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Ana Margarida Ferreira,1 Rodrigo Vilares-Morgado,1,2 Mário Lima-Fontes,1,3 Manuel Falcão,1,2 Fernando Falcão-Reis,1,2 Ângela Carneiro1,2 1Department of Ophthalmology, Local Health Unit of São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Porto, Portugal; 3Department of Biomedicine, Faculty of Medicine of University of Porto, Porto, PortugalCorrespondence: Ana Margarida Ferreira, Department of Ophthalmology of Local Health Unit of São João, Avenida Prof. Hernâni Monteiro, Porto, 4202 – 451, Portugal, Tel +351 912 605 085, Fax +351 225 512 100, Email amargaridapferreira@gmail.comPurpose: To evaluate the progression of chorioretinal atrophic areas associated with myopic choroidal neovascularization (CNV) in high myopic patients followed by a minimum period of 10 years.Patients and Methods: Patients with myopic CNV lesions that achieved clinical and structural remissions over 10 years of follow-up were included. Medical records were reviewed for CNV characterization and treatment, best-corrected visual acuity at baseline (BCVA0), immediately after the last treatment (BCVA1) and at the latest visit (BCVA2). Fundus autofluorescence (FAF) was used to quantify the amount of atrophic area increase per year associated with the treated myopic CNV lesion. The first FAF performed after treatment suspension (FAF1) was compared with the most recent exam (FAF2).Results: Thirty-six eyes from 36 patients were included. Mean total follow-up was 12.38 ± 2.68 years. Mean number of intravitreal injections (IVI) was 12.50 ± 12.40 and 25% of the eyes had previous treatment with photodynamic therapy (PDT). Mean improvement between BCVA0 and BCVA1 was 5.58 ± 15.98 letters (p < 0.001). However, a drop of 8.03 ± 12.25 letters was noticed between BCVA1 and BCVA2. FAF1 was 6.34 ± 4.92mm2 and increased to 9.88 ± 7.56mm2 (3.54 ± 3.79mm2 variation p < 0.001). The mean growth rate of the atrophic area was 0.89 ± 0.84mm2 per year. BCVA2 negatively correlated with FAF2 (k = − 0.498, p = 0.002) being worse in patients with higher atrophic area growth rate (k = − 0.341, p = 0.042). Eyes treated with PDT needed less IVI (5.89 ± 5.21 vs 14.70 ± 13.36, p = 0.008) but had larger FAF1 (9.80 ± 5.33 vs 5.19 ± 4.27, p = 0.013) and FAF2 (16.05 ± 7.10 vs 7.83 ± 6.63, p = 0.003). Hypothyroidism was associated with higher atrophy growth rate (1.55 ± 1.15 vs 0.73 ± 0.67, p = 0.016).Conclusion: This research demonstrates the importance of chorioretinal atrophy progression after myopic CNV lesions regression and its impact on visual prognosis, reporting a mean yearly growth of 0.89 mm2 in atrophic areas. Previous treatment with PDT and hypothyroidism were identified as risk factors associated with larger atrophic areas and worse visual outcomes.Keywords: chorioretinal atrophic lesions, myopic choroidal neovascularization

Mário Lima-Fontes,1,2 Daniel Martinho-Dias,3– 5 Mariana Leuzinger-Dias,1 Ana Maria Cunha,1 Pedro Neves Cardoso,1 Luís Torrão,1 Raúl Moreira,1 Fernando Falcão-Reis,1,6 João Pinheiro-Costa1,6 1Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal; 2Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, 4050-313, Portugal; 3Department of Community Medicine, Information and Decision in Health, University of Porto Faculty of Medicine, Porto, 4050-313, Portugal; 4CINTESIS – Center for Health Technology and Services Research, University of Porto, Porto, 4050-313, Portugal; 5Family Health Unit Ao encontro da Saúde, ACES Santo Tirso-Trofa, Trofa, 4745-559, Portugal; 6Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, 4050-313, PortugalCorrespondence: Mário Lima-Fontes, Department of Ophthalmology, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, Email marioruifontes@gmail.comPurpose: The Covid-19 pandemic introduced significant changes in our daily life, including the widespread use of face masks. The purpose of this study was to assess if significant changes occurred in the microbiological profile of infectious keratitis.Patients and Methods: A retrospective study was performed, based on a survey review of the electronic medical records of all patients with presumed infectious keratitis, between March 2020 and October 2021. The microbiological isolates in this sample (pandemic group) were compared with those obtained in our center between 2009 and 2018 (pre-pandemic group).Results: A total of 194 samples were included in the pandemic group. We obtained a culture-positivity rate of 43.3%, which was significantly higher when compared with the pre-pandemic data (35.15%, p = 0.033). Several further significant differences were found between the pandemic and the pre-pandemic groups: the proportion of bacteria, including gram-positive and gram-negative groups, was higher in our sample (pre-pandemic vs pandemic: 76.78% vs 83.33%, p = 0.010; 53.35% vs 60.71%, p = 0.016; 23.43% vs 34.52%, p = 0.005, respectively); two populations of Gram-positive bacteria found in this study were not isolated in the pre-pandemic sample – Dolosigranulum pigrum and Propionibacterium spp.; and two bacterial isolates were significantly increased in our sample – Corynebacterium spp. (18.41% vs 29.76%, p = 0.003) and Pseudomonas aeruginosa (9.00% vs 16.66%, p = 0.012).Conclusion: In conclusion, significant changes were found in the microbiological profile of infectious keratitis in our center during the Covid-19 pandemic. While these changes could be related to face mask use, more observational and experimental studies are needed to explore this possible association.Keywords: infectious keratitis, Covid-19, face mask, microbiology

Mario Lima-Fontes,1 Mariana Leuzinger-Dias,1 Rita Rodrigues,1 Ricardo Barros-Pereira,1 Manuel Falcão,1,2 Vítor Fernandes,1 Pedro Alves-Faria,1,2 Fernando Falcão-Reis,1,2 Amândio Rocha-Sousa1,2 1Ophthalmology Department, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, 4200-319, PortugalCorrespondence: Mario Lima-Fontes, Department of Ophthalmology, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, Email marioruifontes@gmail.comPurpose: The purpose of this study was to characterize the clinical presentation, management strategy and visual outcomes of patients diagnosed with Terson syndrome and followed in a tertiary centre in Portugal.Patients and Methods: A single-centre retrospective study was performed, based on the survey review of the medical records of every consecutive patient diagnosed with Terson syndrome and followed from January 2018 to August 2021. The change in best-corrected visual acuity (BCVA) from baseline to the final evaluation was the primary outcome.Results: Fifteen eyes from 8 patients (50% female) were included. The mean age at diagnosis was 55± 7 years. The neurological event was traumatic brain injury in 37.5% (n=3) and subarachnoid haemorrhage in 62.5% of the patients (n=5). Bilateral intraocular haemorrhage occurred in 875% (n=7) of the patients. Vitreous and preretinal haemorrhages occurred each in 66.7% (n=10), intraretinal in 30% (n=3) and subretinal in 13.3% (n=2) of the eyes. In 40% of the eyes (n=6), spontaneous resolution of intraocular haemorrhage occurred, while PPV was performed in the remaining 60% (n=9). Ocular haemorrhage detection occurred 58.47 ± 40.94 days after the neurological event (range 11 to 121 days). Baseline BCVA was 1.11 ± 1.01 logMAR and improved to 0.32 ± 0.69 logMAR in the follow-up period (p=0.004). A positive correlation was found between initial and final BCVA (Spearman’s rho = 0.643, p=0.01). Baseline BCVA of eyes undergoing PPV was lower than of those conservatively managed (1.84± 0.72 vs 0.20± 0.28 logMAR, p< 0.001). However, there were no statistically significant differences in final BCVA after surgery or observation (0.56 ± 0.90 vs 0.04 ± 0.04 logMAR, p=0.149). Longer periods between the neurological and the ophthalmological diagnosis were correlated with worse final BCVA (Spearman’s rho = 0.688, p=0.005).Conclusion: Terson syndrome is a potential cause of irreversible visual loss. Diagnosis delay may affect visual prognosis. PPV is indicated when intraocular haemorrhage is dense and does not resolve spontaneously or when visual acuity at presentation is low, allowing for good visual outcomes with minimal complications.Keywords: Terson syndrome, management, vitrectomy, visual outcomes, clinical presentation

Margarida Ribeiro,1,2,&ast; Cláudia Barbosa,3,&ast; Paulo Correia,3 Luís Torrão,1 Pedro Neves Cardoso,1 Raúl Moreira,1 Fernando Falcão-Reis,1,4 Manuel Falcão,1,4 João Pinheiro-Costa1,2 1Department of Ophthalmology, Centro Hospitalar e Universitário São João, Porto, Portugal; 2Department of Biomedicine – Faculty of Medicine of Porto University, Porto, Portugal; 3Faculty of Medicine of Porto University, Porto, Portugal; 4Department of Surgery and Physiology, Faculty of Medicine of Porto University, Porto, Portugal&ast;These authors contributed equally to this workCorrespondence: Margarida Ribeiro, Department of Ophthalmology, Centro Hospitalar e Universitário São João, Alameda Prof. Hernâni Monteiro Porto, 4200-319, Portugal, Email margarida.ribeiro.guimaraes@gmail.comPurpose: We evaluated the Maximum Elevation of Corneal Back Surface adjusted to the same Best Fit Sphere Back (BFSB) between timeline measurements (AdjEleBmax) and the BFSB radius (BFSBR) itself as new tomographic parameters for documentation of ectasia progression and compare them with the most recent and reliable parameters used on keratoconus (KC) progression.Results: We evaluated the performance and the ideal cutoff point of Kmax, D-index, posterior radius of curvature from the 3.0 mm centered on the thinnest point (PRC), EleBmax, BFSBR, and AdjEleBmax as isolated parameters to document KC progression (defined as a significant change in two or more variables), we found a sensitivity of 70%, 82%, 79%, 65%, 51%, and 63% and a specificity of 91%, 98%, 80%, 73%, 80%, and 84% to detect KC progression. The area under the curve (AUC) for each variable was 0.822, 0.927, 0.844, 0.690, 0.695, 0.754, respectively.Conclusion: AdjEleBmax presented a greater specificity, larger AUC, and better performance compared to EleBmax without any adjustment, with similar sensitivity. Although AdjEleBmax and BFSB demonstrated smaller AUC and specificities comparing with Kmax and D-Index, AdjEleBmax still presented a good performance with a reasonable AUC. Since the shape of the posterior surface, more aspheric and curved than the anterior, may facilitate detection of change, we suggest the inclusion of AdjEleBmax in the evaluation of KC progression in conjunction with other variables to increase the reliability of our clinical evaluation and early detection of progression.Keywords: keratoconus, cornea, progression, best fit sphere back, maximum elevation of corneal back surface

Ana Filipa Moleiro,1,2 Gonçalo Godinho,3 Carolina Madeira,4 Ana Faria Pereira,1 Elisete Brandão,1 Fernando Falcão-Reis,1,2 João Nuno Beato,1,2 Susana Penas1,2 1Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; 3Department of Ophthalmology, Centro Hospitalar de Leiria, Leiria, Portugal; 4Department of Ophthalmology, Centro Hospitalar Gaia-Espinho, Gaia, PortugalCorrespondence: Ana Filipa Moleiro, Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Alameda Hernani Monteiro, Porto, 4200-426, Portugal, Tel +351 915689259, Email anafomoleiro@gmail.comPurpose: This work aimed to longitudinally assess the peripapillary (PPCT) and subfoveal (SFCT) choroidal thickness (CT), in patients diagnosed with central (CRVO) or branch retinal vein occlusions (BRVO), correlating SFCT with central macular thickness (CMT) and PPCT with peripapillary retinal nerve fiber layer thickness (pRNFL).Patients and Methods: This was a retrospective longitudinal study of 71 eyes from 71 patients with treatment-naïve retinal vein occlusion (24 CRVO and 40 BRVO). Spectral-domain optical coherence tomography (SD-OCT, Spectralis HRA-OCT, Heidelberg) was used to measure PPCT, SFCT, pRNFL and CMT of the affected and fellow eyes at baseline (acute phase) and at 3 and 9 months post anti-VEGF treatment. IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A p-value ≤ 0.05 was considered statistically significant.Results: Affected eyes presented a thicker baseline PPCT and SFCT compared to their fellow eyes both in CRVO and BRVO (p < 0.05). Both groups presented a significant decrease of PPCT in the affected eyes at 3 months compared to baseline (p < 0.05). At 9 months, compared to 3 months, PPCT remained stable (p > 0.05). Similarly, affected eyes’ SFCT significantly decreased at 3 months (p < 0.05) in both groups. At 9 months, compared to 3 months, SFCT decreased in the CRVO patients (p = 0.047) but remained stable in the BRVO patients (p = 0.850). No correIations between SFCT and CMT were seen at any timepoint in both groups (p > 0.05). PPCT correlates with pRNFL in CRVO at 3 months, although no other correlations were found during the follow-up. In BRVO, PPCT did not show any significant correlation with pRNFL.Conclusion: Both in CRVO and BRVO eyes, PPCT and SFCT at diagnosis are significantly thicker compared to the fellow eye, suggesting a possible increase in CT immediately after the occlusion, which is followed by a decrease at an early follow-up stage.Keywords: biomarkers, vascular retinal diseases, retinal vein occlusions, choroidal thickness, optical coherence tomography

Ana Filipa Moleiro,1,2 Ana Maria Cunha,1 Rodrigo Vilares-Morgado,1,2 António José Cruz,3 Ana Isabel Almeida,4 Fernanda Peixoto,1 Fernando Falcão-Reis,1,2 Jorge Meira,1 Vítor Leal1 1Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Porto, Portugal; 3Department of Infectious Diseases, Centro Hospitalar e Universitário de São João, Porto, Portugal; 4Department of Neuroradiology, Centro Hospitalar e Universitário de São João, Porto, PortugalCorrespondence: Ana Filipa Moleiro, Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, Tel +351 915689259, Email anafomoleiro@gmail.comAbstract: The pandemic caused by SARS-CoV-2 remains a health care concern, despite vaccination programs. Mucormycosis, especially rhino-orbital-mucormycosis, has been described as a severe complication of COVID-19. Although it has been described mostly in India and other developing countries, few cases in the western world have also been described. We present a case of rhino-orbito-mucormycosis after recovery from severe COVID-19 in Portugal. A 75-year-old diabetic and obese man presented with right proptosis associated with right eye pain and low vision one month after recovery from severe COVID-19. Considering the most probable etiology for this clinical picture, anti-fungal therapy with liposomal amphotericin B was promptly initiated, followed by endoscopic sinus debridement. However, due to persistent and progressive infection, and after a multidisciplinary revision of the case, orbital exenteration was performed. One year after surgery, the patient is stable, without clinical or imagological signs of relapse of the disease. Although the evolution of the pandemic, along with vaccination programs, led to a lower incidence of severe COVID-19 disease, there are still patients presenting with severe COVID-19, requiring intensive care and at risk for serious complications. This case illustrates the importance of being aware of the development of post-COVID-19 mucormycosis and the need for close surveillance of patients recovering from severe COVID-19. COVID-19 prompt diagnosis and multidisciplinary approach are essential for a timely intervention achieving better survival while minimizing morbidity.Keywords: Mucorales, SARS-CoV-2, orbit, fungal infections, exenteration

Mário Lima-Fontes,1 Gonçalo Godinho,2 Ana Maria Cunha,1 Carolina Madeira,3 Manuel Falcão,1,4 Fernando Falcão-Reis,1,4 Ângela Carneiro1,4 1Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, Portugal; 2Department of Ophthalmology, Centro Hospitalar de Leiria, Leiria, Portugal; 3Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; 4Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, PortugalCorrespondence: Mário Lima-Fontes, Department of Ophthalmology, Centro Hospitalar Universitário São João, Alameda Professor Hernâni Monteiro, Porto, 4200-319, Portugal, Tel +351 918420563, Fax +351 225513669, Email marioruifontes@gmail.comPurpose: To describe a case of hypotony maculopathy following anti-VEGF intravitreal injection (IVI) in a patient with pseudoxanthoma elasticum (PE).Methods: Clinical case report.Results: A 52-year-old male complained of right eye (OD) vision loss 2 days after an uncomplicated anti-VEGF IVI for the treatment of choroidal neovascularization secondary to angioid streaks. Relevant medical history included PE, pathologic myopia, and a previous pars plana vitrectomy (PPV) due to a retinal detachment. OD best-corrected visual acuity (BCVA) dropped from 6/12 to 6/18 after the IVI. Intraocular pressure (IOP) was 3 mmHg and chorioretinal folds were evident in the posterior pole. Topical dexamethasone and atropine were prescribed, and full recovery was noticed after 3 days. Four months later, the patient developed a new episode of vision loss after another IVI. His BCVA was counting fingers, IOP was 2mmHg, and more noticeable chorioretinal folds were found. This time, an open scleral wound at the injection site was evident and a scleral suture was necessary. Once again, the patient recovered well.Conclusion: Hypotony maculopathy following intravitreal injection is a rare condition. However, the described patient presented several conditions which could be related with poor scleral wound closure: intrinsic scleral fragility due to myopia and pseudoxanthoma elasticum; repeated IVI procedures; and absence of vitreous in the posterior segment due to prior vitrectomy. Despite the good outcome, hypotony maculopathy may be a sight-threatening condition, and special attention is necessary for specific patients with risk factors.Keywords: hypotony maculopathy, intravitreal injection, anti-VEGF, pseudoxanthoma elasticum, angioid streaks

Mário Lima-Fontes,1 Mariana Leuzinger-Dias,1 Fernando Falcão-Reis,1,2 Cristina Sousa1 1Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Porto, PortugalCorrespondence: Mário Lima-Fontes, Department of Ophthalmology, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, Email marioruifontes@gmail.comPurpose: Crocodile tears syndrome is a rare autonomic synkinesia, in which patients tear excessively in response to salivary stimuli. It usually occurs after idiopathic or traumatic facial palsy, as a result of aberrant reinnervation of the lacrimal gland by salivary efferent fibers from either the seventh or ninth cranial nerve.Patients and Methods: We report the case of a 54-year-old woman, with a history of left Bell’s palsy, who attended our ophthalmology clinic due to epiphora of the left eye while eating or speaking, for 6 months.Results: The ophthalmologic evaluation revealed a mild weakening of the frontal and left orbicularis oculi muscles without lagophthalmos. No other abnormalities were found, namely ocular surface swelling, ectropion, or obstruction of the lacrimal outflow system. Schirmer test II in the left eye increased from 12 to 23 mm while the patient was chewing. All these clues led to the diagnosis of crocodile tears syndrome and treatment with botulinum toxin A injection was proposed. One month after the injection of the palpebral lobe of the left lacrimal gland with 6 units of botulinum toxin A, the patient reported an almost complete resolution of the complaints, stated by a decrease in Munk scale and Lac-Q scores. Six months after injection, the patient conveyed recurrence of symptoms and a new treatment session was performed with comparable results.Conclusion: Since crocodile tears syndrome is rare, it is crucial to increase awareness and knowledge about it among ophthalmologists and other medical doctors. Botulinum toxin is a safe and effective treatment modality, dramatically improving these patients’ quality of life.Keywords: crocodile tears, gustatory lacrimation, epiphora, lacrimal gland, botulinum toxin A

Sónia Torres-Costa,1 António Benevides Melo,1,2 Sérgio Estrela-Silva,1,2 Fernando Falcão-Reis,1,2 João Barbosa-Breda1– 4 1Department of Ophthalmology, Centro Hospitalar e Universitário São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; 3UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal; 4Research Group Ophthalmology, Department of Neurosciences, KU Leuven, Leuven, BelgiumCorrespondence: Sónia Torres-CostaOphthalmology Department, Centro Hospitalar Universitário de São João, Alameda Professor Hernani Monteiro, Porto, 4200, Portugal, Tel +351 225 512 100, Fax +351 225 025 766, Email sonia.torres.costa@gmail.comPurpose: To evaluate whether previous clear-cornea phacoemulsification surgery affects the surgical outcomes of trabeculectomy in open-angle glaucoma (OAG).Methods: We performed a retrospective cohort study, which included 82 patients with OAG that underwent trabeculectomy between January 1, 2010, and December 31, 2017. The primary outcome was the probability of surgical failure. Failure was defined as IOP > 21 mmHg or reduced < 20% from baseline, IOP ≤ 5 mmHg in three consecutive visits, need for further glaucoma surgery, phthisis or loss of light perception vision due to glaucoma.Results: Eighty-two eyes (58 phakic and 24 pseudophakic) were included. Phakic group patients were younger than those in the pseudophakic group, 65.8 ± 11.7 vs 76.2 ± 7.9 years (p < 0.001). The most common type of glaucoma was primary OAG [59% (n = 34) phakic vs 63% (n = 15) pseudophakic], followed by exfoliative and pigmentary glaucomas. The mean preoperative IOP was not significantly different between groups nor was the number of preoperative hypotensive medications. The rate of surgical failure was not significantly different between groups at year 1 [17% (n = 10) phakic vs 29% (n = 7) pseudophakic; p = 0.361] nor at year 2 [28% (n = 16) phakic vs 46% (n = 11) pseudophakic; p = 0.110]. No significant differences were observed regarding the postoperative IOP or any secondary outcome measures at year 1 or 2.Conclusion: Previous clear-cornea phacoemulsification surgery does not lead to statistically significant differences in the rate of trabeculectomy failure. Despite not being significant, clinically relevant differences were observed between groups. Future studies with a larger sample and/or randomized are needed to clarify this association.Keywords: trabeculectomy, phacoemulsification, surgical failure, intraocular pressure

Ana Filipa Moleiro,1,2 Gonçalo Godinho,3 Carolina Madeira,4 Ana Faria Pereira,1 Elisete Brandão,1 Fernando Falcão-Reis,1,2 João Nuno Beato,1,2 Susana Penas1,2 1Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; 3Department of Ophthalmology, Centro Hospitalar de Leiria, Leiria, Portugal; 4Department of Ophthalmology, Centro Hospitalar Gaia-Espinho, Gaia, PortugalCorrespondence: Ana Filipa Moleiro, Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Alameda Hernani Monteiro, Porto, 4200-426, Portugal, Tel +351 915689259, Email anafomoleiro@gmail.com

Ana Filipa Moleiro,1,2 Ana Francisca Aires,3 Hélio Alves,4 João Viana Pinto,5 Ângela Carneiro,1,2 Fernando Falcão-Reis,1,2 Luís Figueira,1,4 João Pinheiro-Costa1,4 1Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; 3Faculty of Medicine, University of Porto, Porto, Portugal; 4Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal; 5Department of Otorhinolaryngology, Centro Hospitalar Universitário São João, Porto, PortugalCorrespondence: Ana Filipa MoleiroDepartment of Ophthalmology, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, PortugalTel +35 1915689259Email anafomoleiro@gmail.comPurpose: Although classically classified as a non-inflammatory condition, an inflammatory basis for keratoconus (KC) appears to be a growing evidence. Recently, it has been shown that KC patients have an increased choroidal thickness (CT). Among inflammatory disorders, atopy has been associated with KC development; therefore, the aim of this study was to evaluate if the increased CT in patients with KC is related to atopy.Methods: This is an analytical cross-sectional study of patients with KC. Patients were classified as atopic and non-atopic according to their atopy history (allergic rhinoconjunctivitis (AR), asthma (AA) and/or atopic dermatitis (AD)) and were also classified based on their eye rubbing habits. Choroidal profile of all subjects was evaluated using a Spectralis optical coherence tomography (OCT) device with enhanced depth imaging (EDI) mode. CT was measured and compared between groups at the center of the fovea and at 500 μm intervals along a horizontal section. A multivariable analysis, adjusted for sex, age, spherical equivalent, history of medication and atopy, was performed to assess the influence of atopy in CT.Results: Of the 80 patients included, 51 were atopic and 29 non-atopic. Atopic patients showed a thicker choroid in every measured location than the non-atopic patients (mean subfoveal CT 391.53 μm vs 351.17 μm, respectively), although the differences were not statistically different. The multivariable analysis revealed that being atopic makes the choroid statistically thicker, on average, 55.14 μm, when compared to non-atopic patients (p=0.043). Furthermore, patients who are frequent eye rubbers have significantly thicker choroids than non-rubbers (p=0.004).Conclusion: Although some results do not reach statistical significance, atopic KC patients seem to have thicker choroids compared with non-atopic KC patients, suggesting a possible role for atopy in the choroidal profile of KC. This constitutes a completely new sight in this field of research that needs further investigation.Keywords: atopy, choroid, choroidal thickness, cornea, keratoconus

Ana Maria Cunha,1 Rodrigo Vilares-Morgado,1 Ana Filipa Moleiro,1 Fernando Falcão-Reis,1,2 Olinda Faria1,2 1Department of Ophthalmology, Centro Hospitalar Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, PortugalCorrespondence: Ana Maria CunhaDepartment of Ophthalmology, Centro Hospitalar Universitário de São João, Avenida Prof. Hernâni Monteiro, Porto, 4202 – 451, PortugalTel +35 1225512100Fax +35 1225513669Email ana.cunha.18@gmail.comBackground: Leber hereditary optic neuropathy (LHON) is an optic neuropathy of mitochondrial inheritance. Childhood-onset disease is relatively rare and there are limited data on this important patient subgroup.Case Presentation: We present 3 particular presentations of LHON. Patient 1 was an 8-year-old boy admitted to the emergency department reporting a progressive bilateral visual loss and intermittent headaches. Neuro-ophthalmological examination revealed a bilateral pseudopapilledema. Lumbar puncture identified intracranial hypertension and the brain and orbits magnetic resonance imaging showed T2 hyperintensity in the posterior region of the left optic nerve and the optic chiasm. Patient 2 was a 12-year-old boy admitted to the emergency department reporting painless, progressive central vision loss in the right eye. Fundus examination revealed a hyperemic disc and vascular network papillary and peripapillary vascular microdilations. Three months later, the left eye presented visual loss. Patient 3 was a 6-year-old female child referred to the neuro-ophthalmology specialist due to painless central visual loss in both eyes. Her BCVA was 1/10 and counting fingers in right and left eye, respectively, and fundus examination revealed a pallor optic disc in the temporal sector.Discussion: The phenotype of childhood-onset disease may present itself distinct from classical adult-onset LHON. The absence of classical clinical features could lead to initial misdiagnosis. There should exist a high index of suspicion in children presenting unexplained subnormal vision in order to avoid potential diagnostic delays.Keywords: Leber hereditary optic neuropathy, childhood-onset disease, mitochondrial inheritance

Ana Maria Cunha,1 João Tiago Loja,2 Luís Torrão,1 Raúl Moreira,1 Dolores Pinheiro,3 Fernando Falcão-Reis,1,4 João Pinheiro-Costa1,5 1Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, Portugal; 2Faculty of Medicine, University of Porto, Porto, Portugal; 3Laboratory of Microbiology, Service of Clinical Pathology, Centro Hospitalar Universitário São João, Porto, Portugal; 4Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; 5Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, PortugalCorrespondence: Ana Maria CunhaDepartment of Ophthalmology of São João Hospital, Centro Hospitalar de São João, Avenida Prof. Hernâni Monteiro, Porto 4202 – 451, PortugalTel +351 225512100Fax +351 225513669Email ana.cunha.18@gmail.comPurpose: To determine the microbiological profile, risk factors, treatment and surgical intervention rates of fungal keratitis at a tertiary referral centre.Methods: A retrospective review of microbiological and medical records from hospitalised patients treated for fungal keratitis at Centro Hospitalar Universitário de São João from 2009 to 2019 was conducted.Results: Overall, 43 patients were included in our study. The mean age of patients was 63.7 years and 46.5% were men. In culture were isolated 22 (51.2%) filamentous fungi and 21 (48.8%) yeast. Candida species (n = 20, 46.5%), Fusarium species (n = 10, 23.4%) and Aspergillus species (n = 4, 9.3%) were the most common isolated species. Important risk factors were contact lens use (n = 24, 55.8%), long-term users of topical corticosteroids (n = 19, 44.2%) and previous keratitis (n = 19, 44.2%). Yeast isolates had a statistically significant higher prevalence in long-term users of topical corticosteroids compared to filamentous ones (p = 0.043). Twenty-four cases (55.8%) required surgical intervention, of which 23 cases underwent therapeutic penetrating keratoplasty. Ocular complications, such as evisceration was noted in 12 patients (27.9%) and endophthalmitis in 5 (11.6%). No statistically significant changes of best corrected visual acuity (BCVA) were found after treatment (p = 0.687).Conclusion: Most patients with fungal keratitis have associated risk factors. Filamentous and yeast species have equally prevalent etiologies. In general, our results mirror how difficult and challenging the approach and treatment of fungal keratitis could be.Keywords: fungal keratitis, risk factors, medical therapy, penetrating keratoplasty, visual outcomes

Ana Maria Cunha,1 Tiago Sardinha,2 Luís Torrão,1 Raúl Moreira,1 Fernando Falcão-Reis,1,3 João Pinheiro-Costa1,4 1Department of Ophthalmology, Centro Hospitalar De São João, Porto, Portugal; 2Faculty of Medicine, University of Porto, Porto, Portugal; 3Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; 4Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, PortugalCorrespondence: Ana Maria CunhaDepartment of OphthalmologyJoão, Centro Hospitalar De São, Avenida Prof. Hernâni Monteiro, 4202 – 451, Porto, PortugalTel +351 225512100Fax +351 225513669Email ana.cunha.18@gmail.comPurpose: To report 2-year outcomes of trans-epithelial accelerated corneal collagen crosslinking (TE-ACXL) procedure in the treatment of progressive keratoconus patients.Patients and Methods: Twenty-four eyes from 24 patients who underwent TE-ACXL (6mW/cm2 for 15 minutes) were included in this retrospective interventional study. Best-corrected visual acuity (BCVA), keratometry values, thinnest corneal thickness (PachyMin) and topometric indexes were analysed preoperatively and at 6-month, 12-month, 18-month and 24-month postoperative. Progression was assessed by increase ≥ 1.00D in maximum keratometry (Kmax); increase ≥ 1.00D in corneal astigmatism; decrease ≥ 2% in PachyMin; increase ≥ 0.42 in D-index.Results: There were no complications during or after TE-ACXL. No significant differences (Δ) were observed between baseline and 12-month or 24-month postoperative: ∆BCVA (− 0.08 ± 0.25, p=0.190; − 0.04 ± 0.17, p=0.588), ∆Kmax (− 0.08 ± 1.32, p=0.792; − 1.04 ± 1.89, p=0.135), ∆Astigmatism (− 0.15 ± 0.89, p=0.485; − 0.24 ± 1.38, p=0.609), ∆PachyMin (− 0.56 ± 15.70, p=0.882; 0.56 ± 18.74, p=0.931), ∆Index Surface Variation (∆ISV) (− 2.11 ± 10.27, p=0.395; − 4.67 ± 17.32, p=0.442), ∆Index Vertical Asymmetry (∆IVA) (− 0.05 ± 0.17, p=0.208; − 0.08 ± 0.26, p=0.397), ∆Index Height Decentration (∆IHD) (0.00 ± 0.02, p=0.368; − 0.01 ± 0.04, p=0.484), ∆KI (0.00 ± 0.05, p=0.851; 0.01 ± 0.06, p=0.877) and ∆D-index (0.15 ± 1.14, p=0.572; 0.06 ± 1.36, p=0.892). Eleven to 33% of patients had disease progression at 24-month postoperative according to the parameters used to determine progression.Conclusion: Although some patients maintain disease progression, TE-ACXL seems to be a safe and effective treatment for keratoconus over the 2-year follow-up period. Studies with longer follow-up periods and larger patient cohorts are recommended.Keywords: cornea, keratoconus, disease progression, transepithelial, cross-linking

Jorge Meira, 1,* Maria Luís Marques, 2,* Fernando Falcão-Reis, 1, 3 Eva Rebelo Gomes, 2 Ângela Carneiro 1, 3 1Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, Portugal; 2Department of Allergy and Clinical Immunology, Centro Hospitalar Universitário do Porto, Porto, Portugal; 3Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal*These authors contributed equally to this workCorrespondence: Jorge MeiraDepartment of Ophthalmology of São João Hospital, Avenida Prof. Hernâni Monteiro, Porto 4202 – 451, PortugalTel +351225512100Fax +351225513669Email jorgesmeira@gmail.comIntroduction: Contrast rapid sequence angiography with fluorescein or indocyanine green (ICG) is a diagnostic procedure commonly used in ophthalmology. Adverse reactions to fluorescein and ICG are rare and may be classified as toxic, of hypersensitivity and non-specific. The evaluation and management of a patient with an adverse reaction is a challenge for the majority of ophthalmologists, as is the assessment of risk factors that may contraindicate the procedure.Purpose: We aim to review the concepts underlying adverse reactions to fluorescein and ICG, especially those of hypersensitivity, and present a proposal or the evaluation of the patients in need to perform retinal angiography and for the treatment of immediate reactions to fluorescein and ICG.Methods: The available literature was examined using PubMed-Medline, and using the MeSH terms “fluorescein”, “Indocyanine green”, “ophthalmic dyes”, “retinal angiography”, “adverse reactions”, and “allergic reaction”.Conclusion: This review may help ophthalmologists to identify patients with higher risk of a hypersensitivity reaction and give them tools to recognize patients with suspected hypersensitivity that may benefit from an allergy study.Keywords: fluorescein, indocyanine green, ophthalmic dyes, retinal angiography, adverse reactions, hypersensitivity reaction

Carolina Madeira,1 Ana Vasques,2 João Beato,1 Gonçalo Godinho,1 Luís Torrão,1 Manuel Falcão,1,3 Fernando Falcão-Reis,1,3 João Pinheiro-Costa1,4 1Department of Ophthalmology, Centro Hospitalar de São João, Porto, Portugal; 2Faculty of Medicine, University of Porto, Porto, Portugal; 3Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; 4Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal Purpose: To systematically compare the efficacy of transepithelial accelerated corneal collagen crosslinking (TE-ACXL) with conventional corneal collagen crosslinking (C-CXL) in patients with progressive keratoconus. Methods: Eyes of patients with progressive keratoconus who were treated with C-CXL (3 mW/cm2 for 30 minutes) were compared with those who underwent TE-ACXL (6 mW/cm2 for 15 minutes). Best-corrected visual acuity (BCVA), keratometry values, corneal thickness, and topometric indexes were compared before CXL, and at 2 months, 6 months, and 12 months postoperatively. Results: The study enrolled 26 eyes of which 16 had TE-ACXL and 10 had C-CXL. Both groups were comparable at baseline and 12 months in terms of BCVA (P=0.16 and P=0.57), Kmax (maximum keratometry) (P=0.31 and P=0.73), pachymetry (P=0.75 and P=0.37), index of surface variance (ISV) (P=0.45 and P=0.86), index of vertical asymmetry (IVA) (P=0.26 and P=0.61), and index of height decentration (IHD) (P=0.27 and P=0.86, respectively). We did not observe significant differences between preoperative and 12-month postoperative readings in within-group analysis: ΔKmax (TE-ACXL, -2.13±5.41, P=0.25 vs C-CXL, 0.78±1.65, P=0.17), Δpachymetry (TE-ACXL, 4.10±14.83, P=0.41 vs C-CXL, -8.90±22.09, P=0.24), ΔISV (TE-ACXL, -8.50±21.26, P=0.24 vs C-CXL, 3.80±12.43, P=0.36), ΔIVA (TE-ACXL, -0.12±0.31, P=0.26 vs C-CXL, 0.03±0.18, P=0.61), and ΔIHD (TE-ACXL, -0.03±0.07, P=0.18 vs C-CXL, -0.01±0.03, P=0.88). Conclusion: Both TE-ACXL and C-CXL were similarly effective. Further follow-up is required to determine whether these techniques are comparable in the long-term. Keywords: cornea, keratoconus, crosslinking, transepithelial, riboflavin, ultraviolet radiation, keratometry

Ana Catarina Pedrosa,1 Adriana Reis-Silva,2 João Pinheiro-Costa,1,3 João Beato,1 Paulo Freitas-da-Costa,1,3 Manuel S Falcão,1,2 Fernando Falcão-Reis,1,2 Ângela Carneiro1,2 1Department of Ophthalmology, Hospital de São João, 2Department of Sense Organs, 3Department of Anatomy, Faculty of Medicine, University of Porto, Porto, Portugal Purpose: To evaluate the 5-year results obtained in clinical practice in the treatment of neovascular age-related macular degeneration (nAMD) with anti-VEGF agents. Materials and methods: We retrospectively analyzed all patients with nAMD who initiated anti-VEGF treatment before October 2009. We collected data regarding visual and anatomical outcomes. Results: A total of 278 patients met the selection criteria. The mean number of intravitreal injections was 5.7 in the first year and 3.7 in the fifth year. A positive mean visual acuity variation of +3.7 Early Treatment Diabetic Retinopathy Study letters occurred in the first year, but no significant differences relative to baseline were observed thereafter. The majority of patients (71%) maintained stable visual acuity throughout follow-up. At 5 years, mean central macular thickness remained substantially inferior to baseline (-96.6 µm), and 56% of patients maintained dry retinas. Conclusion: Anti-VEGF therapy leads to long-term visual stabilization in the great majority of patients. Keywords: age-related macular degeneration, choroidal neovascularization, vascular endothelial growth factor, visual acuity

Joana Araújo,1 João Tavares-Ferreira,1 Susana Penas,1,2 Luís Figueira,1,3 Flávio Prézia Paiva,1 Fernando Falcão-Reis1,2 1Ophthalmology Department, São João Hospital, 2Department of Sense Organs, 3Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal Abstract: We report one case of malignant hypertensive retinopathy as a presenting sign of fetal death in utero. Ophthalmic examination (including intravenous fluorescein angiography and optical coherence tomography) and obstetric and systemic evaluation were performed, providing a multidisciplinary approach. A 33-year-old overweight woman (body mass index 47 kg/m2) with no systemic or ocular known disease was admitted to our emergency department with a one-week history of bilateral vision loss and no systemic complaints. On examination, best corrected visual acuity was 1/10 in the right eye and 1/10 in the left eye. Anterior segment examination of both eyes was unremarkable. Ophthalmoscopic fundus findings included bilateral optic disc edema, diffuse cotton wool spots, intraretinal exudates, retinal hemorrhages, and multiple serous retinal detachments involving both maculae. Physical examination revealed a blood pressure of 220/ 110 mmHg. Further systemic workup revealed a previously unknown 35-week pregnancy with a dead fetus. An emergency cesarean section was performed. Pre-eclampsia is a life-threatening disorder for both mother and fetus. This case highlights the need to rule out pre-eclampsia in all women of childbearing age presenting with ocular signs of malignant hypertension, even without external signs of pregnancy. Keywords: hypertensive retinopathy, pre-eclampsia, vision loss

Ricardo António da Rocha-Bastos,1 Sérgio Estrela Silva,1 Flávio Prézia,1 Fernando Falcão-Reis,1,2 António B Melo11Department of Ophthalmology, Hospital São João, Alameda Prof Hernâni Monteiro, Porto, Portugal; 2Department of Sense Organs, Faculty of Medicine, University of Porto, Alameda Prof Hernâni Monteiro, Porto, PortugalAbstract: The presence of pseudoexfoliation material on the surface of an intraocular lens (IOL) is a rare finding. We report a series of seven cases with different patterns of pseudoexfoliation material deposition on the posterior chamber IOLs, recognized 2–20 years after cataract surgery. Six patients had an IOL implanted in the capsular bag and one in the ciliary sulcus. Two patients had undergone posterior capsulotomy. Although the pathophysiological mechanisms and clinical significance of this finding remain unknown, the careful follow-up of pseudophakic patients with known or suspected pseudoexfoliation syndrome is essential to monitor the development or progression of glaucoma, since deposition of pseudoexfoliation material continues even after cataract surgery.Keywords: intraocular lens, glaucoma, exfoliation syndrome, cataract

RA da Rocha-Bastos,1 JR Araújo,1 RS Silva,2 MJ Gil-da-Costa,2 E Brandão,1 NJ Farinha,2,3 F Falcão-Reis,1,4 T Dinah-Bragança1 1Department of Ophthalmology, Hospital São João, 2Hematology and Oncology Unit, Pediatric Hospital, Hospital São João, 3Pediatrics Department, Faculty of Medicine, University of Porto, 4Department of Sense Organs, Faculty of Medicine, University of Porto, Porto, Portugal Purpose: To describe the experience of the Ophthalmology Department of Hospital São João (HSJ), a tertiary health care center in North Region, Portugal, in terms of the diagnosis, treatment, and follow-up of retinoblastoma. Methods: This was a retrospective study of patients diagnosed with retinoblastoma in Hospital São João, between 1978 and 2012. Results: Fifty patients with retinoblastoma were evaluated in our institution between 1978 and 2012. Four patients were excluded due to loss of follow-up. Among the 46 retinoblastoma cases, 33 (71.7%) were unilateral and 13 (28.3%) bilateral, with a mean age at diagnosis of 22.19 months and 6.92 months, respectively (P

Pedro Nuno Brito,1 Sérgio Estrela Silva,1 José Silva Cotta,1 Fernando Falcão-Reis1,21Ophthalmology Department, Hospital S João, Porto, Portugal; 2Faculty of Medicine of Porto, University of Porto, Porto, PortugalPurpose: To report a case of severe, acute ocular hypertension in a 6-year-old child, 7 days after initiating treatment with oral prednisolone, due to nephrotic syndrome.Methods: A 6-year-old female Caucasian child was diagnosed with nephrotic syndrome and treated with oral prednisolone (60 mg/day). Seven days later the child initiated complaints of headache, vomiting, ocular pain, and photophobia. Ophthalmologic examination revealed a severely increased intraocular pressure (IOP) of 52 mmHg in the right eye and 56 mmHg in the left eye. Anterior segment morphology was evaluated with ultrasound biomicroscopy. Optic disc status was evaluated by disc photography, kinetic perimetry, and optical coherence tomography.Results: Treatment was initiated with latanoprost, brimonidine, and the fixed association of timolol and dorzolamide. At each follow-up examination, progressively better control of IOP was obtained. Simultaneous with corticosteroid dosage decrease we were able to reduce antiglaucomatous medication while maintaining IOP under control. Ultrasound biomicroscopy revealed an open angle with normal anterior segment echographic findings. Perimetric evaluation revealed normal visual fields in both eyes. Four months after presentation, steroid treatment had been completed and IOP was 10 mmHg in both eyes without any antiglaucomatous medication. Optical coherence tomography revealed normal retinal nerve fiber layer thickness in all peripapillary sectors.Conclusions: Systemic steroid treatment can cause a severe, acute increase in IOP in children. Children undergoing steroid treatment should have routine ophthalmologic examinations during treatment duration. Prompt antiglaucomatous treatment prevents retinal nerve fiber layer damage and visual acuity loss.Keywords: glaucoma, children, corticosteroid, nephrotic

The aim of this retrospective study was to evaluate if, in ocular normotensive patients, at the time of diagnosis of optic nerve head drusen (ONHD), perimetric mean deviation (PMD) on visual field (VF) examination and retinal nerve fibre layer (RNFL) thickness on optical coherence tomography correlated with intraocular pressure (IOP). There was a significant association between IOP and PMD (Spearman's rho = −0.863, p <.01) and between IOP and RNFL thickness (Spearman's rho = −0.630, p <.01). A higher IOP was associated with a greater functional loss in the VF and a reduction in the RNFL thickness. These results suggest that a clinical trial of IOP reduction should be considered in patients with ONHD to decrease the progression of optic nerve damage over time. [ABSTRACT FROM AUTHOR]