva JV, Vasconcelos KFX, Monte FQ
Endothelial cell rarefaction was also a frequent finding,
although mainly associated with Descemet’s membrane defects.
The acknowledgment that not only the endothelium, but also
Descemet’s membrane detachment may be important in the
pathogeny of corneal oedema following anterior segment surgery
should prompt ophthalmologists to carefully investigate this
change in the postoperative period and institute early treatment
in an attempt to prevent the need for keratoplasty.
As this was a retrospective descriptive study, we hope our
findings will encouragefuture prospective studies that may
confirm our conclusions.
R EFERENCES
1.
Alomar TS, Al-Aqaba M, Gray T, Lowe J, Dua HS. Histological
and confocal microscopy changes in chronic corneal edema: implications for endothelial transplantation. Invest Ophthalmol Vis
Sci. 2011;52(11):8193-207.
2.
Goldman JN, Kuwabara T. Histopathology of corneal edema. Int
Ophthalmol Clin. 1968;8(3):561-79.
3. Stocker FW. The endothelium of the cornea and its clinical implications. Trans Am Ophthalmol Soc. 1953;51:669-786.
4. Patel SP. The bull’s eye: are we off-target for corneal endothelial
cell physiology? J Ophthalmic Vis Res. 2013;8(1):83-5.
5. Naumann GO, Holbach L, Kruse FE. Applied pathology for ophthalmic microsurgeons. Berlin: Springer; 2008.
6.
Murphy C, Alvarado J, Juster R, Maglio M. Prenatal and postnatal cellularity of the human corneal endothelium. A quantitative
histologic study. Invest Ophthalmol Vis Sci. 1984;25(3):312-22.
7. Mulhern M, Barry P, Condon P. A case of Descemet’s membrane
detachment during phacoemulsification surgery. Br J Ophthalmol.
1996;80(2):185-6.
8. Kim T, Hasan SA. A new technique for repairing descemet membrane detachments using intracameral gas injection. Arch
Ophthalmol. 2002;120(2):181-3.
9. Williams KK, Noe RL, Grossniklaus HE, Drews-Botsch C,
Edelhauser HF. Correlation of histologic corneal endothelial cell
counts with specular microscopic cell density. Arch Ophthalmol.
1992;110(8):1146-9.
10. Gonçalves ED, Campos M, Paris F, Gomes JA, Farias CC. [Bullous
keratopathy: etiopathogenesis and treatment: [review]]. Arq Bras
Oftalmol. 2008;71(6 suppl 0):61-4. Portuguese.
11. Yi DH, Dana MR. Corneal edema after cataract surgery: incidence
and etiology. Semin Ophthalmol. 2002;17(3-4):110-4. Review.
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12. Wilson SE, Kaufman HE. Graft failure after penetrating keratoplasty. Surv Ophthalmol. 1990;34(5):325-56. Review.
13. Bell KD, Campbell RJ, Bourne WM. Pathology of late endothelial failure: late endothelial failure of penetrating keratoplasty:
study with light and electron microscopy. Cornea. 2000;19(1):40-6.
14. Santos LN, de Moura LR, Fernandes BF, Cheema DP, Burnier
MN Jr. Histopathological study of delayed regraft after corneal
graft failure. Cornea. 2011;30(2):167-70.
15. Aurora AL, Khandur RC, Singh G. Pathogenesis of corneal graft
failure. Indian J Ophthalmol. 1974;22(2):11-6.
16. Kothari S, Kothari K, Parikh RS. Role of anterior segment optical
coherence tomogram in Descemet’s membrane detachment. Indian J Ophthalmol. 2011;59(4):303-5.
17. Anderson CJ. Gonioscopy in no-stitch cataract incisions. J Cataract Refract Surg. 1993;19(5):620-1.
18. Assia EI, Levkovich-Verbin H, Blumenthal M. Management of
Descemet’s membrane detachment. J Cataract Refract Surg.
1995;21(6):714-7.
19. Lucena AR, Lucena DR, Macedo EL, Ferreira JL, Lucena AR.
[C3F8 use in Descemet detachment after cataract surgery]. Arq
Bras Oftalmol. 2006;69(3):339-43. Portuguese.
20. Kim T, Sorenson A. Bilateral Descemet membrane detachments.
Arch Ophthalmol. 2000;118(9):1302-3.
21. Tai MC, Yieh FS, Chou PI. Repair of near total Descemet’s membrane detachment with intracameral injections of 20% sulfur
hexafluoride gas. J Med Sci. 2002;22(5):231-4.
22. Sonmez K, Ozcan PY, Altintas AG. Surgical repair of scrolled
descemet’s membrane detachment with intracameral injection
of 1.8% sodium hyaluronate. Int Ophthalmol. 2011;31(5):421-3.
23. Pahor D, Gracner B. Surgical repair of Descemet’s membrane
detachment. Coll Antropol. 2001;25 Suppl:13-6.
24. Vastine DW, Weinberg RS, Sugar J, Binder PS. Stripping of
Descemet’s membrane associated with intraocular lens implantation. Arch Ophthalmol. 1983;101(7):1042-5.
Corresponding author:
Karine Feitosa Ximenes
Rua Andrade Furtado, 150, apto 1501, Cocó Fortaleza, CE, Brazil – CEP: 60192-070
Tel: +5585 3262 6781; +5585 9673 3132
E-mail: [email protected]
ORIGINAL ARTICLE
269
Preemptive analgesia of nepafenac 0.1%
in retinal photocoagulation
Analgesia preemptiva com nepafenaco 0,1%
na fotocoagulação da retina
Emerson Fernandes de Sousa e Castro1,2, Erika Araki Okuda2, Vinícius Balbi Amatto2, Hirlana Gomes Almeida1,
Marina Gracia1, Newton Kara-Junior1
A BSTRACT
Objective: To evaluate the preemptive effect of nepafenac 0,1% in patients undergoing retinal photocoagulation for the treatment of
proliferative diabetic retinopathy. Methods: Thirty patients underwent argon laser photocoagulation in both eyes. The contralateral eye of
each patient was the control. The nepafenac and placebo were used 30 minutes before the application of the laser. Both eyes were
photocoagulated in the same day. Pain intensity was assessed by visual analog scale and descriptive pain scale. Results: The analysis of
the interaction instillation versus nepafenac showed that patients in the placebo group had similar levels of pain in both eyes, and the
nepafenac group had significant reduction in pain in the eye that was instilled suspension of 0,1% when compared to the contralateral
eye which received placebo (p = 0.023). Conclusion: This study suggests that a suspension of 0,1% nepafenac helpful for preemptive
analgesia in patients undergoing retinal photocoagulation compared to placebo.
Keywords: Pain/prevent & control; Analgesia; Anti-inflammatory agents, non-steroidal/administration & dosage; Anti-inflammatory
agents, non-steroidal/therapeutic use; Light coagulation; Diabetic retinopathy/drug therapy
RESUMO
Objetivo: Avaliar o efeito preemptivo com nepafenaco 0,1% em pacientes submetidos à fotocoagulação da retina para tratamento da
retinopatia diabética proliferativa. Métodos: Trinta pacientes foram submetidos à fotocoagulação com laser de argônio em ambos os
olhos. O olho contralateral de cada paciente foi o controle. O nepafenaco e o placebo foram utilizados 30 minutos antes da aplicação do
laser. Ambos os olhos foram fotocoagulados no mesmo dia. A intensidade da dor foi avaliada por meio da escala analógica visual e da
escala descritiva de dor. Resultados: A análise da interação instilação versus nepafenaco mostrou que os pacientes do grupo placebo
apresentaram níveis de dor semelhantes em ambos os olhos, e os do grupo nepafenaco apresentaram redução importante do nível de
dor no olho em que foi instilado a suspensão de 0,1% quando comparado ao olho contralateral que recebeu placebo (p=0,023).
Conclusão: Este estudo sugere que a suspensão de 0,1% de nepafenaco foi útil na analgesia preemptiva de pacientes submetidos à
fotocoagulação de retina quando comparada ao placebo.
Descritores: Dor/prevenção & controle; Analgesia; Anti-inflamatórios não esteroides/administração & dosagem; Anti-inflamatórios não esteroides/uso terapêutico; Fotocoagulação; Retinopatia diabética/quimioterapia
1
2
Medical School, São Paulo University, São Paulo/SP, Brazil.
São Paulo State Civil Servants Hospital “Francisco Morato de Oliveira”, São Paulo/SP, Brazil.
This study received no financial support.
The authors declare no conflict of interest.
Received for publication 13/06/2014 - Acceped for publication 11/07/2014
Rev Bras Oftalmol. 2014; 73 (5): 269-72
270
Castro EFS, Okuda EA, Amatto VB, Almeida HG, Gracia M, Kara-Junior N
INTRODUCTION
P
reemptive analgesia aims to reduce the intensity and
duration of pain, both during and after procedures, by
preventing reflex hyperexcitability in the spinal cord(1).
Analgesic agents are not generally used during argon laser
retinal photocoagulation, yet most patients complain of pain
during and after the procedure, despite the use of anaesthetic
eye drops. General anaesthesia or local anaesthetic block,
indicated in cases of intolerable pain, increase the morbidity and
mortality of the procedure(2).
Non-steroidal anti-inflammatory drugs (NSAIDs) with
local or systemic effect have analgesic and antipyretic properties(3).
The only NSAID suitable for topical application is nepafenac
0.1% ophthalmic suspension, which non-selectively inhibits the
cyclooxygenase enzyme and presents superior anti-inflammatory
properties compared to conventional NSAIDs(3). Nepafenac
0.1% has only been approved for the treatment of pain and
inflammation associated with cataract surgery(3).
The aim of this study was to determine whether using an
analgesic agent in addition to the anaesthetics commonly used in
retinal photocoagulation provides any additional benefit.
METHODS
A prospective, randomised, double-blind case-control study
was conducted on 30 consecutive patients diagnosed with
proliferative diabetic retinopathy presenting clear ocular media
who underwent argon laser photocoagulation in both eyes
between June 2011 and May 2012.
The project was approved by the Research Ethics
Committee of the São Paulo State Civil Servants Hospital under
number 094/10 and was authorised by the hospital manager. All
patients provided their free and informed consent.
Exclusion criteria were: presence of retinal abnormalities
associated with other systemic diseases, uncooperative patients,
pregnancy, use of systemic analgesic or anti-inflammatory agents,
and refusal to participate in the study.
The study variables were divided into dependent (pain
level) and independent (age, gender, use of placebo or nepafenac
0.1%). Data were collected through a questionnaire using the
Visual Analogue Scale (VAS) and the Descriptive Pain Scale
(DPS), both frequently used in other studies in the literature(4,5).
Patients were divided into two groups of 15 patients each,
who used either nepafenac 0.1% or placebo. The two groups
were matched for age and gender. A single drop of anaesthetic
eye drops was administered to each patient 5 minutes before
laser application. The study medication was administered 30
minutes before laser application. The contralateral eye was used
as a control, undergoing photocoagulation the same day. Fifteen
minutes after laser application, subjects responded to the VAS
and DPS questionnaire.
For all subjects, photocoagulation was carried out using a
Visulas 532s Zeiss device set to spot size 100 µm, power setting
0.20 mW, time 0.10 seconds, and approximately 200 burns.
The pain response of patients was analysed using mixedmodel ANOVA for multiple factors. This model was chosen due
to the study design which combines paired and unpaired samples.
The pain level was assessed in relation to three variables:
1) anaesthetic eye drops administered to one eye versus non-
Rev Bras Oftalmol. 2014; 73 (5): 269-72
administration to the contralateral eye (paired samples); 2)
nepafenac 0.1% administered to one group versus placebo given
to the other group (unpaired samples); and 3) gender.
Patient age was included as a covariate and its potential
influence was controlled for by the model. The three factors
above were assessed both in isolation and combined. A p-value
<0.05 was adopted for rejection of the null hypothesis.
RESULTS
As illustrated in Table 1, the results from the DPS show
that the effects of age, gender, nepafenac 0.1%, and anaesthetic
eye drops were not statistically significant in isolation, nor were
the interactions between anaesthetic eye drops and age, gender
and nepafenac 0.1%, or anaesthetic eye drops and gender and
nepafenac 0.1%. However, the interactions between anaesthetic
eye drops and gender, and anaesthetic eye drops and nepafenac
0.1% produced statistically-significant results.
Table 1
Isolated and combined effects of the study variables on
patients submitted to photocoagulation.
Isolated effects
F
Age
Genre
Nepafenac 0,1%
Anaesthetic eye drop
2.09
0.37
2.02
0.40
0.1602
0.5470
0.1673
0.5304
F
p-value
0.11
6.97
5.85
0.85
3.59
0.7474
0.0141
0.0232
0.3657
0.0697
Interações
Anaesthetic eye drop x Age
Anaesthetic eye drop x Genre
Anaesthetic eye drop x Nepafenac
Genre x Nepafenac
Anaesthetic eye drop x Genre x Nepafenac
p-value
Figure 1 shows that administering nepafenac 0.1% or a
placebo to men does not alter the level of pain, whereas in women
nepafenac significantly reduces pain perception.
Figure 1: Comparison of anaesthetic eye drops and gender in patients
submitted to photocoagulation between June 2011 and May 2012.
Preemptive analgesia of nepafenac 0.1% in retinal photocoagulation
Figure 2 shows that patients in the placebo group had
similar pain levels in both eyes. However, patients in the nepafenac
group presented a significant reduction of pain perception in
the eye that received nepafenac 0.1% compared to the
contralateral eye, which received no eye drops
271
nepafenac 0.1%, or anaesthetic eye drops and gender and
nepafenac 0.1%. However, the interactions between anaesthetic
eye drops and gender, and anaesthetic eye drops and nepafenac
0.1% produced statistically-significant results.
Figure 1 shows that administering nepafenac 0.1% or a
placebo to men does not alter the level of pain, whereas in women
nepafenac significantly reduces pain perception.
Figure 2 shows that patients in the placebo group had
similar pain levels in both eyes. However, patients in the nepafenac
group presented a significant reduction of pain perception in
the eye that received nepafenac 0.1% compared to the
contralateral eye, which received no eye drops.
CONCLUSION
This study shows that nepafenac 0.1% ophthalmic
suspension was effective for the preemptive analgesia of patients
submitted to retinal photocoagulation compared to placebo,
particularly in women.
R EFERENCES
Figure 2: Comparison of anaesthetic eye drops and nepafenac 0.1%
in patients submitted to photocoagulation between June 2011 and
May 2012.
DISCUSSION
Pain perception varies between individuals and is
dependent on many factors, including cultural and gender
differences, past experience and anxiety levels(2).
Diabetic retinopathy is the most common cause of
blindness among the economically active population in the United
Kingdom(7). Argon laser retinal photocoagulation is an effective
treatment to reduce severe visual loss in proliferative diabetic
retinopathy(8).
As many patients report some degree of pain both during
and after laser treatment(9), several studies have attempted to
identify the best form of analgesia for this procedure(10).
Invasive procedures such as retrobulbar, peribulbar and
subtenon anaesthesia have been suggested, but they can cause
serious complications which limit their use(11). A study carried
out on 60 eyes of 30 patients with proliferative diabetic
retinopathy concluded that topical ketorolac tromethamine 0.5%
is no more effective than artificial tears for relieving pain during
photocoagulation(12).
Preemptive analgesia involves the administration of
analgesics before the painful stimulus, thus preventing or reducing
the hypersensitivity response and pain memory in the nervous
system; this produces long-term benefits for the patient’s quality
of life and helps reduce expenses on further treatments(13).
Another alternative suggested in the literature is to reduce
the retina’s time of exposure to laser, which significantly reduces
the level of pain(14).
As shown in Table 1, the results from the DPS show that
the effects of age, gender, nepafenac 0.1%, and anaesthetic eye
drops were not statistically significant in isolation, nor were the
interactions between anaesthetic eye drops and age, gender and
1.
Alves AS, Campello RA, Mazzanti A, Alievi MM, Faria RX, Stedile
R, Braga FA. Emprego do antiinflamatório não esteróide
ketoprofeno na analgesia preemptiva em cães. Cienc Rural (Santa
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2. Vaideanu D, Taylor P, McAndrew P, Hildreth A, Deady JP, Steel
DH. Double masked randomised controlled trial to assess the
effectiveness of paracetamol in reducing pain in panretinal photocoagulation. Br J Ophthalmol. 2006;90(6):713-7.
3. Weinberger D, Ron Y, Lichter H, Rosenblat I, Axer-Siegel R,
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2000;84(2):135-7.
4. Fortes AC, Martinelli EJ, Ribeiro LG, Corpa JH, Tarcha FA, Rehder
JR. Ação do anestésico tópico diluído e da mitomicina sobre a
sintomatologia e re-epitelização corneana no pós-operatório da
ceratectomia fotorrefrativa. Rev Bras Oftalmol. 2013;72(4):237-43.
5. Lucena CR, Ramos Filho JA, Messias AM, Silva JÁ, Almeida FP,
Scott IU, et al. Panretinal photocoagulation versus intravitreal
injection retreatment pain in high-risk proliferative diabetic retinopathy. Arq Bras Oftalmol. 2013;76(1):18-20.
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2008;2(2):355-68.
7 . British Diabetic Association, Department of Health. St Vincent Joint
Task Force for Diabetes: report of the Visual Impairment Subgroup.
London: British Diabetic Association, Department of Health; 1994.
8 . Tonello M, Costa RA, Almeida FP, Barbosa JC, Scott IU, Jorge R.
Panretinal photocoagulation versus PRP plus intravitreal
bevacizumab for high-risk proliferative diabetic retinopathy (IBeHi
study). Acta Ophthalmol. 2008;86(4):385-9.
9 . Zakrzewski PA, O’Donnell HL, Lam WC. Oral versus topical
diclofenac for pain prevention during panretinal photocoagulation.
Ophthalmology. 2009;116:1168-1744.
10. Tamai M, Mizuno K. Distribution of intra- and extraocular pain
induced by argon laser photocoagulation. Tahoku J Exp Med.
1984;142(4):427-35.
11. Wu WC, Hsu KH, Chen TL, Hwang YS, Lin KK, Li ML, Shih CP, La i
CC. Interventions for relieving pain associated with panretinal photocoagulation: a prospective randomized trial. Eye (Lond).
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Castro EFS, Okuda EA, Amatto VB, Almeida HG, Gracia M, Kara-Junior N
12. Esgin H, Samut HS. Topical ketorolac 0.5% for ocular pain relief
during scatter laser photocoagulation with 532 nm green laser. J
Ocul Pharmacol Ther .2006;22(6):460-4.
13. Grass JA, editor. Problems in anesthesia. vol. 10. Management of
acute pain. Philadelphia:Lippincott-Raven; 1998. p.107-21.
14. Al-Hussainy S, Dodson PM, Gibson JM. Pain response and follow-up
of patients undergoing panretinal laser photocoagulation with reduced exposure times. Eye (Lond). 2008;22(1):96-9.
Rev Bras Oftalmol. 2014; 73 (5): 269-72
Corresponding Author:
Hirlana Gomes Almeida
Rua dos Médicis, 30, apto. 903
CEP: 50070-290 – Recife (PE), Brazil
Tel: +5581 3049 1907
E-mail: [email protected]
ORIGINAL ARTICLE
273
Analysis quantitative and qualitative of the tear
film in patients undergoing PRK and LASIK
with femtosecond
Análise quantitativa e qualitativa do filme lacrimal nos pacientes
submetidos a PRK e LASIK com femtossegundo
Rubens Amorim Leite1, Ricardo Menon Nosé 1, Fábio Bernardi Daga 1, Tatiana Adarli Fioravanti Lui1, Giovana Arlene
Fioravanti Lui2, Adamo Lui-Netto2
A BSTRACT
Purpose: To evaluate tear film stability, ocular surface staining and tear secretion in patients undergoing PRK and femtosecond laser
LASIK. Methods: Twenty eyes of 10 patients submitted to femtosecond laser LASIK and 11 eyes of the 6 patients submitted do PRK
underwent tear film break-up time (TBUT), Schirmer’s basal and lissamine green staining measurements pre and postoperatively
on days 15 (PO 15) and 30 (PO 30). Results: When grouping all eyes TBUT was reduced on PO 15 (p=0.025) and on PO 30 (p=0.001)
compared to preoperative values. No difference was found between PO 15 and PO 30 (p=0.219). Compared to preoperative
measurements, lissamine green test demonstrated a significant increase in score on PO 15 (p=0.021) and a significant reduction on
PO 30 (p=0.010), when both groups were analyzed together (all 42 eyes). No changes in Schirmer’s basal test were detected in all 3
time periods (p=0.107). TBUT, lissamine green and Schirmer’s basal measurements were no different in all 3 time periods when both
groups (PRK and femtosecond laser LASIK) were compared. Conclusion: TBUT and lissamine green measurements were altered
after refractive surgery regardless the technique (PRK or femtosecond laser LASIK). When comparing one technique to the other,
no difference was found in all measurements.
Keywards: Dry eye syndromes; Tears; Refractive surgical procedures; Keratomileusis, laser in situ; Corneal surgery, laser;
Photorefractive keratectomies
RESUMO
Objetivo: Analisar a secreção lacrimal, coloração da superfície ocular e estabilidade do filme lacrimal em indivíduos submetidos à
cirurgia de PRK e LASIK com laser de femtossegundo (femto LASIK). Métodos: Vinte olhos de 10 pacientes submetidos à técnica de
Femto LASIK e 11 olhos de 6 pacientes submetidos à técnica de PRK foram estudados de forma prospectiva, longitudinal e intervencionista.
Tempo de rotura do filme lacrimal (TRFL), teste de Schirmer basal e coloração da superfície ocular com lissamina verde foram
analisados no pré-operatório (pré), no 15º e no 30º dia pós-operatório (15º pós e 30º pós, respectivamente). Resultados: Agrupando
todos os olhos, observou-se que o TRFL reduziu-se de forma estatisticamente significante no 15º pós em relação ao valor pré-operatório
(p=0,025), mantendo-se reduzido no 30º pós (p= 0,001); não houve diferença estatisticamente significativa entre o 15º pós e o 30º pós
(p=0,219). No teste da lissamina verde, houve aumento significativo desse escore, no 15º pós em relação ao período pré-operatório
(p=0,021), havendo, posteriormente, redução no 30º pós (p=0,010). No teste de Schirmer basal, não foi detectada mudança estatisticamente significante ao longo dos três momentos (p=0,107). Comparando-se os testes TRFL, lissamina verde ou Schirmer basal, nos dois
grupos estudados (PRK e LASIK), não houve diferença estatisticamente significante em nenhum dos três momentos (pré, 15º pós e 30º
pós). Conclusão: Evidenciou-se alteração do filme lacrimal nos pacientes submetidos à cirurgia refrativa, quando foram utilizados os
testes de TRFL e lissamina verde. Nas duas técnicas empregadas, não houve diferença estatisticamente significante de alteração do filme
lacrimal, quando comparadas entre si (PRK e LASIK).
Descritores: Síndrome do olho seco; Lágrimas; Procedimentos cirúrgicos refrativos; Ceratomileuse assistida por excimer laser in
situ; Cirurgia da córnea a laser; Ceratectomia fotorrefrativa
1
2
Santa Casa de Misericórdia Hospital, São Paulo/SP, Brazil.
Refractive Surgery Unit, Santa Casa de Misericórdia Hospital, São Paulo/SP, Brazil.
The authors declare no conflict of interest.
Received for publication 24/06/2014 - Accepted for publication 02/07/2014
Rev Bras Oftalmol. 2014; 73 (5): 273-8
274
Leite RA, Nosé RM1, Daga FB, Lui TAF, Lui GAF, Lui-Netto A
INTRODUCTION
METHODS
efractive surgery techniques have been continually
evolving, with photorefractive keratectomy (PRK) and
laser-assisted in situ keratomileusis (LASIK) being the
two most commonly used techniques.Both procedures are
considered safe and produce photoablation of corneal tissue,
thus changing its refractive power.(1,2) Studies show that LASIK
is the most common refractive procedure for mild to moderate
myopia, and there are different devices for creating the corneal
flap. (2,3) Mechanical microkeratomes are the most used,
promoting rapid visual recovery with minimal discomfort..An
alternative is femtosecond laser, an automated device for
creating a corneal flap; it is safer, more reliable and predictable,
and may reduce the risk of epithelial defects and striae on the
corneal flap.(4,5)
In clinical practice, many patients complain of dry eye
sensation after refractive surgery.(1,2)Attention should be given
to this matter, because dry eye syndrome can severely affect a
patient’s quality of life.For example, patients with moderate to
severe dry eye report quantitative quality of life scores similar
to patients with moderate to severe angina or patients
undergoing dialysis.Furthermore, dry eye is the main cause for
dissatisfaction after refractive surgery.(2,5,6)
Several studies based on quantitative tests have
demonstrated an increased incidence of dry eye in the first
monthsafter refractive surgery.(1,2,5-8) Several theories attempt
to explain the onset of the syndrome after refractive
surgery.There is a complex interaction between afferent sensory
nerves of the ocular surface and autonomic efferent nerves of
the lacrimal gland which modulate tear secretion.Any factor
interfering with that relationship can cause dry eye.(1,5) Sensory
nerves of the corneaarisingfrom the ophthalmic and maxillary
branches of the trigeminal nerve penetrate through the limbus,
forming a thick nerve bundle in the anterior third of the cornea;
those nerves then penetrate Bowman’s layer and form the
epithelial-subepithelial plexus between the basal epithelial cells
and Bowman’s layer.When these nerves are cut while creating
the corneal flap in LASIK and during photoablation in PRK,
this harmony is affected, which can cause dry eye. (1,2,5-8) In
addition, postoperative inflammation near the nerve endings
could stimulate the production of cytokines, thus exacerbating
the condition.Furthermore, both refractive surgery techniques
alter the corneal curvature, changing the relationship
betweenthe tear surface and the eyelids during blinking and
affecting tear distribution. (5) Another proposed
pathophysiological mechanism is based on the observation that
the number of goblet cells can be decreasedin patients submitted
to LASIK, probably due to direct damage by the suction
deviceduring the creation of the corneal flap (using either a
microkeratome or femtosecond laser).(4,5)
The aim of this study was to determine whether patients
undergoing PRK and LASIK with femtosecond laser exhibit
postoperativequantitative changes in tear production or
changes in tear film stability and whether any of the two
techniques is associated with a higher incidence of such changes,
using the following tests:tear film breakup time (TFBU), the
basal Schirmer test, and the lissamine green test.
A prospective, longitudinal intervention study was
performed on 31 eyes (16 patients), of which 20 eyes (10 patients)
were submitted to LASIK with femtosecond laser and 11 eyes
(6 patients) underwent PRK.Patients were seen at the Refractive
Surgery Unit of Santa Casa de Misericórdia Hospital, São Paulo,
between August 2012 and May 2013; all procedures were
performed on June 27, 2013 at the Eye Clinic Day Hospital, a
private eye clinic, free of any charge.Patients with contact
lensesdiscontinued their useone month before surgery.
The study was approved by the Research Ethics
Committee of Santa Casa de Misericórdia under number 261728.
Inclusion criteria weresubjects over 21 years of age with
refractive errorsthat had been stable for at least one year, with a
spherical equivalent between -1.50 and - 6.00 dioptres and less
than 2.00 cylindrical dioptres, normal corneal topography, and
without other eye diseases.
Exclusion criteria werepatientsunable to attend follow-up
visits, previous eye surgery, systemic diseases and/or eye diseases
that could alter the tear film, and patients using drugs that could
interfere with tear production.
The decision to use PRK or LASIK was based on each
patient’s corneal thickness and refractive error.
Patients underwent the following tests a week before
surgery (Pre), on the 15th postoperative day (15 PO), and on the
30 thPO day (30 PO): TFBU,the basal Schirmer test, and the
lissamine green test.All tests were performed in the same
environment, in a closed room.
TFBU was performed instilling one drop of fluorescein on
the conjunctival sac.The patient was instructed to blink several
times to distribute the fluorescein evenly, being then submitted
to slit lamp examination with a cobalt blue filter.A digital
stopwatch was used to count the time (in seconds) between the
last blink and the appearance of the first dry spot.
Lissamine green staining was then performed by placing
the lissamine tape in contact with the lacrimal meniscus of the
lower conjunctival sac, with analysis 2 minutes laterusing the van
Bijsterveld classification.The palpebral fissure was divided into
3 areas:lateral bulbar conjunctiva, cornea, and medial bulbar
conjunctiva.In each area, the following classification was used:0,
no staining; 1, isolated thin spots; 2, grouped coarse spots;
3,plaque.The sum for each of these areas was then calculated,
producing the final score (range, 0-9).
After 10 minutes the basal Schirmer test was performed.A
drop of anaesthetic was instilled in the inferior fornix.A strip of
Whatman filter paper No.41, 5-mm wide and 35-mm long, was
then placed between the middle and lateral thirds of the lower
eyelid.After 5 minutes, the strip was removed and the moist part
of the filter paper was measured.
R
Rev Bras Oftalmol. 2014; 73 (5): 273-8
Surgical technique
WaveLight EX500™ (Alcon) excimer laser was used for
PRK.Bandage contact lenses were applied after the procedure
for seven days.Patients were prescribed moxifloxacin 0.5%
(Vigamox™ Alcon) eye drops every 6 hours for 7 days, ketorolac
tromethamine (Acular™, Alcon) eye drops every 6 hours for 3
days, and prednisolone acetate0.12% (Ster MD™, Genom),
which was phased out over six weeks.
Analysis quantitative and qualitative of the tear film in patients undergoing PRK and LASIK with femtosecond
In patients submitted to LASIK, the corneal flap was
created using the LDV Z6™ (Ziemer) femtosecond laser with a
110-µm thickness, and photoablation was done using the
WaveLight EX500™ (Alcon) excimer laser.Patients were
prescribed combined eye drops of moxifloxacin 0.5% +
dexamethasone 0.1% (Vigadexa™, Alcon) for seven days.
275
Chart 1
Distribution of patients submitted to PRK and LASIK
according to gender.
R ESULTS
The following tests were used for statistical analysis:
• Fisher’s exact test for comparing the gender distribution
of patients between the two groups (PRK and LASIK);
• Student’s t-test for independent samples for comparing
the age (years) of patients between the two groups;
• ANOVA with blocks for comparing the results of TFBU
(seconds), lissamine green (score), and basal Schirmer test
(millimetres) at the different time points (Pre, 15 PO and 30 PO),
as well as the LSD method for multiple comparisons when
necessary;
• ANOVA with repeated measures for comparing the
results of TRFL, lissamine green and basal Schirmer test at the
different time points (Pre, Post 15 and Post 30)between the two
groups (PRK vs. LASIK).
Chart 2
One-dimensional scatter plot for the age (years) of
patients submitted to PRK and LASIK.
In all conclusions reached through inferential analysis a
significance level of p = 5% was adopted.
Table 1
Distribution of patients submitted to PRK and LASIK
according to gender and age.
Genre (n%)
Female
Male
Total
Age (years) 0
N
Mean
Median
Minimum
Maximum
Standarddeviation
a
PRK
LASIK
Total
p-value
5 83.3
1 16.7
6 100.0
7 70.0
3 30.0
10 100.0
12 75.0
4 25.0
16 100.0
>0.999a
6
10
16
33.7
33.5
26.0
45.0
32.1
32.0
22.0
52.0
32.7
32.0
22.0
52.0
7.6
9.0
8.3
0.728b
Fisher’s exact test, bStudent’s t-test for independent samples.
In the PRK group 83.3% of patients were female, compared
to 70% in the LASIK group.There were no statistically-significant
differences between groups regarding gender (p >0.999).Mean
age was 33.7 ± 7.6 in the PRK group and 32.1 ± 9.0 in the LASIK
group, and the difference was not significant (p = 0.728). (Table
1, Charts 1 and 2).
The TFBU results for all patients combined were13.2 ± 3.3
preoperatively, 11.3 ± 4.4 at 15 PO, and 10.4 ± 3.2 at 30
PO.Statistically-significant differences were found between Pre
and 15 PO (p = 0.025) and between Pre and 30 PO (p = 0.001),
but not between 15 PO and 30 PO(p = 0.219).The results of the
lissamine green test were1.0 ± 0.9 preoperatively, 1.3 ± 1.0 at 15
PO, and 1.0 ± 1.0 at 30 PO.Statistically-significant differences were
found between Pre and 15 PO (p = 0.021) and between 15 PO
and 30 PO (p = 0.010), but not between Pre and 30 PO(p =
0.768).Finally, the results of the Schirmer testwere17.6 ± 10.6
preoperatively, 14.5 ± 10.8 at 15 PO, and 16.2 ± 11.0 at 30 PO;
there were no statistically-significant differences between the
three time points (p = 0.107) (Table 2).
Rev Bras Oftalmol. 2014; 73 (5): 273-8
276
Leite RA, Nosé RM1, Daga FB, Lui TAF, Lui GAF, Lui-Netto A
Table 2
Mean values and standard deviation of the results ofTFBU (seconds),
lissamine green (score) and basal Schirmer test (millimetres).
p - Valuec p-Valued
Time
Mean ± Standard deviation
Range
pre
15 PO
30 PO
13.2 ± 3.3
11.3 ± 4.4
10.4 ± 3.2
8,0 – 18.0
4,0 – 20.0
6,0 – 16.0
Lissamine
pre
15 PO
30 PO
1.0 ± 0.9
1.3 ± 1.0
1.0 ± 1.0
0,0 – 3.0
0,0 – 3.0
0,0 – 3.0
0.019
0.021*
0.010**
0.768***
Schirmer
pre
15 PO
30 PO
17.6 ± 10.6
14.5 ± 10.8
16.2 ± 11.0
0,0 – 35.0
0,0 – 35.0
0,0 – 35.0
0.107
-
TRFL
0.003
0.025*
0.219**
0.001***
c
ANOVA with blocks, dMultiple comparisons using the LSD method
*Comparison between Pre and 15 PO; **Comparison between 15 PO and 30 PO;
***Comparison between Pre and 30 PO.
Table 3
Means and standard deviationsfor the results of TFBU (seconds), lissamine
green (score) and basal Schirmertest (millimetres).
Test
Teme
PRK
LASIK
p-Value
TRFL
pre
15 PO
30 PO
12.7 ± 2.8
10.5 ± 3.1
10.8 ± 3.0
13.4 ± 3.5
11.8 ± 5.1
10.2 ± 3.4
0.744c
Lissamine
pre
15 PO
30 PO
1.5 ± 0.9
1.7 ± 0.9
1.4 ± 1.1
0.8 ± 0.9
1.1 ± 1.0
0.8 ± 0.9
0.093c
Schirmer
pre
15º PO
30 PO
15.9 ± 10.4
11.9 ± 7.1
13.8 ± 6.9
18.6 ± 10.9
16.1 ± 12.5
17.7 ± 12.9
0.394c
c
p-value for the comparison between PRK and LASIK using ANOVA with repeated measures.
Chart 3
Chart 4
Mean individual profiles for the results of TFBU
(seconds)in patients submitted to PRK and LASIK.
Mean individual profiles for the results of the lissamine
green test (score) in patients submitted to PRK and
LASIK.
Rev Bras Oftalmol. 2014; 73 (5): 273-8
Analysis quantitative and qualitative of the tear film in patients undergoing PRK and LASIK with femtosecond
Chart 5
Mean individual profiles for the results of the
basal Schirmer test (millimetres) in patients
submitted to PRK and LASIK.
When the two groups (PRK and LASIK) were analysed
separately, the following results were found:in the TFBU test,
the values at Pre, 15 PO and 30 PO, respectively, were12.7 ± 2.8,
10.5 ± 3.1, and 10.8 ± 3.0 for the PRK group, and13.4 ± 3.5, 11.8 ±
5.1, and 10.2 ± 3.4 for the LASIK group. There were no
statistically-significant differences between groups (p = 0.744).In
the lissamine green test, the values at Pre, 15 PO, and 30 PO
were1.5 ± 0.9; 1.7 ± 0.9 1.4 ± 1.1 for the PRK group, and0.8 ± 0.9,
1.1 ± 1.0, and 0.8 ± 0.9 for the LASIK group.Again, there were
no significant differencesbetween groups (p = 0.093).In the basal
Schirmer test, the values at Pre, 15 PO and 30 PO were15.9 ± 10.4,
11.9 ± 7.1, and 13.8 ± 6.9 for the PRK group, and18.6 ± 10.9, 16.1
± 12.5, and 17.7 ± 12.9 for the LASIK group.Once again, there
were no statistically-significant differences between groups (p =
0.394) (Table 3).
DISCUSSION
Regarding the sample population of this study, it is
important to stress that there were no statistically-significant
differences between groups (PRK and LASIK)regarding age or
gender (Table 1, Charts 1 and 2) which could influence the
incidence of dry eye in each group.Older patients and women
are more likely to develop dry eye.(6)
When all patients were grouped together, there was a
statistically-significant reduction inTFBU values at 15 POin
relation to preoperative values, and at 30 PO the values had
decreased a little more (but with no significant difference
compared to 15 PO) (Table 2, Chart 3).This is consistent with
some studies in the literature which found a decrease in TFBU.(7,8)
TFBU is an important test to assess the stability of the tear film,
and together with the evaluation of symptoms, it is considered
the most reliable test for dry eye syndrome because it is more
reproducible, i.e. it shows less variation between two tests.(9)Thus,
this study confirms that patients undergoing refractive surgery
have a tendency to develop dry eye.
277
In the lissamine green test, a significant increase was found
at 15 POcompared to the preoperative period, followed by a
significant decrease at 30 PO, reaching a score statistically similar
to preoperative values (Table 2, Chart 4).Lissamine green is an
important dye thatstains damagedcells in the conjunctival and
corneal epithelium, which can be found in patients with lacrimal
film deficiency.Its action is similar to rose bengaldye, but it causes less irritation.The lissamine green test is moderately
reproducible. (9)Itshowed that epithelial cells were actually
damaged in the first two postoperativeweeks regardless of the
surgical technique, with scores returning to normal within a month
after surgery.Such damage may have been caused by the
procedure itself or may be a consequence of dry eye.
In the basal Schirmer test, no statistically-significant
differenceswere found between the three time points (Pre, 15
PO, and 30 PO) (Table 3, Chart 5), in contrast with several other
studies.(1,7,8)As can be seen in the chart, Schirmer test values
tended to decrease postoperatively, but the reduction was not
statistically significant.It should be noted that most previous
studies used the type 1Schirmer test (without instillation of
anaesthetic eye drops) following refractive surgery instead of
the basal Schirmer test used in ourstudy (where anaesthetic eye
drops were instilled in conjunctival sac before placing the
Schirmer strip).The type 1 Schirmer test is probably more affected
after refractive surgery, as it assesses both basal and reflex tear
secretion, while the basal Schirmer test assesses basal secretion
only.However, Nichols et al.(9)showed that the type 1 Schirmer
test has poor reproducibility in patients with mild to moderate
dry eye, being more reliable only in patients with severe dry
eye.This is why we elected to use the basal Schirmer test in this
study.Moreover, the preoperativeevaluation of patients included
an assessment of static refraction with anaesthetic, cycloplegic,
and tropicamide eye drops on the same day as the dry eye tests
were conducted;therefore, the basal Schirmer test was also
preferred to avoid any bias that could have been caused by the
residual influence of those drugs.
It should also be noted that even though all tests were
conducted in the same environment in a closed room, there were
variations in temperature and humidity in the city of São Paulo,
where the experiment was conducted, which could certainly have
influenced results.
Some studies show that patients submitted LASIK have a
higher incidence and a longer duration of dry eye than those
undergoing PRK(7,8).In our study, however, neither technique
was superior to the other in the three time points (Pre, 15 PO
and 30 PO) (Table 3).This may be related to the fact that other
studies used a microkeratome, instead of femtosecond laser, to
create the corneal flap.The introduction of femtosecond laser in
LASIK has created the prospect to reduce the incidence of dry
eye, as it is a safer and more accurate method than the
microkeratome. (4,5) Salomão et al. (10) found that patients
submitted to LASIK whose corneal flap had been created using
the femtosecond laser showed less dry eye than those whose
flap had beencreated with a manual microkeratome.In contrast,
Golas et al.(6)found no statistically-significant differences between
these two groups as regards dry eye symptoms.
It is therefore important to stress the need to observe
patients closely for the development of dry eye after
surgery.Furthermore, according to our results, there were no
significant differences between both surgical techniques as
regards changes in the tear film.
Rev Bras Oftalmol. 2014; 73 (5): 273-8
278
Leite RA, Nosé RM1, Daga FB, Lui TAF, Lui GAF, Lui-Netto A
CONCLUSION
The present study foundchanges in the tear film of patients
submitted to PRK and LASIK with femtosecond laser; in particular, changes were observed in the TFBU and lissamine green
tests, with the latter returning to preoperative values within a
month after surgery.No significant changes were found in the
Schirmer test within the first postoperative month.PRK and
LASIK with femtosecond laser produced similar changes to the
tear film.
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with femtosecond laser and mechanical keratome. J Cataract
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2000; 26(9):1326–31.
8. Nejima R, Miyata K, Tanabe T, Okamoto F, Hiraoka T, Kiuchi T,
Oshika T Corneal barrier function, tear film stability, and corneal
sensation after photorefractive keratectomy and laser in situ
keratomileusis. Am J Ophthalmol. 2005; 139(1):64-71.
9. Nichols KK, Mitchell GL, Zadnik K. The repeatability of clinical
measurements of dry eye. Cornea. 2004;23 3):272–85.
10. Salomão MQ, Ambrósio R Jr, Wilson SE. Dry eye associated with
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Correspondência com o autor:
Rubens Amorim Leite
Rua Doutor Diogo de Faria, no85, apto 72,
Vila Clementino, São Paulo, Brazil.
Phone: (11) 98568-5500
E-mail: [email protected]
ORIGINAL ARTICLE
279
Novel spatula and dissector for safer deep
anterior lamellar keratoplasty
Uso de espátula e dissector para otimização da ceratoplastia
lamelar anterior profunda (DALK)
Gustavo Bonfadini1,2,3, Eun Chul Kim1,4, Mauro Campos3, Albert S. Jun1
A BSTRACT
Objective: We describe a novel spatula and dissector to facilitate the big-bubble technique in deep anterior lamellar keratoplasty
(DALK). Methods: A 29-year-old man who was diagnosed with bilateral keratoconus underwent deep anterior lamellar keratoplasty
(DALK). After 350µm partial thickness incision of the recipient cornea, the Bonfadini dissector was inserted at the deepest point in
the peripheral incision and could be advanced to the center of the cornea safely because of its “semi-sharp” tip. After achieving the
big-bubble (BB) separation of Descemet membrane (DM) from the overlying stroma, the anterior stromal disc was removed.
Viscoelastic material was placed on the stromal bed to prevent uncontrolled collapse and perforation of DM during the paracentesis
blade incision into the BB. We could detect the safe opening of the BB using the Bonfadini dissector by the leakage of air bubbles
into the viscoelastic material. After injecting viscoelastic material into the BB space, we inserted the Bonfadini spatula into the bigbubble safely because of its curved profile and blunt edges. The groove along the length of the Bonfadini spatula enables safe and
efficient incision or the residual stromal tissue using the pointed end of a sharp blade while protecting the underlying DM. After
removal of posterior stroma, the donor button was sutured with 16 interrupted 10-0 nylon sutures. Results: This technique and the
use of the Bonfadini spatula and dissector facilitate exposure of Descemet membrane. Conclusion: The smooth Bonfadini DALK
spatula and dissector facilitate safe and efficient completion of DALK surgery.
Keywords: Deep anterior lamellar keratoplasty; Corneal transplantation/methods; Keratoplasty; Bonfadini dissector; Bonfadini
spatula
RESUMO
Objetivo: Descrevemos o uso de novos instrumentais cirúrgicos para facilitar a técnica de “big-bubble” na ceratoplastia lamelar anterior
profunda (DALK). Métodos: Paciente masculino, 29 anos, foi diagnosticado com ceratocone bilateral e submetido à ceratoplastia
lamelar anterior profunda (DALK). Após incisão da córnea receptora numa profundidade de 350µm de espessura parcial, o dissector
Bonfadini foi inserido no ponto mais profundo da incisão periférica e pode avançar para o centro da córnea com segurança devido à
sua ponta semiafiada. Depois de realizar a “big-bubble” (BB) e atingir a separação da Membrana de Descemet (MD) do estroma
sobrejacente, o disco corneano de estroma anterior foi removido. Um viscoelástico foi colocado sobre o leito do estroma remanescente
para impedir o colapso não-controlado e perfuração da MD durante a incisão na BB com lâmina de paracentese. Verificamos
segurança no rompimento do estroma remanescente com o auxílio do dissector Bonfadini, para liberação da bolha de ar da BB através
do viscoelástico. Depois de injetar o viscoelástico no espaço da BB, inserimos a espátula Bonfadini neste espaço, o que demonstrou-se
seguro devido ao formato curvo e das bordas arredondadas do instrumental. A chanfradura ao longo do comprimento da espátula
Bonfadini permite a incisão pela ponta de uma lâmina afiada, protegendo assim a MD subjacente. Após a remoção do estroma posterior,
o botão doador foi suturado com 16 pontos interrompidos de fio nylon 10.0. Resultados: Esta técnica e o uso da espátula Bonfadini
e dissector facilitam a exposição de membrana de Descemet. Conclusão: A superfície lisa da espátula Bonfadini e dissector, facilitam a
realização segura e eficiente da ceratoplastia lamelar anterior profunda (DALK).
Descritores: Ceratoplastia lamelar anterior profunda; Transplante de córnea/métodos; Ceratoplastia; Dissector Bonfadini; Espátula
Bonfadini
1
Cornea & Anterior Segment Service, Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA;
Rio de Janeiro Eye Bank, Rio de Janeiro, RJ, Brazil;
3
Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil;
4
College of Medicine, Catholic University of Korea, Seoul, Korea.
2
The authors have no public and private financial support, or financial interest
Received for publication 25/02/2014 - Accepted for publication 26/04/2014
Rev Bras Oftalmol. 2014; 73 (5): 279-81
280
Bonfadini G, Kim EC, Campos M, Jun AS
INTRODUCTION
D
eep anterior lamellar keratoplasty (DALK) has been
proposed as an alternative to penetrating keratoplasty
(PK) for the treatment of various corneal diseases not
affecting the endothelium. DALK surgery removes the anterior
layers of the cornea, cleaving the deep stroma from Descemet
membrane (DM). The advantages of the DALK technique for
corneal stromal diseases include absence of endothelial rejection,
avoidance of potential open-sky intra-operative complications
of PK, faster visual rehabilitation due to earlier suture removal,
and a predicted longer graft survival because of the lower rate of
endothelial cell loss (1).
DALK is a time-consuming and technically demanding
procedure. The most frequent intraoperative complication is
perforation of DM while attempting to separate it from the overlying
stroma during creation of the big-bubble (BB) (2). Sarnicola et al.(3)
reported that a smooth spatula and cannula can facilitate a high
percentage of successful DALK and make the procedure more
reliable than compared to air injection with a needle.
In this report, we describe a novel Bonfadini dissector and
spatula for safely manipulating the big-bubble and removing
posterior stroma.
Surgical technique
A 29-year-old man diagnosed with bilateral keratoconus 6
years ago, visited our service complaining of ocular pain and
decreased vision in the right eye. He had worn rigid gas
permeable (RGP) contact lenses for 16 years. His best spectacle
corrected visual acuity OD was 20/80 and OS was 20/25. Slitlamp examination revealed marked corneal stromal scarring and
epithelial punctuate erosions on the right central cornea. Hence,
deep anterior lamellar keratoplasty (DALK) was completed
uneventfully in the right eye.
The operation was performed under sub-Tenon anesthesia
by A.S.J; The technique described by Anwar et al.(4) was followed
with the described modifications. A surgical marking pen was used
to mark the center of the host cornea. An 8.5mm diameter trephine
was used to lightly score the epithelium of the host cornea to
outline the recipient bed. An astigmatic keratotomy blade was
used to incise the recipient cornea to a depth of 350µm along the
8.5mm trephine mark. Through a small peripheral clear cornea
paracentesis, the anterior chamber (AC) was filled with air, and
approximately physiologic intraocular pressure confirmed.
The Bonfadini dissector (Katena Products, USA; Figure
1A) was inserted at the deepest point in the peripheral groove
and was advanced toward the center of the cornea. Once the
Bonfadini dissector was approximately 1-2mm from the apex of
the cone (Figure 1B), it was removed and the Fogla 27 gauge air
injection cannula (Bausch & Lomb Storz Ophthalmic, USA),
attached to a 5mL syringe filled with air was introduced into the
corneal tunnel. Air was then injected into the stroma to achieve
the formation of a big-bubble (figure 1C). The central anterior
stromal disc was removed with an angled crescent knife, and
then air was evacuated through the previously placed paracentesis.
To enter into the big-bubble, we used the Ophthalmic
Viscosurgical Device–Assisted Incision technique (5). A cohesive
viscoelastic (Healon, Abbott Medical Optics) was placed on the
stromal bed and a 1.0mm incision was then created with a
paracentesis blade using only the tip of the blade with a “lifting”
motion to prevent rapid collapse of the bubble which could result
in Descemet membrane perforation. Entry into the big-bubble was
confirmed by the appearance of a small bubble within the overlying
viscoelastic material, which also served to prevent rapid egress of
air from the big-bubble and rapid collapse leading to a higher
probability of perforating the Descemet membrane (figure 1D).
Rev Bras Oftalmol. 2014; 73 (5): 279-81
Entry into the big-bubble was confirmed by the appearance
of a small bubble within the overlying viscoelastic material, which
also served to prevent rapid egress of air from the big-bubble and
rapid collapse leading to a higher probability of perforating the
Descemet membrane (figure 1D). Viscoelastic material was injected
into the pre-Descemet space to expand the potential space and
separate the Descemet membrane from the overlying stromal tissue.
The Bonfadini spatula (Katena Products, USA; figure 2A)
was introduced into the pre-Descemet space. This instrument
has blunt edges and a curved profile to minimize inadvertent
damage to Descemet membrane. The groove along the length of
the Bonfadini spatula serves as a guide to allow for rapid incision
of the posterior stromal tissue using the sharp point of a
Figure 1: The Bonfadini dissector has a fine, rounded tip to enable stromal
dissection while preventing inadvertent perforation of Descemet
membrane (A); use of the Bonfadini dissector to create a deep tunnel
toward the center of the cornea from a peripheral partial thickness groove
incision (B); big-bubble formation by deep, intrastromal air injection with
accompanying stromal opacification (C); opening of the big-bubble with
a sharp blade was detected by air leaking into viscoelastic material
placed on the posterior stromal bed (D)
paracentesis blade (figure 2B). The spatula serves to protect the
DM from inadvertent perforation while incising the posterior
stromal tissue. Once sufficient radial incisions in the posterior
stroma were completed, we removed stroma with cornealscleral
scissors along the peripheral partial thickness groove incision.
The full-thickness donor graft was punched at 8.75mm diameter
from the endothelial side, and the endothelium was stripped
from the posterior surface using surgical spears. The donor button
was then sutured into position with 16 interrupted 10-0 nylon
sutures (figure 2C).
The patient achieved uncorrected visual acuity of 20/125
and 20/60 with pinhole on day 1 postoperatively with a wellattached graft. At 3 months after DALK, his uncorrected visual
acuity was 20/60 and best spectacle corrected visual acuity (-1.25
+ 1.5 x 30 degrees) was 20/25 OD.
DISCUSSION
Corneal transplantation is singular because it is habitually
performed on persons with visual deficiency but with preserved
life expectancy, mobility and social life. A graft not well succeeded
may cause real blindness and permanent misery due to pain and
discomfort (6). To obtain a satisfactory surgical result, there is a
need of an appropriate patient selection and guidance about
their eye problem, the proposed surgery, care and risk per and
post operative as well as the visual rehabilitation perspective (7).
Novel spatula and dissector for safer deep anterior lamellar keratoplasty
281
In the technique described here, viscoelastic material is placed
on the stromal bed before opening the big-bubble (5). We can
detect entry into the big-bubble (BB) by air leaking into the
viscoelastic material. This sign allows a very controlled entry into
the BB as it is readily and immediately visible and prevents rapid
egress of air and collapse of the BB. Once the BB is accessed and
further expanded by injection of viscoelastic into the BB, the design
of the Bonfadini spatula allows it to be manipulated within the
BB space with minimal chance of inadvertent trauma to DM.
The groove along the length of the Bonfadini spatula also
serves as a convenient guide to facilitate rapid incision of the posterior stroma into wedges, which can be excised at the periphery
using standard corneal scissors. Thus, we present the novel Bonfadini
dissector and spatula as aids for the successful completion of DALK
surgery. In summary, the benefits of our proposed technique could
be shown more conclusively in a case–control or prospective study
with a larger number of patients to validate our findings.
Figure 2: The groove along the Bonfadini spatula serves as a guide to
protect Descemet membrane (DM) from inadvertent perforation when
incising the posterior stroma with a blade (A); creation of wedgeshaped incisions of posterior stroma, using a blade guided along the
groove of the Bonfadini spatula. The spatula serves to protect
inadvertent perforation of DM (B); donor button was sutured into
position with 16 interrupted 10-0 nylon sutures (C)
Keratoconus is one of the main indications of keratoplasty
in Brazil (8), and DALK is more cost-effective than penetrating
keratoplasty (PK) (9). Prevention of immune-mediated graft
rejection can be achieved through meticulous surgical technique
such as lamellar surgery (10).
DALK aims to remove and replace total or near-total corneal
stroma while preserving host healthy endothelium. The advantages
of DALK include reducing the risk of endothelial graft rejection,
preservation of host endothelium with minimal surgical trauma,
efficient visual rehabilitation relative to penetrating keratoplasty
(PK), and also fewer intraoperative and postoperative complications
including expulsive hemorrhage, anterior synechia, postoperative
endophthalmitis, and glaucoma in comparison to PK. This procedure
also requires less rigid criteria for donor corneal tissue selection
that is often weighted toward donor endothelium in PK (11).
Major disadvantages of anterior lamellar keratoplasty as
compared to penetrating keratoplasty are the irregularity and
sub-optimal optics of the corneal stromal bed which occur
following manual lamellar dissection techniques (12). These issues
are avoided in DALK. However, the challenge with DALK continues to be the learning curve for novice surgeons when trying
to expose DM (descemetic DALK [dDALK]) versus dissection
in a pre-Descemetic stromal plane (pre-Descemetic DALK
[pdDALK]) (3). The dDALK procedure allows faster visual
recovery than pdDALK(13). Thus, the goal of DALK is to expose
the DM without damage and to achieve dDALK.
Lamellar dissection of the stroma can be performed by a
manual technique using a variety of instruments, including lamellar
knives and dissectors (14). Using the Bonfadini dissector, we could
create a deep tunnel near the corneal center prior to air injection.
The Bonfadini dissector has a fine, rounded tip, which can dissect
stromal tissue relatively easily while reducing the likelihood of
penetrating Descemet membrane. Accessing the deep stroma for
air injection may improve the success of achieving the big-bubble.
The most serious complication during big-bubble DALK
surgery is intraoperative perforation of Descemet membrane,
which may require subsequent conversion to full-thickness
penetrating keratoplasty (15). Perforation of Descemet membrane
is more likely to occur as a result of direct needle trauma during
initial air injection and dissection of the corneal stroma (16). As
well, perforation of DM can occur while opening the big-bubble
and dissecting remaining stroma over Descemet membrane.
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Rossi T. Factors predicting unsuccessful big bubble deep lamellar anterior keratoplasty. Ophthalmologica. 2006;220(6):379-82.
Sarnicola V, Toro P. Blunt cannula for descemetic deep anterior lamellar keratoplasty. Cornea. 2011;30(8):895-8.
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Modified femtosecond laser-assisted sutureless anterior lamellar keratoplasty. Cornea. 2013;32(4):533-7.
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Address reprint requests to:
Albert S. Jun
Cornea and External Disease Service Wilmer Smith Building
5011, The Johns Hopkins Medical Institutions 400 N. Wolfe
Street, Baltimore, MD 21231
Rev Bras Oftalmol. 2014; 73 (5): 279-81
O
282 RIGINAL
ARTICLE
Serological profile of candidates
for corneal donation
Perfil sorológico de candidatos a doação de córneas
Adroaldo Lunardelli1, Richard Beraldini Alvarenga1, Maria Luiza Assmann1, Dário Eduardo de Lima Brum1, Mirna Adolfina Barison1
A BSTRACT
Objective: The purpose of this study is to map the serological profile of candidates to corneal donation at Irmandade Santa Casa de
Misericórdia de Porto Alegre, identifying the percentage of disposal by serology and the marker involved. Methods: There have been
analised – retrospectively – the results of serology of all corneal donors, made between the period of 1st january 2006 and 31st
december 2012. Data analised were related to age, gender and the results of serology pertinent to viral markers (HBsAg, anti-HBc,
anti-HCV and anti-HIV), these, determined by immunosorbent tests (ELISA). Results: In the period of the study, there were 2476
corneal donors at the institution, with a major incidence on the male gender, on an average of 58.7 years old. 23% of retention
because of serological unfitness was also identified, that is, 570 samples were non-negative to any of the used tests. The marker antiHBc was the most prevalent on the studied population, followed by the Hepatitis C virus (HCV) and by the Human Immunodeficiency
Virus (HIV). Conclusion: From the data found through this study, it is essential to have the participation of an efficient service on the
serological evaluation of the candidates to corneal donation, once the security of the receptor must be taken into consideration in a
population of donors with 23% of unfitness prevalence, in which the most prevalent marker is the one of Hepatits B.
Keywords: Serology; Córnea/immunology; Corneal transplantation
RESUMO
Objetivo: O intento deste desígnio é mapear o perfil sorológico dos candidatos a doação de córneas na Irmandade Santa Casa de
Misericórdia de Porto Alegre, identificando o percentual de descarte por sorologia e o marcador envolvido. Métodos: Foram analisados
– retrospectivamente – os resultados da sorologia de todos os doadores de córneas compreendidos entre 01 de janeiro de 2006 a 31 de
dezembro de 2012. Foram avaliados os dados de idade, sexo e os resultados da sorologia pertinentes aos marcadores virais (HBsAg,
anti-HBc, anti-HCV e anti-HIV) determinados por testes imunoenzimáticos (ELISA). Resultados: No período coberto pelo estudo,
houve 2476 doadores de córneas na instituição, com maior ocorrência do sexo masculino e média de 58,7 anos de idade. Foram
verificados 23,0% de retenção por inaptidão sorológica, ou seja, 570 amostras mostraram-se não-negativas para qualquer dos testes
empregados. O marcador anti-HBc foi o mais prevalente na população aferida, seguido pelo vírus da hepatite C (HCV) e pelo vírus da
imunodeficiência humana (HIV). Conclusão: Diante dos dados encontrados por este estudo, torna-se decisiva a participação de um
serviço eficaz no tangente à avaliação sorológica dos candidatos à doação de córnea, uma vez que a segurança do receptor deve ser
considerada numa população de doadores com prevalência de retenção por inaptidão sorológica de 23,0%, donde o marcador mais
prevalente é o de hepatite B.
Descritores: Sorologia; Córnea/imunologia; Transplante de córnea;
1
Serviço de Hemoterapia, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS), Brazil.
Study carried out at Serviço de Hemoterapia, Irmandade Santa Casa de Misericórdia de Porto Alegre, Rio Grande do Sul, Brazil
The authors have no public and private financial support, or financial interest
Received for publication 15/5/2013 - Accepted for publication 14/10/2013
Rev Bras Oftalmol. 2014; 73 (5): 282-6
Serological profile of candidates for corneal donation
INTRODUCTION
C
orneal diseases are the second cause of reversible
blindness around the world and affects a young and active
population, leading to an important economic and social
problem (1). The corneal transplant (keratoplasty) has developed
fast through the last 10 years (2), and it is considered the most
successful procedure among the human tissue transplants (3).
Corneal transplantation is indicated to a huge variety of diseases
and it provides visual recovering, in an efficient form and low
cost, to patients with corneal opacities and irregularities. The
success of this surgical procedure has been set due to the fact
that the cornea is avascular and there are immunological
privileges on this structure. Advances on the surgical technique
(4)
, equipment, materials, methods to preserve the donated cornea
and postoperative handling have also contributed to the success
of the corneal transplants (5). The intervention of the eye banks
is essential in the search for donors, in the interview with the
families, in the quality of processing and distribution of the
donated tissues. The quality control of the whole process and
distribution of donor cornea begins with the selection of the
donors, careful processing using proper techniques of ocular
globe enucleation, preservation of the cornea and evaluation of
parameters, such as donor serology and endothelial cells counting
and the slit lamp evaluation of the donor cornea by an
experienced ophthalmologist (6).
Because of the increase in the number of corneas donated
and kept for longer periods, the careful evaluation becomes an
indispensable procedure and of high responsibility by the ocular tissue banks (7). Positive serologic testing results are one of
the major reasons for discarding donor corneas (8). Despite being
rare, the potential for the transmission of diseases through organ
and tissue grafts exists; even with avascular tissues, as the cornea,
have already demonstrated being a way of contamination and
transmition. There are reports of infections caused by bacteria,
fungi, viruses and even prions acquired by corneal transplant (9).
The Brazilian Law does not allow the use of tissues to transplant
whose donor present positive serology to hepatitis B, hepatitis
C or human immunodeficiency virus (HIV) (9) (according to
Resolução da Diretoria Colegiada – RDC – number 67). The
intention of this study is to map the serological profile of the
candidates of corneal donation at Irmandade Santa Casa de
Misericórdia de Porto Alegre (ISCMPA), and identify the
percentage of disposal by serology and the marker involved.
283
Genescreen HIV 1/2 version 2 Bio-Rad). To Hepatitis C, the
research of anti-HCV antibodies was made with the kit HCV 3.0
Ortho improved by SAVe. To Hepatitis B, anti HBc and HBsAg
were measured through the kits anti-HBc Plus Bio-Rad and
HBsAg Ultra Bio-Rad, respectively. The results of each serology
were classified as fit (negative, according to manufacturer’s
criteria) or unfit (inconclusive or positive, according to
manufacturer’s criteria). The data is shown in absolute numbers
or percentages. No statistical analysis was applied because it is
exposed descriptive data.
R ESULTS
This study shows that, on average, Irmandade de Santa
Casa de Misericórdia de Porto Alegre receives 353 corneas
donations a year. During the period of the study, there were
2476 corneal donors at the institution (figure 1), mostly from the
male gender (56% male, figure 2) and average of 58,7 years old
(±15,5, standard deviation) and median and mode of 61 and 62,
respectively. Table 1 shows the age distribution of 2182 donors,
from whom there had been access to the referred parameter.
Twenty-three per cent of retention because of serological
unfitness was also identified, that is, 570 samples were nonnegative to any of the used tests (figure 3). The marker anti-HBc
was the most prevalent on the studied population, followed by
the hepatitis C virus (HCV) and by the human immunodeficiency
virus (HIV), as shown on table 2.
Figure 1: Distribution of the number of candidates to corneal donation
stratified per year
M ETHODS
There have been analysed – retrospectively – the results of
serology of all corneal donors at ISCMPA between the period
of 1st january 2006 and 31st december 2012. Data was obtained
through the analisys of the electronic data bank of the institution,
Irmandade Santa Casa de Misericórdia de Porto Alegre. All
corneas which were captured, evaluated and kept are there in
this data bank. There have been evaluated data related to age,
gender and the results of serology pertaining to viral markers
(HBsAg, anti-HBc, anti-HCV and anti-HIV). The blood samples
were obtained according to conditions of accessibility. The blood
was kept in a dry and non-preservative tube, centrifuged to 3000
rpm for five minutes and the supernatant serum was used to
dosages of immunoenzymatic tests (ELISA). Two tests to detect
HIV were used: Genescreen Ultra HIV AgAb Bio-Rad and
Figure 2: Distribution of corneal donors, showing the percentage of
individuals from the male (M) and female (F) gender
Rev Bras Oftalmol. 2014; 73 (5): 282-6
284
Lunardelli A, Alvarenga RB, Assmann ML, Brum DEL, Barison MA
DISCUSSION
Figure 3: Distribution of the percentual of individuals according to
serological fitness
Table 1
Distribution of the percentual of corneal donors
according to age range
Age range
(%)
≤ 20
21 to 30
31 to 40
41 to 50
51 to 60
61 to 70
71 to 80
≥ 81
3.16
4.17
4.95
10.72
25.44
26.49
24.66
0.41
Total
100.0
Table 2
Distribution of corneal donors stratified by serology
Test
Frequency
Percentage
on the total
of donors
Percentage
on the total
of restraints
1.58
55.26
19.82
7.89
4.74
6.67
2.11
1.40
0.35
0.18
HBsAg
A-HBc
HCV
HIV
A-HBc + HBsAg
A-HBc + HCV
A-HBc + HIV
A-HBc + HCV + HIV
A-HBc + HBsAg + HIV
HCV + HIV
9
315
113
45
27
38
12
8
2
1
0.36
12.72
4.56
1.82
1.09
1.53
0.48
0.32
0.08
0.04
Total
570
23.0
Rev Bras Oftalmol. 2014; 73 (5): 282-6
100.0
The cornea is the most commonly transplanted tissue in
the world (2); however, one of the major restrictions for the
increase of transplants is due to the number of donations (10). In
many states of Brazil, the lack of ocular tissues and eye banks
which are able to provide corneas in adequate number and
quantity to be transplanted is, unfortunately, real (11). However,
efforts have been made to change this reality (12).
This study shows, according to other authors, that there
is a high percentage of donors of the male gender (9,13). The
minimum and maximum ages of a donor for the usage of the
tissue vary according to medical regulations of each eye bank
(1)
. In this study, the minimum and maximum ages found were
of 3 and 84, respectively. The age average found in this study
(58.6 years old) supports other studies, which show an age
average of 60 (1,9), despite other works refer to minimum ages
even lower (3,13,14). Scientific literature shows that there is no
restriction of age to corneas donated and age is not issue to
low survival of the graft; what’s more, quality in the
biomicroscopic and specular microscopic evaluation of the
endothelium have to be taken into consideration when using
corneas (7). However, old age is taken as a limiting factor, once
most surgeons prefer not to use corneas from patients over 75
years old. This age is arbitrary, once the age of the donor does
not seem to be related to the survival of the graft (1), though,
factors as advanced age range and presence of debilitating
diseases tend to coexist and increase the chances of finding a
worse evaluation of quality when compared to corneas of young
donors and/or trauma deaths (7). Studies show that corneas of
donors in advanced ages can be perfectly acceptable for
transplants, showing that these tissues when coming from older
donors (over 80 years old) present a lower chance of failure or
post transplant rejection than younger corneas (15). There are
eye banks that stipulate a minimum age for donation, and it can
reach 10 years old (1,11). Because of this, scientific literature is
conflicting and inconclusive about the effect of the age of donors
related to the survival of the transplanted cornea (16,17).
Viral infections transmitted through transplants have
already been reported, once the viruses remain in the tissue after
the collection; because of this, the serological screening is an
important precondition to the tissue banks (8) and the clinic
screening does not exclude the undertaking of serological tests. In
this study, the corneas to be used in donation, 23% (570) were
retained for being considered serologically inappropriate. This
percentage is lower than the ones found in other studies, for
instance, an eye bank in São Paulo, Brazil, registered a disposal of
33.4% in 2006-2007 (9) or the eye bank in Cascavel, a city in the
state of Paraná, also in Brazil, reported a serological disposal of
51.8% (11); however, the percentage found in this study is higher
than the one found in a study in Minas Gerais, Brazil, where 9% of
1668 corneas were discarded because of positive serology (18). It is
important to mention that the commercial tests are not
recommended to serum of corpses; however, there are not specific
tests to this end. The corpse sample is usually of low quality. In
many cases, the serological tests can show false-positive results in
samples post-mortem, which can lead to an unnecessary disposal
of the cornea. The time of collection after death and the immediate
separation of the serum (centrifugation) are two steps that can
affect the quality of the sample (8). It is crucial that the multidisciplined team – militant in the procedures of collection and
Serological profile of candidates for corneal donation
storage of ocular tissues – is shrewd to proceed to the blood
collection as soon as possible after the death of the donor and
make the centrifugation of the collected material right after that.
These measures increase serological tests in quality. What’s more,
it is clear that the combination between the lower period of time
from death to the preservation of the material generates better
quality of the cornea. Among the explanations of the influence
from the time of death and enucleation and/or preservation of the
corneal tissue quality are the possible metabolical alterations or
even anatomical alterations in the cornea during this process (15).
The Brazilian Law (RDC 67 from 30th september 2008)
demands two serological tests to the detection of hepatitis B
(HBsAg and anti-HBc), which exclude donors in case of positivity.
In this study, the major part (55.26%) of retentions is due to
anti-HBc (table 2) individually, which represents 12.72% from
the total of donations. A study made with corneal donors in the
region of Cascavel (state of Paraná) revealed disposal because
of isolated positivity of anti-HBc of 47.4% on the total of donors.
It has already been reported that, in this city, positivity to antiHBc in donors of blood is significantly higher than in other
regions of the same state; however, when the presence of the
DNA of hepatitis B virus was detected (a more sensitive and
specific test to determine the potential of infectivity of the virus)
in donors of blood with positive serology to anti-HBc and
negative to HBsAg, there had reached to the result of inexistence
of the DNA of the hepatitis B virus in the samples (11). Experts
question the adoption of serology anti-HBc to screening corneas
(18)
due to its high sensitivity but low specificity (11). The Eye Bank
Association of America forebodes only the undertaking of
HBsAg as a screening method to hepatitis B, not including in its
routine the anti-HBc (11). This idea does not seem reasonable, for
most tests used to the serological diagnosis being very sensitive
and specific; they cannot detect all cases of hepatitis B. Several
studies show that, after undertaking the conventional screening
(HBsAg and anti-HBc), when making the research of anti-HBs
in the individuals non-reagent to HBsAg, but reagent to antiHBc, 10 to 34% will be also non-reagent to anti-HBs, being
classified as anti-HBc isolated (19). The presence of this profile is
consistent with (a) old infection with low levels of anti-HBs, (b)
period of immunological window, (c) false positive reaction and
(d) HBsAg chronic carrier non-detectable. Through tests of
amplification of nucleic acids, it was proved the presence of the
DNA of the hepatitis B virus in 1.34% of donors HBsAg negative
with anti-HBc positive (19). The detection of cases with anti-HBc
isolated can be avoiding not only the transmission of wild strain
(not detected due to the low viral load present in individuals
with non-detectable levels of HBsAg) but also the transmission
of mutant strains (19). Nowadays, the non-detection of HBsAg
marker due to the appearance of these mutant strains has been
cause of concern. The analytic sensitivity of tests to the detection
of HBsAg may rely on the genotype or subtype of the hepatitis
B virus (19).
In this study, the presence of anti-HBc together with HBsAg
was found in 4.74% of unable donors, reaching 1.09% of the
total of donations. This rate is similar to the one in the region of
Cascavel, which shows 1.5% of retention to this association of
markers (11). This profile is consistent with the acute phase or the
chronic carry of hepatitis B (20).
Also, in this study there is a report on table 2 about the
prevalence of 4.56% to HCV and 1.82% to HIV. These levels are
285
superior to the ones found in eye banks of São Paulo (9) and
Cascavel (11). The presence of anti-HBc together with HCV was
found in 38 candidates to donation, prevailing 1.53% (6.67%
among the retained ones). This situation is common, and it can
represent several other situations, among them, hidden hepatitis
B in patients with chronic hepatitis C (21,22).
The usage of nucleic acid tests to confirm (or not) positive
results is foreboded once these tests would really detect the
existence of infection, for antibodies detected through traditional
serological methods could persist for longer time after active
infection has stopped; however, one of the limiting factors to
serological screening with acid nucleic tests are the costs (9). Tissue
Banks must evaluate the usage of this kind of test because they
reduce the risk of viral infections caused by grafts (8). This ideal
situation is still not tangible to our reality, because of the excessive
burden of the process.
The plurality of professionals involved in a transplant of
cornea is imperative facing the extensive work done in this
process. It is essential, though, that the teams are aligned with
the development of the work. It is essential to have the
participation of an efficient service on the serological evaluation
of the candidates to corneal donation, once the security of the
receptor must be taken into consideration in a population of
donors with high unfitness prevalence. In this context, the
adoption of nucleic acid tests will enhance quality to the process
in a near future.
Works like this one are of elementary importance because
they bring – to the scientific community – the profile of the corneal
tissues donated, and from these data, they enable institutions to
take measures in relation to implementing services of eye banks
based on the knowledge they have about the target public. In
our study, we show retention of 23% for serological unfitness.
This index is considered high if compared to serological retention
of blood donation, for instance. This fact occurs because there is
no clinic retention to candidates of corneal donation, once the
personal interview is impossible to be made, as the donors are
corpses. The most prevalent marker was referent to Hepatitis B,
followed by HCV and HIV. This study confirms the validity and
the importance of serological tests so to exclude positive
serological corneas to prevent infections, which could be
transmitted to eventual cornea receptors
Aknowlodgements
The authors thank Marcela Migliavacca Alvarenga for their
translation support.
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Filho C. Causes of nonuse of corneas donated in 2007 in Minas
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Corresponding author:
Dário Eduardo de Lima Brum
Serviço de Hemoterapia, Irmandade Santa Casa de Misericórdia
de Porto Alegre
Rua Professor Annes Dias, nº 295- CEP 90020-09 - Porto Alegre
(RS), Brazil - Phone: 55 (51) 3214-8263
E-mail: [email protected]
ORIGINAL ARTICLE
287
Sealing the gap between conjunctiva and
Tenon’s capsule in primary pterygium surgery
Adição do selamento entre conjuntiva e cápsula de Tenon
em cirurgia de pterígio primário
Ricardo Alexandre Stock1, Luan Felipe Lückmann2, Gabriel Alexander Ken-Itchi Kondo2, Elcio Luiz Bonamigo1
A BSTRACT
Objective: To assess the results of an alternative surgical approach in the excision of primary pterygium by analyzing the rates of
recurrence and of intraoperative and postoperative complications. Methods: Retrospective cross-sectional study based reviewing
the clinical records of individuals subjected to surgery for pterygium, with conjunctival autograft transplantation, fibrin glue and
intraoperative application of mitomycin C. In addition, sealing was performed by suturing the gap between the conjunctiva and
Tenon’s capsule. A total of 36 eyes from 35 individuals were subjected to the assessed techniques. The study variables were
complications of surgery and recurrence rates during a minimun follow-up period of 6 months. Results: No recurrence occurred
during the follow-up period. One graft (2.8%) exhibited partial retraction, but pterygium did not recur. The intraocular pressure
increased in one eye (2.8%) and was controlled by clinical methods. Conclusion: Eyes in which a barrier was established between the
conjunctiva and Tenon’s capsule by sealing the gap between them showed an absence of recurrence in the sample studied. However,
there is the need of a random prospective study with a control group for a more accurate conclusion on the efficacy of the technique.
Keywords: Pterygium/surgery; Autografts; Transplantation, autologous; Mitomycin/therapeutic use; Fibrin tissue adhesive; Recurrence
RESUMO
Objetivo: Avaliar os resultados de uma abordagem cirúrgica alternativa na excisão de pterígio primário por meio da observação das
taxas de recidiva e de complicações intraoperatórias e pós-operatórias. Métodos: Estudo retrospectivo e transversal realizado a partir da
revisão de prontuários de pacientes submetidos à cirurgia de pterígio com transplante autólogo de conjuntiva, cola de fibrina e aplicação
intraoperatória de mitomicina C. Além disso, foi realizado através de sutura, o selamento da lacuna entre a conjuntiva e cápsula de Tenon.
No total, 36 olhos de 35 pacientes foram submetidos à técnica. As variáveis do estudo foram complicações da cirurgia e taxas de recidiva
durante um período mínimo de 6 meses de seguimento. Resultados: Não foram constatadas recidivas durante o tempo de seguimento.
Um enxerto (2,8%) desenvolveu retração parcial, sem posterior recorrência do pterígio, e um olho (2,8%) apresentou aumento da
pressão intraocular, que foi controlada clinicamente. Conclusão: A criação de uma barreira entre a conjuntiva e cápsula de Tenon, por
meio do selamento da lacuna, mostrou ausência de recidiva na amostra estudada. Necessita-se, no entanto, de um estudo prospectivo
randomizado com grupo controle para uma conclusão mais precisa da eficácia da técnica.
Descritores: Pterígio/cirurgia; Autoenxerto; Transplante autólogo; Mitomicina/uso terapêutico; Adesivo tecidual de fibrina; Recidiva
1
2
Department of Ophthalmology, Universidade do Oeste do Estado de Santa Catarina, Campus de Joaçaba (SC), Brazil;
Student, Medical School, Universidade do Oeste do Estado de Santa Catarina, Campus de Joaçaba (SC), Brazil.
Study conducted at the Department of Ophthalmology, Universidade do Oeste de Santa Catarina - Campus de Joaçaba, SC, Brazil
The authors have no public and private financial support, or financial interest
Received for publication 01/07/2014 - Accepted for publication 11/07/2014
Rev Bras Oftalmol. 2014; 73 (5): 287-90
288
Stock RA, Lückmann LF, Kondo GAKI, Bonamigo EL
INTRODUCTION
P
terygium, from the Greek, “pterygos”, small wing, is a
triangle- or trapezoid-shaped fibrovascular growth of the
conjunctiva, usually located in the nasal side of the sclera
and extending towards the cornea (1,2). Its growth over time can
cause visual and esthetic problems, impairing the quality of life
of the patients and consequently requiring surgical removal.
Although it is a common eye problem, its standard surgical
treatment has not yet been established. The high rates of
postoperative recurrence, which exhibit remarkable variation
among studies, are the main challenge patients and surgeons
must address. Simple excision with bare sclera was widely
performed in the past; however, the associated recurrence rates
were unacceptable, as they could reach as high as 50% (²). In
addition to other factors that influence the treatment outcomes,
such as the pterygium morphological characteristics, some
demographic variables and the postoperative regimen, surgical
parameters not yet fully elucidated lead to divergent results (3).
In this regard, some authors observed that a gap is inevitably
created between the conjunctiva and Tenon’s capsule after the
excision of pterygium and Tenon’s resection, through which
fibrovascular tissue remnants can pass to cause recurrence. By
closing this gap during surgery, the recurrence rate achieved in one
study was only 3.1% in all the groups, thus pointing to the potential
utility of this technique (3). Therefore, the aim of this study was to
assess the response to surgical treatment of primary pterygium
including sealing of the gap between the conjunctiva and Tenon’s
capsule, combined with conjunctival autograft transplantation using
fibrin glue and the application of mitomycin C (MMC).
METHODS
The clinical records of individuals subjected to excision of
primary pterygium using intraoperative MMC, nonpedunculated conjunctival autograft transplantation fixated with
fibrin glue and the sealing of the gap by means of a suture between
the conjunctiva and Tenon’s capsule, from february 2011 to august
2012, were retrospectively reviewed. The records were available
at the database of BellotoStock Ophthalmology Center (Centro Oftalmológico BellotoStock), where the patients were
assisted before and after surgery. During this period, this
technique was applied to all of the patients who underwent
pterygium surgery.
Only individuals who were followed up for at least six
months after surgery were included in the study. Cases of
recurrent pterygium and cases that did not complete the
minimum follow up period were excluded from analysis. The
total sample comprised 36 eyes from 35 individuals. The following
data were collected before surgery: age, gender and pterygium
localization.
The same surgeon (R.A.S.) performed all the surgical
procedures at Santa Terezinha University Hospital (Hospital
Universitário Santa Terezinha - HUST), Joaçaba (SC), Brazil,
always using the same surgical and antiseptic techniques. The
surgical technique was based on the one described by Liuet al. (3)
The procedure started with peribulbar anesthesia using 2%
lidocaine and 0.75% bupivacaine in 1:1 ratio. Asepsis was
performed using 5% povidone-iodine followed by the placement
of sterile surgical drapes and the eye speculum.
Using conjunctival scissors, the pterygium body and
underlying Tenon’s capsule were dissected. The underlying
Tenon’s capsule was minimally resected 1mm below the
conjunctival edge, and cauterization was kept to a minimum. A
Rev Bras Oftalmol. 2014; 73 (5): 287-90
surgical sponge was soaked in 0.02% MMC (Ophtalmos, São
Paulo, Brazil) and placed on the bare sclera for two minutes. The
sponge was then removed, and the eye was copiously irrigated
with a balanced salt solution (BSS – Alcon, Fort Worth, USA).
Finally, the pterygium head was resected.
The gap invariably created between the conjunctiva and
the underlying Tenon’s capsule following pterygium excision
was first identified using two 0.12-mm forceps, one to grab
the conjunctiva and the other to grab the Tenon’s capsule.
The gap was then sealed by means of continuous suture with
Vicryl 8.0 (Ethicon, Johnson & Johnson, São Paulo, Brazil) of
both tissues, which blocked the emanation of fibrovascular
tissue and restored the normal morphological features of the
caruncle (Figure 1)(4). The surgeon trained for the procedure
by attending the course “Surgical Strategies for Recurrent
Pterygium With or Without Motility Restriction” promoted
by the American Academy of Ophthalmology (AAO) and
taught by Scheffer C. G. Tseng MD PhD.
Figure 1: Concept of sealing of the gap; fibrovascular tissue sandwiched
between the conjunctiva (pink) and the Tenon capsule (green) flattens
the caruncle (A, solid arrow) and anteriorly displaces the semilunar
fold (A, broken arrow), causing recurrent pterygium (D); this gap is
invariably created when the pterygium head and body is removed
(B); the gap is best demonstrated by two 0.12-mm forceps grabbing
each tissue edge (E); when the gap is sealed, the dome-shaped caruncle
is recreated by pulling the Tenon capsule when it naturally retracts
posteriorly (C, arrow), and the surrounding conjunctival edge is also
bent and rounded (F)
Source: Liu et al., JAMA, 2012.
The techniques to elaborate and fixate the conjunctival
autograft were based on the techniques described by Kenyon
et al. (4) and Koranyi et al. (5), respectively. The ipsilateral inferior conjunctival graft was marked horizontally and vertically
and dissected without the Tenon’s capsule and with a margin
of 2 mm larger than the excised conjunctiva measurements.
The free conjunctival graft was then transplanted to the
receiving bed while complying with the limbus to limbus origin.
The graft was fixed to the receiving site using fibrin glue
Evicel® (Omrx Biopharmaceuticals, Ramat Gan, Israel). First,
one drop of fibrinogen solution was applied to the scleral
bed; then,the graft was placed on the bed, and one drop of
thrombin and calcium chloride solution was applied on top.
The excess glue was removed, and the graft was trimmed
wherever necessary. Finally, moxifloxacin (Vigamox®, Alcon,
São Paulo, Brazil) was administered, followed by a single
subconjunctival application of betamethasone (Celestone®,
Mantecorp, São Paulo, Brazil). An dressing was applied, which
was removed 24 hours later.
During the postoperative period, the following was
prescribed: one drop of moxifloxacin eyedrops (Vigamox®,
Alcon, São Paulo, Brazil) every four hours over 15 days; one
drop of prednisolone acetate (PredFort®, Allergan, São Paulo,
Sealing the gap between conjunctiva and Tenon’s capsule in primary pterygium surgery
Brazil) every two hours over 15 days, tapered along two months;
and one drop of eye lubricant (Optive®, Allergan, São Paulo,
Brazil) every three hours as needed.
The patients were assessed on days 1, 15, 30, 60, 120 and
180 and then every three months as to occurrence of relapse,
which was defined as any growth of fibrovascular tissue that
reached the corneal surface and extended beyond the limbus in
the area corresponding to the excised pterygium. The Vicryl
suture was removed two weeks after surgery with scissors under
a slit lamp following the instillation of anesthetic eye drops. In
the follow-up visits, the participants were subjected to slit lamp
biomicroscopic examination, assessment of visual acuity and
degree of conjunctival hyperemia and measurement of the
intraocular pressure (IOP), and external photographs of all the
eyes were acquired. To construct tables and graphics, the data
were entered in a Microsoft Excel 2007 (Microsoft Corporation,
Redmond, USA) spreadsheet. The study started after approval
by the Research Ethics Committee of the University of West
Santa Catarina on july 25 2012, ruling nº 66686.
289
Figure 2: A) Clinical appearance of partial graft retraction two weeks
after surgery; B) Appearance three months after surgery; C)
Appearance six months after surgery
R ESULTS
The sample comprised 35 volunteers, 18 males (51.4%)
and 17 females (48.6%). Twenty-one participants (60%) had
pterygium in the right eye (RE), 13 (37.1%) in the left eye (LE)
and one (2.9%) in both eyes. All the lesions were primary and
located on the nasal side of the sclera (table 1).
Table 1
Demographic and clinical data of individuals with primary
pterygium treated by gap sealing
Average age in years
Age in years (minimum and maximum)
Gender (n)
Male
Female
Pterygium side (n)
Right eye
Left eye
Both eyes
44.37 (±10.72)
29 – 71
18 (51.4%)
17 (48.6%)
21 (60%)
14 (37.1%)
1 (2.9%)
The average age of the participants on the date of surgery
was 44.37 years old, standard deviation (SD) ± 10.87, varying
from 29 to 74 years old. Fourteen participants (40%) were 20 to
39 years old, 17 (48.5%) were 40 to 59 years old, and four (11.5%)
were 60 years old or older.
The duration of follow-up lasted 6 to 22 months, mean= 9
months, SD= ±3.69, and all of the patients completed the
minimum follow-up period adopted. None of the 36 eyes exhibited
pterygium recurrence during the follow-up period. No
intraoperative complications occurred. One eye (2.8%) exhibited
partial graft retraction, which did not require additional
intervention and was not classified as recurrence due to later
occurrence of conjunctivalization, which was complete by day 30
after surgery (figure 2). Another eye (2.8%) exhibited a moderate
increase in the IOP, which was successfully handled by
discontinuing the corticoid eye drops and introducing
antiglaucoma eye drops. The esthetic results of the grafts were
satisfactory, and the donor sites exhibited full recovery in all
cases, while no instance of symblepharon, graft loss or excessive
bleeding occurred during or after surgery (figure 3)
Figure 3: A) Clinical appearance before surgery; B) Clinical
appearance six months after surgery
DISCUSSION
Although many attempts have been made at improving
the surgical treatment of pterygium, there is not yet a consensus
on the ideal technique, and the recurrence rates after surgical
excision exhibit remarkable variation among studies. Recently,
quite complex approaches have been developed to reduce such
variation and the rates of recurrence. The technique selected in
this study was the surgical excision of the pterygium, with minimal
resection of Tenon’s capsule combined with conjunctival autograft
transplantation using fibrin glue and intraoperative application
of MMC, which are usual techniques, in addition to an alternative
procedure: the sealing of the gap between the conjunctiva and
Tenon’s capsule by means of suture. The proponents of this
technique (3) recommend the resection of Tenon’s capsule to be
minimal and its suture with the conjuntiva to be continuous.
The aim of surgical sealing is to hinder the propagation of
residues of the fibrovascular tissue across the gap created
between the conjunctiva and Tenon’s capsule after the pterygium
excision, thus preventing its recurrence (3). Although the study
that first demonstrated the efficacy of this procedure was
conducted with individuals exhibiting multiple pterygium
recurrence, the authors suggested the possibility of applying it to
the treatment of primary pterygium (3). That comment motivated
the performance of this study, which included a sample exclusively
composed of individuals with primary pterygium. The sealing of
the gap by continuous sutures was successful in all the treated
eyes, and the continuous sutures proved to be effective to restore
a normal caruncle compared to the use of anchored sutures or
anchored sutures combined with fibrin glue (3). The procedure
was brief, and the gaps were easily identified in all cases.
Rev Bras Oftalmol. 2014; 73 (5): 287-90
290
Stock RA, Lückmann LF, Kondo GAKI, Bonamigo EL
In contrast to other authors (3) who used cryopreserved
amniotic membrane grafts, conjunctival autografts were preferred
in this study. This choice was based on the results of a randomized
study (6) and an official AAO report (7) describing significantly
lower recurrence rates in the cases in which conjunctival
autografts were used versus amniotic membrane grafts.
One further peculiarity of the conjunctival grafts in the
present study was the donor site. As a rule, grafts are taken from
the ipsilateral upper conjunctiva; however, in this study, they
were taken from the ipsilateral inferior conjunctiva to preserve
the upper conjunctiva in case the patients might require
antiglaucoma surgery in the future. In addition, one study failed
to find a significant difference in the recurrence rates when the
upper or inferior conjunctival quadrants were used as donor
sites for primary pterygium surgery (8).
In this study, conjunctival autograft transplantation and the
intraoperative application of MMC as an adjuvant treatment were
added to gap sealing. The combination of those two procedures for
the treatment of primary pterygium, involving fixation of the
conjunctival graft to the sclera by means of suture, has been successfully
employed in comparative studies (9,10).With regard to recurrent
pterygium, two recent studies reported excellent results using a
modification of that technique, which consisted of fixing the conjunctival
graft with fibrin glue instead of sutures (11,12). The use of fibrin glue
helps to reduce the rate of recurrence, postoperative discomfort and
the duration of surgery. For those reasons, it was used in this study
(5,13)
.Those results are lent further support by an official report
published by the AAO, according to which the combination of
conjunctival autograft transplantation and MMC results in lower
rates of recurrence following the excision of pterygium, compared to
each procedure alone (7).In addition, the combination of the two
procedures allows reduction of the dose and the intraoperative
exposure of MMC, which makes the technique safer (14).
Using these technical improvement (i.e., gap sealing,
conjunctival autograft transplantation fixated with fibrin glue and
intraoperative MMC), the recurrence rate was ideal, i.e., 0%, during
the follow-up period. Among the studies that applied a similar
technique, only one achieved 0% recurrence (10), while the other
studies reported low recurrence rates, to wit, 2% (9), 3.5% (11) and
9.2% (14). In one study that performed conjunctival autograft
transplantation only with fibrin glue, but did not include gap sealing,
the recurrence rate was higher, at 11.3% (15).In the study most similar to this one, which also performed gap sealing in all the treated
eyes, the adjusted recurrence rate was 3.1% in all the groups (3).
The average duration of follow-up after surgery was 9
months; a period of 6 months is considered sufficient to detect
50% to 86% of the instances of relapse (16), while 93% of such
cases are detected when follow-up is extended to 9 months (17).
Moderate inflammation might occur during the first two
weeks after surgery due to the presence of the Vicryl suture,
which fully disappears following its removal. For that reason,
topical corticoids should be used more intensively during that
period, and the dose should be reduced after suture removal.
No intraoperative complications occurred in this series. In one
eye (2.8%), the graft exhibited partial retraction during the first
days after surgery, but no intervention was required, and
pterygium did not recur. The retraction was possibly due to
excessive Tenon’s capsule remnants identified on slit lamp
examination. That complication also occurred in one of the 28
eyes treated in another study (11). One eye (2.8%) exhibited a
moderate increase in IOP, which was attributed to the topical
corticoid used after surgery. That condition was fully controlled
following discontinuance of the corticoid eye drops and the
institution of clinical treatment.
Rev Bras Oftalmol. 2014; 73 (5): 287-90
CONCLUSION
The pterygium recurrence rate was 0% in the studied
sample, and the two post-operative complications receded
spontaneously or with the aid of a clinical treatment. Although
the result was promising, a prospective randomized trial
comparing groups treated with and without sealing of the gap
between the conjunctiva and Tenon’s capsule is needed to
establish more precise conclusions regarding the efficacy of that
technique in the treatment of primary pterygium.
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Segev F, Jaeger-Roshu S, Gefen-Carmi N, Assia EI. Combined
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Frucht-Pery J, Raiskup F, Ilsar M, Landau D, Orucov F, Solomon
A. Conjunctival autografting combined with low-dose mitomycin
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Ophthalmol. 2006;141(6):1044-50.
Shehadeh-Mashor R, Srinivasan S, Boimer C, Lee K, Tomkins O,
Slomovic AR. Management of recurrent pterygium with intraoperative mitomycin C and conjunctival autograft with fibrin glue.
Am J Ophthalmol. 2011;152(5):730-2.
Bakshi R, Gupta H, Khurana C, Sachdev MS. Conjunctival limbal
autograft with fibrin glue with mitomycin-C in managing recurrent pterygium. Cornea. 2003;22:598-603.
Koranyi G, Seregard S, Kopp ED. The cut-and-paste method for
primary pterygium surgery: long-term follow-up. Acta Ophthalmol
Scand. 2005;83(3):298-301.
Wong VA, Law FCH. Use of mitomycin C with conjunctival autograft in pterygium surgery in Asian-Canadians. Ophthalmology. 1999;106(8):1512-5.
Coral-Ghanem R, Oliveira RF, Furlanetto E, Ghanem MA, Ghanem
VC. Transplante autólogo de conjuntiva com uso de cola de fibrina
em pterígios primários. Arq Bras Oftalmol. 2010;73(4):350-3.
Avisar R, Arnon A, Avisar E, Weinberger D. Primary pterygium
recurrence time. Isr Med Assoc J. 2001;3(11):836-7.
Ti S, Chee S, Dear K, Tan D. Analysis of variation in success rates
in conjunctival autografting for primary and recurrent pterygium. Br J Ophthalmol. 2000;84(4):385-9.
Corresponding author:
Ricardo Alexandre Stock
Rua Rio Branco, 589 – Joaçaba (SC), Brazil
Telephone: +55 (49) 3522-0788 - Fax:+55 (49) 3522-5059
E-mail: [email protected]
ORIGINAL ARTICLE
291
Visual impairment, rehabilitation and
International Classification of Functioning,
Disability and Health
Deficiência visual, reabilitação e Classificação Internacional
de Funcionalidade, Incapacidade e Saúde
Marissa Romano da Silva1, Maria Inês Rubo de Souza Nobre2, Keila Monteiro de Carvalho3, Rita de Cássia Ietto Montilha2
A BSTRACT
Objective: To describe the characteristics of people with visual impairment who participated in the Visual Rehabilitation Groups,
according to the ICD-10 and the International Classification of Functioning, Disability and Health (ICF). Methods: Quantitative,
cross-sectional survey, developed in a university rehabilitation research center between october and december 2012. The users
from the Visual Rehabilitation Groups were invited; 13 of them agreed to participate. We performed an occupational therapy
evaluation – with anamnesis, performance evaluation and functional vision assessment – an analysis of medical charts and patient
description with the use of the ICF. Results: The major causes of visual impairment were diabetic retinopathy, glaucoma, optical
neuritis and keratoconus. Some functions and structures of the body, performance and capabilities in activities and participation,
environmental factors facilitators or limiters were highlighted in this study, allowing the description of the characteristics of each
participant through the functionality and the improvement of the therapeutic planning. Assistive technologies, optical and nonoptical aids used and their everyday benefits were presented. Conclusion: Visual loss, at any level, led to functional impairments,
limiting and restricting the participation and performance in everyday activities, interfering with the individuals’ independence,
autonomy and quality of life. However, the use of optical aids, non-optical aids and environmental adaptations proved to be
beneficial for increasing the functionality, showing the influence of external factors on the performance. Knowing and recognizing
the existence of diversities within the visual impairment universe allows us to understand who the treated individual is, avoiding
the generalization by the visual condition. The ICF showed to have a fundamental role in this context.
Keywords: International Classification of Functioning Disability and Health; International Classification of Diseases;
Rehabilitation; Blindness; Low vision; Activities of daily living
1
Masters in Health, Interdisciplinary and Rehabilitation Program, Faculdade de Ciências Médicas, Universidade Estadual de Campinas,
Campinas (SP), Brazil;
2
Centro de Estudos e Pesquisas em Reabilitação “Prof. Dr. Gabriel O.S. Porto”, Faculdade de Ciências Médicas, Universidade Estadual de
Campinas, Campinas (SP), Brazil;
3
Department of Ophtmalogy, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas (SP), Brazil.
The authors have no public and private financial support, or financial interest
Received for publication 17/06/2014 - Accepted for publication 13/07/2014
Rev Bras Oftalmol. 2014; 73 (5): 291-301
292
Silva MR, Nobre MIRS, Carvalho KM, Montilha RCL
RESUMO
Objetivo: Descrever as características das pessoas com deficiência visual participantes de Grupos de Reabilitação Visual, segundo a
CID-10 e a Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Métodos: Pesquisa quantitativa de corte
transversal, desenvolvida em um centro universitário de pesquisas em reabilitação entre outubro e dezembro de 2012. Usuários de
Grupos de Reabilitação Visual foram convidados, sendo 13 os que aceitaram participar. Foi realizada avaliação de terapia ocupacional
– com anamnese, avaliação de desempenho e avaliação funcional da visão – consulta aos prontuários e a classificação dos participantes
utilizando a CIF. Resultados: As principais causas de deficiência visual foram retinopatia diabética, glaucoma, neurite óptica e ceratocone.
Algumas funções e estruturas do corpo, desempenho e capacidades em atividades e participação, fatores ambientais facilitadores ou
limitadores foram destacados neste estudo, possibilitando descrever as características de cada participante por meio de sua funcionalidade e auxiliando no planejamento terapêutico. Tecnologias assistivas, auxílios ópticos e não ópticos utilizados e seus benefícios cotidianos foram apresentados. Conclusão: A perda visual, em qualquer nível, levou a prejuízos funcionais, limitando e restringindo a
participação e o desempenho em atividades cotidianas, interferindo na independência, autonomia e qualidade de vida dos sujeitos.
Entretanto, o uso de recursos ópticos, não ópticos, auxílios e adaptações ambientais mostraram-se benéficos para a ampliação da
funcionalidade, evidenciando a influência de fatores externos no desempenho do indivíduo. Conhecer e reconhecer a existência da
diversidade dentro do universo da deficiência visual possibilita entender quem é o sujeito atendido, evitando a generalização pela
condição visual, tendo a CIF papel fundamental nesse contexto.
Descritores: Classificação Internacional de Funcionalidade, Incapacidade e Saúde; Classificação Internacional de Doenças;
Reabilitação; Cegueira; Baixa visão; Atividades cotidianas
INTRODUCTION
C
urrent estimates of the World Health Organization reveal
that there are 314 million visually impaired people in the
world – 269 million of these have subnormal vision and
45 million are blind (1-3), including uncorrected refractive errors.
Etiologies are related to biological and contextual factors, mostly
preventable, treatable and curable (2,4-5), associated to nutritional
and infectious factors, lack of available technology, tobacco use,
ultraviolet radiation exposure, vitamin A deficiency, high body
mass index and metabolic disorders (1-2,5). The main causes of
visual impairment in the world are uncorrected refractive error,
cataracts, age-related macular degeneration, diabetic retinopathy,
trachoma and corneal opacity (1-3,5-6).
Vision is an afferent which is able to promote integration
with other sensory information. It is a continuous stimulus that
enables self-directed and intentional motor conducts, critical to
locate and identify distant objects that cannot be captured by
other senses, understand spatial relations, the position of the body
in relation to space, capture effectively and quickly the environment
in safe and confident manner, maintaining proper body posture,
among other functions (7-9).
Visual loss causes a sensory imbalance, to which the
human body itself is not prepared to face, requiring adaptation
and support (7). Thus, any visual impairment affects the
individual’s health in all its aspects and brings it to functional
impairments, generating interference in quality of life (9-11).
Activities ranging from independent mobility inside and outside
the house, carrying out basic and instrumental daily actions
such as bathing, dressing, going to the grocery store or the
bank, as well as to social activities, leisure and work, all of them
may represent impairment in the daily life of the visually
impaired (11-13). Along with the individual limitations there are
the physical and social environmental factors that may
constitute, respectively, architectural and attitudinal barriers.
Rehabilitation is inserted in this context which can be
defined as a process that is built according to the individuals´
constant identification of needs and demands, involving their
current health condition, interests, context and expectations.
Actions in rehabilitation should include the assistance of a
Rev Bras Oftalmol. 2014; 73 (5): 291-301
multispecialty team in order to provide timely and complete
support to individuals with disabilities (2,11,14-15). According to the
experiences of Lamoureux et al. (12), Aciem e Mazzotta (13) e
Bittencourt et al. (16), the rehabilitation of the visual impairment
has shown to be effective in the improvement of the users´ quality
life in the services studied.
To assist in this process, the International Classification of
Functioning, Disability and Health (ICF) is to establish tasks as a
standardized language on health and its conditions, enabling
scientific basis for understanding health and its correlated states ,
comparing health actions on the same subject, helping in the
decision making for the individualized rehabilitation process (17).
The ICF puts functioning and disability under new perspectives,
recognizes disability as a condition not of a minority but as an
inherent human experience. Considering the strong influence of
the context, it comprehends the relationship of health and
environment as dynamic, which may give rise to changes in the
health status of the subject. Moreover, it changes the focus in the
disease classification since it favors the classification of the impacts
of this disease on the individuals’ lives (17). The ICF is a milestone
in legitimizing the Social Model in health and human rights, enabling
communication between the Biomedical and Social Models.
The university research center in rehabilitation involved
in this research works on the rehabilitation of the visually
impaired. One of the modalities of assistance which are practiced
concerns the Visual Rehabilitation Groups, which are proposed
to discuss immediate issues related to disability and rehabilitation,
enabling participants to share their difficulties and strategies in
solving them.
This research was conducted with the aim of describing
the characteristics of people with visual impairments, participants
in the Visual Rehabilitation Groups, according to the
International Classification of Diseases, Tenth Revision (ICD10) and the ICF.
METHODS
This is a quantitative cross-sectional research, developed
in a university research center in rehabilitation.
To participate in the study, the subjects should have the
ICD-10 corresponding to visual impairment (18), aged over 18
Visual impairment, rehabilitation and International Classification Of Functioning, Disability And Health
years and attending the Visual Rehabilitation Group of a
university research center. As exclusion criteria is the non
acceptance and not signing the consent form.
The users inserted in the Visual Rehabilitation Groups
(total = 19), from october to december 2012 were invited, with
the elucidated objectives and procedures of the research.
Thirteen people agreed to participate in this study.
After the acceptance of those who attended, it was asked
on a date and time for signing the consent form and the evaluation
of the occupational therapy. At this time, the medical records of
each participant were consulted as source of data on the cause
of the visual loss, visual acuity and other information related to
the eye health. Evaluation of the occupational therapy comprising
history, performance evaluation and functional vision assessment
was performed.
Such procedures which lasted about 40 minutes were
videotaped and analyzed by two examiners, and described using
the International Classification of Functioning, Disability and
Health (ICF).
The ICF belongs to the family of international
classifications developed by the WHO which encompasses
aspects of human health and components related to welfare. It
describes them in terms of health domains (such as seeing,
hearing, and walking) and health-related fields (such as
transportation, social interaction). It is proposed to describe
situations related to the human functioning and restrictions, as
an organizing structure of information in a model that can be
“significant, integrated and accessible” (17).
This classification is divided into two sections, part 1 refers
to the functionality and disability and part 2 concerns
contextual factors. Each one of the parts is subdivided into two
components, which receive specific alphanumeric codes in order
to be differentiated: part 1 includes the functions of the body
(letter b for body), Body Structures (letter s for structure) and
activities and participation (letter d for domain), while part 2
covers the environmental factors (letter e for environment)
and personal factors (17).
The functions and structures of the body relate to
physiological functions and anatomical parts of the body,
respectively. Problems in the functions and/or structures of the
body are considered impairments. Activities and participation
include, in this order, the execution of a task by the individual
293
and his involvement in everyday situations. Difficulties in
implementing the activities are called limitations while problems
in performing these activities are called participation restrictions.
Finally, environmental factors include the physical, social and
attitudinal environment in which individuals are placed. For
the ICF, all these components interact dynamically, considering
functioning, disability and health as an interactive and
evolutional process (17).
The components of the classification are followed by
numerical codes, the first is representative of the number of the
chapter (one digit), followed by the second level (two digits) and
the third and fourth levels (one digit each). The codes are only
complete when adding the qualifier, which indicates the magnitude of the issue. The qualifiers are present after the period (or
delimiter). Without the qualifier number, the codes of the ICF
have no meaning. The components of part 1 (Body Functions
and Structures, Activities and Participation) are qualified by the
same general range of numbers (0-4). For the Functions and
Structures of the body the qualifier is the magnitude of the
impairment. The Structures of the body receive three different
levels of qualifiers, the first qualifier for the degree of the
commitment generated (0-4), the second corresponds to the
nature of structural change (0-7) and finally brings the third
location of this change (0-7) (table 1). For the component
Activities and Participation are the constructs of this Performance
and Capacity. The Performance (first qualifier) is what the subject
does in his usual environment, while capacity (second qualifier)
is what the subject is able to do in his likely maximum level of
functionality without assistance. The third qualifier refers to the
level of the subject’s ability to perform that activity with assistance.
Finally, for the Environmental Factors, qualifiers can be called
barriers or facilitators, depending on the effects of that factor in
the subject’s life. Any barriers as facilitators have the same
numerical scale (0-4), but the separation between the code and
the domain qualifier takes place by means of a period (.) for
barriers and a plus sign (+) for facilitators.
After classification, the results of the participants were
described in tables and charts with frequencies of ophthalmic
diagnoses, limitations, restrictions, physical and attitudinal
environmental barriers (17).
The study was approved by the Ethics Committee on
Research by the ruling nº 143.693/2012.
Table 1
Structures of the body
First qualifier
xxx.0
xxx.1
xxx.2
xxx.3
xxx.4
NO Impairment
LIGHT Impairment
MODERATE Impairment
SEVERE Impairment
COMPLETE Impairment
Second qualifier
Third qualifier
0 No change in the structure
1 Total absence
2 Partial absence
3 Additional part
4 Abnormal dimensions
5 Discontinuity
6 Deflected position
7 Qualitative changes in the structure,
including accumulation of fluid
0 More than one region
1 Right
2 Left
3 Both sides
4 Front part
5 Back part
6 Proximal
7 Distal
Source: WHO, 2003
Rev Bras Oftalmol. 2014; 73 (5): 291-301
294
Silva MR, Nobre MIRS, Carvalho KM, Montilha RCL
Table 3
R ESULTS
The sample consisted of 13 participants, 54% were female,
mean age of 44 years (± 18.42), and a large share of it in relation
to the employment condition is off work (62%). The main causes of visual impairment which were presented were diabetic
retinopathy, glaucoma, keratoconus and optic neuritis (15% each).
With regard to the type of visual impairment, 77%, presented
low vision, most of them were acquired (92%) (table 2).
Number of participants by gender,
according to visual impairment
Gender
H54.0a
ƒ %
H54.1b
ƒ
%
H54.2
ƒ
%
n=13
Total
ƒ
%
Female
Male
Total
1
2
3
3
2
5
3
2
5
7
6
13
8
15
23
23
15,5
38,5
23
15,5
38,5
54
46
100
a
H54.0: Blindness in both eyes; bH54.1: Blindness, one eye, low vision in the other; c
H54.2: Subnormal vision in both eyes
Table 2
Sample characterization
n=13
ƒ
Gender
Female
Male
Average age
Marital status
Married
Single
Divorced
Widow/Widower
Work Conditions
On sick leave
Employed
Retired
Unemployed
Ophthalmic Diagnosiss
Diabetic retinopathy
Glaucoma
Optic neuritis
Keratoconus
Retinitis pigmentosa
Macular chorioretinitis
Age-related macular degeneration
Central serous maculopathy
Cortical
Visual Impairment
Acquired
Congenital
Ophthalmologic diagnosis and body structure
changes, according to the ICF
7
54
6
46
44 (±18,42)
6
46
5
38
1
8
1
8
8
2
2
1
62
15
15
8
2
2
2
2
1
1
1
1
1
15
15
15
15
8
8
8
8
8
12
1
92
8
Visual Condition (CID-10)
H54.0 Blindness in both eyes
3
H54.1 Blindness, one eye, low vision in the other 5
H54.2 Subnormal vision in both eyes
5
23
38,5
38,5
According to the ICD-10, 23% attendees are blind in both
eyes (H54.0), 38.5% are blind in one eye and low vision in the
other (H54.1) and 38.5% with low vision in both eyes (H54.2)
(table 3).
According to the causes of visual impairment, the most
affected structures of the eyeball (s220) were: retina (s2203),
structure of the cranial nerves (optic nerve, optic tract) (s1106)
and cornea (s2201) (table 4).
Rev Bras Oftalmol. 2014; 73 (5): 291-301
Table 4
%
n=13
Ophtalmologic Diagnosis
Body
structure
ICF
Diabetic Retinopathy
Retina
s2203
Retinitis Pigmentosa
Retina
1
Macular Chorioretinitis
Retina
1
Age-related macular degeneration Retina
1
Central serous maculopathy
Retina
1
Cortical
Optic tract s1106
Optic neuritis
Optic nerve
2
Keratoconus
Cornea
s2201
Glaucoma
Eyeball
s220
ƒ
%
2
46
1 23
2
2
15,5
15,5
With regard to body functions by the ICF classification,
the monocular acuity of farsighted vision (b21001) for the right
eye (RE) presented 1 subject with moderate disability (.2), 5
individuals with severe disabilities (.3) and other 7 people with
complete deficiency (.4), while for the left eye (LE) 7 participants
were classified with moderate disability (.2), 3 with severe
disabilities (.3) and 3 with complete deficiency (.4) for this domain.
For binocular acuity of short-sighted vision (b21002), 1 participant
presented no difficulty (.0), another subject presented mild
disability (.1), 6 subjects showed moderate disability (.2) and 5
presented complete deficiency (.4). Other body functions related
to vision are described in table 5 as functions of the visual field
(b2101), light sensitivity (b21020), color vision (b21021), contrast
sensitivity (b21022) and quality of the visual image (b21023).
The analysis of the data related to the component activities
and participation, the tasks that are highlighted in this study
showed higher difficulty within the repertoire of activities of the
participants or significant change in the distribution of subjects
compared to the performance and the ability to perform each
task, with and without assistance. These activities include the
areas of Reading (d166) and the accomplishment of the daily
chores (d640), and the categories of walking on different surfaces
(d4502) and socialization (d9205).
In fields that refer to environmental factors, 4 participants
considered the immediate family (e310), extended family (e315)
and friends (e320) and their attitudes (e410, e415, e420), as complete facilitators (+4) of process of acceptance of disability,
inclusion in the Visual Rehabilitation service and resumption of
the daily activities. However, the strangers’ individual attitudes
(e445) to 9 participants are deemed social barriers such as light
Visual impairment, rehabilitation and International Classification Of Functioning, Disability And Health
(.1) to moderate (.2). For a participant (S12), the strangers’
attitudes represent complete barriers (.4), preventing her from
leaving her residence to perform certain activities in the
community.
Products and assistive technology for mobility and personal
transportation in internal and external environments (e1201)
are often used by 5 people and are considered complete
facilitators (e1201 +4) for 4 participants. In the case of visual
impairment, this device is the white cane. The cane was presented
to 8 other participants and they were trained in groups of visual
rehabilitation of a university research center, concerning its correct
and safe use since they do not use it daily.
Products and assistive technology for communication
(e1251), representing specialized writing devices, hardware and
software, glasses or contact lenses are used by all the participants
to assist in transmitting and receiving information. In addition,
all participants reported that they benefit from products and
technology used in designing, building and construction (e150),
mainly in the categories of entering and exiting public buildings
(e1500), such as ramps and level thresholds, and direction,
guidance course and designation of places (e1502), using written
signs or in Braille signs and embossed surface of the floors.
The intensity of light (e2400) is identified by 8 participants
as a barrier such as from moderate (.2) to complete (.4) limiting
the involvement and performance in the daily activities. As for
the quality of light (e2401), 11 participants reported as a facilitator
from moderate (+2) to complete (+4), enabling them to fulfill
their activities accurately and safely.
Regarding non-optical devices, all participants reported
using them in everyday life, the most cited: light control, use of
contrast, aid to writing and electronic magnification, for carrying
out the activities, especially reading. Three participants who are
blind use a writing guide for signing their names. As for optical
devices, 6 participants use these aids. Out of these, 4 participants
use the aid for near and 5 use it for far sight.
It is possible to illustrate the CIF rankings in visual
impairment through S1 (table 5). With this example there is an
attempt to guide the understanding and comprehension of the
ICF domains and their practical applicability.
The first participant, JVC, 67, is married, 3 daughters and,
on sick leave, presents the ophthalmic glaucoma diagnosis and
ICD-10 of blindness in both eyes (H54.0). According to the ICF,
J. presents complete deficiency in all the Functions of the body
(.4), since it is a case of blindness. The structure of the body is
most affected, according to the diagnosis of glaucoma, the eyeball
(s220.473) completely affected (.4) with a qualitative change in
the structure, including accumulation of fluid (7), in both eyes
(3). Regarding the activities and participation for the activity of
reading (d166) J. presents complete constraint (.4 ) and total
participation restrictions (. 4).Without the aid of assistive
technology, however, when added to the task of using external
resources, the participant begins to perform the activities with
less limitations (d166.443). In the activity walking on different
surfaces (d4502), the participant has considerable limitation (.3)
and restriction (.3), but when there is the use of an aid for
wandering the performance comes to moderate difficulty
(d4502.332). For the activity accomplishing the daily chores
(d640) she shows complete limitation (.4), severe restriction (.3),
but with the use of aids she shall perform such activities with
slight difficulty (d640.431). Lastly, for the activity of socialization
(d9205), J. shows severe difficulty (.3), with little restriction (.1),
and after the use of resources, her limitation ceases to exist
295
(d9205.310). For the domains related to environmental factors,
S1 is aided by the white cane daily and benefits from this feature
completely (e1201+4), while products and assistive technology
for communication are used by her (as specialized writing devices,
hardware and software), but they facilitate her daily activities
moderately (e1251+2). Products and technology used in designing,
building and construction for entering and exiting public buildings
(e1500), such as ramps and level thresholds are considerable
facilitators (e1500+3), enabling her to transit in public buildings
with higher security, independence and autonomy. Products and
technology used in design, architecture and construction for
direction indication, route guidance and designation of places
(e1502), using cards in Braille represent for this person, at the
time of the evaluation a moderate facilitator (e1502+2) since she
has not mastered Braille yet. The intensity of light (e2400) and
Quality of light (e2401) for S1 are not considered barriers or
facilitators due to their visual condition: blindness in both eyes. J.
considers the immediate family (e310), extended family (e315),
Friends (e320) and their attitudes as complete facilitators in her
everyday life. However, she identifies the strangers’ Individual
attitudes (e445) as moderate barriers, discouraging both
engagement and conducting social activities.
DISCUSSION
This research was conducted with the aim of describing
the characteristics of people with visual impairment,
rehabilitation group participants, according to the ICD-10 and
the ICF. After assessing thirteen participants, and following the
ICF´s classification, it was possible to identify the causes of visual
impairment, the functions and structures of the body with
disabilities, the main limitations and constraints faced by these
people, the type of disability according to the ICD-10 the
frequency of gender, average age, among other characteristics of
this population.
It was found that the prevalence of low vision in relation
to blindness is compatible with national and international findings
(1-3,5-6,19-22)
. Two major eye diseases found in this study (glaucoma
and diabetic retinopathy) are the causes of visual impairment
highlighted in Brazilian and global studies with several
populations (3,6,19-21,23-26). While glaucoma and age-related macular
degeneration are the major causes of visual impairment in
subjects from 50 years old on, brazilian studies highlight these
diseases in this age group (4,20,23).
According to the WHO (6), the number of individuals over
50 years old exceeds the visually impaired other age groups.
However, there is the small number of people over this age
inserted the Visual Rehabilitation Groups (n = 3) and that may
be the cause of such low demand for health services. The group
of people, mostly elderly, with high predisposition to acquire
diseases and high need for the access to the health services, is not
being assisted due to low demand, either by distance from places
of care, poor financial conditions or inadequate and little
stimulating support from the family (4,27-28).
The architectural and attitudinal barriers found in cities as
they can be seen in the social nucleus may discourage the subject
to seek services. The search for rehabilitation is delayed if the
network does not encourage support, if the barriers are limiting
and if there is not easy access to the health care services, to all of
these there is the visual impairment itself, which is limiting and
imposes restrictions as identified in this study (28). In a study by
Rev Bras Oftalmol. 2014; 73 (5): 291-301
296
Silva MR, Nobre MIRS, Carvalho KM, Montilha RCL
Table 5
Characteristics of the subjects according to ophthalmologic diagnosis, ICD-10 and ICF
Diagnosis
S1
S1
S3
S4
Glaucoma
Glaucoma
Optic
Neuritis
Diabetic
retinopathy
ICD-10
H54.0
H54.0
H54.0
H54.1
Body
functions
b21001.4 (RE*)
b21001.4 (LE**)
b21002.4
b2101.4
b21020.4
b21021.4
b21022.4
b21023.4
b21001.4 (RE)
b21001.4 (LE)
b21002.4
b2101.4
b21020.4
b21021.4
b21022.4
b21023.4
b21001.4 (RE)
b21001.4 (LE)
b21002.4
b2101.3
b21020.3
b21021.3
b21022.3
b21023.3
b21001.4 (RE)
b21001.2 (LE)
b21002.2
b2101.1
b21020.1
b21021.0
b21022.0
b21023.2
Rev Bras Oftalmol. 2014; 73 (5): 291-301
Body
structures
s1106.423
s 220.473
s1106.423
s220.473
s1106.423
s2203.273
ICF
Activities and
participation
d166.443
d4502.332
d640.431
d9205.310
d166.443
d4502.321
d640.221
d9205.220
d166.432
d4502.320
d640.221
d9205.332
d166.221
d4502.110
d640.310
d9205.100
Environment
factors
e1201+4
e1251+2
e1500+3
e1502+2
e2400.0
e2401+0
e310+4
e315+4
e320+4
e410+4
e415+4
e420+4
e445.2
e1201+4
e1251+1
e1500+2
e1502+1
e2400.0
e2401+0
e310+4
e315+4
e320+4
e410+4
e415+4
e420+4
e445.0
e1201+4
e1251+2
e1500+3
e1502+4
e2400.3
e2401+3
e310+3
e315+3
e320+2
e410.1
e415+3
e420+2
e445.2
e1201+3
e1251+4
e1500+3
e1502+4
e2400.2
e2401+4
e310+4
e315+4
e320+3
e410+4
e415+4
e420+3
e445.0
J.V.C., female,
67 years old,
married,
3 daughters,
on sick leave
A.M.S., male,
74 years old,
widower,
7 children,
retired
V.V.S., male,
47 years old,
divorced,
3 daughters,
on sick
leave
J.M.R., male,
31 years old,
single,
1 son,
on sick
leave
Visual impairment, rehabilitation and International Classification Of Functioning, Disability And Health
Diagnosis
S5
S6
S7
S8
Diabetic
retinopathy
Retinitis
pigmentosa
AMD
Optic
neuritis
ICD-10
H54.1
H54.1
H54.1
H54.2
Body
functions
b21001.4 (RE)
b21001.2 (LE)
b21002.2
b2101.0
b21020.0
b21021.0
b21022.0
b21023.2
b21001.4 (RE)
b21001.2 (LE)
b21002.2
b2101.2
b21020.0
b21021.2
b21022.3
b21023.1
b21001.4 (RE)
b21001.2 (LE)
b21002.2
b2101.2
b21020.0
b21021.0
b21022.1
b21023.2
b21001.3 (RE)
b21001.3 (LE)
b21002.4
b2101.2
b21020.3
b21021.0
b21022.2
b21023.3
Body
structures
s2203.273
s2203.411(RE)
s2203.222(LE)
s2203.223
s1106.323
ICF
Activities and
participation
d166.210
d4502.210
d640.110
d9205.310
d166.221
d4502.320
d640.110
d9205.300
d166.311
d4502.221
d640.110
d9205.200
d166.331
d4502.321
d640.211
d9205.332
297
Environment
factors
e1201+1
e1251+4
e1500+1
e1502+3
e2400.2
e2401+4
e310+4
e315+4
e320+4
e410+4
e415+4
e420+4
e445.1
e1201+1
e1251+2
e1500+1
e1502+3
e2400.2
e2401+3
e310+4
e315+3
e320+2
e410+4
e415+3
e420+2
e445.2
e1201+0
e1251+3
e1500+3
e1502+3
e2400.1
e2401+3
e310+4
e315+3
e320+2
e410+4
e415+4
e420+2
e445.0
e1201+4
e1251+2
e1500+4
e1502+4
e2400.4
e2401+3
e310+4
e315+4
e320+3
e410+4
e415+4
e420+3
e445.1
R.C.G., female,
29 years old,
single,
pedagogue
E.A.A., female,
34 years old,
single,
1 son,
cleaner
B.P., female,
83 years old,
single,
retired.
H.M.V., male,
33 years old,
married,
1 daughter,
on sick
leave
Rev Bras Oftalmol. 2014; 73 (5): 291-301
298
Silva MR, Nobre MIRS, Carvalho KM, Montilha RCL
Diagnosis
S9
S11
S12
Body
functions
b21001.2(RE)
b21001.2 (LE)
b21002.0
b2101.2
b21020.0
b21021.0
b21022.0
b21023.1
Macular
C
chorioretinitis
AO
S10
ICD-10
Central
serous
maculo
pathysequel
Keratoconus
Keratoconus
H54.2
H54.2
H54.2
H54.2
b21001.3 (RE)
b21001.3 (LE)
b21002.4
b2101.3
b21020.2
b21021.0
b21022.2
b21023.3
b21001.3 (RE)
b21001.2 (LE)
b21002.2
b2101.0
b21020.2
b21021.0
b21022.1
b21023.2
b21001.3 (RE)
b21001.2 (LE)
b21002.1
b2101.0
b21020.1
b21021.0
b21022.1
b21023.3
Rev Bras Oftalmol. 2014; 73 (5): 291-301
Body
structures
s2203.223
s2203.373
s2201.263
s2201.263
ICF
Activities and
participation
d166.110
d4502.110
d640.100
d9205.000
d166.331
d4502.320
d640.221
d9205.332
d166.110
d4502.220
d640.321
d9205.320
d166.110
d4502.221
d640.211
d9205.310
Environment
factors
e1201+0
e1251+4
e1500+2
e1502+3
e2400.0
e2401+4
e310+4
e315+4
e320+4
e410+4
e415+4
e420+4
e445.2
F.S.A., female,
29 years old,
married
1 son,
unemployed
e1201+0
e1251+4
e1500+1
e1502+3
e2400.4
e2401+3
e310+4
e315+4
e320+4
e410+4
e415+3
e420+3
e445.2
D.C.F., male,
43 years old,
married,
2 daughters,
on sick
leave
e1201+1
e1251+4
e1500+2
e1502+4
e2400.3
e2401+4
e310+4
e315+4
e320+3
e410+4
e415+4
e420+3
e445.2
R.D.A.A., male,
48 years old,
single,
on sick
leave
e1201+2
e1251+4
e1500+3
e1502+4
e2400.2
e2401+4
e310+4
e315+4
e320+3
e410+4
e415+4
e420+3
e445.4
Visual impairment, rehabilitation and International Classification Of Functioning, Disability And Health
Diagnosis
S13
Cortical
ICD-10
H54.2
Body
functions
b21001.3(RE)
b21001.3(LE)
b21002.2
b2101.2
b21020.0
b21021.0
b21022.0
b21023.3
Body
structures
s1106.452
ICF
Activities and
participation
d166.220
d4502.220
d640.110
d9205.221
299
Environment
factors
e1201+0
e1251+4
e1500+3
e1502+3
e2400.1
e2401+2
e310+4
e315+4
e320+4
e410+4
e415+4
e420+3
e445.2
M.V.C.B., female,
33 years old,
married,
pregnant,
on sick
leave
(*) RE: right eye; (**) LE: left eye
Douglas et al. (29), the social and individual barriers found in the
sample population prevented considerably the frequent outing
of these people from their homes, the public transport was
identified during the study as a major barrier in the subjects’
daily basis activities, besides the challenge to create awareness
among the visual impaired population who sees the restraints of
mobility as inherent to their condition, thus failing to access the
health services.
The visual functions with disabilities which were here
presented implicated, at various levels, the activities and
participation of the users, either under limiting or even disabling
forms, these implications were also identified in studies of
Marback, Temporini & Kara-Júnior (11) and Aciem & Mazzotta
(13)
. However, from the analysis of the obtained results it can be
seen that the use of optical and non-optical devices were shown
to be an effective aid for increasing the functionality with
improved performance and participation in the daily activities
and they can lead to increased self-esteem and social participation,
as evidenced in other national and international researches (13,24,3032)
. In the research conducted by Carvalho et al. (23), the optical
devices prescribed for the visually impaired old people, after the
assessment and knowledge of the visual category of each individual, their individual needs and aspects of their daily life, they
helped in improving the functional performance and were
recognized by the elderly as valid resources for managing their
everyday activities.
The findings of this study allow us to highlight the Basic
Activities of Daily Life (ADLs), such as functional communication
(d166), functional mobility (d4502) and socialization (d9205),
were more implicated in this group of participants, than the Instrumental Activities of Daily Living such as household chores
(d640). Although ADLs are less complex activities – in relation
to required skills, the participants at the time of the survey are in
the beginning of the rehabilitation process.
Owsley et al. (33) , during the tracking of the vision
rehabilitation services in the United States and the characteristics
of the population assisted, found that reading is a performing
task that is more compromised, about 85.9% of assisted subjects
presented difficulty in reading, so as in this study, in which 76.92%
presented impairment in the reading performance from
moderate (.2) to complete (.4). When it comes to mobility (41.2%)
and household chores (39.1%), these activities are shown as
difficult to implement, though less prominently (33).
The performance data of socialization, in which 7 people
reported severe difficulty and 1 person complete difficulty in
social performance (d9205), meets Cunha’s and Enumo’s speech
(8)
, which argues that deficiency leads to social losses. For other
participants evaluated and ranked, social environmental factors
are not barriers to their acceptance and engagement in activities,
but facilitators. On the other hand, there are physical
environments that are not prepared to receive the visually
impaired, causing limitations and restrictions on the participation
of people in public and private environments, creating real
barriers, interfering with the right to come and go, and as
mentioned previously, discouraging the access to and search for
health services (4,27-29).
The context of the health network, which is highlighted
here, refers to the rehabilitation of the visual impaired. The
rehabilitation goes beyond empowering, training or presenting
resources, techniques and strategies to the individuals in dealing
with their environment. It aims to take actions to facilitate and
promote their social inclusion and integration, enabling the
individuals to perform daily with autonomy, independence and
quality of life. Visual rehabilitation groups stand for sources of
experience for the participants, legitimizing capabilities, the
possibilities for action, assisting in the reconstruction of their
personal and social identities (13). It is important to highlight that
the family members participate actively in some meetings, so
they are constantly guided and kept close. The rapprochement
of the family during the rehabilitation process is essential for the
engagement, attendance and stimulation of the visually impaired.
The visual loss at any level, studied in this research, was the
cause of the functional impairment, regarding the independence
of the activities in the daily living and, consequently, the quality
of life of the individuals. In order to enable the participants to
reach their maximum functionality and their well-being it is crucial
in the habilitation and rehabilitation care process to count on a
multi-skilled team and knowledge in order to encompass the
individual as a whole being and rehabilitate him effectively (2,1115,33)
. This wide and global approach is carried out at the research
center as well as in the approach of the Visual Rehabilitation
Group from the assessment until the discharge process. This
Rev Bras Oftalmol. 2014; 73 (5): 291-301
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Silva MR, Nobre MIRS, Carvalho KM, Montilha RCL
approach leads the therapeutic goals to be plotted according to
the user’s individual needs in all aspects and his rehabilitation is
closely monitored and is planned properly.
The archaic concept of disability as irreversible condition
and applied to small groups that should be medicalized and
rehabilitated to bring the individual to the maximum of the
expected standard of functionality, brings forth - and still does discrimination and segregation.
In order to educate society that disability is inherent to the
human diversity, constant actions are required and performed.
Another significant struggle within the universe of disability
refers to the different forms of limitations and the constraints
that are usually faced. Impaired people experience their
disabilities in different ways; they perform and participate in
their daily activities on their own terms due to their personal
factor, preferences, settings, facilitators, barriers, different history
and culture. The lack of understanding that the same deficiency
leads to various restrictions and limitations for each person who
experiences it may lead to misconceptions, myths and prejudices
in several areas, whether educational, legislative, financial,
technological. It is precisely the importance of researching on
the diversity within human diversity, i.e., within the peculiarities
of the visual impairment, which are based on the rehabilitation
process. It is this diversity that is the source of action in health. To
research the diversity is to seek forms of intervention based on
the needs and individualized demands.
An example of diversity within the universe of visual
impairment can be seen in Table 5. The S3 individual, considered
blind in both eyes (H54.0), compared to S1 and S2, both with
blindness in both eyes by the ICD-10, has less limiting and
restrictive functional responses related to the visual impairment.
When the same individual (S 3) is compared to S 8 and S 10,
considered visually impaired with low vision in both eyes (H54.2),
his performance and ability to perform daily activities is similar
or slightly lower. These different responses within this universe
allow the understanding about the individual who is assisted
by the clinic such as his singularities. It is extremely important
to plan the rehabilitation conduct preventing the generalization
by the visual condition. The ICF has an essential role in this
context, since it comes to discuss, extend and articulate the
concepts about disability.
Used as a tool in this study, the ICF proved to be a suitable
tool for classifying visual disabilities that should be incorporated
into the professional practice in the health field in order to
guide actions centered on the needs of the individual with low
vision or blindness, to turn the rehabilitation process
individualized and effective. It is suggested that the ICF does
not guide actions alone, but combined with other standardized
structured and semi-structured assessment and mainly with
the observation and approach to the subject assisted to improve
strategic interventions that may be conducted.
CONCLUSION
The visual loss, at any level, led to functional impairments,
limiting and restricting the individuals’ participation and
performance in the daily activities interfering with their
independence, autonomy and their quality of life. However, the
use of optical resources, non optical, aids and environmental
adaptations proved to be beneficial for increasing the
Rev Bras Oftalmol. 2014; 73 (5): 291-301
functionality, showing the influence of external factors on the
individual’s performance.
Knowing and recognizing the existence of diversity within
the universe of visual impairment allows the understanding who
the assisted subject is, avoiding the generalization by the visual
condition. From this research it was possible to describe the
characteristics of each individual diagnosed with visual
impairment according to the ICD-10, and classify him according
to the ICF. This process showed that the classification in the ICF
favors the rehabilitation conduct since it covers the individual in
his particularities and context, reaching his individual sphere
that is embedded in a socio-cultural context historiography, based
in unique and complex needs.
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Montilha RC, Temporini ER, Nobre MI, Gasparetto ME, KaraJose N. Utilização de recursos ópticos e equipamentos por escolares
com deficiência visual. Arq Bras Oftalmol. 2006;69(2):207-11.
Haddad MA, Sampaio MW, Haddad M, et al. Auxílios para baixa
visão. In: Sampaio MW, Haddad MA, Costa Filho HA, Siaulys
MO. Baixa visão e cegueira: os caminhos para a reabilitação, a
educação e a inclusão. Rio de Janeiro: Cultura Médica; Guanabara
Koogan; 2010. p.113-39.
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Corresponding of author:
Rua Primo Chiorlin, nº 80
CEP: 13105-556 – Campinas (SP), Brazil
E-mail: [email protected]
Rev Bras Oftalmol. 2014; 73 (5): 291-301
ORIGINAL ARTICLE
302
Knowledge about primary open angle
glaucoma among medical students
Nível de conhecimento sobre glaucoma primário de
ângulo aberto entre os estudantes de medicina
Saulo Costa Martins1, Marcos Henrique Mendes1, Ricardo Augusto Paletta Guedes2, Vanessa Maria Paletta Guedes3,
Alfredo Chaoubah 4
A BSTRACT
Objective: To assess the knowledge of primary open-angle glaucoma among medical students from Federal University of Juiz de
Fora. Methods: In this cross sectional study, we conducted a survey among students attending the last two years of Medical School.
The questionnaire consisted in 11 questions about epidemiology, risk factors, symptoms, diagnosis, treatment and primary openangle glaucoma (POAG) consequences. The students were also asked if they considered their knowledge about POAG sufficient.
Students’ characteristics (age, sex and intended area of specialization) were identified. Results: Women comprised 52.9% of the
students. Only 22.5% identified POAG as having a genetic origin. Almost half of them (46.1%) did not know that POAG is asymptomatic
and 1 out of 3 students did not know that glaucoma blindness is irreversible. The great majority (91.2%) correctly identified
tonometry as an important tool for diagnosis and that glaucoma can be treated through medications (70.6%) or surgery (71.6%).
However, few students identified fundoscopy (35.3%) and perimetry (28.7%) as important tools for glaucoma assessment. Almost
everyone (95.1%) considered their knowledge insufficient. Conclusion: The majority of the participants believe that their knowledge
of POAG is insufficient. This gap can lead to some serious consequences from both individual (blindness) and collective (negative
impact in health system and society) perspectives.
Keywords: Glaucoma, open-angle/diagnosis; Glaucoma, open-angle/prevention & control; Ophthalmology/education; Medical,
students; Education, medical
RESUMO
Objetivo: Avaliar o conhecimento dos alunos de graduação do curso de Medicina da Universidade Federal de Juiz de Fora em relação
ao glaucoma primário de ângulo aberto. Métodos: Neste estudo transversal, aplicou-se aos alunos dos 5º e 6º ano um questionário
contendo 11 questões referentes a epidemiologia, fatores de risco, sintomas, diagnóstico, tratamento, consequências do glaucoma e por
último se consideram os conhecimentos adquiridos na universidade como suficientes. Características dos alunos (idade, sexo, especialidade pretendida) foram identificadas. Resultados: Entre os estudantes, 52,9% eram mulheres. A origem genética da doença foi identificada
por 22,5%. Quase a metade (46,1%) não sabia que o glaucoma na maioria das vezes é assintomático. Aproximadamente 1 em cada 3
alunos não sabia que a cegueira do glaucoma era irreversível. A grande maioria (91,2%) identificou corretamente que a tonometria era
um exame importante na avaliação do glaucoma e que o tratamento poderia ser clínico (70,6%) ou cirúrgico (71,6%). Porém, poucos
alunos deram a real importância para os exames de fundoscopia (35,3%) e campimetria (28,7%). Quase a totalidade (95,1%) dos
entrevistados considerou o próprio conhecimento como insuficiente. Conclusão: A maioria dos entrevistados acha que o conhecimento
sobre glaucoma primário de ângulo aberto adquirido na graduação é insuficiente. Tal desconhecimento pode levar a oportunidades de
diagnóstico perdidas e gerar consequências graves tanto do ponto de vista individual (cegueira) quanto do ponto de vista coletivo
(impacto para o sistema de saúde e sociedade).
Descritores: Glaucoma de ângulo aberto/diagnóstico; Glaucoma de ângulo aberto/prevenção & controle; Oftalmologia/educação;
Estudantes de Medicina; Educação em graduação de Medicina
1
Medical Student, Medical School of the Federal University of Juiz de Fora (UFJF), Juiz de Fora/MG, Brazil.
Ophthalmologist, Researcher at the Federal University of Juiz de Fora (UFJF), Juiz de Fora/MG, Brazil.
3
Ophthalmologist, Head of the Ophthalmology Department, Santa Casa de Misericórdia Hospital, Juiz de Fora; Researcher at the Federal
University of Juiz de Fora (UFJF), Juiz de Fora/MG, Brazil.
4
Professor and Researcher at the Department of Statistics, Federal University of Juiz de Fora (UFJF), Juiz de Fora/MG, Brazil
2
Work conducted at the Federal University of Juiz de Fora (UFJF), Juiz de Fora/MG, Brazil.
The authors declare no conflict of interest.
Received for publication 25/09/2012 - Accepted for publication 29/8/2014
Rev Bras Oftalmol. 2014; 73 (5): 302-7
Knowledge about primary open angle glaucoma among medical students
INTRODUCTION
G
laucoma is a chronic optic neuropathy with marked
changes in the optic disc and the retinal nerve fibre
layer, leading to significant visual field changes(1-3).
The disease is classified according to the mechanisms of
obstruction of aqueous humour drainage as primary open angle
glaucoma (POAG), primary angle closure glaucoma (PACG),
and secondary glaucoma(4).
According to the World Health Organization, glaucoma is
the second leading cause of blindness in the world (12.3%) after
cataract (47.8%). Studies in Brazil have found a prevalence of
3,4% for glaucoma, with POAG being the most prevalent type
(2.4%)(1). It is important to note that cataract blindness can be
reversed with surgical treatment, while glaucoma blindness is
irreversible(5).
Several predictive and prognostic risk factors have been
described for POAG, such as increased intraocular pressure
(IOP), family and genetic history, ethnic origin, myopia, and diabetes mellitus(1,2). Of these, IOP is more consistently associated
with glaucoma and is the most important factor, as it is the only
one that can be acted upon effectively(1-3).
The disease is asymptomatic in its early stages, and its
insidious onset often leads to late diagnosis(1-3). Thus, it is estimated
that over half of glaucoma cases remain undiagnosed and
untreated(6,7).
Given that ophthalmic consultations represent 9% of all
medical visits and that ophthalmologists are unevenly distributed
throughout the country, it is clear that general practitioners have
an important role in the prevention of blindness(8,9).
In this context, medical education should train medical
students to diagnose, refer patients appropriately, and even treat
some of the most prevalent and disabling eye diseases, including
glaucoma(5,10,11). For POAG in particular, students should learn
to identify its key risk factors, refer patients for glaucoma testing,
and stress the importance of prevention, especially in higherrisk cases. Medical education should also stress the need to
promote adhesion to continuous treatment, which contributes
to reducing disease progression(5).
However, studies have shown that the basic knowledge of
ophthalmology among undergraduate students is insufficient,
suggesting the need to reassess the way ophthalmology is taught
in medical school(8,10).
It is thus important to study the knowledge of POAG
among students who will soon become general practitioners,
offer them appropriate training, and contribute to discussions
on curriculum reform.
The aim of this study was to assess the level of knowledge
of POAG among students in the last two years of Medical School
in the Federal University of Juiz de Fora, Brazil.
M ETHODS
A cross-sectional observational study was conducted from
August to September 2012. The sample included medical students
of the Federal University of Juiz de Fora (UFJF), and a sampling
error of ±4.5% was considered. The study subjects were
approached while in the university, being randomly selected and
invited to answer the questionnaire voluntarily, free of any charge.
303
Inclusion criteria were: medical students over 18 years of
age attending the 9th, 10th, 11th or 12th semesters and immediately
available to answer the questionnaire. Students in other
semesters, who were not immediately available to answer the
questionnaire, who refused to participate, who did not answer
the questionnaire in full, or who did not provide their Free and
Informed Consent were excluded from the study.
Participants were approached in a standardised manner
by a trained researcher, having previously provided their free
and informed consent to answer the questionnaire individually
and voluntarily. Two medical students were responsible for data
collection. Training on data collection was done during a pilot
study conducted on 16 subjects in order to test the instrument,
identify difficulties in understanding the questions, make
appropriate changes to the questionnaire, and organise the
field work.
The data collection instrument was a structured
questionnaire (Appendix 1) including 11 questions on the risk
factors, symptoms, diagnosis, treatment, and consequences of
glaucoma, aimed at testing the knowledge of subjects about the
condition. Student characteristics (age, sex, and the medical
specialty they intended to pursue) were collected.
SPSS software (SPSS Inc., Chicago, USA) was used to
prepare the database and for statistical analysis. Results were
analysed using a confidence interval of 95% and a p-value under
0.05.
The study followed the guidelines on human research
provided for in Resolution 196/96 of the Brazilian National
Health Council/Ministry of Health. The study was submitted to
the Research Ethics Committee of Santa Casa de Misericórdia
Hospital in Juiz de Fora, having been approved under Opinion
73374/2012.
R ESULTS
In total, 102 students were invited and agreed to participate
in the study. They were distributed as follows: 25 in the 9th semester,
27 in the 10th semester, 25 in the 11th semester, and 25 in the 12th
semester. The mean age (± standard deviation) of respondents
was 24.9 (±2.2) years. Most respondents (52.9%) were female.
Only 2.9% of respondents intended to specialise in
ophthalmology, while 80.4% intended to pursue another medical
specialty and 16.7% had not yet chosen a specialty.
A family history of glaucoma was found in 15.7% of
respondents. Approximately 7% were unaware of glaucoma cases in their family, while most respondents (76.5%) stated there
were no cases of the disease in their family.
Figure 1 shows the responses of students when asked about
the leading cause of irreversible blindness worldwide. Most
students (59.8%) gave the correct answer, glaucoma. However,
25.5% of respondents chose diabetic retinopathy. All students
intending to specialise in ophthalmology answered correctly, but
among the other students (those intending to pursue another
specialisation, or still undecided), 26.3% thought the correct
answer was diabetic retinopathy.
Glaucoma blindness was classified as irreversible by 64.7%
of respondents, but 17.6% thought it was reversible with some
treatment, and a similar number did not know the answer, i.e.
35.3% of students (approximately 1 in 3) did not know that
Rev Bras Oftalmol. 2014; 73 (5): 302-7
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Martins SC, Mendes MH, Guedes RAP, Guedes VMP, Chaoubah A
glaucoma blindness is irreversible. There were no significant
differences between answers when respondents were grouped
based on their intended medical speciality (p = 0.964, chi-squared
test), study semester (p = 0.076, chi-squared test), or a family
history of glaucoma (p = 0.122, chi-squared test).
POAG was identified as the most common type of glaucoma
by 58.8%, but 19.6% (1 in 5) did not know what the answer.
Again, no differences were found between groups based on
intended medical speciality (p = 0.387, chi-squared test), study
semester (p = 0.045, chi-squared test), or a family history of
glaucoma (p = 0.782, chi-squared test).
Most students (67.6%) wrongly thought IOP was a causal
factor of POAG. Only 22.5% correctly identified genetic factors
as a cause of POAG, and 16.7% did not know the answer. There
were no differences between groups based on intended medical
speciality, study semester, or a family history of glaucoma.
and symptoms were mentioned by respondents as part of the
clinical picture of POAG: sudden loss of central vision (24.5%);
eye pain (33.3%); red eye (9.8%); tearing (11.8%); periocular
headache (24.5%); frontal headache (5.9%); photophobia
(11.8%). There were no differences between groups based on
intended medical speciality, study semester, or a family history of
glaucoma.
The vast majority of respondents (91.2%) correctly replied
that tonometry (IOP measurement) is an important test in the
assessment of glaucoma. However, only 35.3% considered
fundus examination and 28.7% considered perimetry as
important tests for glaucoma. There were no differences
between groups based on intended medical speciality, study
semester, or a family history of glaucoma.
Figura 3: Possibilidades de tratamento do glaucoma primário de ângulo aberto segundo os entrevistados
Figure 1: Leading cause of irreversible blindness, according to respondents.
Figure 2 shows the variables identified by the respondents
as risk factors for POAG. High IOP was mentioned by 88.2% of
students, but many other important factors were missed by most
students, including: hypertension (49%); diabetes mellitus
(26.5%); myopia (4.9%); ocular trauma (15.7%); corticosteroids
(43.1%); and black race (15.7%). A family history of glaucoma
was correctly identified as a risk factor by 72.5% of respondents.
There were no differences between groups based on intended
medical speciality, study semester, or a family history of glaucoma.
Figure 3 shows the distribution of answers regarding the
treatment of glaucoma. Most respondents correctly replied that
glaucoma can be treated medically (70.6%) and surgically
(71.6%). Laser therapy, however, was only mentioned as a
treatment alternative by 23.5% of respondents. There were no
differences between groups based on intended medical speciality,
study semester, or a family history of glaucoma.
Figura 4: Proportion of respondents who thought they had acquired
sufficient knowledge on primary open-angle glaucoma during medical
school.
Figure 2: Risk factors of primary open-angle glaucoma, according to
respondents.
In total, 15.7% of respondents stated they did not know
what the signs and symptoms of POAG were. Only 53.9%
correctly replied that POAG was asymptomatic. Several signs
Rev Bras Oftalmol. 2014; 73 (5): 302-7
Figure 4 shows the proportion of respondents who
considered they had learned enough about POAG during their
medical studies.
DISCUSSION
This study found that students in the last two years of
medical school at the Federal University of Juiz de Fora feel
Knowledge about primary open angle glaucoma among medical students
unable to identify the main epidemiological and clinical
characteristics and the therapeutic possibilities for POAG. This
was confirmed by their responses to the standardised
questionnaire used in this study.
General clinical knowledge is key to increasing the number
of early POAG diagnoses and therefore the number of patients
who receive treatment. Furthermore, misconceptions and
knowledge gaps are important barriers to preventive eye health
actions(5,12). Assessing the knowledge of medical students in the
last years of medical school is a tool that can be used to prompt
reflections on the knowledge of physicians, as many of those
students will soon be managing patients(5).
This assessment is particularly relevant because an increase
in the prevalence of glaucoma is expected worldwide as a result
of population ageing and insufficient ophthalmic resources for
effective intervention against the condition(5).
In our sample, most respondents correctly ranked
glaucoma as the most prevalent cause of irreversible blindness
worldwide, although approximately one quarter of them thought
the correct answer was diabetic retinopathy. This could suggest
that preventive campaigns led by organisations such as the
American Diabetes Association and the Brazilian Diabetes
Society raise more awareness than glaucoma campaigns. This is
evidenced by the continuous, broad-scope nature of programmes
like the Hiperdia (Hypertension and Diabetes) campaign and
the National Diabetic Retinopathy Campaign(13,14) and the lack
of investment and programme continuity in actions such as the
Glaucoma Campaign by the Brazilian Ministry of Health(5,14).
Furthermore, there is a greater focus on diabetes during medical
education because it involves more subjects in the medical
curriculum, while glaucoma is only studied during the
ophthalmology course.
As regards the classification of glaucoma, most students
correctly identified POAG as the most common type of glaucoma,
but it is noteworthy that 1 in 5 respondents did not know what
the most common type of glaucoma was.
One of the most common sources of error in the
assessment of glaucoma is to consider elevated intraocular
pressure as a causal factor. High IOP is only a risk factor(1), and
there are cases of ocular hypertension that never progress to
glaucoma. Likewise, there are cases of glaucoma with normal
IOP levels(1). When asked about the causal factor of POAG,
most respondents incorrectly answered that an elevated IOP
was a causal factor. Only 22.5% correctly mentioned genetic
factors as the cause of POAG.
On the other hand, and contradictorily (a causal factor
cannot be a risk factor at the same time!), most respondents
correctly identified elevated IOP as an important risk factor for
glaucoma. A family history of glaucoma was correctly identified
as a risk factor by 72.5% of respondents. POAG is a multifactorial
disease, and it is essential that physicians know its risk factors(1).
The subjects of this study were medical students who will soon
become medical doctors, a large part of which will probably work
in Primary Health Care. Since primary care is the gateway to a
network of services providing universal access, it is responsible
for coordinating care in the network in all of its dimensions(5).
The results of this study, however, indicate a gap in the functions
of primary care with regard to eye health, i.e. the need to recognise
risk factors in order to prevent and control certain causes of
preventable blindness and visual impairment(5).
305
Recognising the clinical presentation of glaucoma is key to
preventing and controlling the condition (5). Glaucoma is a
neurodegenerative disorder characterised by insidious and
progressive retinal ganglion cell degeneration (3), and it is
asymptomatic in its early stages(1,2,5). Thus, physicians should know
that patients with suspected or confirmed glaucoma will not
present with exuberant symptoms or directly complaining of
ocular involvement. This assessment of the knowledge of the
clinical features of POAG among medical students found that
15.7% did not know the signs and symptoms of POAG, and just
over half of respondents (53.9%) correctly stated that POAG is
most often asymptomatic.
When asked about the key tests for diagnosing POAG, the
vast majority of respondents correctly identified tonometry as
an important test. However, important tests such as fundus
examination and perimetry and were only mentioned by a few
respondents. This study indicates a serious deficiency in medical
education, as glaucoma is a disease of the optic nerve (optic
neuropathy) whose evaluation (diagnosis and management) can
only be done through adequate and reliable fundus examination
and perimetry(1).
Current recommendations for the treatment of POAG
include lowering the IOP, which remains the only demonstrated
treatable risk factor for the disease(3). This can be done through
medical, surgical and laser treatment. In our study, most
respondents correctly stated that glaucoma can be treated
medically and surgically. Laser treatment is also an alternative,
but it was only mentioned by 23.5% of participants.
In all questions there were no differences between groups
based on intended medical speciality, study semester, or a family
history of glaucoma. This shows that misconceptions regarding
important factors related to glaucoma are not limited to a particular class in medical school. It also suggests that patients with
glaucoma and their families do not receive proper guidance and
have insufficient knowledge about the condition.
In this study, almost all participants felt their knowledge of
glaucoma was insufficient. A similar study conducted with
students in the last semesters of medical schools in the state of
São Paulo found significant gaps in the knowledge of
ophthalmology of future general practitioners(15), while a study
conducted at the Federal University of Piauí in 2011 found that
99.1% of students felt insecure about treating eye disorders(10).
The results of our work are thus in line with those of studies
conducted in other medical schools, showing that students
recognise the gaps in their ophthalmology training and
consequently feel unprepared to manage patients with eye
complaints. This suggests the need to change how the subject is
taught — ophthalmology courses should be targeted at primary
care(16), with a stronger focus on prevention and early diagnosis.
CONCLUSION
The results of this study show that most respondents think
the knowledge of glaucoma they acquired during medical school
was insufficient. This gap creates major misconceptions about
key issues such as the aetiology, risk factors, clinical picture, and
treatment of glaucoma, which can lead to missed diagnoses with
serious individual (blindness) and collective (impact on the
healthcare system and society) consequences.
Rev Bras Oftalmol. 2014; 73 (5): 302-7
306
Martins SC, Mendes MH, Guedes RAP, Guedes VMP, Chaoubah A
Appendix 1
Questionnaire applied to medical students.
Age: ___________________ Sex: _______________________ Semester: _____________________________________________
Intended specialization :____________________________________________________________________________________
Do you have any family members with glaucoma?
Yes
No
I don’t know
The most prevalent cause of irreversible blindness worldwide is:
Catarat
Glaucoma
Age-related macular degeneration
Diabetic retinopathy
I don’t know
Glaucoma can lead to blindless. Glaucoma blindless is:
Reversible with any tyoe of treatment (medical or surgical)
Reversible only through surgical treatment
Irreversible
I don’t know
The most common yype of glaucoma is:
Primary open angle glaucoma
Primary narrow angle glaucoma
Congenital glaucoma
Secondary glaucoma
I don’t know
The causes of primary angle glaucoma include :
Genetic factors
Elevated intraocular pressure
Infection
I don’t know
Please mark the main risk factors for primary open angle
glaucoma (one or more):
Elevated intraocular pressure
High blood pressure
Diabetes
Neurological disease
Young age
Hiperopia
Myopia
Family history of glaucoma
Eye trauma
Corticosteroids
Black race
R EFERENCES
1.
2.
Sociedade Brasileira de Glaucoma. 3º Consenso Brasileiro. glaucoma primário de ângulo aberto. São Paulo: BestPoint; 2009.
Disponível em: http://www.sbglaucoma.com.br/pdf/consenso03.pdf
National Health and Medical Research Council (NHMRC). A
guide to glaucoma for primary care providers. A companion document to NHMRC Guidelines for the screening, prognosis, diagnosis, management and prevention of glaucoma. Camberra, Australia: NHMRC; 2011. Disponível em: http://www.nhmrc.gov.au/
_files_nhmrc/publications/attachments/cp113_b_glaucoma_
guide_healthcare_workers.pdf
Rev Bras Oftalmol. 2014; 73 (5): 302-7
Please mark the most common signs and symptons of primary
open angle glaucoma:
Sudden loss of central vision
Eye pain
Red eye
Tearing
Periocular headache
Frontal headache
Photofobia
The condition is mostly asynptomatic
I don’t know
The main diagnostic tests for glaucoma include:
Visual acuity
Fundus examination
Measuring intraocular pressure (tonometry)
Perimetry
Magnetic resonance imaging
I don’t know
Glaucoma can be treated using (one or more):
Eye drops
Surgery
Laser
No treatment exists for the condition
I don’t know
Successful glaucoma treatment promotes:
Cure
Disease control, preventing blindness
Symptomatic releief, although the condition inevitably leads
to blindness
No treatment exists for the condition
I don’t know
Do you think the knowledge of glaucoma you acquired during
medical school is sufficient to recognise a possible case of primary
open angle glaucoma?
Yes
No
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estudantes de Medicina da Universidade Federal do Piauí. Rev
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Temporini ER, Kara-José N, Gondim EL, Dantas FJ.
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14. Brasil. Ministério da Saúde. Secretaria Executiva. Departamento
de Apoio à Descentralização. Coordenação-Geral de Apoio à
Gestão Descentralizada. Diretrizes operacionais dos Pactos pela
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N. Aspectos do ensino de graduação em oftalmologia. Arq Bras
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Corresponding author:
Saulo Costa Martins
Rua Doutor Constantino Paletta 10/401 - Centro
CEP: 36015-450, Juiz de Fora (MG), Brazil
E-mail: [email protected]
Rev Bras Oftalmol. 2014; 73 (5): 302-7
308
CASE REPORT
Central retinal artery occlusion associated
with patent foramen ovale
Oclusão de artéria central da retina associada
ao forame oval patente
Patrícia Regina de Pinho Tavares 1, Mariana Rezende de Oliveira 2, Eduardo de Castro Miranda Diniz3 , Rafael Mourão
Agostini4 , Daniela Vieira de Aguiar5
A BSTRACT
Central retinal artery occlusion it’s a disease most encountered in older patients, however it can be seen in children and young
persons. In this situation the principal causes are cardiac abnormalities, and the patent foramen ovale is the most observed. The
purpose of this study is to report a case of central retinal artery occlusion in a young patient with patent foramen ovale and, also,
describe the importance of a detailed management in cases of retinal vascular occlusions.
Keywords: Central retinal artery/pathology; Cardiac abnormalities; Foramen ovale, patent; Retinal artery occlusion; Young
adult; Case reports
RESUMO
Oclusão da artéria central da retina é uma doença comumente encontrada em pacientes idosos, mas pode também ser vista em crianças
e adultos jovens. Nestes, as principais causas são anomalias cardíacas, sendo o forame oval patente o mais observado. O objetivo do
trabalho é relatar o caso de um paciente jovem com oclusão da artéria central da retina apresentando persistência de forame oval e,
também, salientar a importância de uma propedêutica detalhada nos casos de oclusões vasculares da retina.
Descritores: Artéria central da retina/patologia; Anomalias cardíacas; Forame oval patente; Oclusão da artéria retiniana; Adulto
jovem; Relatos de casos.
1
Oculoplastic Surgery Department, Ophthalmic Centre of Minas Gerais, Belo Horizonte/MG, Brazil.
Oculoplastic Surgery Department, Eye Clinic of Santa Casa de Belo Horizonte, Belo Horizonte/MG, Brazil.
3
Glaucoma Department, Ophthalmic Centre of Minas Gerais, Belo Horizonte/MG, Brazil.
4
Retina Department, Eye Clinic of Santa Casa de Belo Horizonte, Belo Horizonte/MG, Brazil.
5
Retina Department, Eye Clinic of Santa Casa de Belo Horizonte, Belo Horizonte/MG, Brazil.
2
The authors declare no conflict of interest.
Received for publication 20/10/2011 - Accepted for publication 27/3/2012
Rev Bras Oftalmol. 2014; 73 (5): 308-10
Central retinal artery occlusion associated with patent foramen ovale
Table 1
INTRODUCTION
C
entral retinal artery occlusion (CRAO) is characterised
by a sudden, painless and severe loss of vision. It generally
affects adults around the age of 60, and rarely below the
age of 30. Men are more likely to be affected than women. In the
large majority of cases, vision is worse than 20/400, but some
patients present a cilioretinal artery which preserves a central
vision of about 20/40 or better. Its most common cause is
thrombosis due to atherosclerosis at the level of the lamina
cribrosa(1). However, in young patients it is most frequently
associated with cardiac disorders, trauma, haemoglobinopathies
and ocular abnormalities such as optic disc drusen and
peripapillary arterial loop(2).
This paper describes a case of CRAO in a young patient
with patent foramen ovale. To the best of our knowledge, this is
the first such case report in the Brazilian literature.
CASE REPORT
RVS, a 19-year-old male student, was referred to the Santa
Casa de Belo Horizonte Eye Clinic (MG) with a sudden and
painless loss of visual acuity in the left eye (LE) occurring
approximately 20 days earlier. He had no history of any disease,
trauma, or use of medications or illegal drugs, including cigarettes.
Ophthalmic examination found a visual acuity of 20/20 in the
right eye (RE) and hand motion in the LE, showing no
improvement with use of a pinhole. Biomicroscopy found an
afferent pupillary defect in the LE and no changes in the RE.
Intraocular pressure was 10 mmHg. Fundus examination showed
optic disc and retinal pallor, arteriolar narrowing, flame-shaped
haemorrhages and sequelae of oedema in the macular region,
accumulation of hard exudates in the fovea, and mild macular
star formation.
Due to suspected retinal vascular disease, the patient was
referred for thromboembolism screening (Table 1), retinal
fluorescein angiography, optical coherence tomography (OCT),
and cardiac and haematological evaluation.
In the assessment of thromboembolic events, only the
transthoracic echocardiogram was abnormal, showing an
interatrial septum with a small right-to-left shunt suggestive of
patent foramen ovale. Retinal fluorescein angiography (Figure
1) found hypofluorescent spots corresponding to the retinal
haemorrhages and increased foveal hypofluorescence suggesting
ischemia. OCT (Figure 2) found increased thickness and
reflectivity of the internal layers of the retina corresponding to
intracellular oedema and ischemia, attenuating the optical signals
from the external retinal layers (RPE/Bruch membrane/
choriocapillaris complex). The patient is currently taking
acetylsalicylic acid 100 mg/day as prescribed by his cardiologist.
309
Protocol for retinal thrombosis and vasculitis of the Retina
and Vitreous Unit, Santa Casa de Misericórdia, Belo Horizonte.
· SimpleRetinography
· Angiography
· Coagulation testing
· Homocysteine
· Protein electrophoresis
· Complete blood count:
factors VII, IX, XI,
fibrinogen
anemia – Hb, electrophoresis,
search for sickle cells, bilirubin,
Serun Fe, transderrin, ferritin,
WBC/platelet count – mieloproliferative/ disorders /
neoplasms
· Fasting serum glucose
· Erytrocyte sedimentatiom rate
· ANF
· Lupus anticoagulant
· Anticardiolipin IgG/IgM
· Antiphospholipid
· Antithrombin B
· Protein C and S
· Factor V Leiden
· Prothrombin gene
· C3 – CH50
· Urea e creatinine
· Urinalysis (sediments analysis)
· VDRL – FTA-Abs
· PPD
· Toxoplasmosis IgM/IgG
· Anti-HIV
· CMV
· Herpes virus
· Hepatitis B, A e C
mutation
Figure 1A a 1D: Retinography and fluorescein angiography showing
signs of central retinal arteryocclusion.
DISCUSSION
According to the RECO (Retinal Emboli of Cardiac
Origin) study, 45% of patients under 45 years of age with CRAO
also present cardiac abnormalities, of whom 27% need to take
anticoagulants or undergo cardiac surgery(3).
Patent foramen ovale is the most common congenital
cardiac abnormality, and it can cause cerebral and systemic emboli
Figure 2: Optical coherence tomography of patient with central retinal
artery occlusion
Rev Bras Oftalmol. 2014; 73 (5): 308-10
310
Tavares PRP, Oliveira MR, Diniz ECM , Agostini RM , Aguiar DV
before the age of 55 years(4). In cases of large patent foramen
ovale with spontaneous right-to-left shunt, surgical treatment is
recommended(5). In the case presented here, the patient had a
small patent foramen ovale without spontaneous shunt, being
therefore eligible for medical treatment with an anticoagulant.
The occurrence of CRAO stresses the importance of a
detailed systemic evaluation to identify its exact aetiology, with
careful follow-up to prevent further thromboembolic events. For
this reason, specialist services should have a screening protocol
for cases of retinal vascular occlusion.
4.
5.
Ho IV, Spaide R. Central retinal artery occlusion associated with
a patent foramen ovale. Retina. 2007;27(2):259-60.
Kramer M, Goldenberg-Cohen N, Shapira Y, Axer-Siegel R,
Shmuely H, Adler Y, et al. Role of transesophageal
echocardiography in the evaluation of patients with retinal artery occlusion. Ophtalmology. 2001;108(8):1461-4. Comment in
Ophthalmology. 2002;109(5):829; author reply 829.
R EFERENCES
1.
2.
3.
Liesegng TJ, Skuta GL, Cantor LB, editors. Basic and Clinical
Science Course. Section 12: Retina and vitreous. San
Francisco:American Academy of Ophthalmology; 2005. p.54-79.
Sharma S, Brown GC. Retinal artery obstruction. In: Ryan SJ.
Retina, 3rd ed. St. Louis: Mosby; 2001. Vol. 1, p.1350-67.
Clifford L, Sievers R, Salmon A, Newson RS. Central retinal artery occlusion: association with patent foramen ovale. Eye (Lond).
2006;20(6):736-8.
Rev Bras Oftalmol. 2014; 73 (5): 308-10
Corresponding author:
Patrícia Regina de Pinho Tavares
R. Alvarenga Peixoto, 580-401
CEP 30180120, Belo Horizonte (MG), Brazil.
Telephone: +5531 3657 3583 or +5531 8891 8537
E-mail: [email protected]
CASE REPORT 311
Adult dacryocystocele
Dacriocistocele no adulto
Silvia Helena Tavares Lorena 1 , João Amaro Ferrari Silva
2
ABSTRACT
The dacryocystocele represents a dilated lacrimal sac and is often considered as having a congenital etiology. However, dacryocystocele
is a rare disease in adults. The clinical feature is characterized by a painless bulge in the medial region of the orbit, below the medial canthal
ligament. The lacrimal excretion test, endoscopy, computerized tomography and magnetic resonance image are used to make the diagnosis
of dacryocystocele. Similar to pediatric patients, endoscopic marsupialization of the cyst with nasal stenting seems to be the appropriate
therapy. In some cases the treatment consists of external dacryocystorhinostomy.
Keywords: Orbit; Nasolacrimal duct obstruction; Dacryocystocele; Dacryocystorhinostomy
RESUMO
A dacriocistocele representa um saco lacrimal dilatado e é frequentemente considerada como tendo uma etiologia congênita. No entanto,
dacriocistocele é uma doença rara em adultos. A característica clínica se caracteriza por um abaulamento indolor na região medial da
órbita, inferior ao ligamento cantal medial. O teste de excreção lacrimal, endoscopia, tomografia computadorizada e ressonância
magnética são utilizados para fazer o diagnóstico de dacriocistocele. Semelhante a pacientes pediátricos, marsupialização endoscópica
do cisto nasal e a colocação de stent parece ser a terapêutica adequada. Em alguns casos o tratamento consiste na dacriocistorrinostomia
externa.
Descritores: Órbita; Obstrução do ducto lacrimal; Dacriocistocele; Dacriocistorrinostomia
1
2
Post-Graduation (Ph.D.) Programme at the Lacrimal Pathways Unit, Federal University of São Paulo (UNIFESP), São Paulo/SP, Brazil.
Lacrimal Pathways Unit, Federal University of São Paulo (UNIFESP), São Paulo/SP, Brazil.
Work conducted at the Lacrimal Pathways Unit, Federal University of São Paulo (UNIFESP), São Paulo/SP, Brazil.
The authors declare no conflict of interest.
Received for publication 11/11/2011 - Accepted for publication em 3/9/2012
Rev Bras Oftalmol. 2014; 73 (5): 311-13
312
Lorena SHT , Silva JAF
INTRODUCTION
D
acryocystocele is characterised by a dilated lacrimal sac
and is often regarded as a congenital condition. However,
it is a rare disease in adults. It presents as a painless
bulge in the medial region of the orbit below the medial ligament.
Its mechanism involves an acquired obstruction at the level of
Krause’s valve and obstruction proximal to the common canaliculus,
at the level of Rosenmuller’s valve.(1-3)
In a patient with nasal obstruction, the differential diagnosis
includes masses such as haemangioma, glioma, encephalocele,
and dermoid cyst, as well as congenital bone anomalies such as
choanal atresia.(4,5)
The tear secretion test, endoscopy, computed tomography,
and magnetic resonance imaging can be used to diagnose the
condition.
Dacryocystocele in adults should be considered as an
obstruction of the nasolacrimal duct, and intranasal examination
should be performed before external dacryocystorhinostomy.(68)
Similar to paediatric patients, endoscopic marsupialization of
the nasal cyst with stent placement seems to be the appropriate
therapeutic approach. Some cases can be treated with external
dacryocystorhinostomy.(9-11)
CASE REPORT
A white, 42-year-old woman presented with epiphora in
the right eye and progressive ipsilateral nasal congestion
starting 4 months earlier. She had no history of epistaxis, facial
fracture, or sinus and nasal disorders. Ophthalmic examination
found a soft mass in the medial region of the right orbit (Figure
1). Biomicroscopy showed no hyperaemia in the bulbar
conjunctiva and no anterior chamber reaction. The Milder test
was intensely positive. Catheterisation found a soft stop after
introducing the Bowman probe 9 mm into the canaliculus. The
Jones 1 test was negative. Examination of the left eye was normal, including eyelid position. Right anterior rhinoscopy found
no mass below the inferior turbinate. The patient was prescribed
prophylactic antibiotic therapy and cold packs, and the
dacryocystocele resolved after 2 weeks, progressing to chronic
dacryocystitis. The patient will undergo external
dacryocystorhinostomy.
DISCUSSION
Dacryocystocele in the medial orbital region is a relatively
rare condition, but congenital dacryocystocele has been
recognised as an individual disease since 1933(12). Congenital
dacryocystocele is found almost exclusively in paediatric
patients(13), and it has a specific natural history, clinical features,
disease mechanism, and treatment. Lacrimal sac dilation occurs
because of distal nasolacrimal duct obstruction and functional
obstruction of the common canaliculus. In cases of nasolacrimal
duct obstruction, secretions can accumulate in the lacrimal sac,
culminating in its dilation and obstructing the common
canaliculus. Another mechanism proposed for dacryocystocele
involves folds in the common canaliculus due to a dilated lacrimal sac and Rosenmuller’s valve malfunction secondary to
oedema and inflammation.(13) Children with dacryocystocele
are treated with antibiotics, massage, and cold compresses, and
if medical treatment is ineffective, probing and irrigation of the
lacrimal pathway associated with intranasal endoscopic
marsupialisation of the cyst are then indicated.(14)
There are a few reports of dacryocystocele in adults(15).
Its clinical picture includes painless bulging of the medial region
of the orbit below the medial ligament. The lacrimal secretion
test, endoscopy, computed tomography, and magnetic resonance
imaging can be used to diagnose the condition.(16) The disease
mechanism of dacryocystocele is similar in adults and children,
but the nasolacrimal duct obstruction in adults is acquired. A
complication of dacryocystocele is chronic dacryocystitis.(17)
Treatment involves placement of a nasolacrimal stent or
dacryocystorhinostomy.(18,19)
It may be necessary to differentiate dacryocystocele from
a tumour of the lacrimal sac.(20,21) Adult dacryocystocele can be
adequately diagnosed through studies such as ultrasound
imaging, computed tomography, and magnetic resonance
imaging. Computed tomography has become the most
important method for locating and characterising an orbital
mass. CT can determine the correct anatomical diagnosis by
showing the dacryocystocele in the lacrimal sac and is also
helpful in differentiating dacryocystocele from other masses
that can affect the medial canthus in adults. An orbital tumour
in the medial orbital region such as haemangioma,
neurofibroma, lymphangioma, or rhabdomyosarcoma can be
seen on CT as a solid mass.
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Figure 1. Frontal and lateral images of right dacryocystocele.
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Ansari SA, Pak J, Shields M. Pathology and imaging of the lacrimal
drainage system. Neuroimaging Clin N Am. 2005;15(1):221-37.
Lelli GJ, Levy RL. Epidermoid cyst masquerading as dacryocystocele: case report and review. Orbit. 2011;30(2):114-5.
Debnam JM, Esmaeli B, Ginsberg LE. Imaging characteristics of
dacryocystocele diagnosed after surgery for sinonasal cancer.
AJNR Am J Neuroradiol. 2007;28(10):1872-5.
Weber AL, Rodriguez-DeVelasquez A, Lucarelli MJ, Cheng HM.
Normal anatomy and lesions of the lacrimal sac and duct: evalu-
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Nicolai P.[Dacryocystocele in the adult: etiology, diagnosis and
treatment]. ActaOtorhinolaryngol Ital. 2001;21(2):100-4.
Day S, Hwang TN, Pletcher SD, Bhatki A, McCulley TJ. Interactive image- guided endoscopic dacryocystorhinostomy. Ophthal
Plast Reconstr Surg. 2008;24(4):338-40.
Plaza G, Nogueira A, González R, Ferrando J, Toledano N. Surgical treatment of familial dacryocystocele and lacrimal puncta
agenesis. Ophthal Plast Reconstr Surg. 2009;25(1):52-3.
Song HY, Lee DH, Ahn H, Kim JH, Kang SG, Yoon HK, et al.
Lacrimal system obstruction treated with lacrimal polyurethane
stents: outcome of removal of occluded stents. Radiology.
1998;208(3):689-94.
Yazici B, Yazici Z, Parlak M. Treatment of nasolacrimal duct
obstruction in adults with polyurethane stent. Am J Ophthalmol.
2001;131(1): 37-43.
Duke-Elder SS, editor. System of ophthalmology: normal and
abnormal development: congenital deformities. St Louis: Mosby;
1964. Vol. 3, Pt 2. p. 934-41.
Rand PK, Ball WS Jr, Kulwin DR. Congenital nasolacrimal
mucoceles: CT evaluation. Radiology. 1989;173(3):691-4.
Shashy RG, Durairaj V, Holmes JM, Hohberger GG, Thompson
DM, Kasperbauer JL. Congenital dacryocystocele associated with
intranasal cysts: diagnosis and management. Laryngoscope.
2003;113(1):37-40. Erratum in Laryngoscope. 2005;115(4):759.
Durairaj, Vikram [corrected to Durairaj, Vikram D].
Yip CC, McCulley TJ, Kersten RC, Bowen AT, Alam S, Kulwin
DR. Adult nasolacrimal duct mucocele. Arch Ophthalmol.
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2003;121(7):1065-6.
16. PerryLJ, Jakobiec FA, Zakka FR, Rubin PA. Giant
dacryocystomucopyoce in na adult a review of lacrimal sac enlargements with clinical and histopathologic differencial diagnoses. Sury Ophthalmol. 2012;57(5):474-85.
17. Meyer JR, Quint DJ, Holmes JM, Wiatrak BJ. Infected congenital
mucocele of the nasolacrimal duct. AJNR Am J Neuroradiol.
1993;14(4):1008-10.
18. Perena MF, Castillo J, Medrano J, De Gregorio MA, Loras E,
Cristobal JA. Nasolacrimal polyurethane stent placement: preliminary results. Eur J Ophthalmol. 2001;11(1):25-30.
19. Eloy P, Martinez A, Leruth E, Levecq L, Bertrand B. Endonasal
endoscopic dacryocystorhinostomy for a primary dacryocystocele in an adult. B-ENT. 2009;5(3):179-82.
20. Fliss DM, Freeman JL, Hurwitz JJ, Heathcote JG. Mucoepidermoid carcinoma of the lacrimal sac: a report of two cases, with
observations on the histogenesis. Can J Ophthalmol.
1993;28(5):228-35.
21. Sabet SJ, Tarbet KJ, Lemke BN, Smith ME, Albert DM. Granular
cell tumor of the lacrimal sac and nasolacrimal duct: no invasive
behavior with incomplete resection. Ophthalmology.
2000;107(11):1992-4.
Corresponding author:
Silvia Helena Tavares Lorena
Rua Flórida 1404, Brooklin
CEP: 04561-030, São Paulo/SP, Brazil
E-mail: [email protected]
Rev Bras Oftalmol. 2014; 73 (5): 311-13
314
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Medicine, disponível, na “List of Journal Indexed in Index
medicus” no endereço eletrônico: http://www.ncbi.nlm.nih.gov/
entrez/query.fcgi?db=journals.
Para todas as referências, citar todos os autores até seis. Quando em número maior, citar os seis primeiros autores seguidos da
expressão et al.
Artigos de Periódicos:
Dahle N, Werner L, Fry L, Mamalis N. Localized, central optic
snowflake degeneration of a polymethyl methacrylate intraocular
lens: clinical report with pathological correlation. Arch
Ophthalmol. 2006;124(9):1350-3.
Arnarsson A, Sverrisson T, Stefansson E, Sigurdsson H, Sasaki
H, Sasaki K, et al. Risk factors for five-year incident age-related
macular degeneration: the Reykjavik Eye Study. Am J Ophthalmol.
2006;142(3):419-28.
Livros:
Yamane R. Semiologia ocular. 2a ed. Rio de Janeiro:
Cultura Médica; 2003.
Capítulos de Livro:
Oréfice F, Boratto LM. Biomicroscopia. In: Yamane R.
Semiologia ocular. 2ª ed. Rio de Janeiro:
Cultura Médica; 2003.
Dissertações e Teses:
Cronemberger S. Contribuição para o estudo de alguns aspectos da aniridia [tese]. São Paulo: Universidade Federal de São
Paulo; 1990.
Publicações eletrônicas:
Herzog Neto G, Curi RLN. Características anatômicas das vias
lacrimais excretoras nos bloqueios funcionais ou síndrome de
Milder. Rev Bras Oftalmol [periódico na Internet]. 2003 [citado
2006 jul 22];62(1):[cerca de 5p.]. Disponível em:
www.sboportal.org.br
Tabelas e Figuras: A apresentação desse material deve ser
em preto e branco, em folhas separadas, com legendas e respectivas numerações impressas ao pé de cada ilustração. No
verso de cada figura e tabela deve estar anotado o nome do
manuscrito e dos autores. Todas as tabelas e figuras também
devem ser enviadas em arquivo digital, as primeiras preferencialmente em arquivos Microsoft Word (r) e as demais em arquivos Microsoft Excel (r), Tiff ou JPG. As grandezas, unidades e
símbolos utilizados nas tabelas devem obedecer a nomenclatura nacional. Fotografias de cirurgia e de biópsias onde foram
utilizadas colorações e técnicas especiais serão consideradas
para impressão colorida, sendo o custo adicional de responsabilidade dos autores.
Legendas: Imprimir as legendas usando espaço duplo, acompanhando as respectivas figuras (gráficos, fotografias e ilustrações) e tabelas. Cada legenda deve ser numerada em algarismos
arábicos, correspondendo as suas citações no texto.
Abreviaturas e Siglas: Devem ser precedidas do nome completo quando citadas pela primeira vez no texto ou nas legendas
das tabelas e figuras.
Se as ilustrações já tiverem sido publicadas, deverão vir acompanhadas de autorização por escrito do autor ou editor, constando a fonte de referência onde foi publicada.
O texto deve ser impresso em computador, em espaço duplo,
papel branco, no formato 210mm x 297mm ou A4, em páginas
separadas e numeradas, com margens de 3cm e com letras de
tamanho que facilite a leitura (recomendamos as de nº 14). O
original deve ser encaminhado em uma via, acompanhado de
CD, com versão do manuscrito, com respectivas ilustrações,
digitado no programa “Word for Windows 6.0.
A Revista Brasileira de Oftalmologia reserva o direito de não
aceitar para avaliação os artigos que não preencham os critérios
acima formulados.
Versão português-inglês: Seguindo os padrões dos
principais periódicos mundiais, a Revista Brasileira de Oftalmologia
contará com uma versão eletrônica em inglês de todas as edições.
Desta forma a revista impressa continuará a ser em português e a
versão eletrônica será em inglês.
A Sociedade Brasileira de Oftalmologia, Sociedade Brasileira
de Catarata e Implantes Intraoculares e Sociedade Brasileira de
Cirurgia Refrativa, se comprometem a custear a tradução dos
artigos para língua inglesa, porém seus autores uma vez que
tenham aprovado seus artigos se disponham a traduzir a versão
final para o inglês, está será publicada na versão eletrônica
antecipadamente a publicação impressa (ahead of print).
* Nota importante: A “Revista Brasileira de Oftalmologia”
em apoio às políticas para registro de ensaios clínicos da
Organização Mundial de Saúde (OMS) e do Intemational
Committee of Medical Joumal Editors (ICMJE), reconhecendo a
importância dessas iniciativas para o registro e divulgação
internacional de informação sobre estudos clínicos, em acesso
somente aceitará para publicação, a partir de 2008, os artigos
de pesquisas clínicas que tenham recebido um número de
identificação em um dos Registros de Ensaios Clínicos validados
pelos critérios estabelecidos pela OMS e ICMJE, disponível no
endereço: http://clinicaltrials.gov ou no site do Pubmed, no item
<ClinicalTrials.gov>.
O número de identificação deverá ser registrado abaixo do
resumo.
Os trabalhos poderão ser submetidos pela Internet, pelo site rbo.emnuvens.com.br
Rev Bras Oftalmol. 2014; 73 (5): 316-17
316
Revista
Brasileira de
Oftalmologia
Declaração dos Autores (é necessária a assinatura de todos os autores)
Em consideração ao fato de que a Sociedade Brasileira de Oftalmologia está interessada em editar o manuscrito a ela
encaminhado pelo(s) o(s) autor(es) abaixo subscrito(s), transfere(m) a partir da presente data todos os direitos autorais para a
Sociedade Brasileira de Oftalmologia em caso de publicação pela Revista Brasileira de Oftalmologia do manuscrito............................................................. . Os direitos autorais compreendem qualquer e todas as formas de publicação, tais como na
mídia eletrônica, por exemplo. O(s) autor (es) declara (m) que o manuscrito não contém, até onde é de conhecimento do(s)
mesmo(s), nenhum material difamatório ou ilegal, que infrinja a legislação brasileira de direitos autorais.
Certificam que, dentro da área de especialidade, participaram cientemente deste estudo para assumir a responsabilidade por
ele e aceitar suas conclusões.
Certificam que, com a presente carta, descartam qualquer possível conflito financeiro ou de interesse que possa ter com o
assunto tratado nesse manuscrito.
Título do Manuscrito___________________________________________________________________________
Nome dos Autores_______________________________________________________________________________
_____________________________________________________________________________________________
Minha assinatura abaixo indica minha total concordância com as três declarações acima.
Data____________Assinatura do Autor____________________________________________________________
Data____________Assinatura do Autor____________________________________________________________
Data____________Assinatura do Autor_____________________________________________________________
Data____________Assinatura do Autor_____________________________________________________________
Data____________Assinatura do Autor____________________________________________________________
Data____________Assinatura do Autor_____________________________________________________________
Rev Bras Oftalmol. 2014; 73 (5): 318