O Tracoma no Município de Botucatu - Estado de São Paulo: medidas de Detecção, Educação em Saúde, Prevenção e Tratamento

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Periocular basal cell carcinoma: cost of topical immunotherapy versus estimated cost of surgical treatment

Purpose: The objective of this study was to compare the estimated cost of clinical and surgical treatment for basl cell carcinoma of the eyelid. Methods: This was a pilot study of 12 patients with basal cell carcinoma receiving treatment with 5% imiquimod cream at the ocular plastic surgery center, medical school University of Sao Paulo (HC-FMUSP, Brazil). The cost of clinical treatment was estimated based on the time of treatment and amount of medication consumed by patients in the home setting. The cost of surgical treatment was estimated by ophthalmologists with experience in reconstructive plastic surgery based on analysis of images of the same patients. Surgeons responded to a questionnaire with four questions about surgical technique, surgical materials required, estimated duration of surgery and type of anesthesia. Results: Immunotherapy lasted from 8 to 12 weeks. All patients reported each cold-stored sachet with 5% imiquimod cream lasted 3 days. According to the institution, a box with 12 sachets costs BRL 480.00. Patients required 1.58-3.11 boxes for complete treatment, corresponding to a total cost of BRL 758.40-1,492.80. Based on image analysis, surgeons evaluated surgery would require 1-3 hours. The estimated cost of surgery room and staff was BRL 263.00, to which the cost of supplies was added. Thus, the total cost of surgical treatment was BRL 272.61-864.82. On the average, immunotherapy was 57,64% more costly than surgical treatment. Conclusions: Malignant eyelid tumors are a common finding in clinical ophthalmology. Surgery is still the treatment of choice at our institution, but immunotherapy with 5% imiquimod cream may be indicated for patients with multiple lesions or high surgical risk and for patients declining surgery for reasons of fear or esthetic concerns. The ability to estimate costs related to the treatment of malignant eyelid tumors is an important aid in the financial planning of health care institutions. Further studies should evaluate the possibility of institutions equating the cost of immunotherapy and surgical treatment by acquiring similar but less expensive medications.

Photodynamic therapy in periocular basal cell carcinoma: Case report

The authors report the use of photodynamic therapy with methyl aminolevulinate (Metvix (R)) in a patient with nodular and infiltrative basal cell carcinoma in the right lower eyelid. Side effects on the eye were evaluated weekly. After 12 weeks of treatment, to confirm cure the patient was submitted to a 2-mm punch biopsy, the anatomopathological findings of which were negative for neoplasia. Photodynamic therapy with methyl aminolevulinate was shown to be an attractive alternative to surgical excision(-)the current gold standard treatment worldwide.

Ambient levels of air pollution induce clinical worsening of blepharitis

Background: Even though air pollutants exposure is associated with changes in the ocular surface and tear film, its relationship to the clinical course of blepharitis, a common eyelid disease, had not yet been investigated. Our objective was to investigate the correlation between air pollution and acute manifestations of blepharitis. Method: We recorded all cases of changes in the eyelids and ocular surface, and rated clinical findings on a scale from zero (normal) to two (severe alterations). Daily values of carbon monoxide, particulate matter smaller than 10 mu m in diameter and nitrogen dioxide concentrations and meteorological variables (temperature and relative humidity) in the vicinity of the medical service were obtained. Specific linear regression models for each outcome were constructed including pollutants as independent variables (single pollutant models). Temperature and humidity were included as confounding variables. Results: increases of 28.8 mu g/m(3) in the concentration of particulate matter and 1.1 ppm in the concentration of CO were associated with increases in cases of blepharitis on the day of exposure (5 cases, 95% CI: 1-10 and 6 cases, 95% CI: 1-12, respectively). Conclusion: Exposure to usual air pollutants concentrations present in large cities affects, in a consistent manner, the eyes of residents contributing to the increasing incidence of diseases of the eyelid margin. (C) 2011 Elsevier Inc. All rights reserved.

Correction of Severe Ptosis with a Silicone Implant Suspensor: 22 Years of Experience

Background: Patients with severe ptosis caused by poor or absent function of the levator muscle but with good frontalis muscle excursion usually benefit from a frontalis sling procedure. This is currently carried out using organic or inorganic material to connect the upper eyelid to the frontalis muscle. Methods: The aim of this study was to evaluate retrospectively 112 patients who underwent frontalis sling procedures between 1989 and 2011 using a preformed silicone implant suspensor to correct severe ptosis. Results: The results obtained using this technique were good or fair in 95.54 percent of the cases and poor in 4.46 percent of the cases. The authors discuss the results of the study and the cases in which the procedure should be indicated and highlight the advantages of the method. Conclusion: The availability of this low-cost sterile device, together with the fact that it is ready to use, requires less invasive surgery, saves time, and is sufficiently versatile to allow adjustments to be made at any time, makes the silicone eyelid sling an attractive choice for correcting ptosis. (Plast. Reconstr. Surg. 129: 453e, 2012.)

Endophthalmitis: A Rare but Devastating Metastatic Bacterial Complication of Hemodialysis Catheter-Related Sepsis

There are many infectious complications related to vascular access in patients undergoing maintenance hemodialysis. We report two cases of endophthalmitis as a metastatic infection associated with a tunneled catheter and a temporary dual lumen catheter. Both patients were diabetic. A 61-year-old female on maintenance hemodialysis by a jugular tunnelized catheter during the past year was receiving parenteral antibiotics for catheter salvage due to fever episodes in the last 3 months. She was admitted to the hospital presenting pain, proptosis, conjunctival hyperemia, corneal infiltrate, and visual acuity of no light perception (NLP). A 51-year-old male recently undergoing hemodialysis by a temporary dual lumen catheter presented fever. His catheter was removed, but he was admitted to the hospital presenting fever, decreased vision, edema, and pain in his left eye. On examination, eyelid edema, conjunctival hyperemia, purulent secretion, hypopyon in the pupils, and visual acuity of NLP were verified. A diagnosis of endogenous endophthalmitis was made in both patients on clinical grounds and computed tomography. Evisceration of the left eye was the first option of treatment for both patients due to poor vision. Cultures of the eviscerated ocular globes showed Staphylococcus hemolyticus and Staphylococcus aureus, respectively. After evisceration, both patients received treatment, had a good outcome, and were discharged to continue their hemodialysis program. Metastatic bacterial endophthalmitis is a rare complication of dialysis catheter-related bacteremia. When suspected, urgent ophthalmologic evaluation and treatment are needed to reduce the risk of losing vision in the affected eye.

Combined pre- and subtemporal transtentorial approach for epidermoid cysts of the cerebellopontine angle

Objective Epidermoid cysts of the cerebellopontine angle (CPA) can be a surgical challenge for the pediatric neurosurgeon. Ideally, total removal must be achieved; however, occasional adhesions of these tumors to vital neurovascular structures and extension far beyond the midline may preclude their total removal. The aims of this article are to present an alternative surgical approach to these lesions and to provide the rationale for this technique. Material and methods A 16-year-old boy was admitted to our pediatric neurosurgery department with a 1-year history of nonspecific headaches. His neurological examination showed right-sided dysmetria and gait ataxia. Magnetic resonance scans showed a space-occupying lesion on the right CPA with low intensity on T-1-weighted images and high intensity on T-2-weighted images. Results Craniotomy for tumor excision via pre- and subtemporal transtentorial approach was performed disclosing a 3.5 x 3 x 2.8-cm(3) well-encapsulated tumor, which was confirmed to be an epidermoid cyst. The postoperative course was uneventful. Conclusions A combined pre- and subtemporal approach utilizes a wide opening of the tentorium and the option of supratentorial retraction of the cerebellum to provide an excellent angle of approach to CPA lesions involving the anterolateral aspect of the brain stem in children.

Ocular manifestations of Noonan syndrome

Purpose: To describe the ophthalmological characteristics in a group of Noonan syndrome patients with proven mutations in the PTPN11 gene. Methods: Thirty-five Noonan syndrome patients with PTPN11 gene mutations underwent ophthalmological exams, which consisted of external inspection, slit-lamp biomicroscopy examination and an ophthalmoscopic examination after instillation of 1.0% tropicamide or 1.0% cyclopentolate. Results: All 35 patients had at least one abnormality upon ophthalmological examination. The eyelid and external eye abnormalities were the prevailing features, followed by prominent corneal nerves on slit-lamp exam. Fundus changes were detected in 8% of the subjects, mainly associated with high myopia. No statistically significant differences were observed among the patients presenting specific mutations in the PTPN11 gene. Conclusions: The current study further supports the finding that ocular symptoms account for a large fraction of the clinical manifestations of NS. Additional characteristics are described here. The roles for the various mutations of PTPN11 in ocular development are yet to be established.

The last mangroves of Marajo Island - Eastern Amazon: Impact of climate and/or relative sea-level changes

The dynamics, over the last 7500 years, of a mangrove at Marajo Island in northern Brazil were studied by pollen and sedimentary facies analyses using sediment cores. This island, located at the mouth of the Amazon River. is influenced by riverine inflow combined with tidal fluctuations of the equatorial Atlantic Ocean. Herbaceous vegetation intermingled with rainforest dominates the central area of the island, while varzea is the main vegetation type along the littoral. In particular, the modem northeastern coastal zone is covered by a mosaic of dense rainforest, herbaceous vegetation, mangroves, varzea, and restinga. The integration of pollen data and fades descriptions indicates a tidal mud flat colonized by mangroves in the interior of Marajo Island between similar to 7500 cal yr BP and similar to 3200 cal yr BP. During the late Holocene, mangroves retracted to a small area (100-700 m in width) along the northeastern coastal plain. Mangrove expansion during the early and mid Holocene was likely caused by the post-glacial sea-level rise which, combined with tectonic subsidence, led to a rise in tidal water salinity. Salinity must have further increased due to low river discharge resulting from increased aridity during the early and mid Holocene. The shrinking of the area covered by mangrove vegetation during the late Holocene was likely caused by the increase in river discharge during the late Holocene, which has maintained relatively low tidal water salinity in Marajo Island. Tidal water salinity is relatively higher in the northeastern part of the island than in others, due to the southeast-northwest trending current along the littoral. The mixing of marine and riverine freshwater inflows has provided a refuge for mangroves in this area. The increase in flow energy during the last century is related to landward sand migration, which explains the current retraction of mangroves. These changes may indicate an increased exposure to tidal influence driven by the relative sea-level rise, either associated with global fluctuations or tectonic subsidence, and/or by an increase in river water discharge. (C) 2012 Elsevier B.V. All rights reserved.

Surgical treatment of globe subluxation in the active phase of the myogenic type of Graves orbitopathy: case reports

The purpose of the present article is to present and discuss two cases of globe subluxation in the active phase of myogenic Graves' orbitopathy and to evaluate the prevalence of this phenomenon. Two patients with the myogenic variant of Graves' orbitopathy that had being treated with oral and intravenous steroid pulses developed globe subluxation. Both had to have urgent eyelid and orbital decompression. After these observations, we reviewed the medical records of a sample of 284 patients (482 orbits) who had had orbital decompression at our Institution from 1992 to 2010, with a search for cases presenting severe proptosis or globe subluxation in the active phase of myogenic Graves' orbitopathy. No patient had to have decompression for globe subluxation in the active phase of Graves' orbitopathy. The prevalence of this event as an indication for surgery in the myogenic variant of Graves' orbitopathy was therefore 0.7% (2/284) or even less. The combination of lowering the upper eyelid and orbital decompression had a dramatic therapeutic effect on these patients despite the presence of intense inflammatory signs in the orbits. In conclusion, patients affected with the myogenic variant of Graves' orbitopathy may develop globe subluxation. Urgent surgical treatments should not be postponed despite the presence of active inflammation.

Influence of miniscrew dental root proximity on its degree of late stability

Purpose of this study was to evaluate the influence of miniscrew dental root proximity on its late stability degree. 40 miniscrews were inserted between maxillary second premolars and first molars for anterior retraction. Post-surgical radiographs were used to measure the septum width in the insertion site, insertion height, distal and mesial distance from miniscrew to dental root, and the smallest distance between miniscrew and dental root. The miniscrews were divided in two groups according to septum width: ?3 mm (20 miniscrews) and >3 mm (20 miniscrews). The soft tissue in the insertion site, sensitivity during load, plaque around the miniscrew, and evaluation period were also considered. The results showed no significant difference in miniscrew mobility degree and success rate between groups. Miniscrew dental root proximity did not influence the stability and success rate when the distance between the miniscrew and dental root indicated no periodontal ligament invasion. The overall success rate was 90% and no variable was associated with miniscrew failure. Nevertheless, patient sensitivity was frequently associated with some degree of mini-implant mobility. The septum width did not influence the stability and success rate of this anchorage system, but the extreme root proximity did.

Terapia fotodinâmica em carcinoma basocelular periocular: relato de caso

Os autores descrevem a aplicação de terapia fotodinâmica com cloridrato de aminolevulinato de metila (Metivix®) em uma paciente com carcinoma basocelular padrão misto (nodular e infiltrativo) em pálpebra inferior de olho direito. Os efeitos colaterais sobre o olho foram avaliados semanalmente. Foi submetida à biòpsia incisional com punch de 2 mm para controle de cura após 12 semanas de tratamento. O anátomopatológico revelou ausência de neoplasia. O tratamento padrão ouro reconhecido mundialmente é a exérese da lesão, porém a terapia fotodinâmica com cloridrato de aminolevulinato de metila (MAL) surge como uma opção terapêutica à cirurgia.

Tricoadenoma palpebral: tratamento cirúrgico associado à blefaroplastia estética

O tricoadenoma é um tumor cutâneo benigno, assintomático, raro e de crescimento lento. Existem poucos casos relatados na literatura e identificamos apenas um descrito na região palpebral. Apresentamos o caso de uma paciente portadora de tricoadenoma no canto externo da pálpebra inferior direita, tratada com excisão cirúrgica associada a blefaroplastia.

The evolutionary implications of hemipenial morphology of rattlesnake Crotalus durissus terrificus (Laurent, 1768) (Serpentes: Viperidae: Crotalinae)

Most amniotes vertebrates have an intromittent organ to deliver semen. The reptile Sphenodon and most birds lost the ancestral penis and developed a cloaca-cloaca mating. Known as hemipenises, the copulatory organ of Squamata shows unique features between the amniotes intromittent organ. They are the only paired intromittent organs across amniotes and are fully inverted and encapsulated in the tail when not in use. The histology and ultrastructure of the hemipenes of Crotalus durissus rattlesnake is described as the evolutionary implications of the main features discussed. The organization of hemipenis of Crotalus durissus terrificus in two concentric corpora cavernosa is similar to other Squamata but differ markedly from the organization of the penis found in crocodilians, testudinata, birds and mammals. Based on the available data, the penis of the ancestral amniotes was made of connective tissue and the incorporation of smooth muscle in the framework of the sinusoids occurred independently in mammals and Crotalus durissus. The propulsor action of the muscle retractor penis basalis was confirmed and therefore the named should be changed to musculus hemipenis propulsor.The retractor penis magnus found in Squamata has no homology to the retractor penis of mammals, although both are responsible for the retraction of the copulatory organ

Structuring of polymer surface by evaporation of sessile microdrops

In this thesis, we investigated the evaporation of sessile microdroplets on different solid substrates. Three major aspects were studied: the influence of surface hydrophilicity and heterogeneity on the evaporation dynamics for an insoluble solid substrate, the influence of external process parameters and intrinsic material properties on microstructuring of soluble polymer substrates and the influence of an increased area to volume ratio in a microfluidic capillary, when evaporation is hindered. In the first part, the evaporation dynamics of pure sessile water drops on smooth self-assembled monolayers (SAMs) of thiols or disulfides on gold on mica was studied. With increasing surface hydrophilicity the drop stayed pinned longer. Thus, the total evaporation time of a given initial drop volume was shorter, since the drop surface, through which the evaporation occurs, stays longer large. Usually, for a single drop the volume decreased linearly with t1.5, t being the evaporation time, for a diffusion-controlled evaporation process. However, when we measured the total evaporation time, ttot, for multiple droplets with different initial volumes, V0, we found a scaling of the form V0 = attotb. The more hydrophilic the substrate was, the more showed the scaling exponent a tendency to an increased value up to 1.6. This can be attributed to an increasing evaporation rate through a thin water layer in the vicinity of the drop. Under the assumption of a constant temperature at the substrate surface a cooling of the droplet and thus a decreased evaporation rate could be excluded as a reason for the different scaling exponent by simulations performed by F. Schönfeld at the IMM, Mainz. In contrast, for a hairy surface, made of dialkyldisulfide SAMs with different chain lengths and a 1:1 mixture of hydrophilic and hydrophobic end groups (hydroxy versus methyl group), the scaling exponent was found to be ~ 1.4. It increased to ~ 1.5 with increasing hydrophilicity. A reason for this observation can only be speculated: in the case of longer hydrophobic alkyl chains the formation of an air layer between substrate and surface might be favorable. Thus, the heat transport to the substrate might be reduced, leading to a stronger cooling and thus decreased evaporation rate. In the second part, the microstructuring of polystyrene surfaces by drops of toluene, a good solvent, was investigated. For this a novel deposition technique was developed, with which the drop can be deposited with a syringe. The polymer substrate is lying on a motorized table, which picks up the pendant drop by an upward motion until a liquid bridge is formed. A consecutive downward motion of the table after a variable delay, i.e. the contact time between drop and polymer, leads to the deposition of the droplet, which can evaporate. The resulting microstructure is investigated in dependence of the processes parameters, i.e. the approach and the retraction speed of the substrate and the delay between them, and in dependence of the intrinsic material properties, i.e. the molar mass and the type of the polymer/solvent system. The principal equivalence with the microstructuring by the ink-jet technique was demonstrated. For a high approach and retraction speed of 9 mm/s and no delay between them, a concave microtopology was observed. In agreement with the literature, this can be explained by a flow of solvent and the dissolved polymer to the rim of the pinned droplet, where polymer is accumulated. This effect is analogue to the well-known formation of ring-like stains after the evaporation of coffee drops (coffee-stain effect). With decreasing retraction speed down to 10 µm/s the resulting surface topology changes from concave to convex. This can be explained with the increasing dissolution of polymer into the solvent drop prior to the evaporation. If the polymer concentration is high enough, gelation occurs instead of a flow to the rim and the shape of the convex droplet is received. With increasing delay time from below 0 ms to 1s the depth of the concave microwells decreases from 4.6 µm to 3.2 µm. However, a convex surface topology could not be obtained, since for longer delay times the polymer sticks to the tip of the syringe. Thus, by changing the delay time a fine-tuning of the concave structure is accomplished, while by changing the retraction speed a principal change of the microtopolgy can be achieved. We attribute this to an additional flow inside the liquid bridge, which enhanced polymer dissolution. Even if the pendant drop is evaporating about 30 µm above the polymer surface without any contact (non-contact mode), concave structures were observed. Rim heights as high as 33 µm could be generated for exposure times of 20 min. The concave structure exclusively lay above the flat polymer surface outside the structure even after drying. This shows that toluene is taken up permanently. The increasing rim height, rh, with increasing exposure time to the solvent vapor obeys a diffusion law of rh = rh0  tn, with n in the range of 0.46 ~ 0.65. This hints at a non-Fickian swelling process. A detailed analysis showed that the rim height of the concave structure is modulated, unlike for the drop deposition. This is due to the local stress relaxation, which was initiated by the increasing toluene concentration in the extruded polymer surface. By altering the intrinsic material parameters i.e. the polymer molar mass and the polymer/solvent combination, several types of microstructures could be formed. With increasing molar mass from 20.9 kDa to 1.44 MDa the resulting microstructure changed from convex, to a structure with a dimple in the center, to concave, to finally an irregular structure. This observation can be explained if one assumes that the microstructuring is dominated by two opposing effects, a decreasing solubility with increasing polymer molar mass, but an increasing surface tension gradient leading to instabilities of Marangoni-type. Thus, a polymer with a low molar mass close or below the entanglement limit is subject to a high dissolution rate, which leads to fast gelation compared to the evaporation rate. This way a coffee-rim like effect is eliminated early and a convex structure results. For high molar masses the low dissolution rate and the low polymer diffusion might lead to increased surface tension gradients and a typical local pile-up of polymer is found. For intermediate polymer masses around 200 kDa, the dissolution and evaporation rate are comparable and the typical concave microtopology is found. This interpretation was supported by a quantitative estimation of the diffusion coefficient and the evaporation rate. For a different polymer/solvent system, polyethylmethacrylate (PEMA)/ethylacetate (EA), exclusively concave structures were found. Following the statements above this can be interpreted with a lower dissolution rate. At low molar masses the concentration of PEMA in EA most likely never reaches the gelation point. Thus, a concave instead of a convex structure occurs. At the end of this section, the optically properties of such microstructures for a potential application as microlenses are studied with laser scanning confocal microscopy. In the third part, the droplet was confined into a glass microcapillary to avoid evaporation. Since here, due to an increased area to volume ratio, the surface properties of the liquid and the solid walls became important, the influence of the surface hydrophilicity of the wall on the interfacial tension between two immiscible liquid slugs was investigated. For this a novel method for measuring the interfacial tension between the two liquids within the capillary was developed. This technique was demonstrated by measuring the interfacial tensions between slugs of pure water and standard solvents. For toluene, n-hexane and chloroform 36.2, 50.9 and 34.2 mN/m were measured at 20°C, which is in a good agreement with data from the literature. For a slug of hexane in contact with a slug of pure water containing ethanol in a concentration range between 0 and 70 (v/v %), a difference of up to 6 mN/m was found, when compared to commercial ring tensiometry. This discrepancy is still under debate.