Pedro Candelária’s research while affiliated with Centro Hospitalar Universitário de Lisboa Central and other places

Purpose To evaluate the clinical presentation, microbiological results and treatment used in cases of infectious keratitis diagnosed in Centro Hospitalar Lisboa Central (CHLC) between July 2009 and July 2013 Methods Retrospective analysis of data from patients who underwent microbiological examination for suspected infectious keratitis between July 2009 and July 2013 in the CHLC (n=86 patients) Results The most prevalent risk factor was the use of contact lenses. Of the 93 samples taken, 59 (63.4%) were positive for at least one pathogen. A total of 64 microorganisms were isolated with 35 (54.8%) being Gram‐negative, 25 (41.9%) Gram‐positive and 2 (3.2%) fungi. The most prevalent pathogen was Pseudomonas aeruginosa. In two patients, Acanthamoeba cysts were isolated by confocal microscopy. Hospitalization was needed in 64.0% of cases. The treatment of choice was the use of fortified eyedrops of vancomycin and ceftazidime. In seven patients surgical therapy was needed for infection control. Conclusion Our work draws attention to the morbidity associated with this disease and reinforces the importance of conducting microbiological studies in these patients. The main predisposing factor in our population was the use of contact lens, with Gram‐negative microorganisms being isolated in the majority of cases.

Purpose To assess whether corneal confocal microscopy (CCM) can detect alterations in corneal nerve morphology in patients with Parkinson disease. Methods Twenty‐five patients with Parkinson disease and 25 control subjects were examined. Patients underwent neurological and complete ophthalmological evaluation. Corneal sensitivity testing was performed with a Cochet‐Bonnet esthesiometer and corneal sub‐basal nerve morphology assessment with confocal microscopy (Heidelberg Retina Tomograph II/Rostock Cornea Module). CCM was used to quantify corneal nerve fibre density, tortuosity, length and branch density. Results Patients with Parkinson disease had decreased corneal sensation in comparison with controls. Corneal nerve fiber morphology differed in both groups, with a lower global fiber density, branch density and higher tortuosity in Parksinson patients (p<0,05). These parameters were found to be related to dopaminergic medication exposure. Conclusion We found a decreased corneal sensation and corneal nerve fiber changes in patients with Parkinson disease. CCM may be used to detect signs of peripheral neuropathy and follow patients in dopaminergic therapy.

Purpose To determine the reproducibility of keratometric parameters obtained by OCULUS® Pentacam® HR in the evaluation of keratoconus progression. Methods Thirty nine eyes of 25 patients from the Cornea Department of the Centro Hospitalar de Lisboa Central were included in the study. Fourteen eyes presented with clinical and topographic diagnosis of keratoconus (stage 1‐3) and were defined as the “keratoconus without ring” group; 9 eyes had already an intrastromal ring implanted and were defined as the “keratoconus with ring”; the remaining 16 eyes, without clinical or topographic evidence of disease, were used as controls. Every eye was submitted to identical methodology: 5 consecutive keratometric measurements obtained with OCULUS® Pentacam® HR; central keratometry, SKmax, minimal pachymetry and anterior chamber depth were used to determine the existence of statistically significant reproducibility. Results Overall significant measurement variability was obtained in the “keratoconus without ring” group (Km 0.129 D vs 0.0375 D, SKmax 0.507 D vs 0.0625 D, Minpach 5.429 μm vs 2.5625 μm, ACD 0.024 mm vs 0.0194 mm), with highest variability in the subgroup of patients with more advanced disease. In the “keratoconus with ring” group statistically significant variability was found for all parameters except for anterior chamber depth (Km 0.289 D vs 0.0375 D, SKmax 0.444 D vs 0.0625 D, Minpach 4.333 μm vs 2.5625 μm, ACD 0.024 mm vs 0.0194 mm). Conclusion Keratometric measurements obtained with OCULUS® Pentacam® HR should be assessed cautiously in the evaluation of keratoconus progression, with or without intrastromal ring; the use of single measurements is unadvised.

Purpose: The authors present an analysis of subsequent surgical procedures performed and outcomes in patients with keratoconus following intracorneal ring segment insertion. Setting: Department of Ophthalmology - Centro Hospitalar Lisboa Central - Lisbon, Portugal Methods: A retrospective study of 422 eyes (326 patients) with keratoconus submitted by the same surgical team to intracorneal ring segment insertion between 2006 and 2013. Demographic data, surgical indications, type of procedure, visual outcome, refractive outcome and complications were studied. A comparison between the eyes that required a second surgical procedure and the others was performed. The safety and efficacy of the procedures was also studied. Results: 4.2% (n=15) of the eyes were submitted to a subsequent surgical procedure after intracorneal ring segment insertion. The second surgical procedure was performed in average 20.1 months after the first. Indications for surgery included keratoconus progression (40%; n=6), cataract (33.3%, n=5), ring segment migration (20%; n=3) and extrusion (6.7%; n=1). Cataract surgery was performed in 33.3% (n=5) of the reoperated eyes, implantation of new intracorneal ring segments in 26.7% (n=4), deep anterior lamellar keratoplasty in 13.3% (n=2), penetrating keratoplasty in 13.3% (n=2) and cross-linking in 13.3% (n=2). There were no postoperative complications. A significant improvement in corrected distance visual acuity and manifest refraction was obtained (p<0.05). Conclusions: Only a small percentage of the patients submitted to intracorneal ring segments insertion had to be reoperated. Furthermore, only 66.6% of the subsequent procedures were related to keratoconus and a good outcome was achieved. The low rate of re-intervention suggests that the progression of keratoconus submitted to ring segment implantation may not be clinically significant. Our study suggests that ICRS implantation has revolutionized the keratoconus standard of treatment, leaving more aggressive procedures to the severe and refractive spectrum of the disease.

Purpose: The authors present an analysis of the indications, outcomes and complications of amniotic membrane transplantation in patients with ocular surface disease. Setting/Venue: Department of Ophthalmology - Centro Hospitalar Lisboa Central - Lisbon, Portugal. Methods: A retrospective study of 44 eyes of 42 patients with ocular surface disease submitted to amniotic membrane transplantation was performed. The patients were transplanted between 2006 and 2013 by the same surgical team. Biomicroscopy with slit-lamp examination and photographs was performed. The outcome established for each patient depended on the initial pathology. Results: Patients were in average 65.2 years old. 52.3% were female. Indications for transplantation were refractory corneal ulcer (29.5%), persistent epithelial defect (25.0%), band keratopathy (11.4%), descemetocele (4.5%), superficial corneal macula (4.5%), multiple or recurrent pterygium (4,5%), symblepharon lysis (4.5%), bleb leak (4.5%), total limbal insufficiency (4.5%), partial limbal insufficiency (2.3%), corneal irregularity after pterygium surgery (2.3%) and acute chemical burn (2.3%). The outcome and success rate depended on the indication for transplantation. Complication rate was 2.3% (n=1) and consisted in contamination of the storage medium. Conclusions: Amniotic membrane transplantation is an important therapeutic alternative in treating ocular surface diseases, as it is an easy, efficient and reproducible procedure associated with a low complication rate. Treatment should be decided on an individual basis. Multicenter controlled and randomized trials are still needed to further establish its efficacy.

Purpose To analyse corneal nerve morphology alterations in patients with chronic renal failure by in vivo corneal confocal microscopy (CCM). Methods A prospective study was conducted in 30 patients (30 eyes) with pre‐dialysis chronic renal failure (CRF) and 30 aged‐matched healthy volunteers (30 eyes). A complete ophthalmologic examination, esthesiometry (Cochet‐Bonnet esthesiometer), in vivo CCM (Heidelberg Retina Tomograph II/Rostock Cornea Module) and neurological evaluation were performed. Results Corneal sensation was reduced in pre‐dialysis CRF patients compared with control subjects. Nerve fiber density, length and branch density were reduced and tortuosity was increased in the CRF group (p<0,05). These parameters were related with severity of neuropathy. Conclusion In vivo CCM may be a valuable method for diagnosis of uremic neuropathy and may be used to grade its severity.

Purpose: To compare intraocular pressure (IOP) measurements with dynamic contour tonometry (DCT) and Goldmann applanation tonometry (GAT) after Descemet’s stripping automated keratoplasty (DSAEK). Setting: Department of Ophthalmology - Centro Hospitalar Lisboa Central - Lisbon, Portugal Methods: Transverse observational study of 22 eyes of 19 patients with successful DSAEK. IOP was measured with DCT and GAT and central corneal thickness (CCT) was determined using anterior chamber OCT. IOP measurements were compared and the CCT influence was evaluated. A control group with 22 eyes of 17 patients was also created. Results: Mean IOP in pressure in patients with DSAEK evaluated by GAT was 13.9±3.7 and 17.4±3.3 with DCT. Mean CCT in these patients was 601.8±58.9. In the control group mean IOP evaluated by GAT was 13.5±2.4 and by DCT was 16.5±2.6. In this group mean CCT was 535.1±39.1. The IOP values obtained with DCT were in average higher than those obtained with GAT in both samples. The difference between the two IOP evaluating methods was similar in both groups. In the group of patients with DSAEK, no statiscally significant correlation was found between CCT and the different IOP evaluating methods. Conclusions: The IOP difference between GAT and TCD wasn’t influenced in a statistically significant way by the CCT that was artificially increased in the patients with DSAEK. Therefore, both GAT and CCT can be used safely and reliably in these patients.

Purpose: To present a retrospective study of 51 eyes of 47 patients submitted to Descemet Stripping Automated Endothelial Keratoplasty. Introduction: Endotelial keratoplasty is the preferred surgical approach when treating endothelial disease. There are various indications for DSAEK. The most common indication for DSAEK is pseudophakic bullous keratopathy and Fuchs endothelial dystrophy. It has also been proved to be useful in different genetic diseases (congenital hereditary endothelial dystrophy and irido-corneal-endothelial dystrophy) and edema from endothelial dysfunctions. The surgical procedure includes stripping Descemet’s membrane and endothelium from the recipient and attaching the donor tissue using air tamponade. Methods: A retrospective study of 51 eyes of 47 patients submitted to DSAEK and operated by the same surgical team from 2009 to 2012 was performed. Indications, visual acuity progress and complications were analyzed. The safety and efficacy of the procedure was also studied. Results: Patients had a mean age of 71 years when operated and 64.7% were women. Pseudophakic bullous keratopathy was the indication in 58.8% of the cases, Fuchs endothelial dystrophy in 39.2% and bullous keratopathy after AC IOL implantation in 2%. In 13.7% of the cases the DSAEK procedure was performed together with phacoemulsification and IOL implantation. There were no intraoperative complications. Preoperative average visual acuity was 0.19 and best postoperative average visual acuity was 0.44. The postoperative complication rate was 21.6% and included dislocations, graft failures, pupillary block angle closure, vitritis and macular oedema. Conclusion: There was a significant average visual acuity increase, comparable to the increase verified by other published studies. Postoperative complication rate was also within the expected results. The results demonstrated a fast visual recovery and less postoperative inflammation. DSAEK is now a safe and approved alternative to penetrating keratoplasty and it must be considered in the treatment of the patients that have endothelial dysfunction without stromal pathology.

Purpose: To present a clinical case of a patient with a corneal ulcer and descemetocele treated with amniotic membrane transplantation. The procedure has been described has an adjunctive or alternative therapy in ocular surface disorders. This is especially relevant in non-healing corneal lesions as there is an increased risk of perforation. Setting/Venue: Department of Ophthalmology, Centro Hospitalar de Lisboa Central, Lisbon Methods: The authors present a clinical case of a 79-year-old female patient, who was sent to the cornea outpatient unit due to a descemetocele in the left eye. The descemetocele appeared 2 months after having a corneal ulcer that was treated with topical antibiotics. The patient was submitted to amniotic membrane transplantation. The clinical case was documented, photographs were taken before and after the procedure and the surgical procedure was also filmed. Results: The descemetocele was covered with amniotic membrane according to the techniques described in the literature. There were no complications during the procedure. There was a complete repair of the ocular surface. The patient presents an aesthetic and functional rehabilitation. Conclusions: Amniotic membrane transplantation has been proved to be a useful surgical approach to severe ocular disorders. The case reported illustrates the success in achieving corneal surface repair with a significant reduction in inflammation and corneal scarring.