ABSTRACT Purpose: To describe a 2019 acute toxoplasmosis outbreak in the city of São Paulo, Brazil, and to evaluate the laboratory serological profile for toxoplasmosis for three consecutive years. The ophthalmological manifestations of the patients involved in the outbreak were also studied. Methods: A cross-sectional descriptive study of a toxoplasmosis outbreak in São Paulo, Brazil, between February and May 2019. Epidemiological data were described, as were the observed ocular manifestations. As part of this study the number of patients with positive IgM toxoplasmosis serology was obtained from a large laboratory network (DASA) for three consecutive years, including the year of the outbreak (2018, 2019, 2020). Results: Eighty-three individuals were identified in the outbreak and two clusters were studied. The clinical picture of at least 77% of the patients, the epidemiological analysis, and the short incubation period (5-8 days) suggested contamination by oocysts. Serological laboratory data analysis revealed an increase of positive toxoplasmosis IgM in 2019 of 73% compared to the previous year. Ophthalmological examination revealed that at least 4.8% of the patients developed toxoplasmic retinochoroiditis, none of whom had been treated during the acute systemic disease. Conclusion: Our findings indicate vegetable contamination as the possible source of this outbreak, a high prevalence of toxoplasmosis in São Paulo during the outbreak period, and a drop in the number of tests during the COVID-19 pandemic. Retinochoroiditis was observed in at least 4.8% of the cases. We confirm the need to implement effective means for the prevention, diagnosis, and treatment of the disease. This may involve raising awareness among the population of the importance of vegetable hygiene, and improved quality control of food and water.

ABSTRACT Purpose: To describe a 2019 acute toxoplasmosis outbreak in the city of São Paulo, Brazil, and to evaluate the laboratory serological profile for toxoplasmosis for three consecutive years. The ophthalmological manifestations of the patients involved in the outbreak were also studied. Methods: A cross-sectional descriptive study of a toxoplasmosis outbreak in São Paulo, Brazil, between February and May 2019. Epidemiological data were described, as were the observed ocular manifestations. As part of this study the number of patients with positive IgM toxoplasmosis serology was obtained from a large laboratory network (DASA) for three consecutive years, including the year of the outbreak (2018, 2019, 2020). Results: Eighty-three individuals were identified in the outbreak and two clusters were studied. The clinical picture of at least 77% of the patients, the epidemiological analysis, and the short incubation period (5-8 days) suggested contamination by oocysts. Serological laboratory data analysis revealed an increase of positive toxoplasmosis IgM in 2019 of 73% compared to the previous year. Ophthalmological examination revealed that at least 4.8% of the patients developed toxoplasmic retinochoroiditis, none of whom had been treated during the acute systemic disease. Conclusion: Our findings indicate vegetable contamination as the possible source of this outbreak, a high prevalence of toxoplasmosis in São Paulo during the outbreak period, and a drop in the number of tests during the COVID-19 pandemic. Retinochoroiditis was observed in at least 4.8% of the cases. We confirm the need to implement effective means for the prevention, diagnosis, and treatment of the disease. This may involve raising awareness among the population of the importance of vegetable hygiene, and improved quality control of food and water.

RESUMO Objetivos: o principal objetivo deste estudo foi descrever pacientes com achados vasculares retinianos temporalmente relacionados à vacinação contra COVID-19. Com maior notificação de possíveis eventos adversos similares, esperamos compreender a real dimensão e relevância do que foi apresentado. Métodos: Onze pacientes com queixas visuais após vacinação contra COVID-19 foram estudados. Os dados analisados foram: idade, gênero, tipo de vacinação, tempo de aparecimento de sintomas, achados sistêmicos, antecedentes pessoais, acuidade visual com melhor correção, biomicroscopia e imagem retiniana multimodal (retinografia colorida, red-free, SD-OCT, OCTA e angiofluoresceinografia). Os critérios de inclusão foram a presença de alterações oftalmológicas ocorridas dentro de 30 dias após a primeira ou segunda dose de qualquer vacina contra COVID-19. Resultados: Onze pacientes foram incluídos: 5 com oclusão arterial (45,4%), 4 com oclusão venosa (36,4%) e 2 (18,2%) com alterações não específicas vasculares sugestivas de isquemia retiniana como exsudatos algodonosos. A idade média dos pacientes foi de 57 anos (DP=16; com intervalo de 27 a 84 anos). A média de tempo de aparecimento de sintomas após a vacinação foi de 10 dias (DP=5,4; com intervalo de 3 a 16 dias). Nove dos onze pacientes eram do sexo feminino (81,8%). Fatores de risco sistêmicos foram observados em 36,4% dos pacientes. Dois pacientes tiveram sintomas neurológicos e visuais, com oclusão arterial. 36,4% dos pacientes tiveram infecção prévia por COVID-19 no último ano. Sete pacientes (63,6%) receberam a vacina ChAdOx1 nCoV-19 (AZD1222). Conclusões: nossos dados sugerem que eventos retinianos temporalmente relacionados à vacinação contra COVID-19 são possíveis, porém raros. A relação entre estes eventos pós-vacinais exigem futura atenção antes de maiores conclusões.

ABSTRACT Purpose: The primary purpose of this study was to assess vascular retinal findings temporally related to COVID-19 vaccination. With greater information regarding all possible future adverse events, we hope to understand the real dimension and relevance of what was presented. Methods: Eleven patients with visual complaints after COVID-19 vaccination were enrolled. Data on the following were included: age, sex, vaccine, time of symptom onset, systemic findings, medical history, best-corrected visual acuity, and ocular findings by slit-lamp biomicroscopy as well as multimodal retinal imaging (color fundus, red-free photography, spectral-domain optical coherence tomography, optical coherence tomography angiography, and fluorescein-angiography). Inclusion criteria were the presence of ophthalmologic signs within 30 days after the first or second dose of any COVID-19 vaccine. Results: Of 11 patients, five had arterial occlusion (45.4%), four had venous occlusion (36.4%), and two (18.2%) had nonspecific vascular alterations suggestive of retinal ischemia such as cotton-wool spots. The mean age was 57 (SD = 16; range: 27-84) years. The mean time of symptoms onset was 10 (SD = 5.4; range: 3-16) days. Nine patients were female (81.8%). Systemic risk factors were observed in 36.4% of patients. Two patients had both neurological and visual symptoms, with arterial occlusion. Overall, 36.4% patients had COVID-19 in the previous year. Seven patients (63.6%) received ChAdOx1 nCoV-19 (AZD1222) vaccine. Conclusions: Our data suggest that retinal events temporally related to COVID-19 vaccination are possible but are very rare. The relationship of these events with post-COVID-19 vaccination warrants further attention to derive a meaningful conclusion.

Resumo Objetivo: Demonstrar a eficácia do cloridrato de acetilcolina 1% na obtenção da miose intraoperatória na cirurgia de catarata pela técnica de facoemulsificação. Métodos: Pacientes com diagnóstico de catarata e indicação de cirurgia foram selecionados para participar do presente estudo. Todos os pacientes foram operados pela técnica de facoemulsificação convencional pelo mesmo cirurgião, todos foram submetidos à aplicação de 0,2 ml do cloridrato de acetilcolina 1% na câmara anterior ao final do procedimento cirúrgico. A medida do diâmetro pupilar foi realizada imediatamente antes do início da cirurgia, imediatamente antes do uso do cloridrato de acetilcolina 1% e após 2 minutos. Resultados: Foram estudados 30 olhos de 30 pacientes, destes, 18 eram do sexo feminino, a média de idade do estudo foi de 69,5 anos com desvio padrão de 7,2 anos. A média do diâmetro pupilar imediatamente antes do início da cirurgia foi 7,55 mm com desvio padrão de 0,56mm, a média do diâmetro pupilar imediatamente antes do uso do cloridrato de acetilcolina 1% (após implante da lente intraocular no saco capsular) foi 7,1mm com desvio padrão de 0,57mm. A média do diâmetro pupilar após 2 minutos da aplicação da acetilcolina na câmara anterior foi de 3,4 mm com desvio padrão de 0,66mm. O tempo médio de ação máxima do medicamento foi de 64 segundos, com desvio padrão de 8 segundos. A média da pressão intraocular no primeiro dia do pós-operatório foi de 19,1 mmHg com desvio padrão de 2,45mmHg. Conclusão: O estudo acima mostrou que a acetilcolina apresenta boa eficácia na obtenção de miose intraoperatória na cirurgia de facoemulsificação, permitindo uma maior facilidade na confecções das suturas corneanas ou corneo-escleral, reduzindo a incidência de sinéquias anteriores periféricas. Concluimos que o cloridrato de acetilcolina 1% é um importante medicamento na obtenção da miose intraoperatória na cirurgia de catarata.

Abstract Objective: To test the efficacy of Acetylcholine chloride use in obtaining intraoperative miosis on phacoemulsification cataract surgery. Methods: Patients with cataract diagnosis and elected for surgical phacoemulsification procedure were selected. All patients underwent conventional phacoemulsification procedure performed by a single surgeon and all patients had 0.2 ml of Acetylcholine chloride 1% irrigated in the anterior chamber at the end of the surgery. The pupillary diameter was measured immediately before the beginning of surgery, immediately before and two minutes after the use of acetylcholine chloride 1%. Results: A total of 30 eyes from 30 patients were included in the study. 18 were female, and mean age was of 69.5 years with a 7.2y standard deviation on the population study. The mean pupillary diameter immediately before the beginning of surgery was 7.5 mm with a standard deviation of 0.56 mm; the mean pupillary diameter immediately before the acetylcholine chloride 1% use (after the intraocular lens im-plantation) was 7.1 mm with a standard deviation of 0.57 mm. The mean pupillary diameter two minutes after the use of acetylcholine chloride 1% in the anterior chamber was 3.4 mm with standard deviation of 0.66 mm. The mean maximum action time of ACH chloride 1% was 64 seconds, with a standard deviation of 8 seconds. The mean intraocular pressure on the first postoperative day was 19.1 mmHg with a standard deviation of 2.45 mmHg. Conclusion: We conclude that acetylcholine chloride 1% is an important drug to obtaining intraoperative miosis in cataract surgery.

Resumo O Lúpus Eritematoso sistêmico (LES) é uma doença autoimune que pode afetar o olho de diversas formas. A coroidopatia lúpica é rara e apresenta-se com descolamento seroso de retina, descolamento do epitélio pigmentar da retina (EPR) e epiteliopatia pigmentar. A maioria dos casos está associada à atividade sistêmica da doença, podendo ser considerada um fator de gravidade e necessidade de imunossupressão intensa. Geralmente apresenta bom prognóstico visual com o tratamento adequado do LES, apesar de alguns casos evoluírem com danos irreversíveis na retina externa e EPR. Descrevemos um caso de coroidopatia secundaria ao LES com atividade multisistêmica com boa evolução após tratamento clínico com imunossupressão sistêmica.

Abstract Systemic lupus erythematosus (SLE) is an autoimmune disease in which can affect the eye in different ways. Lupus choroidopathy is rare and include retinal pigment epithelium (RPE) detachment and/or serous retinal detachment and pigment epitheliopathy. Most cases are associated with systemic disease activity and can be considered a factor of gravity and need for intense immunosuppression. Usually has good visual prognosis with proper treatment of SLE, although some cases may have irreversible damage to the outer retina and RPE. We describe a case of choroidopathy secondary to SLE during its multisystem activity with good clinical outcome after treatment with systemic immunosuppression.

RESUMO Objetivo: Ceratites bacterianas ocorrem mundialmente e apesar dos novos desenvolvimentos permanece como uma condição que pode levar à cegueira. Avaliar a presença de herpes simples (-1 e -2) e vírus varicella zoster (VZV) por reação em cadeia quantitativa de polimerase em tempo real (qPCR) em raspados corneanos de pacientes com ceratite bacteriana. Métodos: Sessenta e cinco pacientes com ceratite infecciosa foram submetidos a raspados corneanos estudados para gram, Giemsa, cultura e qPCR (grupo de estudo). Foram avaliados fatores de risco e epidemiológicos. O grupo controle foi composto por 25 casos de úlcera dendrítica típica por herpes analisados por qPCR. Resultados: Do grupo de estudo (n=65), nove pacientes (13,8%) apresentaram cultura, qPCR e raspado negativos. Cinquenta e seis (86,2%) pacientes apresentaram cultura positiva, 51 para bacteria, 4 para fungo e 1 para ameba. A qPCR identificou 10 pacientes do grupo de cultura positiva para bactéria que também foram positivos para vírus, um VZV e 9 para HSV-1. Dos 25 pacientes que compunham o grupo controle, 21 apresentaram qPCR positivo para HSV-1. Conclusão: Herpes pode estar presente em pacientes com úlceras de córnea bacterianas e a qPCR pode ser útil na sua detecção.

ABSTRACT Objective: Bacterial keratitis occurs worldwide, and despite recent developments, it remains a potentially blinding condition. This study assesses the presence of herpes simplex virus (HSV-1 and -2) and varicella zoster virus (VZV) by quantitative real-time polymerase chain reaction (qPCR) in corneal scrapings from patients with bacterial keratitis. Methods: A total of 65 patients with clinical diagnoses of infectious corneal ulcers prospectively underwent clinical eye examinations. Corneal scrapings were investigated by Gram staining, Giemsa staining, culture, and qPCR (the study group). Risk factors and epidemiological data were recorded. The control group comprising 25 eyes with typical herpes dendritic keratitis was also analyzed by qPCR. Results: From the study group (n=65), nine patients (13.8%) had negative smears, cultures, and qPCR findings. Fifty-six (86.2%) patients had positive cultures: 51 for bacteria, 4 for fungi, and 1 for amoebae. Of the patients who had positive bacterial cultures, qPCR identified 10 patients who were also positive for virus: one for VZV and nine for HSV-1. Of the 25 patients in the control group, 21 tested positive for HSV-1 by qPCR analysis. Conclusions: Herpes may be present in patients with bacterial corneal ulcers, and qPCR may be useful in its detection.

RESUMO Relatamos um caso de sarcoidose ocular com IgM e IgG positivos para toxoplasmose. Mulher jovem com quadro ocular bilateral de dor, vermelhidão, edema palpebral e panuveíte com periflebite. Os testes laboratoriais mostraram IgM e IgG positivos para toxoplasmose, teste tuberculínico anérgico. Realizou-se tratamento tópico da uveíte anterior e antibióticos orais para toxoplasmose, sem melhora. Tomografia de órbita mostrou aumento das glândulas lacrimais bilaterais e radiografia de tórax foi consistente com sarcoidose pulmonar, auxiliando no diagnóstico de sarcoidose ocular presumida. Iniciou-se prednisona e metotrexato orais, sem antibióticos, com melhora clínica e oftalmológica, sem recidivas em 1 ano de follow-up. Sarcoidose ocular é um importante diagnóstico diferencial que exige anamnese e exame oftalmológico cuidadosos. Exames complementares, como raio-X, tomografia computadorizada e avaliação clínica e laboratorial ajudam na avaliação e exclusão de outras causas. O tratamento consiste principalmente no uso de corticosteróide e imunossupressores.

ABSTRACT We report a case of ocular sarcoidosis with positive immunoglobulin (Ig) M and IgG serology for toxoplasmosis. The patient was a young female with red painful eyes, bilateral eyelid edema, and panuveitis with periphlebitis. In laboratory testing, she was IgM and IgG positive for toxoplasmosis and anergic in the tuberculin test. Topical treatment for anterior uveitis and oral antibiotics for toxoplasmosis were started, without improvement. Orbit tomography showed increased lacrimal glands bilaterally, and chest X-ray radiographic findings were consistent with pulmonary sarcoidosis, which supported the presumed ocular sarcoidosis diagnosis. The patient was treated with oral prednisone and methotrexate without antibiotics. She showed clinical and vision improvement without recurrences during the 1-year follow-up. Ocular sarcoidosis is an important differential diagnosis requiring careful anamnesis and ophthalmological examinations. Ancillary tests, such as X-ray radiography, tomography, and clinical and laboratory evaluations may help rule out other causes. Treatment mainly consists of corticosteroids and immunosuppression.

RESUMO O presente trabalho tem como objetivo avaliar o efeito de doses de AIB e de coletas sucessivas de microestacas na micropropagação de clones de Eucalyptus grandis x E. urophylla e Eucalyptus urophylla x E. globulus. Tufos contendo de seis a oito gemas dos clones in vitro, foram transferidos para frascos de vidro -250 mL, em meio semissólido JADS, sendo feitas coletas a cada 20 dias para o clone Eucalyptus grandis x E. urophylla e a cada 30 dias para o Eucalyptus urophylla x E. globulus. Nas condições in vitro, foram avaliados: número de brotos > 0,5 cm, número de microestacas > 2 cm, comprimento da maior microestaca e vigor dos brotos. Nas condições ex vitro, na casa de vegetação e casa de sombra, foram avaliados: altura da muda, sobrevivência, diâmetro do colo, porcentagem de emissão de raiz na extremidade inferior do tubete, vigor das mudas. Em pleno sol (ex vitro), foram avaliados: altura da muda, sobrevivência, diâmetro do colo, número de raízes, volume de raiz, vigor das mudas, e matéria seca da parte aérea e da raiz. Observou-se boa produtividade de microestacas in vitro no decorrer das coletas, sendo ajustados níveis de AIB para cada clone, variando de 0,25 a 0,50 mg L-1 para o clone Eucalyptus grandis x E. urophylla e de 0,75 a 1,0 mg L-1 para o clone Eucalyptus urophylla x E. globulus. Nas condições ex vitro, a dosagem de AIB apresentou efeito residual, proporcionando bom enraizamento e sobrevivência, entre 0,25 a 0,50 mg L-1 de AIB para o clone Eucalyptus grandis x E. urophylla e 0,50 a 1,0 mg L-1 para o clone Eucalyptus urophylla x E. globulus.

ABSTRACT This study aims to evaluate the effect of IBA concentrations and microcuttings successive collections in the micropropagation of Eucalyptus grandis x E. urophylla and Eucalyptus urophylla x E. globulus clones. Clumps containing six to eight buds of clones established in vitro were transferred to a 250 mL glass flask in JADS semisolid medium. Successive collections were performed every 20 days for Eucalyptus grandis x E. urophylla clone and every 30 days for Eucalyptus urophylla x E. globulus clone. The following variables were evaluated under in vitro conditions: number of shoots > 0.5 cm, number of microcuttings > 2 cm, length of the longest microcutting, and shoots vigor. Under ex vitro conditions, in the greenhouse and shade house, the following variables were evaluated: seedling height, percentage of survival, stem diameter, percentage of root observed at the lower end of the tube, and seedling vigor. In full sun (ex vitro), the following variables were analyzed: seedling height, stem diameter, survival, number of roots, root volume, seedling vigor, and shoot and root dry matter. Good in vitro microcuttings productivity was observed over the successive collections. IBA levels were adjusted for each clone, ranging from 0.25 to 0.50 mg L-1 for Eucalyptus grandis x E. urophylla clone, and from 0.75 to 1.0 mg L-1 for Eucalyptus urophylla x E. globulus clone. IBA concentrations led to residual effects under ex vitro conditions, providing good rooting and survival for Eucalyptus grandis x E. urophylla and Eucalyptus urophylla x E. globulus clones at IBA concentrations between 0.25 and 0.50 mg L-1 and between 0.50 and 1.0 mg L-1, respectively.

RESUMO Síndrome DRESS (drug reaction with eosinophilia and systemic symptoms) é uma reação adversa a medicamentos rara e potencialmente fatal, associada à rash cutâneo, febre, eosinofilia e lesão de múltiplos órgãos. Algumas drogas podem desencadeá-la, como: alopurinol, anticonvulsivantes, vancomicina, sulfametoxazol-trimetoprim, sulfadiazina-pirimetamina, entre outras. Descrevemos dois casos que desenvolverem DRESS síndrome durante tratamento ocular. O primeiro caso apresentou os sintomas durante tratamento para endoftalmite pós-operatória tardia com antibióticos tópicos, cefalotina e meropenem intravenosos e injeção intravítrea de vancomicina e ceftazidima; não podemos identificar a droga causadora, pois múltiplas medicações foram utilizadas. O segundo caso desenvolveu os sintomas durante tratamento clássico para toxoplasmose ocular, então a associação com sulfadiazina-pirimetamina foi mais clara. Como muitos oftalmologistas prescrevem regularmente drogas que podem desencadear a síndrome DRESS, esse diagnóstico deve ser lembrado já que pode levar a sérias complicações.

ABSTRACT Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and potentially fatal adverse drug reaction associated with skin rash, fever, eosinophilia, and multiple organ injury. A number of pharmacological agents are known to cause DRESS syndrome such as allopurinol, anticonvulsants, vancomycin, trimethoprime-sulfamethoxazole, and pyrimethamine-sulfadiazine. Here, we describe two patients who developed DRESS syndrome during ocular treatment. The first case was being treated for late postoperative endophthalmitis with topical antibiotics, intravenous cephalothin, meropenem, and intravitreal injection of vancomycin and ceftazidime before symptoms developed. We were unable to identify the causal drug owing to the large number of medications concurrently administered. The second case presented with DRESS syndrome symptoms during ocular toxoplasmosis treatment. In this case, a clearer association with pyrimethamine-sulfadiazine was observed. As a result of the regular prescription of pharmacological agents associated with DRESS syndrome, ophthalmologists should be aware of the potentially serious complications of DRESS syndrome.

RESUMO Objetivo: Analisar o uso do PCR em tempo real (qPCR) na detecção do DNA do T. gondii no sangue periférico e no humor aquoso de pacientes com lesões de retinocoroidite focal, ativa por toxoplasmose. Métodos: Cinquenta e cinco pacientes com uveite infecciosa foram incluídos neste estudo. Os pacientes foram atendidos entre 2009 a 2013, no Departamento de Oftalmologia e Ciências Visuais da Universidade Federal de São Paulo. Quarenta e três pacientes tiveram o diagnóstico de lesões de retinocoroidite focal, ativa por toxoplasmose e, os outros 12 tiveram o diagnóstico de uveíte infecciosa não toxoplásmica e, por isso foram usados como grupo controle. A técnica de qPCR foi utilizada na detecção de DNA do T. gondii em amostras de sangue periférico e humor aquoso. Resultados: O qPCR foi positivo para o DNA do T. gondii em 37,21% (16/43) das amostras de humor aquoso, 2,33% (1/43) nas amostras de sangue periférico e, 16,27% (7/43) em ambas amostras simultaneamente. Conclusão: O qPCR foi capaz de detectar o DNA do T. gondii em pacientes com lesões de retinocoroidite focal, ativa por Toxoplasmose, no sangue bem como, no humor aquoso, podendo ajudar no diagnostico.

ABSTRACT Purpose: To evaluate the ability of real-time quantitative PCR (qPCR) for detectingToxoplasma gondii DNA in the peripheral blood and aqueous humor of patients with toxoplasmic active focal necrotizing retinochoroiditis. Methods: Fifty-five patients with infectious uveitis seen from 2009 to 2013 at the Department of Ophthalmology and Visual Sciences of the Federal University of São Paulo were enrolled in this study. Forty-three patients had toxoplasmic active focal necrotizing retinochoroiditis, and the remaining 12 had non-toxoplasmic infectious uveitis and served as controls. qPCR analysis forT. gondii DNA was performed on the patients' peripheral blood and aqueous humor samples. Results: The qPCR was positive for T. gondii DNA in 37.21% (16/43) of the aqueous humor samples and 2.33% (1/43) of the peripheral blood samples; further, 16.27% (7/43) of the patients had positive results in both their blood and aqueous humor samples. Conclusion: qPCR was able to detect T. gondii DNA in patients with toxoplasmic active focal necrotizing retinochoroiditis in the blood as well as the aqueous humor and can help with the diagnosis of the disease.

RESUMOApresentamos os casos de três meninas (duas de seis anos e uma de onze anos), com uveíte bilateral e suspeita de catarata em ambos os olhos e doença de Vogt-Koyanagi-Harada (VKH) em dois casos. No terceiro caso, oftalmia simpática e suspeita de catarata em um olho e trauma com ceratoplastia penetrante no outro olho. Após controle da inflamação, indicou-se facoemulsificação sem LIO. No per-operatório, após retirada da membrana epicristaliniana, a transparência do cristalino foi percebida, não sendo realizada a facoemulsificação. No período de acompanhamento as pacientes não desenvolveram catarata e a acuidade visual variou de 20/30 a 20/100. O exame de fundoscopia reforçou o diagnóstico de VKH e oftalmia simpática. Portanto, é muito importante que o oftalmologista esteja sempre atento quando se deparar com um caso de uveíte com suspeita de catarata, porque, por trás da membrana epicristaliniana pode existir um cristalino transparente, o que leva a uma conduta terapêutica menos agressiva.

ABSTRACTHere we present the cases of three female children, of whom two were aged 6 years and one was aged 11 years. Two of the three children had bilateral uveitis and suspected cataract and Vogt-Koyanagi-Harada (VKH) disease. The third one had uveitis and suspected cataract in one eye and sympathetic ophthalmia (SO), and had undergone penetrating keratoplasty in the fellow eye following a trauma. After controlling the inflammation, we planned to perform phacoemulsification without intraocular lens implantation. However, intraoperatively, after removing the epilens membranes, the lenses appeared clear, and therefore phacoemulsification was not performed. During follow-up, the patients did not develop cataract, and visual acuity levels ranged from 20/30 to 20/100. Fundoscopy revealed VKH disease and SO. Ophthalmologists should not always assume that patients with uveitis have cataract; a transparent lens may exist behind the epilens membrane, allowing a less aggressive therapeutic approach.

RESUMO Objetivos: Avaliar o implante intravítreo de liberação lenta de dexametasona 0,7 mg no tratamento do edema macular cistóide (EMC) secundário à uveíte intermediária refratária a corticosteroides orais. Métodos: Estudo retrospectivo da acuidade visual melhor corrigida, inflamação intraocular, pressão intraocular (PIO), retinografia, tomografia de coerência óptica (OCT), inflamação e reações adversas de cinco pacientes (mulheres, idade média 35 anos) com o edema macular cistóide tratado com implante de dexametasona. Pacientes foram avaliados em 7 consultas até o 150o dia pós implante. Rsultados: Quatro pacientes apresentaram parsplanite bilateral e um, uveíte intermediária bilateral associada à artrite idiopática juvenil. Seis implantes foram inseridos sob anestesia tópica. O tempo médio de acompanhamento foi de 5 meses. A acuidade visual melhorou em todos os olhos. A tomografia de coerência óptica mostrou afinamento da mácula em todos os olhos e houve correlação entre a acuidade visual e a retina mais fina. Não ocorreu evento adverso grave. Não ocorreu aumento significativo na pressão intraocular. Conclusão: O implante intravítreo é eficaz no tratamento do edema macular cistóide secundário a uveíte intermediária refratária a esteróides sistêmicos.

ABSTRACT Purpose: To evaluate the use of a slow-release dexamethasone 0.7-mg intravitreal implant for cystoid macular edema (CME) secondary to intermediate uveitis and refractory to systemic steroids. Methods: A retrospective study of the best-corrected visual acuity (BCVA), intraocular inflammation, intraocular pressure (IOP), fundus photography, optical coherence tomography (OCT), inflammation, and adverse reactions of five patients (women, mean age of 35 years) with cystoid macular edema treated with a dexamethasone implant. Patients were evaluated in seven visits until the 150th day after the implant. Results: Four patients had bilateral pars planitis and one had bilateral intermediate uveitis associated with juvenile idiopathic arthritis. Six dexamethasone devices were implanted, under topical anesthesia (one each in six eyes, five patients). The mean follow-up time was 5 months. The best-corrected visual acuity improved in all eyes that received an implant, with five having improvements of two or more lines. Optical coherence tomography showed thinning of the macula in all eyes treated, and we saw a correlation between the best-corrected visual acuity and retinal thinning. No serious adverse events occurred and no significant increase in intraocular pressure was observed. Conclusions: Slow-release dexamethasone intravitreal implants can effectively treat CME secondary to intermediate uveitis and refractory to systemic steroids.

RESUMO Elucidar os efeitos adversos do uso de medicações imunossupressoras em pacientes com uveíte não diagnosticada por sífilis. Avaliação de quatro pacientes com uveíte por sífilis submetidos a tratamento com drogas imunossupressoras por suspeita de uveíte secundária a doenças reumáticas, que desenvolveram perda visual permanente. Sífilis deve ser sempre um diagnóstico diferencial nas doenças inflamatórias oculares, principalmente antes do início de terapia imunossupressora.

ABSTRACT Permanent visual loss can be caused by improper use of immunosuppressive therapy in cases of uveitis without differential diagnosis of syphilitic uveitis. We present four cases of syphilitic uveitis that were incorrectly diagnosed as being secondary to rheumatic diseases and were subsequently treated with immunosuppressive therapy, leading to permanent visual loss. These cases highlight the importance of ruling out syphilis in the differential diagnosis of inflammatory ocular diseases before starting use of immunosuppressive therapy.

Relatar a ocorrência de pontos amarelo-esbranquiçados perivasculares pré-retinianos em 12 pacientes com sífilis ocular. Série de casos de 12 pacientes examinados entre março e outubro de 2012 no setor de uveítes da UNIFESP. Após confirmação diagnóstica de sífilis ocular, retinografias e OCT (optical coherence tomography) foram realizados para verificar a localização dos pontos e os pacientes foram tratados com penicilina cristalina IV por 14 dias. Dados demográficos incluíram 11 homens (91,6%), 19 olhos, mediana de idade de 38,1 anos, e a manifestação clínica principal foi panuveíte (7 pacientes, 58,3%), sendo bilateral em 4. Dez fizeram uso de prednisona oral (83,3%). VDRL (Venereal Disease Research Laboratory) sanguíneo foi positivo em 8 pacientes (66.7%), VDRL no líquor foi negativo em 7 de 9 coletados (77,8%), FTA-Abs sanguíneo foi positivo em 100% e 8 pacientes (66,7%) eram HIV positivos, AV após tratamento melhorou em 10 olhos (55,6%), não se alterou em 7 (38,9%) e piorou em 1 olho (5,6%). Embora ainda não reconhecida na literatura como uma manifestação típica da sífilis ocular, este achado é muito comum na prática clínica. Acreditamos que esses pontos são devidos a perivasculite secundária à infecção pelo treponema. É importante os reconhecer e lembrar que a sífilis pode se apresentar de várias formas, incluindo essa apresentada aqui.

Here we report the occurrence of pale yellowish perivascular preretinal dots in 12 patients with ocular syphilis. A case series of these patients was examined between March and October 2012 at the Uveitis Sector of Universidade Federal de São Paulo. After diagnostic confirmation of syphilis, fundus photographs and optical coherence tomography (OCT) were performed to verify the localization of the dots, and patients were treated with IV crystalline penicillin for 14 days. The study comprised 11 men (91.6%), 19 eyes, median presentation age of 38.1 years, and panuveitis as the main clinical manifestation (seven patients, 58.3%), being bilateral in four. Ten patients were taking oral prednisone (83.3%). Serum panels performed by the Venereal Disease Research Laboratory (VDRL) showed positive results in eight patients (66.7%), whereas VDRL cerebrospinal fluid (CSF) tests were negative in seven of nine collected (77.8%). However, serum FTA-Abs was positive in 100% of patients, and eight patients (66.7%) had HIV infection. The best corrected visual acuity (BCVA) presented after treatment improved in 10 eyes (55.6%), did not change in seven eyes (38.9%), and worsened in one eye (5.6%). Although not yet acknowledged in the literature as a typical manifestation of ocular syphilis, these are very common findings in clinical practice. We believe that preretinal dots are due to perivasculitis secondary to treponema infection. It is important recognize them and remember that syphilis can present in several forms, including the one presented in this study.