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Nadyr A Damasceno,1,2 Juliana Angélica Estevão Oliveira,2 Nicolas A Yannuzzi,3 Harry Flynn Jr,3 Mauricio Maia,2 Eduardo F Damasceno,4 Michel Eid Farah2 1HNMD, Hospital Naval Marcilio Dias, Department of Ophthalmology, Rio de Janeiro, RJ, Brazil; 2UNIFESP, Universidade Federal de São Paulo, Department of Ophthalmology, São Paulo, SP, Brazil; 3BPEI, Bascom Palmer Eye Institute, Department of Ophthalmology, Miami, FL, USA; 4UFF, School of Medicine, Universidade Federal Fluminense, Department of Ophthalmology, Niteroi, RJ, BrazilCorrespondence: Eduardo F Damasceno, School of Medicine, Universidade Federal Fluminense, Department of Ophthalmology, Marques Do Paraná 303, Niterói, RJ, 2550-030, Brazil, Email e_damasceno@yahoo.comPurpose: To assess ocular pain in patients undergoing multiple intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) who have previous factors that may influence pain sensitivity.Methodology: This is a prospective, observational, case series study involving patients who underwent multiple (≥ 3) pro re nata intravitreal injections of ranibizumab or aflibercept to treat any cause of chorioretinal vascular disease. Ocular pain was assessed by the numerical analog scale during intravitreal injection. For this study, the main variable was ocular pain and the secondary variables included age, sex, previous history of glaucoma, primary retinal vascular disease, severe dry eye history, trigeminal pain, scleral buckle surgery, collagen diseases, fibromyalgia, severe migraine history, pars plana vitrectomy, scleral thickness measurements, and type of anti-VEGF.Results: In a total of 894 patients, 948 eyes (4822 intravitreal injections), 793 patients (88.6%) had ocular pain sensitivity between no pain to mild pain, 80 patients (8.9%) had moderate ocular pain, 15 patients (1.6%) had severe ocular pain, and 6 patients (0.7%) had extremely severe ocular pain. Patients with severe dry eye (p = 0.01) and previous history of scleral buckle surgery (p = 0.01) showed a significant correlation with ocular pain during intravitreal injection. Pars plana scleral thickness (> 550 um) and diabetic neuropathy were associated with ocular pain but did not meet the criteria for statistical significance (p = 0.09 and p = 0.06, respectively).Conclusion: Dry eye and prior scleral buckle surgery may contribute to pain associated with intravitreal injection. These issues should be taken into consideration in patients undergoing multiple intravitreal injections.Keywords: Ocular pain, multiple intravitreal injections, anti-VEGF, special risk factors

Nadyr A Damasceno,1,2 Eduardo F Damasceno,1,3 Nicolas A Yannuzzi,1 Ashley M Crane,1 Nidhi Relhan,1 William E Smiddy,1 Harry W Flynn Jr1 1Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA; 2Department of Ophthalmology, Hospital Naval Marcilio Dias, Rio de Janeiro, RJ, Brazil; 3Department of Ophthalmology, Universidade Federal Fluminense, Niteroi, RJ, BrazilCorrespondence: Harry W Flynn JrBascom Palmer Eye Institute, 900 N.W. 17th Street, Miami, FL 33136, USATel +1 305-243-2020Email HFlynn@med.miami.eduPurpose: To report both the unoperated clinical course and the surgical outcomes of eyes with a central foveal bouquet (CB) secondary to idiopathic epiretinal membranes (iERMs).Design: Retrospective, consecutive, and observational case series.Methods: All patients examined between January 1, 2014, and December 31, 2019, for evaluation of epiretinal membrane with a CB lesion identified on spectral domain optical coherence tomography (SD-OCT) were included. Exclusion criteria included vitreoretinal comorbidities associated with secondary ERMs and an absence of CB lesions on SD-OCT. Patients were divided into two groups: those who were followed with observation (Group I) and those who received surgery (Group II). Each group had 3 different types of mechanical abnormalities of the CB previously described as cotton ball sign, subfoveal detachment, or acquired vitelliform lesion, without a subanalysis discrimination.Main Outcome Measures: Best-corrected visual acuity (BCVA) at baseline and last follow-up, subjective metamorphopsia, central retinal thickness (CMT), mechanical stress lesions of the CB, and resolution or evolution of the CB lesions during the follow-up interval.Results: Two hundred seventy-six eyes with iERM were reviewed, and 46 eyes met the inclusion criteria. Among these, 21 of 46 (46%) were observed, and 25 of 46 (54%) underwent surgery. Metamorphopsia was identified in 61.9% of patients in Group I and 81.2% of patients in Group II, at baseline. The mean BCVA was 0.19 ± 0.17 (20/30) in Group I and 0.31 ± 0.33 (20/40) in Group II at presentation. At the final exam, patients in Group I achieved a mean BCVA of 0.24 ± 0.18 (20/30), while patients in Group II obtained a mean BCVA of 0.15 ± 0.21 (20/30). Spontaneous resolution of the CB sign occurred in 5 of 21 eyes (23.8%) that were observed, whereas, after surgery, the CB sign resolved in 16 of 25 eyes (61.5%). Mean CMT was 422 ± 84.2μm in Group I and 531 ± 143.9μm in Group II, at baseline, while at the latest follow-up, the mean CMT was 400 ± 40.8μm in the cases followed with observation and 454 ± 148.7μm in the surgical cases.Conclusion: The clinical course and surgical outcomes of CB findings in iERM are favorable in terms of visual acuity. However, those receiving surgery had an increase in visual acuity and resolution of the CB abnormality.Keywords: foveal tractional lesions; idiopathic epiretinal membrane lesions; central foveal bouquet; clinical outcomes; surgical outcomes,

Soraya Alessandra Horowitz, 1 Nadyr P Damasceno, 1 Eduardo F Damasceno 2 1Department of Ophthalmology, Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil; 2Department of Ophthalmology, Universidade Federal Fluminense, Niteroi, BrazilCorrespondence: Soraya Alessandra Horowitz; Nadyr P DamascenoDepartment of Ophthalmology, Hospital Naval Marcílio Dias (HNMD), 185 Rua Cesar Zama, Lins, Rio de Janeiro, BrazilEmail horowitzsoraya@gmail.com; nadyrdamasceno@yahoo.comAbstract: To report a treatment of radiation retinopathy in a patient exposed to ionizing radiation for a period of 2 years. A 26-year-old female patient with no comorbidities diagnosed with myelodysplasia confirmed by bone marrow biopsy. She presented a complaint of bilateral progressive visual acuity reduction. At the ophthalmologic examination, she presented alterations suggestive of radiation retinopathy as well as macular thickness to optical coherence tomography (OCT) of over 500 μm. The patient underwent intravitreal injection (0.05 mL) of ranibizumab (Lucentis®) monthly in both eyes and follow-up through visual acuity and OCT examination. She presented reduction of macular edema as well as a slight improvement of visual acuity. In this case, the treatment of radiation retinopathy with intravitreal injection of ranibizumab (Lucentis) was relatively useful, with a slight improvement of visual acuity, due to the regression of macular edema, not being curative.Keywords: retinopathy abnormalities, retina/radiation effects, intravitreal injection, angiogenesis inhibitors/therapeutic use, macular edema, improvement of visual acuity

Eduardo F Damasceno,1,2 Nadyr A Damasceno,1,3 Ashley M Crane,1 Nicolas A Yannuzzi,1 Nidhi Relhan,1 William E Smiddy,1 Harry W Flynn1 1Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, FL, USA; 2Department of Ophthalmology, Universidade Federal Fluminense, Niteroi, RJ, Brazil; 3Department of Ophthalmology, Hospital Naval Marcilio Dias, Rio de Janeiro, RJ, BrazilCorrespondence: Harry W FlynnDepartment of Ophthalmology, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, 900 N.W. 17th Street, Miami, Florida 33136, USATel +1-305-326-6118Fax +1-305-326-6417Email HFlynn@med.miami.eduBackground/aims: To report the clinical course of patients with idiopathic epiretinal membranes (iERMs) and good baseline best-corrected visual acuity (BCVA) managed without surgical treatment.Methods: Retrospective, observational case series of patients with iERMs and 20/50 or better BCVA who did not undergo surgery between January 2014 and December 2017 with a 1-year follow-up. Secondary epiretinal membranes were excluded. iERMs were stratified into two groups: Group I (BCVA 20/30 or better) and Group II (BCVA 20/40 to 20/50). The main outcome measures included baseline and final follow-up BCVA, central macular thickness (CMT) on OCT.Results: The study included 174 eyes (145 patients): 139 eyes (79.8%) had typical iERMs and 35 eyes (18%) had LMH. For Group I typical iERMs, the logMAR baseline and final mean BCVA were 0.09 ± 0.1 (Snellen equivalent 20/25) and 0.10 ± 0.1 (20/25+) respectively (p = 0.22). In this group, the baseline and final mean CMT were 335 ± 73μm and 342 ± 78μm, respectively (p = 0.47). For Group II typical iERMs, the logMAR baseline and final mean BCVA were 0.3 ± 0.1 (20/44) and 0.4 ± 0.2 (20/45) respectively (p = 0.31). In this group, the baseline and final mean CMT were 386 ± 95μm and 391 ± 93μm, respectively (p = 0.84).Conclusion: The clinical course of patients with iERM and good baseline BCVA is generally favorable without surgery and includes stable BCVA and OCT measurements after at least one year.Keywords: epiretinal membrane, pars plana vitrectomy, optical coherence tomography

Soraya Horowitz1, Nadyr A Damasceno1, Felipe Muralha2, Maurício B Pereira3, Mauricio Maia2, Eduardo F Damasceno3 1Department of Ophthalmology, Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil; 2Department of Ophthalmology, The Universidade Federal de São Paulo, Brazil; 3Department of Ophthalmology, Universidade Federal Fluminense, Niterói, BrazilCorrespondence: Eduardo F DamascenoMarques do Paraná, 303 Niteroi, 20530050 BrazilTel +55 212 562 2343Email e_damasceno@yahoo.comPurpose: To evaluate diathermy to minimize sclerotomy leakage during small-gauge vitrectomy and prevent ocular hypotony.Methods: This observational prospective study included 327 patients (327 eyes) who underwent diathermy to close the sclerotomy sites during 23-gauge pars plana vitrectomy (PPV). All patients were operated by a single surgeon (ED) and evaluated at 30 and 60 days postoperatively. Patients with glaucoma, topical/systemic steroids use exceeding 30 days, ocular inflammation, or trauma were excluded. Chi-square, Kruskal–Wallis, Fisher Exact test, and multivariate statistical analyses were performed to evaluate potential risk factors. The primary outcomes were open sclerotomies, leakage, and ocular hypotony.Results: Sclerotomies remained open in 12 (3.6%) and 2 (0.6%) patients, respectively, at 30 and 60 days postoperatively, revealing no case of ocular hypotony. Leakage only occurred in four patients (1.2%) during week 1 postoperatively. Multivariate analysis indicated that additional vitreoretinal surgeries and longer surgeries were risk factors for persistent sclerotomy opening.Conclusion: Diathermy was safe and feasible to close sclerotomies. Vitreoretinal surgery reoperations and longer surgeries were the most significant (P

Luciana MC Soriano,1 Nadyr A Damasceno,1,2 Guilherme Herzog Neto,1 Eduardo F Damasceno11Department of Ophthalmology, Universidade Federal Fluminense, Niterói, Brazil; 2Department of Ophthalmology, Hospital Naval Marcílio Dias, Rio de Janeiro, BrazilPurpose: To compare the clinical profile of patients with chronic dacryocystitis (CDC) with and without associated chronic rhinosinusopathies who had been submitted to external dacryocystorhinostomy (EDCR).Methods: This was a retrospective, observational, and longitudinal study that included all patients diagnosed with CDC who were submitted to EDCR at the Antonio Pedro University Hospital. Patients were divided into two groups, with and without rhinosinusopathies (Group I and Group II, respectively). The following variables were assessed to compare the Group I and Group II: age, ethnicity, epiphora, discharge by expression of the lacrimal sac, duration of the CDC, and previous history of CDC exacerbation.Results: The study included a total of 78 patients, 22 patients (28.2%) in Group I and 56 patients (71.8%) in Group II. The mean age was 64.3 (±19.7) years. In Group I and II predominated elderly, female, and White (p=0.93, p=0.38, p=0.77). In relation to the clinical characteristics, most of the patients presented epiphora and discharge by compression of the lacrimal sac in both Groups (p=0.61, p=0.44). In relation to a previous history of exacerbations of the CDC, six patients in Group I and four patients in Group II presented it as purulent discharge (p=0.04).Conclusion: Chronic rhinosinusopathies may favor episodes of exacerbations of chronic dacryocystitis in particular with the presence of purulent discharge.Keywords: rhinosinusopathies, acquired nasolacrimal duct stenosis, chronic lacrimal fluid retention, acute rhinosinusitis

Nadyr A Damasceno,1 Nadia C Miguel,2 Marcelo Palis Ventura,3 Miguel Burnier Jr,4 Marcos P Avila,5 Eduardo F Damasceno3 1Ophthalmology Department, Hospital Naval Marcílio Dias, 2Laboratory of Neurohistology and Cell Ultrastructure, Instituto de Ciências Biomédicas, Universidade Federal do Rio de Janeiro, Rio de Janeiro, 3Ophthalmology Department, Universidade Federal Fluminense, Niterói, Brazil; 4Ophthalmology Department, McGill University, Montreal, QC, Canada; 5Ophthalmology Department, Universidade Federal de Goiás, Goiania, Brazil Purpose: The aim of study was to evaluate the cross-link using riboflavin and ultraviolet A (UVA) for improving scleral wound healing.Materials and methods: This was an experimental study involving four New Zealand rabbits (eight eyes). Therapy procedure was chosen for the right eye and control procedure for the left one. UVA irradiation of 365 nm with a surface irradiance of 3 mW/cm2 and a photosensitizer of riboflavin drops were applied for 30 minutes on the right eye at 2 mm from the limbus. Sclerotomy incision was performed at 2 mm from the limbus in both right (on the cross-link-treated area) and left eye. Then, 30 days after surgery, a morphological analysis and histological staining with hematoxylin–eosin and picrosirius red were performed, and the sclerotomy cicatrization of right and left eyes was compared. The variables investigated were as follows: sclerotomy incision pictures and measurements were made using the ImageJ Software. Scleral thickness was measured (employing the anterior optical coherence tomography and the digital caliper). Collagen fiber density stained with picrosirius red staining was measured using the Image Pro Plus software.Results: The morphological analysis showed that in all samples, the right eye presented sclerotomy closure, and in two eyes, among them, there were no visible edges of the sclerotomies incision. The left eye presented sclerotomy closure and incision edges. The Image Pro Plus demonstrated a higher density of collagen fibers in the right eye when compared to the left one. The statistical analysis was significant when compared to the collagen fiber density in the treated eyes with the control eyes.Conclusion: The cross-link procedure resulted in a better sclerotomy wound healing. Keywords: sclerotomy wound healing, cross-linking, ultraviolet A, riboflavin

Luiz Cláudio Santos de Souza Lima,1 Adalmir Morterá Dantas,2 Guilherme Herzog Neto,1 Eduardo França Damasceno,1 Helena Parente Solari,1 Marcelo Palis Ventura1 1Department of General Surgery, Federal Fluminense University, Niteroi, 2Department of Ophthalmology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Purpose: To compare anisometropic hypermetropic amblyopic and strabismic amblyopic responses to pattern electroretinogram (PERG) and pattern visual evocated potential (PVEP). Materials and methods: Fifty-six patients – 18 hypermetropic anisometropic amblyopic children (mean age 9.70±2.5 years), 19 strabismic amblyopic children (mean age 10.30±2.6 years) and 19 normal emetropic subjects (mean age 10.10±2.2 years) – were enrolled in this study. After routine ophthalmic examination, PERG and PVEP were recorded in response to checks reversed at the rate of two reversals/second stimulating macular area. Results: The difference between hypermetropic anisometropic amblyopia and strabismus amblyopia with respect to P100/P50/N95 wave latencies (P=0.055/0.855/0.132) and P100/P50/N95 amplitudes (P=0.980/0.095/0.045) was not statistically significant. However, there was a significant statistical difference between strabismic amblyopia group and controls for P100/P50/N95 latencies (P=0.000/0.006/0.004). Conclusion: Our findings indicated that despite clinical differences between anisometropic amblyopic and strabismic amblyopic patients, no differences were found in the responses of PVEP and PERG. The abnormal components of the PVEP and PERG in amblyopic subjects could reflect a retinal dysfunction in the visual pathway. Keywords: amblyopia, strabismus, pattern electroretinogram, pattern visual evocated potential, anisometropia

Purpose: To report a case of paracentral acute middle maculopathy (PAMM) due to branch retinal artery occlusion (BRAO) as a complication of COVID-19., Methods: A case report evaluated through spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography, and OCT angiography., Results: A 55-year-old man complained of blurred vision in the right eye. He presented with anosmia and tested positive for COVID-19 one week before. Fundus examination revealed a superior temporal whitening of the retina, SD-OCT showed a hyperreflective band-like lesion on the nuclear layer consistent with PAMM., Conclusion: COVID-19 infection involves inflammatory and thrombotic events. Even patients with just anosmia may have complications such as BRAO associated with PAMM., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In this case study, the authors describe peculiar bilateral cotton wool-like retinal lesions associated with macular edema in a patient with COVID-19 who was vaccinated with a single dose of AstraZeneca one month earlier. This patient had no pulmonary or systemic cardiovascular complications from COVID-19, as reported in other papers that found retinal lesions. However, the patient was diagnosed with idiopathic myopathy when discovering the SARS-CoV-2 infection. The patient was a 22-year-old white female with no previous history of morbidity, complaining of blurred vision in both eyes seven days after testing positive for SARS-CoV-2 by PCR (using nasal and oral swab) and confirmed through ELISA blood test (IgM positive). There was no ancillary test revealing diabetes mellitus. The patient presented with scattered whitish cotton wool-like lesions and a few hemorrhages on the posterior pole in fundus examination. On spectral domain optical coherence tomography (SD-OCT), there were hyperreflective lesions in the nerve fiber layer, ganglion cell layer, inner nuclear layer, and inner and outer plexiform layers at the site corresponding to the whitish cotton wool-like lesions in the posterior fundus photos. Moreover, the macula of both eyes had intraretinal and subretinal fluid, reversible with corticosteroid therapy. In conclusion, COVID-19 has been associated with capillary disorders at different target sites such as retina, lungs, and central nervous system. Similarly, vaccination against SARS-CoV-2 has been linked to retinal complications in the literature; however, cotton wool-like lesions have not yet been reported. There are many questions yet to be answered about the implications of COVID-19 infection and its vaccines.

Purpose: To evaluate the occurrence of transient central retinal artery occlusion following intravitreal anti-vascular endothelial growth factor injection., Methods: Prospective, observational study of 807 patients (807 eyes) who were given intravitreal injections of ranibizumab or aflibercept to treat any cause of retinal vascular diseases between 1 January 2017 and 30 November 2018 at the Federal Fluminense University Hospital in Niteroi, and a private facility in Rio de Janeiro, Brazil. Patients who did not present transient central retinal artery occlusion were excluded., Results: Among 4069 injections, only 18 patients (0.44%) presented transient central retinal artery occlusion, 14 mild cases (77.7%), and 4 severe cases (22.3%). The clinical factors associated with more severe cases of transient central retinal artery occlusion were the duration of the transient central retinal artery occlusion ( p  = 0.001), number of prior injections ( p  = 0.01), and a positive carotid Doppler test ( p  = 0.01). Twelve cases (66.6%) had positive carotid artery obstruction (atheroma plaque size ≥70%) while 6 cases (33.3%) had negative carotid artery obstruction (atheroma plaque size <70%). The age group >60 years old ( p  = 0.06), cup/disc ratio >0.6 ( p  = 0.06), and pseudophakic lens status were also factors with association with transient central retinal artery occlusion, although did not meet criteria for statistical significance. The only patient who experienced a recurrent episode of transient central retinal artery occlusion had diabetic macular edema, positive carotid Doppler test, and cup/optic disc ratio >0.6., Conclusion: Transient central retinal artery occlusion is a rare adverse event that can appear in patients with retinal vascular disease receiving anti-vascular endothelial growth factor therapy. The atheroma plaque size and the number of prior injections can be associated with the severity of the event.

Outer retinal tubulation (ORT) is a retinal finding that can mimic intraretinal fluid and has been identified with spectral-domain optical coherence tomography in patients with age-related macular degeneration (AMD). The purpose of this review is to summarize the findings related to the pathogenesis of ORT and its clinical implications. Studies reporting the pathogenesis and the clinical implications of ORT in patients with AMD were identified and summarized. A total of 18 studies were included in this review. The body of evidence to date regarding ORT in patients with AMD indicates that ORT is a structure associated with advanced macular diseases that does not require anti-vascular endothelial growth factor treatment. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:870-876.]., (Copyright 2018, SLACK Incorporated.)

Objective: To identify the causes of low visual acuity and systemic morbidities that limit ambulation and access to eye care in geriatric clinics in Rio de Janeiro., Methods: This cross-sectional study evaluated 187 patients from three geriatric clinics in Rio de Janeiro between January 2010 and January 2011. The inclusion criteria were individuals with a visual acuity of less than of equal to 20/200 in either eye (118 individuals), without optical correction. The exclusion criteria were individuals who refused to participate and those unable to undergo screening because of mental disabilities (6 individuals). Of the 187 individuals evaluated, 63 had visual acuity above 20/200., Results: A total of 118 individuals with a visual acuity of ≤20/200 effectively participated in the study after meeting the inclusion and exclusion criteria. In addition, 57 participants (48.3%) presented systemic disabling morbidities. Of the 118 individuals with low visual acuity, 27.96% had cataract and 26.27% had refractive errors., Conclusion: Most of the patients from geriatric clinics experienced ocular morbidities, but their proper treatment resulted in improved visual acuity. A more socially oriented problem associated with eye care involved the difficulty of access to ophthalmologic consultations.