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- Seronegative Myasthenia Gravis: A Rare Disease Triggered by SARS-CoV-2 or a Coincidence?Publication . Castro Silva, Beatriz; Saianda Duarte, Miguel; Rodrigues Alves, Nuno; Vicente, Patricia; Araújo, JoséMyasthenia gravis (MG) results from the production of autoantibodies against the neuromuscular junction, leading to muscle weakness. Although the exact cause is not fully understood, it is known that the onset and exacerbations of MG can occur after viral infections. We present the case of a patient with no prior history of MG with new-onset proximal muscle weakness and ptosis, following SARS-CoV-2 infection, This case underscores the potential for autoimmune diseases to be triggered by SARS-CoV-2.
- A Novel Use of Temporary ICL During DMEK to Prevent Gas-Induced Opacification of a Scleral-Fixated Carlevale IOL.Publication . Zúñiga, Martina Aguilera; Güell, José Luis; Gris, Óscar; Salmoral, Alberto; Martín, Carlos; Moura-Coelho, NunoPurpose: To report a novel surgical strategy using a temporary implantable collamer lens (ICL) during Descemet membrane endothelial keratoplasty (DMEK) to prevent gas-induced opacification of a scleral-fixated Carlevale intraocular lens (IOL) in a vitrectomized eye. Observations: A 68-year-old male with a history of blunt trauma, pars plana vitrectomy, and Carlevale IOL implantation developed irreversible corneal edema. DMEK was performed with the intraoperative placement of an inverted ICL in the anterior chamber, serving as a protective barrier between the gas tamponade and the IOL. The ICL was explanted two weeks later, without complications. The endothelial graft remained well attached throughout the follow-up period, with no intraoperative or postoperative adverse events. The optical clarity of the Carlevale IOL was preserved, and no ICL-related complications were observed. Best-corrected visual acuity (BCVA) improved from logMAR 1.00 preoperatively to logMAR 0.22 by 3 months, with stability maintained through the 6-month follow-up period. Conclusions and importance: Temporary ICL implantation during DMEK may be an effective strategy to prevent gas-induced opacification in eyes with hydrophilic IOLs. Unlike IOL exchange, which adds surgical trauma, or gas-minimizing strategies, which risk detachment, this approach preserves full tamponade while safeguarding IOL clarity.
- Persistent Proinflammatory Cytokine Profile in the Tear Fluid of Stable Keratoconus: Rethinking Clinical Quiescence.Publication . Gil, Pedro; Quadrado Gil, João; Cruz, Nuno; Costa, Celso; Rodrigues-Santos, Paulo; Sousa, Luana Madalena; Almeida, Jani Sofia; Fernandes, Rosa; Alves, Nuno; Rosa, Andreia; Murta, JoaquimPurpose: Keratoconus is traditionally classified as a noninflammatory corneal ectasia, despite growing evidence suggesting an underlying inflammatory component. This study evaluates whether patients with stable keratoconus exhibit persistent inflammatory activity in tear fluid compared to healthy controls. Methods: Cross-sectional case-control study. Keratoconus progression was evaluated using tomographic and clinical criteria. Tear fluid samples were collected under standardized conditions and concentrations of nine cytokines (IFN-γ, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12p70, IL-17A, and TNF-α) were quantified using a multiplex assay. Group comparisons, correlation analyses, and receiver operating characteristic (ROC) curves were performed to evaluate cytokine expression and network behavior. Results: A total of 23 stable keratoconus patients and 25 age-matched healthy controls were included. The stable keratoconus group exhibited significantly elevated levels of tear fluid inflammatory cytokines compared to controls (all P < 0.05, except IL-2). Spearman correlation heatmaps revealed a coordinated cytokine network in the keratoconus group, suggesting persistent immunological activation despite clinical quiescence. No significant correlations were observed between cytokine levels and keratoconus staging indices. ROC analysis indicated moderate discriminatory performance of IL-6 (area under the curve = 0.68). Conclusions: Even clinically stable keratoconus is associated with a distinct proinflammatory tear fluid cytokine profile, challenging the traditional paradigm of keratoconus as a noninflammatory disease. These findings highlight the potential utility of tear fluid-based inflammatory biomarkers in keratoconus and suggest inflammation may persist independently of clinical progression. Translational relevance: This study highlights the potential role of tear-based inflammatory biomarkers for monitoring disease activity, understanding keratoconus pathophysiology and guiding adjunctive anti-inflammatory therapies in keratoconus beyond structural stabilization.
- Fluocinolone Acetonide 0.2 µg/Day Intravitreal Implant in Non-Infectious Uveitis Affecting the Posterior Segment: EU Expert User Panel Consensus-Based Clinical Recommendations.Publication . Pleyer, Uwe; Pavesio, Carlos; Miserocchi, Elisabetta; Heinz, Carsten; Devonport, Helen; Llorenç, Víctor; Burke, Tomás; Nogueira, Vanda; Kodjikian, Laurent; Bodaghi, BahramBackground: Non-infectious uveitis affecting the posterior segment of the eye (NIU-PS) is an inflammatory disease, which can significantly impair visual acuity if not adequately treated. Fluocinolone-acetonide sustained-release-0.2 µg/day intravitreal (FAc) implants are indicated for prevention of relapse in recurrent NIU-PS. The aim here was to provide treating clinicians with some consensus-based-recommendations for the clinical management of patients with NIU-PS with 0.2 µg/day FAc implants. Methods: A European-clinical-expert-group agreed to develop a consensus report on different issues related to the use of FAc implants in patients with NIU-PS. Results: The Clinical-expert-panel provided specific recommendations focusing on clinical presentation (unilateral/bilateral) of the NIU-PS; systemic involvement of NIU-PS and the lens status. Treatment algorithms were developed; one that refers to the management of patients with NIU-PS in clinical practice and another that establishes the best clinical scenarios for the use of FAc implants, both as monotherapy and as adjuvant therapy. Additionally, the Clinical-expert-panel has provided recommendations about the use of the FAc implants in a clinical-setting. The Clinical-expert-panel also considered the safety profile of FAc implants and their possible implications in the daily practice. Conclusions: As more clinical experience has been gained using FAc implants, it was necessary to update the clinical recommendations that guide patient management in the clinic. The current consensus document addresses relevant issues related to the use of FAc implants on different types of patients with various etiologies of NIU-PS, and was conducted to standardize approaches to help specialists obtain better clinical outcomes.
- Genetic Testing of Patients with Inherited Retinal Diseases in the European Countries: An International Survey by the European Vision Institute.Publication . Calzetti, Giacomo; Schwarzwälder, Kerstin; Ottonelli, Giorgia; Kaminska, Karolina; Strauss, Rupert Wolfgang; Baere, Elfride De; Leroy, Bart P; Audo, Isabelle; Zeitz, Christina; Cursiefen, Claus; Stingl, Katarina; Boon, Camiel J F; Marques, João Pedro; Santos, Cristina; Ayuso Garcia, Carmen; Escher, Pascal; Cordeiro, M Francesca; D'Esposito, Fabiana; Charbel Issa, Peter; Lotery, Andrew; Lin, Siying; Michaelides, Michel; Rivolta, Carlo; Scholl, Hendrik P NIntroduction: The purpose of this project was to explore the current standards of clinical care genetic testing and counseling for patients with inherited retinal diseases (IRDs) from the perspective of leading experts in selected European countries. Also, to gather opinions on current bottlenecks and future solutions to improve patient care. Methods: On the initiative of the European Vision Institute, a survey questionnaire with 41 questions was designed and sent to experts in the field from ten European countries. Each participant was asked to answer with reference to the situation in their own country. Results: Sixteen questionnaires were collected by November 2023. IRD genetic tests are performed in clinical care settings for 80% or more of tested patients in 9 countries, and the costs of genetic tests in clinical care are covered by the public health service to the extent of 90% or more in 8 countries. The median proportion of patients who are genetically tested, the median rate of genetically solved patients among those who are tested, and the median proportion of patients receiving counseling are 51-70%, 61-80%, and 61-80%, respectively. Improving the education of healthcare professionals who facilitate patient referrals to specialized centers, improving access of patients to more thorough genotyping, and increasing the number of available counselors were the most advocated solutions. Conclusion: There is a significant proportion of IRD patients who are not genetically tested, whose genetic testing is inconclusive, or who do not receive counseling. Educational programs, greater availability of state-of-the-art genotyping and genetic counselors could improve healthcare for IRD patients.
- PRESERFLO Microshunt™ versus Non-Penetrating Deep Sclerectomy for Glaucoma Management, One-Year Results.Publication . Cunha, Bruna; Gil, Pedro; Lopes, Edgar; Elisa-Luís, Maria; Reina, Maria; Gomes, Teresa; Cardigos, JoanaPurpose: To compare the short-term efficacy and safety of the PRESERFLO™ MicroShunt (PF) versus Non-Penetrating Deep Sclerectomy (NPDS) with Esnoper®. Methods: Retrospective comparative cohort study at a tertiary hospital including 79 eyes from 79 patients submitted to surgery (32 PF implantation, Group 1 and 47 NPDS, Group 2) between January 2022 and August 2023, with one year follow-up. Outcome measures included intraocular pressure (IOP), complications, surgical duration, postoperative major and minor interventions. Surgical failure was defined as IOP>21 mmHg or <20% reduction from baseline, IOP<5 mmHg, major postoperative intervention, or loss of light perception. Conversely, success was defined as the absence of these failure criteria: complete success without glaucoma medications, and qualified success with. Results: Baseline characteristics, including age, sex, IOP, number of IOP-lowering medications, and visual field defects, were comparable between groups (p>0.05). After one year, IOP decreased significantly in both groups (PF: 20.13±6.20 to 15.00±3.15 mmHg; NPDS: 19.57±5.73 to 13.30±3.59 mmHg, both p<0.001). Complete success rates were 28.1% for PF and 40.4% for NPDS (p=0.189), while surgical failure was significantly higher in the PF group (65.6% vs 38.3%, p=0.015). Major reinterventions were more frequent with PF (10 vs 3, p=0.005), partly due to encapsulated blebs, while NPDS required more minor interventions (2 vs 17, p=0.002). Complication rates were similar (31.3% vs 14.9%, p=0.073), but surgical duration was shorter in the PF group (60.03±17.95 min vs 69.91±15.23 min, p=0.008). Conclusion: PF and NPDS share comparable safety profiles. Although PF surgery is faster, it is associated with a higher rate of major postoperative interventions and failure. NPDS, while requiring more minor interventions, such as goniopuncture and needling, rarely demands major re-interventions. NPDS is known for its meticulous and technically challenging technique, but once mastered, it can result in fewer invasive re-interventions and improved efficacy.
- Tear Meniscus and Corneal Sub-basal Nerve Plexus Assessment in Primary Sjögren Syndrome and Sicca Syndrome Patients.Publication . Cardigos, Joana; Barcelos, Filipe; Carvalho, Helena; Hipólito, Diogo; Crisóstomo, Sara; Vaz-Patto, José; Alves, NunoPurpose: To evaluate lower tear meniscus and corneal sub-basal nerve plexus in primary Sjögren's syndrome (pSS) and Sicca syndrome patients. Methods: Cross-sectional study of 116 patients with Sicca syndrome associated with pSS and not associated with Sjögren's syndrome (non-SS Sicca) and 20 normal control subjects. Tear meniscus height and area were measured using anterior segment optical coherence tomography; corneal sub-basal nerve plexus density, length, and tortuosity were evaluated using in vivo confocal microscopy. Data analysis was performed using IBM-SPSS Statistics 24.0. Results: Corneal sub-basal nerve plexus density and length were significantly lower, and tortuosity was significantly higher in pSS and non-SS Sicca groups than in normal control subjects (P < 0.001; P = 0.018, respectively). Corneal sub-basal nerve plexus presented a strong association with Schirmer test I and tear breakup time. Cutoff values of sub-basal nerve plexus density (36.5 nerve/mm) and length (12.5 mm/mm) presented 80.2% to 81.9% sensitivity and 85% specificity for detecting Sicca syndrome patients. No significant differences were found between the 3 groups regarding tear meniscus height and area. Conclusions: Corneal sub-basal nerve plexus in vivo confocal microscopy may be a useful tool in the assessment of dry eye disease in Sicca syndrome, complementing the information provided by the conventional modalities used in dry eye disease evaluation.
- Application of Optical Coherence Tomography Angiography for Microvascular Changes in Patients Treated with Hydroxychloroquine: a Systematic Review and Meta-AnalysisPublication . Ferreira, A; Anjos, R; José-Vieira, R; Afonso, M; Abreu, AC; Monteiro, S; Macedo, M; Andrade, J; Furtado, MJ; Lume, MBackground: Retinal toxicity with long-term hydroxychloroquine (HCQ) treatment is a major concern. This systematic review aims to assess the application of optical coherence tomography angiography (OCTA) to detect microvascular alterations in patients under HCQ. Methods: PubMed, Scopus, Web of Science, and Cochrane Library databases were systematically searched until January 14, 2023. Studies using OCTA as a primary diagnostic method to evaluate the macular microvasculature of HCQ users were included. Primary outcomes were macular vessel density (VD) and foveal avascular zone (FAZ) at the superficial (SCP) and deep (DCP) capillary plexus. Meta-analysis was performed using a random-effects model. Results: Of 211 screened abstracts, 13 were found eligible, enrolling 989 eyes from 778 patients. High-risk patients due to longer duration of treatment presented lower VD in the retinal microvasculature than those with low-risk in SCP (P = 0.02 in fovea; P = 0.004 in parafovea) and in DCP (P = 0.007 in fovea; P = 0.01 in parafovea). When compared with healthy controls, HCQ users had lower VD in both plexus-no quantitative synthesis was presented. Conclusions: Microvascular changes were found in autoimmune patients under HCQ treatment without any documented retinopathy. However, the evidence produced so far does not allow to draw conclusion concerning the effect of drug as studies were not controlled for disease duration.
- Cost Comparison Between Defocus Spectacle Lens and Compound Atropine in Myopia Treatment in the Portuguese SettingPublication . Barros da Silva, P; Ludovico, I; Basilio, AL; Guimarães, SINTRODUCTION: The rising prevalence of myopia poses a substantial global concern. Low concentration atropine and defocus spectacle lens (DSL) are the most widely used myopia prevention treatment in Portugal. Atropine drops must be compounded in pharmacies, because there is still no commercial low concentration atropine approved in Portugal. There are no studies with enough evidence to prefer one treatment over the other, so cost might be a decisive factor. Our purpose was to compare the costs between DSL and compound atropine for myopia progression prevention in Portugal. METHODS: We collected data on compound atropine from different pharmacies in Portugal, monofocal (MF) lenses prices from the four most common brands in Portugal and DSL price from brand representatives. Cost estimates were done per year of four consecutive years of myopia prevention treatment, considering different scenarios according to the need of spectacle lens exchange. We compared costs of low dose compound atropine plus MF lens versus DSL in the different scenarios. RESULTS: Atropine treatment proved more cost-effective than DSL treatment only when there was a requirement for lens exchange every 6 months or less (609.25€ for atropine versus 780.00€ for DSL per year of treatment). When myopia progression prevention is more effectiveand the need of lens exchange is equal or greater than 12 months, DSL treatment showed to be less expensive than mean values of atropine treatment plus MF lens (390.00€ for DSL vs 464.59€ for atropine, per year of treatment). CONCLUSION: DSL take a cost advantage in prevention of myopia progression, in situations when there is a need of lens exchange within once a year or less frequently. However, atropine plus MF lenses might be a less expensive in cases whenever there is a need of lens exchange every 6 months or more frequently. It is essential to conduct further studies focusing on the costeffectiveness of different treatment options for preventing myopia progression
- The 2021 Portuguese Society of Ophthalmology Joint Guidelines with Paediatric Rheumatology on the Screening, Monitoring and Medical Treatment of Juvenile Idiopathic Arthritis-Associated UveitisPublication . Leal, I; Miranda, V; Fonseca, C; Barbosa-Breda, J; Cordeiro Sousa, D; Mesquita-Marques, P; Araújo, J; Silva, MI; Pedrosa, AC; Palmares, J; Furtado, MJ; Macedo, M; Lages, V; Fonseca, S; Gonçalves, R; Ruão, M; Gomes Rodrigues, F; Ribeiro, M; Proença, R; Almeida, M; Liverani, M; Morais Pina, S; Bernardo, M; Nogueira, V; Guerra Pinto, R; Pinto Ferreira, F; Pinto Proença, R; Domingues, I; Guedes, M; Cordeiro, M; Fragata, F; Berens, O; Gregório, T; Brito, I; Oliveira-Ramos, F; Fonseca, JE; Figueira, LAim: To develop the first Ophthalmology joint guidelines with Paediatric Rheumatology with recommendations on the screening, monitoring and medical treatment of juvenile idiopathic arthritis-associated uveitis (JIA-U), endorsed by the Portuguese Society of Ophthalmology (SPO). Methods: A systematic literature review was conducted to include publications up to July 14th 2020, with no language restrictions, in order to include all the international position papers/guidelines concerning the medical management of JIA-U and randomised clinical trials assessing the efficacy and safety of medical treatment in this field. We searched through MEDLINE (PubMed), Scopus, Web of Science and Cochrane Library. The Delphi modified technique to generate consensus was used. Preliminary evidence statements were subject to an anonymous agreement assessment and discussion process using an online survey, followed by further discussion and update at a national meeting. A draft of the manuscript with all recommendations was then circulated among all participants and suggestions were incorporated. The final version was again circulated before publication. Results: Twenty-six recommendations were developed focusing on the following topics: general management (3), screening and follow-up of uveitis (4), treatment (17) and health education in JIA-U among patients and families (2). Conclusion: These guidelines were designed to support the shared medical management of patients with JIA-U and emphasize the need for a multidisciplinary approach between Ophthalmology and Paediatric Rheumatology regarding the comprehensive care of JIA-U. We acknowledge that updating these recommendations will be warranted in the future, as more evidence becomes available.