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PURPOSE: The aim of this study was to evaluate the quality of life (QOL) after intrastromal ring implantation in patients with keratoconus. METHODS: This was a prospective, randomized, interventional study. We analyzed 60 eyes of 30 patients aged 16 to 35 years who were treated at the Department of Ophthalmology and Visual Sciences, Federal University of São Paulo, Brazil. The Visual Function Questionnaire (VFQ-25) and Short-Form 36 Questionnaire (SF-36) were used before intracorneal ring segment (ICRS) implantation and at 3, 6, and 12 months after surgical intervention. RESULTS: The mean corrected visual acuity improved from a mean of 0.32 ± 0.2 logMAR (20/40) preoperatively to 0.14 ± 0.11 logMAR (20/25) 1 year postoperatively ( P = 0.001). The mean spherical equivalent varied from -7.24 ± 3.47 preoperatively to -4.13 ± 2.41 postoperatively ( P = 0.001). The overall composite score for the VFQ-25 improved from 55.1 preoperatively to 80.4 1 postoperatively ( P = 0.001). SF-36 showed statistically significant improvement in all scores. When analyzing the correlation between visual acuity and VFQ composite score, a significant correlation was found between both variables (Pearson correlation coefficient of -0.40, P = 0.001). CONCLUSIONS: Patients with keratoconus had increased psychological symptoms and lower QOL and improved psychosocial criteria associated with corneal remodeling and decreased visual dependence on others after surgery. Extrapolation of these data to the whole keratoconus population suggests that ICRS implantation could improve QOL in these patients.

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Purpose: In vitro evaluation of rose bengal (RB) photoactivated by our custom-built green light-emitting diode (LED) source for the growth inhibition of bacterial strains and rapidly growing mycobacterial (RGM) isolates in infectious keratitis. Methods: Six corneal clinical bacteria isolates were included in this study: two Gram-positive bacteria (methicillin-resistant Staphylococcus aureus [MRSA] and Staphylococcus epidermidis), two Gram-negative bacteria (Pseudomonas aeruginosa and Serratia marcescens), and two RGM (Mycobacterium chelonae and Mycobacterium abscessus). Microorganisms were cultured and incubated at specific conditions and prepared in suspensions to adjust their concentration to 104 cells/mL. Different treatments were conducted in triplicates: Group I, no treatment; Group II, treated with 0.1% rose bengal alone (exposed to dark for 30 minutes); Group III, exposed to custom green LED for 30 minutes (12.87 J/cm2); and Group IV, treated with 0.1% rose bengal and exposed to custom green LED for 30 minutes. Agar plates were incubated at specific conditions and photographed after growth for pixel analyses. Results: Complete growth inhibition of all bacteria and RGM was observed in Group IV. MRSA and S. epidermidis in Group II also showed complete growth inhibition. Conclusions: The custom-built green LED presented good activity by photoactivating RB and inhibiting micro-organism growth. For the first time, we demonstrated the expressive growth inhibition effect of RB against S. epidermidis, RGM, and S. marcescens. Clinical treatment with RB may offer an alternate adjunct therapy for corneal surface infections. Translational Relevance: Validating in vitro the custom-built green LED encourages the clinical application for the treatment of infectious keratitis.

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This case report describes tecovirimat treatment for a patient with monkeypox virus­related keratouveitis.

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Aim: To evaluate the vision-related quality of life with the National Eye Institute Refractive Error Quality of Life (NEI-RQL) questionnaire in patients with astigmatism secondary to radial keratotomy surgery who underwent topography-guided photorefractive keratectomy. Methods: Prospective non-randomized clinical trial. This study included 15 patients (30 eyes) aged > 21 years, mean age 55.1 (SD, 3.5) years, 53.3% female, with astigmatism ≤ - 6.00 D resulting from radial keratotomy, which could have been associated with hyperopia ≤ + 6.00 D. Photorefractive keratectomy with topography-guided custom ablation treatment was used in all cases. The patients answered the NEI-RQL questionnaire preoperatively and at 4 and 48 months after topography-guided photorefractive keratectomy. The following data were collected: age, sex and education level, pre-operative refraction data, visual acuity with or without correction, pachymetry, and keratometry. Results: There was a significant difference between pre-and postoperative NEI-RQL scores for the domains clarity of vision, near vision, far vision, diurnal fluctuation, activity limitations, glare, symptoms, correction dependence, appearance, and satisfaction with correction (p < 0.001). Conclusion: Topography-guided photorefractive keratectomy improved vision-related quality of life in patients with a history of irregular astigmatism secondary to radial keratotomy.

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OBJECTIVE: To verify corneal alterations in patients with keratoconus who wear scleral contact lenses (ScCLs), focusing on corneal endothelial assessment. METHODS: Scleral contact lenses were fitted in 22 patients with keratoconus. During a 90-day follow-up, patients were assessed in three visits: at baseline, after 30 days, and after 90 days. Patients underwent visual acuity measurement, slitlamp biomicroscopy of the anterior segment, specular microscopy of the corneal endothelium, corneal pachymetry, measurement of the clearance between the cornea and the lens, and follow-up of ectasia. RESULTS: Variables related to endothelial morphology and pachymetry values did not change significantly over time. Central clearance measurements decreased in the 90-day period. No progression of corneal ectasia was observed, neither were infectious or inflammatory processes in the same period. CONCLUSION: Daily wear of ScCLs in patients with keratoconus was not associated with adverse effects on the cornea or endothelium over a period of 90 days nor was there evidence of disease progression. Central clearance values diminished over that period, but the significance of this observation remains unclear.

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Individuals with suspected COVID-19 symptoms (n=202) were tested using nasopharyngeal RT-qPCR. All individuals underwent corneal esthesiometry measurements using the Cochet-Bonnet esthesiometer during their first visit; 50 participants underwent an additional measurement at a mean interval of 32.5 (17.8) days. COVID-19 was confirmed in 101 subjects (50%) using nasopharyngeal PCR. The mean time from symptom onset to disease diagnosis and corneal esthesiometry was 4.2 (2.1) days. Mean corneal esthesiometry findings based on the positive and negative PCR status indicated no statistical difference. This study demonstrated that COVID-19 had no effect on corneal esthesiometry in individuals with acute-phase COVID-19.

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We report a case of a patient with necrotizing infection of the conjunctiva and Tenon's capsule caused by Streptococcus pyogenes, a rare and atypical ophthalmologic condition. A 50-years-old male patient with acute red-eye, purulent discharge, and pain diagnosed with post-septal cellulitis presented with a yellowish and dense membrane covering the ocular surface with necrotic Tenon's capsule. Patient was hospitalized, and intravenous antibiotics were initiated (ceftriaxone and clindamycin). Topical antibiotics and corticosteroids were also administered, and the infection was eradicated in 2 weeks. Ancillary exams excluded rheumatologic involvement. Conjunctival culture confirmed Streptococcus pyogenes growth. Tenon's biopsy revealed unspecific acute inflammatory necrosis. This is an uncommon condition in daily ophthalmological clinic. Literature review reported 3 cases associated with previous ocular surgery.

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Coronaviruses gained public attention during the severe acute respiratory syndrome (SARS) outbreak in East Asia in 2003 and spread of Middle Eastern respiratory syndrome (MERS) in 2012. Direct human-to-human contact and droplet are the main methods of transmission. Viral stability in aerosols on different surfaces supports evidence on indirect viral acquisition from fomites through the mucous membranes of the mouth, nose, and eyes. Given the pandemic circumstances, the level of evidence in COVID-19 and ophthalmology regarding eye infection, conjunctival transmission, and viral shedding through tears is insufficient. Presently, conjunctival transmission of coronaviruses has not been confirmed and remains controversial. Considering the physiology of the lacrimal system and ocular surface, the eyes are considered an immunoprotective site, with several antiviral molecules and anti-inflammatory proteins. Nevertheless, they represent an interface with the exterior world and face daily putative aggressors. Understanding the host's ocular surface immunological and protective environment is crucial to clarify the potential of the conjunctiva as an entry route for SARS-CoV-2 and as part of this viral infection. We will discuss hypothetical ocular surface transmission mechanisms and related counterarguments addressed to both angiotensin-converting enzyme 2 receptors found on the conjunctival and corneal epithelia and lactoferrin, lysozyme, lipocalin and secretory IgA levels in the tear film. Hopefully, we will promote better understanding of this organ in COVID-19 infection and the potential transmission route that can be helpful in setting recommendations on best practices and protective guidelines to mitigate the disease spread.

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PURPOSE: The purpose of this article is to report a bilateral conjunctivitis case in a patient with confirmed 2019 novel coronavirus disease (COVID-19). CASE REPORT/OBSERVATIONS: A 24-year-old healthy man developed severe conjunctivitis in his right eye, followed by his left eye 4 days after fever and myalgia. He reported yellowish conjunctival discharge, foreign body sensation, redness, and tearing, and those symptoms were resolved in 10 days. Analyses of nasopharyngeal secretions identified SARS-CoV-2 by polymerase chain reaction (PCR). CONCLUSION: Mild COVID-19 can cause severe bilateral conjunctivitis. The ophthalmologist may be aware of conjunctival secretions, a possible path of infection, during eye checkup.

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Purpose: To evaluate the impact of instillation angle and nozzle tip geometry on cross-contamination risk of multidose ocular solution bottles. Methods: Pseudomonas aeruginosa solution was passed exclusively on the outside of the nozzle to simulate contamination on the exterior of topical agents. Three drops were administered from angles of 90° and 45° from bottles with either a round or sharp tip geometry, and the cultures were examined for growth. Two-hundred sixteen cultures from nine lubricant eyedrop brands currently existing in the Brazilian market were assessed for bacterial growth. Results: After seven days, bacterial contamination was detected in 53.7% of cultures when drops were administered at 90° and in 70.4% of cultures at 45°. Eyedrops collected from a rounded nozzle tip and an instillation angle of 90° transmitted bacteria in 69.4% of cases, whereas those administered from a sharp tip transmitted bacteria in only 22.2% of cases (P = 0.001). At an instillation angle of 45°, contamination was identified in 83.3% of bottles with a rounded tip geometry and in only eight of 18 bottles (44.4%) from those with a sharp nozzle geometry (P = 0.005). Conclusions: Adjusting the instillation angle of eyedrop solutions to 90°, as well as using a nozzle geometry that prevents flow of the solution to the side of the bottle, significantly reduced contamination rates. Translational Relevance: Standardizing drop bottles and adjusting delivery angle shows promise in reducing contamination rates and may critically impact the quality of care for patients requiring topical therapeutic agents.

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PURPOSE: The purpose of this review was to compare the efficacy of rectus muscle plication versus resection on the treatment of horizontal strabismus and to evaluate the exodrift after each technique. METHODS: A research was performed in Latin American and Caribbean Literature on Health Sciences (LILACS); MEDLINE; and Cochrane Central Register of Controlled Trial (CENTRAL). The database was searched by 30 June 2019. The selection was restricted to articles published in English, Spanish, or Portuguese. There were no date restrictions in the search. A minimum mean follow-up of six months was required to access the primary outcomes. Motor alignment success was defined as postprocedure deviation within 10 prism diopters (PD) of orthotropia. RESULTS: Seven studies were eligible for inclusion. The grouped success rate after plication was 66% (95% CI = [43%-89%]), and the grouped success rate after resection was 68% (95% CI = [43%-89%]). High heterogeneity was observed between the estimations. There was no difference between the mean amount of deviation corrected in prism diopters, when using the mixed-model approach (SMD = 0.12; 95% CI = -0.2-0.44; p=0.45). The undercorrection rates were also analyzed. The combined odds ratio was 1.37 (95% CI = 0.59-3.16; p=0.462), and there was no statistical significance. CONCLUSION: Plication of horizontal extraocular muscles reveals to be an alternative to resection in strabismus surgery, with similar results. Exodrift is observed after plication and after resection in the treatment of exotropia, but randomized clinical trials are necessary to analyze and compare the follow-up.

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We aimed to evaluate the chemical composition, production yield, and economic viability of Minas Frescal cheese produced with milk from buffaloes supplemented with açai seed as a substitute for corn meal. The experiment used five Murrah crossbred buffaloes with a mean body weight of 577 ± 20.4 kg, maintained under Megathyrsus maximus cv. Mombaça grazing in a 5 × 5 Latin square design. The treatments comprised four concentrate supplements, in which açai seed replaced corn meal at 0, 33, 66, and 100% substitution, and a control with no concentrate supplementation. Replacement of corn meal with açai seed in buffalo diet had no effect on chemical composition of produced cheese (P > 0.05) nor was there any difference in chemical composition between the control group and animals supplemented with concentrate (P > 0.05). The adjusted cheese yield (kg cheese/cow/day) demonstrated a quadratic pattern with maximum production at 33% açai seed substitution (P < 0.05). Hence, the profitability index (percentage of gross revenue) was greatest at this replacement level. In conclusion, 33% açai seed replacement of corn meal in the supplement of buffalo under a grazing regime improved the individual yield of Minas Frescal cheese without changing its chemical composition.

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We describe here a case of a 21-year-old woman who presented with low visual acuity, pain, and hyperemia in the left eye for 45 days. Her eye had extensive corneal infiltrate, with melting and a central perforation that was glued with cyanoacrylate, but with Seidel (+). She underwent tectonic corneal transplantation, and anterior chamber lavage with subconjunctival infiltration with voriconazole, as well as intracameral injections of amphotericin B. Laboratory tests revealed Paecilomyces lilacinus as the infectious agent. The patient was then maintained with oral voriconazole and eye drops for three months, after which the infection was considered cured. However, in the sixth postoperative month she presented with endothelial rejection, and two weeks later signs of recurrence of the fungal infection. She was treated with two further washes of the anterior chamber and subconjunctival injection of voriconazole, followed by intravenous voriconazole that was replaced with drops after ten days. The infection initially worsened, but then regressed, and at last follow-up, the patient was still infection-free.

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PURPOSE: To assess ocular surface disease (OSD) in glaucoma using clinical parameters, self-report assessment, and keratograph analysis. METHODS: A total of 30 glaucoma patients and 27 subjects with cataracts (control group) were enrolled in the study. Only glaucoma patients who were using at least 1 topical intraocular pressure-lowering medication were included. An ophthalmological examination was performed, including tear break-up time (BUT), assessment of conjunctival hyperemia and keratitis, and completion of the Ocular Surface Disease Index (OSDI) questionnaire. All the patients underwent keratograph analysis including noninvasive BUT, meibography, tear meniscus height, and redness scale. Quality of life was also assessed in all the patients using National Eye Institute Visual Function Questionnaire (NEI VFQ)-25. The comparison of OSD between the 2 groups was assessed. RESULTS: There was a significant difference in OSD: keratitis and conjunctival hyperemia were worse in the glaucoma group (P=0.009 and 0.008, respectively). The glaucoma group had significantly worse scores on the OSDI questionnaire (32.53±20.75 vs. 20.42±18.77; P=0.007). For the keratograph assessment, the glaucoma group had significantly smaller tear meniscus height (0.22±0.08 vs. 0.24±0.04, respectively; P=0.041); worse bulbar redness (2.06±0.67 vs. 1.70±0.45, respectively; P=0.021); higher meibography grades (2.34±1.01 vs. 1.52±0.64, respectively; P=0.001); and worse noninvasive keratograph tear BUT (5.45±4.16 vs. 8.40±5.65, respectively; P=0.023). Patients with glaucoma had a worse quality of life (60.73±18.25 vs. 76.62±8.03, respectively; P=0.039). CONCLUSIONS: Our findings not only confirm the high prevalence of clinical findings of OSD in glaucoma patients but also reveal new objective parameters measured by keratograph analysis.

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PURPOSE: To report the outcomes of implantation of the Boston Type I keratoprosthesis in three patients with Acanthamoeba keratitis (AK), a severe infection that can lead to significant visual loss. OBSERVATIONS: Case series reporting three patients with difficult cases of AK that needed multiple corneal transplantations and glaucoma surgeries. All patients were implanted with the Boston Type I keratoprosthesis device. The main outcomes measure were the visual function and anatomical retention after implantation of the Boston Type I keratoprosthesis. All patients retained the device over the long-term and had good visual function. In one patient a retroprosthetic membrane developed and in another patient an epithelial lip developed over the anterior surface of the keratoprosthesis. The visual acuities range from 20/25 to 20/80 in the implanted eyes. CONCLUSIONS AND IMPORTANCE: The Boston Type I keratoprosthesis resulted in good anatomic and functional results after multiple graft failures after AK.

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Purpose: The purpose of this review was to examine the efficacy of botulinum toxin in the treatment of infantile esotropia and to evaluate the average response of BT and its complication rates. Methods: A research was performed in the Latin American and Caribbean Literature on Health Sciences (LILACS), MEDLINE, and Cochrane Central Register of Controlled Trial (CENTRAL). The database was searched between December 28, 2016 and January 30, 2017. The selection was restricted to articles published in English, Spanish, or Portuguese. There were no date restrictions in the search. Results: Nine studies were eligible for inclusion. The grouped success rate of BT treatment in infantile esotropia was 76% (95% confidence interval [CI]: 61%-89%). For the success rate, I2 of 94.25% was observed, indicating a high heterogeneity (P < 0.001). The complication rates were also analyzed. The grouped consecutive exotropia (XT) rate was 1% (95% CI: 0%-2%). The grouped ptosis rate was 27% (95% CI: 21%-33%). The grouped vertical deviation rate was 12% (95% CI: 4%-22%). The mean change of the deviation after BT injection was -30.7 (95% CI: -37.7, -23.8), demonstrating a significant improvement in alignment. Conclusions: Botulinum toxin injection into medial recti muscles reveals to be a safe procedure and a valuable alternative to strabismus surgery in congenital esotropia, especially in moderate deviations.

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Acanthamoeba is a free-living amoeba that causes severe corneal infection (Acanthamoeba keratitis) and produces a variety of extracellular enzymes, called exoproteome. Since physicochemical characters are suggested being associated with therapeutic profile and clinical severity of the infection, we investigated the physicochemical properties of proteolysis mediated by amoebic exoproteome. Corneal scraping was collected from a patient who showed typical symptoms of acute Acanthamoeba keratitis. Axenic amoeba was phylogenetically identified by 18S rDNA sequencing analysis. Effects of pH, temperature and diamidines on proteolysis mediated by exoproteome were assessed using zymography assays. Proteolytic enzymes were most active at pH 7.0 and 37 °C. Calcium ions decreased enzymatic activity. The main components of amoebic exoproteome were characterized as serine proteases. We demonstrated for the first time that commercial antimicrobial diamidines used for Acanthamoeba keratitis therapy inhibit enzymatic activity of amoebic exoproteome. Results showed the thermostability of Acanthamoeba proteases, which suggest a long-term effect of these virulence factors at the central and peripheral cornea with possible role in degradation of extracellular matrix components. Our findings open new perspectives about the complementary and unreported properties of antimicrobial compounds of the diamidine class on the inhibition of enzymatic activity and presumptive control of amoebic infection in the cornea.

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Acanthamoeba keratitis is a sight-threatening infectious disease. Resistance of the cystic form of the protozoan to biocides and the potential toxicity of chemical compounds to corneal cells are the main concerns related to long-term treatment with the clinically available ophthalmic drugs. Currently, a limited number of recognized antimicrobial agents are available to treat ocular amoebic infections. Topical application of biguanide and diamidine antiseptic solutions is the first-line therapy. We consider the current challenges when treating Acanthamoeba keratitis and review the chemical properties, toxicities, and mechanisms of action of the available biocides. Antimicrobial therapy using anti-inflammatory drugs is controversial, and aspects related to this topic are discussed. Finally, we offer our perspective on potential improvement of the effectiveness and safety of therapeutic profiles, with the focus on the quality of life and the advancement of individualized medicine.

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PURPOSE: The aim of this study was to compare the cellular susceptibility patterns and morphologic changes in the corneal endothelium associated with the use of fourth-generation fluoroquinolones. METHOD: Endothelial susceptibility was assessed through intracameral injection of besifloxacin, gatifloxacin, and moxifloxacin. Human umbilical vein endothelial cells (HUVECs) were used as the standard cellular lineage to assess the quantitative toxicity of each antibiotic solution. Qualitative changes in the morphologic character of the corneal structure and the endothelial layer were generated using a combination of ex vivo and in vivo assays. Experimental assays were conducted in triplicate, and the results were statistically analyzed. RESULTS: At 1 hour of exposure, all HUVECs exposed to antibiotics showed viability above 85%, after 3 hours of exposure to besifloxacin, gatifloxacin, and moxifloxacin, the percentages of viable cells were 68.3 ± 4.0 (P < 0.001), 90.7 ± 4.2 (P < 0.05), and 93.3 ± 1.5 (P > 0.05), respectively. All fluoroquinolones tested showed toxicity to HUVECs, resulting in significant (P < 0.001) loss of cellular viability after 24 hours of drug exposure. Giant endothelial cells were observed in animals treated with the 3 fluoroquinolones in contrast to the absence of these abnormal cells in the untreated group. Early cellular detachment was seen in the endothelial layer after exposure to gatifloxacin and moxifloxacin. CONCLUSIONS: We concluded that injection of fourth-generation fluoroquinolones in the aqueous humor did not adversely affect the corneal endothelium. However, these results suggested that prophylactic intracameral injection of besifloxacin, gatifloxacin, or moxifloxacin, if needed, should be administered as a last therapeutic resource in clinical practice, with careful and constant monitoring of corneal endothelium.

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