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Joana Santos-Oliveira,1 Rita Teixeira-Martins,1 Ana Margarida Ferreira,1 João Paulo Macedo,1 Cláudia Oliveira-Ferreira1,2 1Department of Ophthalmology, Centro Hospitalar Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, PortugalCorrespondence: Joana Santos-Oliveira, Department of Ophthalmology, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, Email joana.santos.oliveira@ulssjoao.min-saude.ptPurpose: Ozurdex® is a dexamethasone intravitreal implant approved for the treatment of macular edema secondary to branch or central retinal vein occlusion, non-infectious uveitis affecting the posterior segment of the eye, and diabetic macular edema.Patients and Methods: We report a case of an accidental injection of the implant into the crystalline lens, successfully managed by surgery afterwards. The case description is supported by Anterior Segment Optical Coherence Tomography (AS-OCT) images.Results: A 69-year-old male was observed for bilateral diabetic macular edema. He had previously been treated with bevacizumab and aflibercept, with an incomplete anatomical response (< 20% reduction in central macular thickness). The patient consented to undergo a bilateral intravitreal dexamethasone injection (dexamethasone intravitreal implant (0.7 mg)). The procedures were uneventful, except for an extensive conjunctival hemorrhage in the right eye. An appointment was scheduled for fifteen days later, however the patient missed it. Four months later, he referred OD vision loss, which occurred a few days after the injection, and the implant was found within the right crystalline lens. An AS-OCT was done to better understand the implant’s location and entry point. Due to decreased visual acuity, the patient was scheduled for surgery. A phacoemulsification surgery with a three-piece hydrophobic intraocular lens implantation in the sulcus associated with anterior vitrectomy was done.Conclusion: The injection of a dexamethasone implant is becoming increasingly common. Nonetheless, it must always be carried out carefully, to avoid complications. If the implant is accidentally injected into the crystalline lens, the AS-OCT can help determine its exact location, which is important for preparing the surgical plan and determining the appropriate timing.Keywords: crystalline, intravitreal injections, lens, macular edema

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

Rodrigo Vilares-Morgado,1,2 Ana Margarida Ferreira,1,2 Ana Maria Cunha,1,2 Raúl Moreira,1,2 Luís Torrão,1,2 Pedro Neves-Cardoso,1,2 João Pinheiro-Costa1– 3 1Department of Ophthalmology, Centro Hospitalar Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine of Porto University, Porto, Portugal; 3Department of Biomedicine, Faculty of Medicine of Porto University, Porto, PortugalCorrespondence: Rodrigo Vilares-Morgado, Department of Ophthalmology, Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, Porto, 4202-451, Portugal, Tel +351 914 471 067, Fax +351 225 512 100, Email vilaresmorgador@gmail.comPurpose: To report the 4-year outcomes of transepithelial accelerated corneal collagen crosslinking (TE-ACXL) in the treatment of eyes with progressive keratoconus (KC).Methods: Eyes of patients who underwent TE-ACXL (6mW/cm2 for 15 minutes) for progressive KC and presented 48 months of follow-up were included. Corrected distance visual acuity (CDVA), keratometry measurements (Kmax, maximum keratometry, Kmean, mean keratometry and Astg, corneal astigmatism), thinnest corneal thickness (PachyMin), and topographic, and tomographic indices (specifically the posterior radius of curvature from the 3.0 mm centered on the thinnest point of the cornea (PRC), and the D-index) were analysed preoperatively and every 12 months after TE-ACXL, up to 48 months. Progression after TE-ACXL was considered when eyes presented ≥ 1 criteria: (1) increase of ≥ 1D in Kmax or increase of ≥ 0.75D in Kmean or increase of ≥ 1D in Astg; (2) reduction of ≥ 0.085 mm in PRC; (3) decrease ≥ 5% in PachyMin.Results: 41 eyes from 30 patients were included, with a mean age at crosslinking of 20.90± 4.69 years. There was a significant increase in Kmean (+0.64± 1.04 D, p< 0.001; +0.98 ± 1.49 D, p< 0.001; +1.27± 2.01 D, p< 0.001; +1.13± 2.00 D, p=0.006) and a significant decrease in PRC throughout follow-up (− 0.12± 0.22, p=0.002; − 0.15± 0.24, p< 0.001; − 0.17± 0.43, p=0.021; − 0.16± 0.43, p=0.027). PachyMin decreased significantly at 36 and 48 months (− 8.50± 15.93 μm, p=0.004; − 7.82± 18.37, p=0.033). According to our progression criteria, there was a major progression rate throughout follow-up (57.1%, 61.1%, 58.8%, and 67.9%, respectively). Surgery and follow-up were uneventful in all subjects. Eleven eyes (26.8%) required further procedures, ≥ 36 months after the initial TE-ACXL, due to persistent progressive disease.Conclusion: TE-ACXL proved to be a safe therapeutic option for progressive KC. However, its efficacy is deemed unsatisfactory, as a notable proportion of affected eyes may continue to advance within a 4-year timeframe, necessitating additional procedures to halt the disease’s course.Keywords: progressive keratoconus, trans-epithelial corneal crosslinking, epi-on crosslinking, keratoconus progression

Rodrigo Vilares-Morgado,1,2 Vera Correia,3 Ana Margarida Ferreira,1 Flávio Alves,1 António Benevides Melo,1,3 Sérgio Estrela-Silva,1,3 Joana Araújo,1,3 João Tavares-Ferreira,1,3 Marta Silva,1 Amândio Rocha-Sousa,1,2 Angela Carneiro,1,2 João Barbosa-Breda1,2,4 1Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Porto, Portugal; 2UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; 3Faculty of Medicine, University of Porto, Porto, Portugal; 4KULeuven, Research Group Ophthalmology, Department of Neurosciences, Leuven, BelgiumCorrespondence: Rodrigo Vilares-Morgado, Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Alameda Professor Hernâni Monteiro, 4202 – 451, Porto, Portugal, Tel +351 914 471 067, Fax +351 225 512 100, Email vilaresmorgador@gmail.comPurpose: To evaluate whether repeated intravitreal injections (IVI) with an anti-vascular endothelial growth factor (anti-VEGF) agent are associated with glaucomatous progression in eyes with glaucoma spectrum diseases (GSD).Methods: Single-center, retrospective, longitudinal study of patients with bilateral and similar GSD who: (1) received ≥ 8 IVI in only one eye during the study period; (2) had ≥ 2 retinal nerve fiber layer thickness (RNFL) measurements obtained by spectral-domain optical coherence tomography (SD-OCT) at least 12 months apart. The primary outcome was the absolute RNFL thickness change, comparing injected and fellow uninjected eyes. Linear mixed effects models were constructed, including a multivariable model.Results: Sixty-eight eyes from 34 patients were included, 34 injected and 34 fellow uninjected eyes. Average baseline age was 67.68± 21.77 years with a follow-up of 3.66± 1.89 years and 25.12± 14.49 IVI. RNFL thickness decreased significantly from 80.92± 15.78 to 77.20± 17.35 μm (p< 0.001; − 1.18± 1.93 μm/year) in injected eyes and from 79.95± 17.91 to 76.61± 17.97 μm (p< 0.001; − 1.07± 0.98 μm/year) in uninjected eyes. In a multivariable linear mixed model of injected eyes, only higher baseline RNFL thickness (p < 0.001) significantly predicted higher absolute RNFL thickness loss. Neither absolute RNFL thickness variation (p=0.716) nor RNFL rate (p=0.779) was significantly different between paired injected and uninjected eyes. Absolute IOP variation was not significantly different between groups (16.62± 4.77 to 15.09± 4.34 mmHg in injected eyes and 17.68± 5.01 to 14.50± 3.39 mmHg in fellow uninjected eyes; p=0.248). The proportion of eyes receiving glaucoma medical treatment increased significantly in both groups (55.9% to 76.5% in injected eyes; p=0.039; 58.8% to 76.5% in uninjected eyes; p = 0.031). The number of glaucoma medications also increased significantly in both groups (1.03± 1.11 to 1.59± 1.18 glaucoma medications in injected eyes; p=0.003; 1.09± 1.11 to 1.56± 1.19 glaucoma medications in uninjected eyes; p=0.003).Conclusion: Repeated IVI do not seem to accelerate glaucomatous progression. Future studies with a longer follow-up are needed.Keywords: glaucoma, intravitreal injections, progression, optical coherence tomography, retinal nerve fiber layer thickness

António M Ferreira,1,2 Francisco Costa,2 António Tralhão,2 Hugo Marques,3 Nuno Cardim,1 Pedro Adragão1,2 1Cardiology Department, Hospital da Luz, 2Cardiology Department, Hospital Santa Cruz- CHLO, 3Radiology Department, Hospital da Luz, Lisbon, Portugal Abstract: Use of both magnetic resonance imaging (MRI) and pacing devices has undergone remarkable growth in recent years, and it is estimated that the majority of patients with pacemakers will need an MRI during their lifetime. These investigations will generally be denied due to the potentially dangerous interactions between cardiac devices and the magnetic fields and radiofrequency energy used in MRI. Despite the increasing reports of uneventful scanning in selected patients with conventional pacemakers under close surveillance, MRI is still contraindicated in those circumstances and cannot be considered a routine procedure. These limitations prompted a series of modifications in generator and lead engineering, designed to minimize interactions that could compromise device function and patient safety. The resulting MRI-conditional pacemakers were first introduced in 2008 and the clinical experience gathered so far supports their safety in the MRI environment if certain conditions are fulfilled. With this technology, new questions and controversies arise regarding patient selection, clinical impact, and cost-effectiveness. In this review, we discuss the potential risks of MRI in patients with electronic cardiac devices and present updated information regarding the features of MRI-conditional pacemakers and the clinical experience with currently available models. Finally, we provide some guidance on how to scan patients who have these devices and discuss future directions in the field. Keywords: pacemakers, magnetic resonance imaging, MRI, MRI-conditional devices, safety

Danay Dupeyrón,1,2 Monique Kawakami,1 Adriana M Ferreira,1 Paolin Rocio Cáceres-Vélez,3 Jacques Rieumont,4 Ricardo Bentes Azevedo,3 José Carlos T Carvalho1 1Laboratório de Pesquisa em Fármacos, Centro de Ciências Biológicas e da Saúde, Colegiado de Farmácia, Universidade Federal do Amapá, Brazil; 2Programa de Pós-Graduação em Biodiversidade Tropical, Universidade Federal do Amapá, Brazil; 3Departamento de Genética e Morfologia, Instituto de Ciências Biológicas, Universidade de Brasília, Brazil; 4Departamento de Química – Física, Facultad de Química, Universidad de la Habana, Cuba Abstract: Despite recent advances in nonsteroidal anti-inflammatory drug (NSAID) formulations, the design of targeted delivery systems to improve the efficacy and reduce side effects of NSAIDs continues to be a focus of much research. Enteric nanoparticles have been recognized as a potential system to reduce gastrointestinal irritations caused by NSAIDs. The aim of this study was to evaluate the effect of EUDRAGIT® L100, polyethylene glycol, and polysorbate 80 on encapsulation efficiency of indomethacin within enteric nanoparticles. Formulations were developed based on a multilevel factorial design (three factors, two levels). The amount of polyethylene glycol was shown to be the factor that had the greatest influence on the encapsulation efficiency (evaluated response) at 95% confidence level. Some properties of nanoparticles like process yield, drug–polymer interaction, particle morphology, and in vitro dissolution profile, which could affect biological performance, have also been evaluated. Keywords: nonsteroidal anti-inflammatory, indomethacin, enteric polymer, polyethylene glycol, nanoparticles

Background: Emergence of polyantimicrobial resistant strains of hospital pathogens has presented a challenge in the provision of good quality in-patient care. Inappropriate use of antibiotics in the hospital is largely responsible for this catastrophe. Bacteriological surveillance of the cases of nosocomial infections is crucial for framing an evidence-based antimicrobial policy for a hospital. Materials and Methods: A prospective study was undertaken among 498 patients from medicine and surgery wards in a tertiary teaching hospital in Goa. The patients were followed up clinico-bacteriologically for the occurrence of nosocomial infections (NI). Antibiotic susceptibility testing was done using Kirby-Bauer disc diffusion method. Results: The overall infection rate was 33.93 ± 4.16 infections per 100 patients. Urinary tract infection was the most common NI (26.63%), followed by surgical site infection (23.67%), wound infection (23%) and nosocomial pneumonia (18.34%). Ninety-seven percent of the isolates were bacterial, while the others were fungal. More than 80% of the NIs were caused by Gram-negative bacteria, predominantly Pseudomonas aeruginosa, Escherichia coli and Aceinetobacter baumanii . Almost 70% of the isolates were resistant to all the antibiotics for which susceptibility was tested; the rest were sensitive to amikacin, cefoperazone-sulbactam and other antibiotics including methicillin, co-trimoxazole, teicoplenin, vancomycin and rifampicin, either singly or in combination. The proportion of MRSA was 71.4%. Resistance to a particular antibiotic was found to be directly proportional to the antibiotic usage in the study setting. Conclusion: Surveillance of nosocomial infections with emphasis on the microbiologic surveillance and frequent antimicrobial audit are critical towards curbing the evil of polyantimicrobial resistant nosocomial infections in a hospital.

Purpose: Adequate preparation of abutment teeth for removable partial denture (RPD) rest seats allows appropriate masticatory force transmission, retention, and stability of supporting structures. It follows that careful preparation will be important for the longevity of the rehabilitation. The present study aimed to clinically evaluate rest seats and undercut areas of abutment teeth in RPD wearers after 2 years of use., Materials and Methods: A total of 193 occlusal, incisal, and cingulum rest seats were evaluated in terms of shape, rest adaptation, wear, caries, fractures, and surface type (enamel, composite resin, or amalgam). Two hundred and fourteen undercut areas were evaluated in terms of surface type (enamel or restoration) and integrity. This study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte, resolution 196/1996, protocol number 11/05., Results: Intact preparations accounted for 92.2% of the total. Application of the Pearson test (p= 0.289) found no statistically significant differences among the materials on which the rest seats were prepared. For the undercut areas, 20.7% of those obtained on restorative material were nonintact. In addition, Fisher's exact test showed a statistically significant difference (p= 0.001) in surface type; enamel surfaces were shown to be 14 times more stable than restored surfaces., Conclusions: The results of this study suggest that rest seats are stable, regardless of the material on which they are prepared. Retentive areas were shown to be more stable when they were located in enamel., (© 2011 by the American College of Prosthodontists.)