Purpose: To report use of widefield fluorescein angiography (FA) for targeted therapy of Coats' disease and familial exudative vitreoretinopathy (FEVR). Study design: Retrospective, non-comparative, consecutive case series. Material and Methods: Patients diagnosed with Coats' disease or FEVR and evaluated with widefield FA, treated with indirect laser from January 1, 2003 to December 31, 2012. Visual acuity (VA) and anatomic status of eyes was evaluated. Results: 17 eyes were treated for Coats' disease, and 25 eyes treated for FEVR. Mean VA in the Coats' group was 20/384 at baseline, and mean VA at the last follow-up was 20/258. In the FEVR group, mean VA was 20/100 at baseline, and 20/358 at last follow-up. None of the Coats' eyes required enucleation or additional surgical intervention. Two of the eyes with FEVR required surgery due to advanced disease. Conclusion: Widefield angiographyguided laser therapy in Coats' disease and FEVR led to visual and anatomic stability in these diseases.

Background: Ophthalmology is the most technologydriven specialty among all the medical specialties. Advances in retinal imaging have proven fundamental to many paradigm shifts in our understanding and treatment of ocular disease. Methods: Literature review. Discussion: This article provides an overview of current, state-of-the-art retinal imaging technologies, as well as highlights many emerging imaging technologies that we believe are likely to transform the provision of eye care. Conclusions: The second decade of the 21st century is an exciting time to be an ophthalmologist, and especially a retinal specialist. However, studies of diagnostic accuracy are more prone to bias than many other forms of clinical research. With the likely imminent proliferation of ocular imaging techniques, standardized and robust methods for their clinical validation will be essential, with reporting of results according to standards for reporting of diagnostic accuracy recommendations.

Purpose: To assess sensibility and specificity, positive and negative predictive values and probability of false-positive and false-negative of the water-drinking test, ibopamine test, frequency doubling perimetry, short-wave automated perimetry and daily curve of intraocular pressure in glaucoma suspects. Design: Cross-sectional study Methods: Glaucoma suspect eyes and normal control eyes from age-matched individuals, both with normal standard achromatic perimetry, were submitted to water-drinking test, ibopamine test, frequency doubling perimetry, short-wave automated perimetry and daily curve of intraocular pressure. Results: We included 45 Glaucoma suspect and 30 normal control eyes. Sensibility and specificity were respectively 75.6% and 100% for daily curve of intraocular pressure; 35.6% and 80% for ibopamine test; 22.2% and 96.7% for short-wave automated peri-metry; 15.6% and 96.7% for water-drinking test; 8.9% and 100% for frequency doubling perimetry. Positive and negative predictive values of the same workups were: 100% and 99.5%; 3.5% and 98.4%; 12% and 98.4%; 8.7% and 98.2%; 100% and 98.2%. False-positive and false-negative probabilities were: 0% and 0.5%; 96.5% and 1.6%; 91.3% and 0%; 88.0% and 1.6%; 0% and 1.9%. Conclusions: The daily curve of intraocular pressure presented the highest sensibility with the highest positive predictive value. Frequency doubling perime-try presented a very low probability of false-negative. Ibopamine test, water-drinking test and short-wave automated perimetry presented a very high probability of false-positive.

Vascular endothelial growth factor (VEGF) plays a major role in the patho-genesis of diabetic retinopathy. Its inhibition by bevacizumab, a monoclonal antibody against all VEGF isoforms, has been shown to be beneficial in the management of both diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Our group has previously demonstrated that multiple intra-vitreal injections of bevacizumab of either 1.25 or 2.5 mg in eyes with DME result in a reduction of macular edema and an improvement in visual acuity. We did not observe any differences in the outcomes between eyes treated with the lower and higher doses of bevacizumab. We also studied the effect of intravitreal bevacizumab in eyes with PDR. Intravitreal bevacizumab is capable of inducing regression of retinal and optic disc neovascularization. However this regression is not permanent and panretinal photocoagulation is needed to consolidate treatment. Caution should be exercised in eyes with advanced PDR since a rapid involution of the fibrovascular proliferation may lead to the development or the progression of a tractional retinal detachment. Thus when using intravitreal be-vacizumab as an adjuvant in diabetic vitrectomies, surgery should be scheduled no more than 4 days after injection. Resumen El factor de crecimiento vascular endotelial (VEGF) juega un rol protagónico en la patogénesis de la retino-patía diabética. Su inhibición por el Bevacizumab, un anticuerpo monoclonal contra todas las isoformas del VEGF, ha demostrado ser benéfica en el manejo tanto del edema macular diabético (EMD) como de la retinopatía diabética proliferativa (RDP). Nuestro grupo ha previamente demostrado que múltiples inyecciones intravítreas tanto de 1,25 o 2,5 mg de bevacizumab en ojos con EMD resultan en la reducción del edema macular y mejoría en la agudeza visual. No se observó diferencia alguna entre los resultados de los ojos tratados con dosis más bajas o altas del bevacizumab. Se estudió también el efecto del bevacizumab intravítreos en ojos con RDP. El bevacizumab intravítreo es capaz de inducir regresión de la neovascularización de la retina y disco óptico. Sin embargo, esta regresión no es permanente y la fotocoagulación panretiniana o vitrectomía son ne-cesarías para consolidar el tratamiento. Se debe tener cautela en ojos con RDP avanzada debido a que la rápida involución de las proliferaciones fibrovasculares pueden conllevar al desarrollo o progresión de un desprendimiento de retina traccional. Por lo tanto al utilizar el bevacizumab intravítreo como adyuvante en la vitrectomía de pacientes diabéticos, la cirugía no debe ser programada más de 4 días después de dicha inyección.

Purpose: To evaluate the quality of life and vision in patients with keratoconus who underwent corneal collagen crosslinking (CXL). Methods: Cross-sectional study performed at a private ophthalmic clinic in the countryside of Rio Grande do Sul. 70 keratoconus patients who underwent CXL were interviewed. To evaluate the quality of life, the instrument Visual Function Questionnaire (VFQ) 25 was used. Results: The averages were high in the following subdomains: color vision, social aspects, dependency, peripheral vision, activities of daily living, near tasks, far tasks, mental health, ability to drive a car, vision and mental health. However, the dimensions of the ocular pain and general health presented low averages in relation to the others. Conclusion: Patients with keratoconus who underwent CXL presented high scores on ten of the twelve evaluated subdomains, which features good visual quality of life. Descriptors: Quality of Life; Keratoconus; Ophthalmology; Nursing; Questionnaire. RESUMO Objetivo: Avallar a qualidade de vida (QV) e de visào dos portadores de ceratocone submetidos ao crosslinking do colágeno corneano (CXL). Métodos: Estudo transversal, realizado em uma clínica oftálmica privada no interior do Rio Grande do Sul. Foram entrevistados 70 portadores de ceratocone submetidos ao CXL. Para avaliar a qualidade de vida foi utilizado o instrumento Visual Function Questionnaire (VFQ) 25. Resultados: As médias mostraram-se altas nos subdomínios: visào de cores, aspectos sociais, dependencia, visào periférica, atividades de vida diària, atividades para perto, atividades para longe, saúde mental, capacidade para dirigir automóveis, visào e saúde geral. Entretanto, as dimensóes da dor ocular e da saúde geral apresentaram médias baixas em relagào às demais. Conclusào: Os portadores de ceratocone subme-tidos ao CXL apresentaram escores altos em dez dos doze subdomínios avaliados, o que caracteriza boa QV visual. Descritores: Qualidade de Vida; Ceratocone; Oftalmologia; Enfermagem; Questionàrio.

Purpose: To review the outcomes, risk factors and morbidity of bacterial keratitis treated with and without topical steroids. Design: Retrospective cohort study. Methods: Demographics, risk factors, culture results, ulcer characteristics, and timing to epithe-lialization, visual acuity and recurrences were recorded. Patients were classified into 2 groups: 1. Topical antibiotics/steroids (ASG), and 2. Antibiotics only group (AOG). Results: Seventy-two eyes were identified. Thirty-seven were classified in the ASG and 35 in the AOG. Predisposing factors were identified in 87.5% of cases. Penetrating keratoplasty, previous surgery, contact lens wear and Herpes simplex keratitis were the most common overall. Microorganisms were identified in 85.5% and 60% of ASG and AOG, respectively. Epithelialization was completed at a mean 17.62 and 16.06 days in ASG and AOG, respectively (p= 0.533). Final mean BSCVA was 1.59±1.07 and 1.64±1.21 log MAR in ASG and AOG, respectively (p= 0.864). The number of gained Snellen lines was 0.13±0.22 in ASG and 0.14±.0.24 in AOG (p= 0.860). There were no recurrences. Conclusion: Although a non-statistical significant delay in re-epithelialization was noted in the ASG, this did not translate into a statistical difference in final BSCVA, gained Snellen lines or recurrence of infection. In this serie, adjuvant topical steroids were not associated with an increase in unfavorable outcomes. Resumen Objetivo: Analizar la morbilidad, factores de riesgo y resultados asociados al tratamiento de queratitis bacteriana con y sin el uso de esteroides tópicos. Diseño: Estudio de cohortes retrospectivo. Métodos: Se analizaron los datos demográficos, factores de riesgo, características de la úlcera, tiempo de re-epitelización, agudeza visual y recurrencias en pacientes con queratitis bacteriana. Los pacientes fueron clasificados en dos grupos: 1. Antibióticos/esteroi-des tópicos (ASG) y 2. Únicamente antibióticos (AOG). Resultados: Se identificaron 72 ojos, de los cuales 37 fueron clasificados en el ASG y 35 en el AOG. Encontramos por lo menos un factor de riesgo en el 87.5% de los casos; siendo los más comunes la queratoplastia penetrante, cirugía ocular previa, uso de lente de contacto y queratitis por Herpes simplex. Los cultivos lograron identificar un agente causal en el 85.5% y en el 60% del ASG y AOG, respectivamente. El epitelio cerró por completo en un promedio de 17.62 y 16.06 días en el ASG y AOG, respectivamente (p= 0.533). En promedio, la agudeza visual corregida al fin del estudio fue de 1.59±1.07 y 1.64±1.21 log-MAR en el ASG y AOG, respectivamente (p= 0.864). En promedio el ASG gano, 0.13±0.22 líneas en la cartilla de Snellen, mientras que el AOG ganó 0.14±.0.24 (p= 0.860). No hubo casos recurrentes. Conclusión: Aunque la re-epitelizacion fue un poco más lenta en el ASG, la diferencia no fue estadísticamente significativa ni se tradujo en cambios significativos en la agudeza visual corregida, el número de líneas ganadas en la cartilla de Snellen o el número de recurrencias. En esta serie, adyuvante encontramos que el uso adyuvante de esteroides tópicos no fue asociado con resultados desfavorables.

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

Purpose: To compare the results of the coaxial ml-crolnclslons cataract surgery technique and bimanual mlcrolnclslons in the Cuban Ophthalmology Institute “Ramón Pando Ferrer” from June 2009 to June 2011. Methods: Sixty-eight patients were evaluated and diagnosed with senile or presenile cataract. Of these, 41 patients (eyes) were operated with coaxial mlcroln-clslons technique and 27 patients (eyes) with blma-nual mlcrolnclslons technique. We determined age, hardness of the nucleus, best corrected visual acuity and uncorrected preoperative and postoperative, mean induced astigmatism, endothelial cell loss, effective phaco time and spherical equivalent. For statistical analysis, the nonparametrlc Mann Whitney test with a significance of 95% was used. Results: Most patients were older than 50 years. An ultrasound effective time of less than a minute was required to emulsify the cataractous lens, which had hardness classified as NO3 by the LOCS III for both techniques. The spherical equivalent behaved as preo-peratlvely planned with a tendency to emmetropia. A significant correction of the keratometrlc and refractive cylinder was obtained. Fully corrected visual acuity was achieved with both techniques. The mean induced as-tlgmatlsm was less than 0.5 diopters, with endothelial cell loss of less than 5% in both groups. Conclusions: Both surgical techniques achieved satisfactory results demonstrating their effectiveness. RESUMEN Objetivo: Comparar los resultados de la cirugía de catarata por las técnicas de microincisiones coaxiales y microincisiones bimanuales en el Instituto Cubano de Oftalmología “Ramón Pando Ferrer” en el período de junio de 2009 a junio de 2011. Métodos: 68 pacientes fueron evaluados y diagnosticados con catarata senil o presenil. De estos, 41 pacientes (ojos) se operaron con la técnica de microincisiones coaxiales y 27 pacientes (ojos) con la técnica de microincisiones bimanuales. Se determinó: edad, dureza del cristalino, agudeza visual mejor corregida y sin corrección preoperatoria y postoperatoria, media del astigmatismo inducido, pérdida celular endotelial, tiempo efectivo de ultrasonido y el equivalente esférico. Para el análisis estadístico, se utilizó el test no paramétrico U de Mann Whitney con una significación del 95%. Resultados: La mayoría de los pacientes tenían edades superiores a 50 años. Se empleó un tiempo efectivo de ultrasonido menor a un minuto para emulsificar los cristalinos cataratosos, los cuales tenían una dureza clasificada como NO3 por el LOCS III para ambas técnicas. El equivalente esférico se comportó según lo planificado en el preoperatorio con tendencia a la emetropía. En el postoperatorio se obtuvo una corrección significativa del cilindro queratométrico y refractivo. Para ambas técnicas quirúrgicas mejoró en su totalidad la agudeza visual con corrección alcanzando su valor máximo. La media del astigmatismo inducido fue menor a 0,5 dioptrías, con una pérdida celular endotelial menor a un 5% en ambos grupos. Conclusiones: Para ambas técnicas quirúrgicas se lograron resultados satisfactorios que demuestran la efectividad de las mismas.

Purpose: To assess the efficacy of one drop of 2% pilocarpine (2% Pi) at night to reverse the intraocular pressure (IOP) peak at 6:00 am in the daily curve of intraocular pressure (DCPo) of pre-perimetric open-angle glaucoma. Methods: We retrospectively analyzed the charts of patients with early glaucoma. We compared the IOP values at 6:00 a.m. in the same eye of two DCPos. In the first DCPo, the patients were without medication, and in the second they were using one drop of 2% Pi between 10:00 and 10:30 p.m. for at least six months. Each DCPo had five IOP measurements taken at 9:00 a.m., 12:00, 6:00 and 10:00 p.m. (Goldmann applana-tion tonometer) and in the morning of the following day at 06:00 a.m. (Perkins tonometer) in a supine position in bed and in darkness before the patient had stood up. The pre-perimetric glaucoma patients, without medication, presented an IOP peak at 6:00 a.m. in the DCPo. This peak represents a difference ≥7 mmHg between the IOP value at 6:00 a.m. and that lesser IOP at any other time in the DCPo. An IOP peak reversion at 6:00 a.m. under 2% Pi occurred when the difference between the IOP at 6:00 a.m. and the lesser IOP was ≤5 mmHg in the DCPo. Patients with secondary glaucoma were excluded. We set the significance level at 5% (P<0.05). Results: Sixty-one eyes of 35 patients with an average age of 56.1 years were included. Under 2% Pi the IOP peak at 6:00 a.m. reversed significantly (X²=7.96; P=0.005) in 44 (72.1%) eyes. The mean IOP dropped from 22.1±2.3 mmHg in the DCPo without medication to 16.8±2.7 mmHg in the DCPo under 2% Pi (t=7.9; P<0.001). Conclusion: One drop of 2% Pi at night is effective to reverse the IOP peak at 6:00 a.m. in pre-peri-metric glaucoma.

The induction of corneal collagen cross-linking by ultraviolet radiation (UV) over a substract of riboflavin was popularized and dubbed as CXL (cross-linking). In 2003, this technique was introduced in the therapeutic arsenal for patients with keratoconus, aiming to halt the progression of the disease. The procedure would enhance biomechanical and biochemical corneal stability by the formation of new covalents bonds in the amino-termial sites of the collagen molecule of the anterior stroma. Such induction depended on the hydrogen singlets free radicals generated by the riboflavin photosensibilization by UV-A. CXL is indicated in corneal thinning and progressive ectasias, as it happens in keratoconus, post-LASIK ectasia and pellucid marginal degeneration. Other anecdotic indications are described in the literature such as treatment of infectious keratitis, control of bullous keratopathy and corneal melting; however, they will not be discussed in this review. The CXL for the treatment of progressive corneal ectasia is a procedure that does not involve sophisticated equipments. It is safe (low odds of complications), not expensive and with high efficacy (halting the progression of ectasia). The great majority of treated patients are young adults. There are some contraindications for this procedure such as minimum corneal thickness of 400 ìçé, which is the most feared. The classic technique was described in 1995 by German researchers and variations of this technique still under evaluation. The CXL is a recent procedure and, besides some favorable results, a long-term follow up (more than 5 years) is needed, to evaluate collateral side effects and potential complications. RESUMO A inducao de novas ligações covalentes entre cadeias de colágeno da córnea pela radiação ultravioleta (UV), tendo como substrato a riboflavina, foi popularizada com a sigla CXL (cross-linking). Em 2003, foi introduzida no arsenal terapêutico de pacientes com ceratocone, com o objetivo de evitar a progressão da doença. O procedimento aumentaria a estabilidade biomecânica e bioquímica da córnea pela formação de novas ligações covalentes entre as porções amino-terminais das moléculas do colágeno no estroma anterior. Tal indução se dá às custas dos radicais livres dos hidrogênio singlets gerados na fotossensibilização da riboflavina pela luz UV-A. O CXL é indicado, em geral, nos afinamentos e ectasias da córnea de caráter progressivo, como acontece no ceratocone, na ectasia pós-LASIK e na degeneração marginal pelúcida. Outras indicações anedóticas são descritas na literatura como, por exemplo, para o tratamento de algumas ceratites infecciosas, para controle da ceratopatia bolhosa e necrólise da córnea; porém, não serão abordadas nesta revisão. O CXL para o tratamento da ectasia progressiva é um procedimento que não envolve equipamentos sofisticados, seguro (com baixas chances de complicações), de baixo custo e alta eficácia (parada da progressão da ectasia). A maioria dos pacientes submetidos tratados é de adultos jovens. Há contraindicações para o procedimento e, dentre estas, a espessura mínima de 400 μm é a mais respeitada. A técnica mais utilizada e considerada como clássica é a descrita em 1995, por pesquisadores alemães. Variações da técnica clássica estão ainda em avaliação. O CXL é um procedimento recente e apesar dos resultados até agora serem favoráveis, acompanhamento a longo prazo (mais de 5 anos) é necessário, inclusive em relação aos efeitos colaterais e potenciais complicações.

Patients with the Hermansky-Pudlak syndrome (HPS) have a triad of clinical findings including: oculocutaneous albinism; a bleeding diathesis; and systemic complications associated with ceroid deposition in several tissues. The syndrome is inherited as an autosomal recessive trait. Several genetic mutations have been reported that cause patients to the various HPS phenotypes. Ophthalmic surgery remains a challenge in patients with the syndrome due to bleeding tendency. Further, pulmonary fibrosis associated to ceroid deposition may lead to decreased pulmonary function in patients with some HPS types. These are important medical issues that every ophthalmic surgeon needs to consider prior to surgery in patients with the syndrome. Co-management in patients with the HPS is of utmost importance in the pre-operative and post-operative periods. Resumen Los pacientes con el síndrome de Hermansky-Pudlak (HPS) tienen una triada de hallazgos clínicos que incluyen: el albinismo oculocutáneo, una tendencia a sangrado y varias complicaciones sistémicas debidas a la deposición de ceroide en varios tejidos del cuerpo. El síndrome se hereda de forma autosómica recesiva. Ahora bien, varias mutaciones genéticas que producen el síndrome han sido reportadas. Esto ha llevado a concluir que hay varios tipos del síndrome. La tendencia al sangrado de los pacientes con HPS hace que la cirugía oftálmica en ellos siga siendo un reto para el oftalmólogo, pues la deposición de ceroide puede conducir a fibrosis pulmonar, la función de los pulmones puede estar disminuida en algunos pacientes con este grupo de enfermedades. El oftalmólogo debe tener presentes estas consideraciones antes de recomendar la cirugía al paciente y escoger el tipo de anestesia a utilizarse. El co-manejo de estos pacientes con el síndrome de Hermansky-Pudlak es de vital importancia en los periodos pre y postoperatorios.

Recent studies such as the Beijing Eye Study, strengthened the clinical impression of post-menopausal women's increased vulnerability to dry eye symptoms. This review article addresses the published literature addressing the impact of hormonal changes, particularly estrogen, on pre-menopausal and post-menopausal women. The impact of the menstrual cycle and hormone replacement therapy have on dry eye symptoms are reviewed. Evidence suggests that the cornea is thinnest at the beginning of the menstrual cycle and thickest by the end of the cycle, when estrogen levels are highest. Interestingly, studies suggest that estrogen may promote dry eye in post-menopausal women, while having protective effects in younger women. Further studies investigating the role of the menstrual cycle, oral contraceptives, and hormone replacement therapy (HRT) on the eye is warranted, particularly to address symptoms, physiological changes, and refractive surgery outcomes. Resumen Estudios recientes, como el “Beijing Eye Study”, han fortalecido la impresión clínica de mujeres posmenopáusicas de una mayor vulnerabilidad a síntomas de ojo seco. Este artículo de revisión aborda la literatura publicada sobre el impacto de los cambios hormonales, especialmente los estrógenos, el anterior a la menopausia y las mujeres posmenopáusicas. El impacto del ciclo menstrual y terapia de reemplazo hormonal en síntomas de ojo seco son revisados. Las evidencias sugieren que la córnea es más fina al principio del ciclo menstrual y más gruesa por el final del ciclo, cuando los niveles de estrógeno son más altos. Curiosamente, los estudios sugieren que el estrógeno puede promover ojo seco en mujeres posmenopáusicas y tener efectos protectores en las mujeres jóvenes. Más estudios que investigan el papel del ciclo menstrual, los anticonceptivos orales y terapia de reemplazo hormonal en el ojo se justifica, en particular para tratar los síntomas, los cambios fisiológicos y los resultados de la cirugía refractiva.

Purpose: To review the epidemiology, clinical features, diagnosis, and management of patients with fungal keratitis. Methods: Review of the literature and summary of personal experience. Results: Fungi may be part of the normal external ocular flora but are found with greater frequency in diseased eyes. Trauma is the most frequent risk factor and often occurs outdoors and involves plant matter. The Gram and Giemsa stains are the most common stains used for the rapid identification of fungi. The only commercially available topical antifungal in the United States is natamycin 5% and it is therefore the first line treatment in most cases. The length of time required for topical treatment is on average 4 to 6 weeks but must be titrated based on clinical response. The most common surgical approach to fungal keratitis is daily debridement with a spatula or blade. Approximately one-third of fungal infections need additional surgical intervention, most commonly in the form of a therapeutic penetrating keratoplasty. The prognosis of fungal keratitis depends on the depth and size of the lesion; small superficial infections respond well to topical therapy. Deep stromal infections and infections with concomitant scleral or intraocular involvement are much more difficult to eradicate. Conclusions: The diagnosis of fungal keratitis can be quite challenging, and treatment requires prolonged antifungal therapy often combined with surgical intervention in the form of penetrating keratoplasty, conjunctival flap, or cryotherapy.