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1 Revista Brasileira de Oftalmologia PUBLICAÇÃO OFICIAL: SOCIEDADE BRASILEIRA DE OFTALMOLOGIA SOCIEDADE BRASILEIRA DE CATARATA E IMPLANTES INTRAOCULARES SOCIEDADE BRASILEIRA DE CIRURGIA REFRATIVA 191 ISSN (Versão impressa) ISSN (Versão eletrônica) Sociedade Brasileira de Oftalmologia WEB OF SCIENCE Indexada nas bases de dados: SciELO Scientific Electronic Library OnLine Disponível eletronicamente: LILACS Literatura Latinoamericana em Ciências da Saúde Coordenação de Aperfeiçoamento de Pessoal de Nível Superior Publicação bimestral Rev Bras Oftalmol, v. 73, n. 4, p , Jul./Ago Editor Chefe Newton Kara-Junior (SP) Editor Executivo Arlindo José Freire Portes (RJ) Co-editores André Luiz Land Curi (RJ) Arlindo José Freire Portes (RJ) Bruno Machado Fontes (RJ) Carlos Eduardo Leite Arieta (SP) Hamilton Moreira (PR) Liana Maria Vieira de Oliveira Ventura (PE) Marcony Rodrigues de Santhiago (RJ) Mario Martins dos Santos Motta (RJ) Maurício Maia (SP) Niro Kasahara (SP) Renato Ambrósio Jr. (RJ) Rodrigo Jorge (SP) Rodrigo Pessoa Cavalcanti Lira (PE) Silvana Artioli Schellini (SP) Walton Nosé (SP) Corpo Editorial Internacional Baruch D. Kuppermann - Califórnia - EUA Christopher Rapuano - Phyladelphia - EUA Curt Hartleben Martkin - Colina Roma - México Daniel Grigera - Olivos - Argentina Deepinder Kauer Dhaliwal - Pittsburg - EUA Felipe A. A. Medeiros - Califórnia - EUA Felix Gil Carrasco - México México Fernando Arevalo - Riyadh - Arábia Saudita Francisco Rodríguez Alvira Bogotá - Colombia Howard Fine - Eugene - EUA Jean Jacques De Laey - Ghent - Bélgica Kevin M. Miller - Califórnia - EUA Lawrence P. Chong - Califórnia - EUA Lihteh Wu San José - Costa Rica Liliana Werner - Utah - EUA Miguel Burnier Jr. - Montreal - Canadá Pablo Cibils - Assunção - Paraguai Patricia Mitiko Santello Akaishi Arábia Saudita Peter Laibson - Phyladelphia - EUA Steve Arshinoff - Toronto - Canadá Corpo Editorial Nacional A. Duarte - Rio de Janeiro - RJ Abelardo de Souza Couto - Rio de Janeiro- RJ Abrahão da Rocha Lucena - Fortaleza - CE Alexandre Augusto Cabral de Mello Ventura - Recife - PE Alexandre H. Principe de Oliveira Salvador BA Alexandre Seminoti Marcon Porto Alegre - RS Ana Carolina Cabreira Vieira Rio de Janeiro RJ Ana Luisa Hofling de Lima - São Paulo - SP André Correa de Oliveira Romano Americana - SP André Curi - Rio de Janeiro - RJ André Luis Freire Portes - Rio de Janeiro - RJ André Marcio Vieira Messias Ribeirão Preto SP Andrea Kara José Senra - São Paulo SP Antonio Marcelo Barbante Casella - Londrina - PR Armando Stefano Crema- Rio de Janeiro- RJ Beatriz de Abreu Fiuza Gomes Rio de Janeiro - RJ Bruna Vieira Ventura - Recife - PE Bruno Diniz Goiânia - GO Carlos Augusto Moreira Jr.- Curitiba- PR Carlos Gabriel Figueiredo - São José do Rio Preto - SP Carlos Ramos de Souza Dias- São Paulo- SP Claudio do Carmo Chaves - Manaus - AM Cristiano Caixeta Umbelino - São Paulo - SP Daniel Lavinsky Porto Alegre - RS David Leonardo Cruvinel Isaac Goiania - GO Diego Tebaldi Q. Barbosa - São Paulo - SP Edmundo Frota De Almeida Sobrinho- Belém- PA Eduardo Buchele Rodrigues Florianópolis - SC Eduardo Cunha de Souza São Paulo - SP Eduardo Damasceno - Rio de Janeiro - RJ Eduardo Dib Rio de Janeiro - RJ Eduardo Ferrari Marback- Salvador- BA Eliezer Benchimol - Rio de Janeiro - RJ Enzo Augusto Medeiros Fulco Jundiaí - SP Eugenio Santana de Figueiredo Juazeiro do Norte - CE Fábio Marquez Vaz Ondina BA Felipe Almeida - Ribeirão Preto - SP Fernando Cançado Trindade - Belo Horizonte- MG Fernando Marcondes Penha - Florianópolis - SC Fernando Oréfice- Belo Horizonte- MG Fernando Roberte Zanetti Vitória - ES Flavio Rezende- Rio de Janeiro- RJ Francisco de Assis Cordeiro Barbosa - Recife - PE Frederico Valadares de Souza Pena Rio de Janeiro - RJ Frederico Guerra - Niterói - RJ Giovanni N.U.I.Colombini- Rio de Janeiro- RJ Guilherme Herzog Neto- Rio de Janeiro- RJ Harley Biccas - Ribeirão Preto - SP Haroldo Vieira de Moraes Jr.- Rio de Janeiro- RJ Hélcio Bessa - Rio de Janeiro - RJ Helena Parente Solari - Niterói - RJ Heloisa Helena Abil Russ Curitiba PR Henderson Celestino de Almeida- Belo Horizonte- MG Hilton Arcoverde G. de Medeiros- Brasilia- DF Homero Gusmao de Almeida- Belo Horizonte- MG Italo Mundialino Marcon- Porto Alegre- RS Iuuki Takasaka Santa Isabel - SP Ivan Maynart Tavares - São Paulo - SP Jaco Lavinsky - Porto Alegre - RS Jair Giampani Junior Cuiabá - MT Jeffersons Augusto Santana Ribeiro - Ribeirão Preto - SP João Borges Fortes Filho- Porto Alegre- RS João Luiz Lobo Ferreira Florianópolis SC João Marcelo de Almeida G. Lyra - Maceió - AL João Orlando Ribeiro Goncalves- Teresina- PI Jorge Carlos Pessoa Rocha Salvador BA JorgeAlberto de Oliveira - Rio de Janeiro - RJ José Augusto Cardillo Araraquara SP José Beniz Neto - Goiania - GO José Ricardo Carvalho L. Rehder- São Paulo- SP Laurentino Biccas Neto- Vitória- ES Leonardo Akaishi - Brasília - DF Leonardo Provetti Cunha - SP Leticia Paccola - Ribeirão Preto - SP Liana Maria V. de O. Ventura- Recife- PE Luiz Alberto Molina - Rio de Janeiro - RJ Manuel Augusto Pereira Vilela- Porto Alegre- RS Marcelo Hatanaka São Paulo SP Marcelo Netto - São Paulo - SP Marcelo Palis Ventura- Niterói- RJ Marcio Bittar Nehemy - Belo Horizonte - MG Marco Antonio Bonini Filho - Campo Grande - MS Marco Antonio Guarino Tanure - Belo Horizonte - MG Marco Antonio Rey de Faria- Natal- RN Marcos Pereira de Ávila - Goiania - GO Maria de Lourdes Veronese Rodrigues- Ribeirão Preto- SP Maria Rosa Bet de Moraes Silva- Botucatu- SP Maria Vitória Moura Brasil - Rio de Janeiro - RJ Mário Genilhu Bomfim Pereira - Rio de Janeiro - RJ Mario Luiz Ribeiro Monteiro - São Paulo- SP Mário Martins dos Santos Motta- Rio de Janeiro- RJ Marlon Moraes Ibrahim Franca - SP Mauricio Abujamra Nascimento Campinas - SP Maurício Bastos Pereira - Rio de Janeiro - RJ Maurício Dela Paolera - São Paulo - SP Miguel Ângelo Padilha Velasco- Rio de Janeiro- RJ Miguel Hage Amaro - Belém - PA Milton Ruiz Alves- São Paulo- SP Moyses Eduardo Zadjdenweber - Rio de Janeiro - RJ Nassim da Silveira Calixto- Belo Horizonte- MG Nelson Alexandre Sabrosa - Rio de Janeiro RJ Newton Kara-José - São Paulo - SP Newton Leitão de Andrade Fortaleza CE Núbia Vanessa dos Anjos Lima Henrique de Faria - Brasília-DF Octaviano Magalhães Júnior - Atibaia - SP Oswaldo Moura Brasil- Rio de Janeiro- RJ Otacílio de Oliveira Maia Júnior Salvador - BA Patrick Frensel de Moraes Tzelikis Brasília DF Paulo Augusto de Arruda Mello Filho São Paulo SP Paulo Augusto de Arruda Mello- São Paulo- SP Paulo Schor - São Paulo - SP Pedro Carlos Carricondo São Paulo SP Pedro Duraes Serracarbassa São Paulo SP Priscilla de Almeida Jorge Recife PE Rafael Ernane Almeida Andrade - Itabuna BA Raul N. G. Vianna - Niterói - RJ Remo Susanna Jr.- São Paulo- SP Renata Rezende - Rio de Janeiro - RJ Renato Ambrosio Jr.- Rio de Janeiro- RJ Renato Luiz Nahoum Curi- Niterói- RJ Richard Yudi Hida São Paulo SP Riuitiro Yamane - Niterói - RJ Roberto Lorens Marback - Salvador - BA Roberto Pinto Coelho Ribeirão Preto SP Rodrigo França de Espíndola São Paulo SP Rogerio Alves Costa- Araraquara- SP Rogerio de Almeida Torres - Curitiba - PR Rubens Belfort Neto São Paulo SP Rubens Camargo Siqueira- São José do Rio Preto- SP Sebastião Cronemberger So.- Belo Horizonte- MG Sérgio Henrique S. Meirelles- Rio de Janeiro- RJ Sérgio Kwitko - Porto Alegre - RS Sérgio Luis Gianotti Pimentel São Paulo SP Silvana Artioli Schellini - Botucatu- SP Suel Abujamra- São Paulo - SP Suzana Matayoshi - São Paulo - SP Tânia Mara Cunha Schaefer Curitiba PR Vitor Cerqueira - Rio de Janeiro - RJ Walter Yukihiko Takahashi São Paulo SP Walton Nose- São Paulo- SP Wener Passarinho Cella - Plano Piloto - DF Wesley Ribeiro Campos- Passos- MG Yoshifumi Yamane- Rio de Janeiro- RJ Redação: Rua São Salvador, 107 Laranjeiras CEP Rio de Janeiro - RJ Tel: (0xx21) Fax: (0xx21) Tiragem: exemplares Edição:Bimestral Secretaria: Marcelo Diniz Editoração Eletrônica: Sociedade Brasileira de Oftalmologia Responsável: Marco Antonio Pinto DG 25341RJ Publicidade: Sociedade Brasileira de Oftalmologia Responsável: João Diniz Contato publicitário: Westinghouse Carvalho Tel: (11) / Revisão: Eliana de Souza FENAJ-RP 15638/71/05 Normalização: Edna Terezinha Rother Assinatura Anual: R$420,00 ou US$280,00 Impressão: Gráfica Stamppa Associada a ABEC - Associação Brasileira de Editores Científicos

2 192 Revista Brasileira de Oftalmologia Rua São Salvador, Laranjeiras - CEP Rio de Janeiro - RJ Tels: (0xx21) Fax: (0xx21) Revista Brasileira de Oftalmologia, ISSN , é uma publicação bimestral da Sociedade Brasileira de Oftalmologia Diretoria da SBO Presidente Marcus Vinicius Abbud Safady (RJ) Vice-presidentes Elisabeto Ribeiro Goncalves (MG) Fabíola Mansur de Carvalho (BA) João Alberto Holanda de Freitas (SP) Ricardo Lima de Almeida Neves (RJ) Tania Mara Cunha Schaefer (PR) Secretário Geral André Luis Freire Portes (RJ) 1º Secretário Sérgio Henrique S. Meirelles (RJ) 2º Secretário Giovanni N. U. I. Colombini (RJ) Tesoureiro Gilberto dos Passos (RJ) Diretor de Cursos Arlindo José Freire Portes (RJ) Diretor de Publicações Newton Kara-Junior (SP) Diretor de Biblioteca Armando Stefano Crema (RJ) Conselho Consultivo Membros eleitos Jacó Lavinsky (RS) Paulo Augusto de Arruda Mello (SP) Roberto Lorens Marback (BA) Conselho Fiscal Efetivos Francisco Eduardo Lopes Lima (GO) Leiria de Andrade Neto (CE) Roberto Pedrosa Galvão (PE) Suplentes Eduardo Henrique Morizot Leite (RJ) Jorge Alberto Soares de Oliveira (RJ) Mizael Augusto Pinto (RJ) SOCIEDADES FILIADAS À SOCIEDADE BRASILEIRA DE OFTALMOLOGIA Associação Brasileira de Banco de Olhos e Transplante de Córnea Presidente: Ari de Souza Pena Associação Maranhense de Oftalmologia Presidente: Romero Henrique Carvalho Bertand Associação Matogrossense de Oftalmologia Presidente: Maurício Donatti Associação Pan-Americana de Banco de Olhos Presidente: Luciene Barbosa de Souza Associação Paranaense de Oftalmologia Presidente: Otavio Bisneto Associação Rondoniense de Oftalmologia Presidente: Lhano Fernandes Adorno Associação Sul Matogrossense de Oftalmologia Presidente: Elson Yamasato Sociedade Alagoana de Oftalmologia Presidente: Mário Jorge Santos Sociedade Brasileira de Administração em Oftalmologia Presidente: Flávio Rezende Sociedade Brasileira de Catarata e Implantes Intraoculares Presidente: Armando Crema Sociedade Brasileira de Cirurgia Plástica Ocular Presidente: Ricardo Morschbacher Sociedade Brasileira de Cirurgia Refrativa Presidente: Renato Ambrósio Jr. Sociedade Brasileira de Ecografia em Oftalmologia Presidente: Norma Allerman Sociedade Brasileira Glaucoma Presidente: Francisco Lima Sociedade Capixaba de Oftalmologia Presidente: Cesar Ronaldo Vieira Gomes Sociedade Catarinense de Oftalmologia Presidente: Ramon Coral Ghanem Sociedade Cearense de Oftalmologia Presidente: Dácio Carvalho Costa Sociedade Goiana de Oftalmologia Presidente: Lúcia Helena Meluzzi Sociedade Norte-Nordeste de Oftalmologia Presidente: Francisco de Assis Cordeiro Barbosa Sociedade de Oftalmologia do Amazonas Presidente: Leila Suely Gouvea José Sociedade de Oftalmologia da Bahia Presidente: André Hasler Príncipe de Oliveira Sociedade de Oftalmologia do Nordeste Mineiro Presidente: Mauro César Gobira Guimarães Sociedade de Oftalmologia de Pernambuco Presidente: João Pessoa de Souza Filho Sociedade de Oftalmologia do Rio Grande do Norte Presidente: Ricardo Maia Diniz Sociedade de Oftalmologia do Rio Grande do Sul Presidente: Afonso Reichel Pereira Sociedade de Oftalmologia do Sul de Minas Presidente: Mansur Elias Ticly Junior Sociedade Paraense de Oftalmologia Presidente: Lauro José Barata de Lima Sociedade Paraibana de Oftalmologia Presidente: Saulo Zanone Lemos Neiva Sociedade Piauiense de Oftalmologia Maria de Lourdes Cristina Alcântara Paz Carvalho do Nascimento Sociedade Sergipana de Oftalmologia Presidente: Bruno Campelo

3 Revista Brasileira de Oftalmologia 193 ISSN (Versão impressa) ISSN (Versão eletrônica) PUBLICAÇÃO OFICIAL: SOCIEDADE BRASILEIRA DE OFTALMOLOGIA SOCIEDADE BRASILEIRA DE CATARATA E IMPLANTES INTRAOCULARES SOCIEDADE BRASILEIRA DE CIRURGIA REFRATIVA Fundada em 01 de junho de 1942 CODEN: RBOFA9 Indexada nas bases de dados: WEB OF SCIENCE SciELO Scientific Electronic Library OnLine Disponível eletronicamente: LILACS Literatura Latinoamericana em Ciências da Saúde Coordenação de Aperfeiçoamento de Pessoal de Nível Superior Publicação bimestral Rev Bras Oftalmol, v. 73, n. 4, p , Jul./Ago Editorial 195 Teaching standardization in ophthalmology A padronização do ensino em oftalmologia Newton Kara-Junior 197 Advances in ophthalmic viscosurgical devices in phacoemulsification Avanços em substâncias viscoelásticas na facoemulsificação Rodrigo França de Espíndola Original Articles Contents - Sumário 199 Analysis of ocular cyclotorsion in lying position after peribulbar block and topical anesthesia Análise da ciclotorção ocular em posição supina após bloqueio peribulbar e anestesia tópica Newton Kara-Junior, Paula C. Mourad, Renata L. B. Moraes, Caroline Piva, Marcony Rodrigues Santhiago 202 Surgical treatment of congenital blepharoptosis Tratamento cirúrgico da blefaroptose congênita Suzana Matayoshi, Ivana Cardoso Pereira, Luiz Angelo Rossato 210 Increased intercellular adhesion molecule-1 immunoreactivity in the sclera-choroid complex in hypercholesterolemia experimental model Aumento da imunorreatividade da molécula de adesão intercelular-1 na esclera e coroide em modelo experimental de hipercolesterolemia Rogil José de Almeida Torres, Lucia de Noronha, Regiane do Rocio de Almeida Torres, Seigo Nagashima, Caroline Luzia de Almeida Torres, Andréa Luchini, Robson Antônio de Almeida Torres, Leonardo Brandão Précoma, Dalton Bertolim Précoma

4 Visual acuity evaluation in children of the elementary school of Curitiba Relação entre acuidade visual e condições de trabalho escolar em crianças de um colégio do ensino fundamental público de Curitiba Carlos Augusto Moreira Neto, Ana Tereza Ramos Moreira, Luciane Bugmann Moreira 220 Visual prognosis of crosslinking for kearatoconus based on preoperative corneal tomography Prognóstico visual de crosslinking para ceratocone com base em tomografia de córnea pré-operatória Bernardo Lopes, Isaac Ramos, Tobias Koller, Theo Seiler,Renato Ambrósio Jr 225 Prevalence of eye diseases and refractive errors in children seen at a referral center for ophthalmology in the central-west region, Brazil Prevalência de doenças oculares e causas de comprometimento visual em crianças atendidas em um Centro de Referência em Oftalmologia do centro-oeste do Brasil Maria Nice Araujo Moraes Rocha; Marcos Pereira de Ávila; David Leonardo Cruvinel Isaac; Luisa Salles de Moura Mendonça; Liene Nakanishi; Luisa Jácomo Auad 230 Intraocular pressure (IOP) after cataract extraction surgery Pressão intraocular (PIO) após cirurgia de extração de catarata Maria Picoto, José Galveia, Ana Almeida, Sara Patrício, Helena Spohr, Paulo Vieira, Fernanda Vaz Review Article Case Reports Errata 237 Donation and waiting list for corneal transplantation in the State of Rio de Janeiro Doação e fila de transplante de córnea no Estado do Rio de Janeiro Gustavo Bonfadini, Victor Roisman, Rafael Prinz, Rodrigo Sarlo, Eduardo Rocha, Mauro Campos 243 Congenital dacryocystocele: case report and treatment Dacriocistocele congênita: relato de caso e conduta Silvia Helena Tavares Lorena, Eliana Domingues Gonçalves, João Amaro Ferrari Silva 246 Palpebral ptosis caused by Pachydermoperiostosis Ptose palpebral causada por Paquidermoperiostose Patricia Regina de Pinho Tavares, Eduardo de Castro Miranda Diniz, Thomaz Fracon de Oliveira, Mariana Rezende de Oliveira, Ícaro Perez Soares 249 Instructions to authors 250 Guidelines for publication of articles in RBO

5 EDITORIAL 195 Teaching standardization in ophthalmology A padronização do ensino em oftalmologia As in basic education, in which students are divided in grades, so the same content is taught to everyone, this standardized trend is seen among ophthalmologists. In the first years of medical residence, the student learns to examine and to understand how the eye functions. In the third year, he defines some areas of preference and learns how to do surgery. When in specialty stage, he chooses an area of action. From then on, in general, he opts for the progressive hiper-specialty: retina, cataract, glaucoma, cornea, etc (1,2). The pattern of background mentioned above encourages progressive acting, in which the specialist only cares for his area. So, each professional would devote his time and energy to study and act in only one segment. The fast technological development in medicine, with so much available knowledge, favors this pattern. Nevertheless, health should not be treated like an assembling line, where the patients go like in a conveyor from one to another sub specialist, depending on the symptoms. Society would not financially bear the mentioned pattern. Althow the seven billion people Worldwide can only survive because of the optimization of productivity in general, secondary to the division of work in a linear sequence of specialized tasks (assemblig line), due to constant gains of efficacy and standardized products. In the health area, this hierarchy leads to a terrible increase of cost, because the hiper-specialist tends to ask for more and more complex supplementary exams, in order to better evaluate the segment in which his acts, also prescribing clinic and surgical treatments, sometimes hasty ones. There is, therefore, a contradiction, in which the excessive standardization of health would take to the loss of efficiency instead of the desired assistance to the population (3-6). As there are also complex ocular problems which will need a logical and elaborate reasoning from the doctor who understands the function of the eye as a whole and integrates his knowledge of various sub specialties. The background and progressive acting do not encourage and do not train the mechanism of thinking and reflecting concerning the eye, the vision and the patient, because in an assembling line each professional does a short and a repetitive task, so no one has the complete domain of the whole. I do not consider wrong the pattern of medical residence or the option of the ophthalmologist in deepen his studies in a sub specialty. What I suggest is that the option of many colleagues who are still in his training should be reconsidered, because they act in only one area. Many times, we trace our professional projects influenced solely in what is happening nowadays, while we should also try to project them facing a near future. In USA, for instance, hiper-specialty has been discouraged by the government, with a consequent cut in the number of scholarships after residence. Therefore, it is possible that overtime the more valued professional is the ophthalmologist who has a general background and who is prepared to adequately conduct not only classic diseases but also the complex ones, referring only very specific cases. We are sure that the hiper-specialist will never disappear, but maybe there will be a smaller work market, also because technological developments progressively allow that a smaller number of professionals could see a greater number of people. In relation to the more demanding patients, they will always value the professional who discusses the clinical reasoning and explains the problem and the healing possibilities in a coherent manner, or better, will value the ophthalmologist with a good general knowledge and who is trained to reflect about the symptoms, the diseases and the patients needs. The standardized background of the medical residence or the supplementary stage does not generally give priority to the teaching of those characteristics mentioned, but offers the adequate tools for acquiring them, mainly by getting the students closer to the professors in an academic environment. Rev Bras Oftalmol. 2014; 73 (4): 195-6

6 196 Kara-Junior N Nevertheless, I believe that it is in the stage of a fortuitous post-graduation (master or doctorate) that the young doctor will have better conditions of learning and training his reasoning over his practice, for those are the principles of scientific research. While the linear and standardized system of the medical residence train the students, in general, with the same knowledge, the graduate program tends to optimize the individual potential of each student, by opening his mind and preparing him to access knowledge above the text book, knowledge acquired by means of reasoning, and also by giving him means to solve diverse and complex problems. Newton Kara-Junior Chief Editor of Revista Brasileira de Oftalmologia Professor Colaborador, Livre-docente e Professor do Programa de Pós-graduação da Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil. REFERENCES 1. Chamon, W, Schor P/ Teaching ophthalmology to the medical student: a novel approach. Arq Bras Oftalmol. 2012;75(1): Ventura CC, Gomes ML, Carvalho BV, Ventura LO, Brandt CT. Características e deficiências dos programas de pós-graduação em oftalmologia no Brasil segundo pós-graduandos participantes. Rev Bras Oftalmmol. 2012;71 (3): Bar-Yam Y. Making things work. Solving Complex Problems in a Complex World. Cambridge, MA: Nesci Knowledge Press; Nye DE. Amercia s assembly line. Cambridege: MIT Press; Burgierman DR. O mundo está muito complexo. São Paulo: Abril; Estacia P, Reginatto RC, Nunes TT, Silva TM, Pasqualotti A. Avaliação do custo de colírios lubrificantes a base exclusivamente de carboximetilcelulose no mercado brasileiro. Rev Bras Oftalmol. 2013;72(5): Rev Bras Oftalmol. 2014; 73 (4): 195-6

7 EDITORIAL 197 Advances in ophthalmic viscosurgical devices in phacoemulsification Avanços em substâncias viscoelásticas na facoemulsificação Charles Kelman performed the first phacoemulsification (PHACO) procedures in the posterior chamber, but because he wanted surgeons to rapidly learn the technique, he chose to luxate the lens into the anterior chamber, where there was always the risk of endothelial damage if viscoelastic substances (VESs) were not used. 1 In the mid-80s, with the improvement of phacoemulsifiers and the introduction of foldable intraocular lenses (IOLs), VESs, continuous curvilinear capsulotomy, and emulsification of the lens nucleus into the capsular bag, the advantages of PHACO became more clear and the technique gained acceptance among patients. 2,3 VESs were originally described for use in cataract surgery by Miller and Stegmann in The first VES on the market was composed of 1% sodium hyaluronate (Healon) and was released by Pharmacia in that same year. 4 The main functions of VESs are maintaining anterior chamber volume, especially during capsulorhexis, and protecting the endothelium during PHACO. VESs can also increase intraoperative mydriasis, break synechiae, prevent the formation of free radicals, fragment nuclei (viscofracture), facilitate IOL implantation and/or explantation, act as a mechanical barrier against vitreous loss or haemorrhage, help remove nuclear fragments and cortical debris (viscoexpression), and even facilitate visualisation of the anterior chamber during surgery when used on the cornea (positive lens). It is essential for cataract surgeons to know the properties of different VESs, with their advantages and disadvantages, in order to select the appropriate product for each patient. It is often preferable to combine the characteristics of the two types of solutions (cohesive and dispersive) during the different stages of PHACO. The well-established soft shell technique, described by Arshinoff in 1999, combines a low-viscosity (dispersive) viscoelastic with a high-viscosity (cohesive) solution in an outer and an inner layer, respectively. 5 However, it is difficult to combine the different physical properties of different solutions in a single agent. Viscoelastic aqueous solutions are composed of long chains of natural polymers such as sodium hyaluronate, hydroxypropylmethylcellulose (HPMC), and chondroitin sulfate. VESs can be classified according to their physical (or rheological) properties as cohesive or dispersive. Cohesive solutions have a high molecular weight and long molecular chains (high viscosity), forming a compact mass in the anterior chamber and helping maintain space (and pressurisation) during PHACO. Because of this behaviour they can be easily removed at the end of surgery, but they are also more likely to increase intraocular pressure (IOP) by obstructing the trabecular meshwork. 6 Dispersive solutions have a low molecular weight and small molecular chains (low viscosity) which provide high tissue adherence. These solutions are more effective in covering and protecting tissues (especially the endothelium) during PHACO. Their main drawback is that they are more difficult to remove after surgery because they are more fragmented, being aspirated in separate parts; however, they do not increase IOP as much as cohesive VESs. 6 VES selection is based on the surgeon s experience, the surgical case, and available resources. Using more than one type of VES during surgery is preferable in most cases, but it increases the final cost of the procedure. Most surgeons and physicians in training in Brazil do not have access to several types of VES for each patient. Using the correct surgical technique and adequate surgical instruments and phacoemulsifiers can help reduce the need for a variety of solutions. In the latest survey conducted in Brazil in 2009, HPMC was the VES most commonly used by Brazilian surgeons (60.8%), 7 probably due to the low cost of this dispersive agent and its wide use in the Brazilian national health system (SUS) and in patients covered by private insurance plans. In contrast, most American Rev Bras Oftalmol. 2014; 73 (4): 197-8

8 198 Espíndola RF and Canadian surgeons use DuoVisc (39%), followed by DisCoVisc (16%). 8 In the latest survey by the American Society of Cataract and Refractive Surgery (ASCRS), 37% of surgeons used DuoVisc (Viscoat and ProVisc), while only 2% used HPMC. 9 Using a high quality VES can be critical in special situations that require maximum control of the intraoperative environment, including hypermature cataracts, paediatric cases, cornea guttata/fuchs dystrophy, shallow chambers, zonular weakness, small pupils, and floppy iris syndrome. 7,10 In selected cases, health insurance plans and even the Brazilian national health system should provide a greater variety of VESs for surgery. Using a combination of different VESs, as is done by most surgeons in developed countries, not only improves refractive outcomes but also facilitates the surgical technique and promotes better endothelial protection, which is important for the cornea in the medium and long term. In recent years the outcomes of PHACO have been improving due to several innovations. With the advent of femtosecond laser-assisted surgery, cataract surgeons have been improving their outcomes. Studies show that previous laser therapy of the lens nucleus (fracture and softening ) reduces the ultrasound time required to aspirate fragments during PHACO, 11 decreases corneal oedema in the early postoperative period, and provides a faster visual recovery, which translates into benefits for patients. According to some authors, the reduced need for ultrasound during femtosecond laser-assisted surgery means the procedure can be performed using only one type of VES or even without any VES at all. 12 However, VES remains critical for better outcomes, even when laser is used. It is worth noting that in addition to ultrasound times, other variables can affect the corneal endothelium during PHACO, including the biomechanical effects of the saline solution (turbulence and volume) and the direct mechanical trauma caused by surgical instruments, nuclear fragments, and the IOL. VESs minimise the effects of these factors on the endothelium, leading to clearer postoperative corneas. In conclusion, VESs are critical to the success of PHACO, and a combination of VESs with different characteristics should be made available to most surgeons, especially in more challenging cases. Rodrigo França de Espíndola Assistant of Refractive Surgery and Student Program Graduate Assistant, School of Medicine, University of São Paulo, São Paulo, SP, Brazil. REFERENCES 1. Ambrósio R Jr, Crema A. Tratado Brasileiro de Catarata e Cirurgia Refrativa. In: História da cirurgia de catarata. São Paulo: Cultura Médica, Guanabara Koogan; Temporini ER, Kara-Junior N, Holzchuh N; Kara-Jose N. Popular beliefs regarding the treatment of senile cataract. Rev Saúde Pública. 2002;36 (3): Marback RF, Temporini ER, Kara-Junior N. Emotional factors prior to cataract surgery. Clinics. 2007;62(4): Balazs EA, inventor; Biotrics, Inc, assignee. Ultrapure hyaloronic acid and the use thereof. US patent October 17, Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique. J Cataract Refract Surg. 1999; 25(2): Espíndola RF, Castro EFS, Santhiago MR, Kara-Junior N. A clinical comparison between DisCoVisc and 2% hydroxypropylmethylcellulose in phacoemulsification: a fellow eye study. Clinics. 2012;67(9): Santhiago MR, Gomes BAF, Gaffree FFP, Varandas VS, Filho AAC. Tendências evolutivas dos cirurgiões de catarata presentes no IV congresso brasileiro de catarata e cirurgia refrativa. Rev Bras Oftalmol. 2009;68(1): Sorensen T, Chan CC, Bradley M, Braga-Mele R, Olson RJ. A comparison of cataract surgical practices in Canada and the United States. Can J Ophthalmol. 2012;47(2): Leaming DV. Practice styles and preferences of ASCRS members-2003 survey. J Cataract Refract Surg. 2004;30(4): Kara-Junior N, Santhiago MR, Kawakami A, Carricondo PC, Hida WT. Mini-rhexis for white intumescent cataracts. Clinics. 2009;64(4): Alió JL, Abdou AA, Puente AA, Zato MA, Nagy Z. Femtosecond laser cataract surgery: updates on technologies and outcomes. J Refract Surg. 2014; 30(6): Dick HB, Gerste RD, Rivera RP, Schultz T. Femtosecond laser-assisted cataract surgery without ophthalmic viscosurgical devices. J Refract Surg. 2013;29(11): Rev Bras Oftalmol. 2014; 73 (4): 197-8

9 ORIGINAL ARTICLE 199 Analysis of ocular cyclotorsion in lying position after peribulbar block and topical anesthesia Análise da ciclotorção ocular em posição supina após bloqueio peribulbar e anestesia tópica Newton Kara-Junior 1 ; Paula C. Mourad 1 ; Renata L. B. Moraes 2 ; Caroline Piva 3 ; Marcony Rodrigues Santhiago 1 ABSTRACT Purpose: Evaluate the magnitude of cyclotorsion during cataract surgery in patients with indication for intraocular toric lenses comparing the results after peribulbar and after topical anesthesia.methods: This prospective study comprised 112 eyes that underwent cataract surgery with implantation of toric intraocular lens by topical anesthesia or peribulbar block. We estimated how many degrees of cyclotorsion occurred after topical anesthesia and peribulbar block with the patient in supine position. A tag was performed in the position of 180 degrees of the right eye and zero degrees of the left eye, with the patient seated. Afterwards, it was requested a change to the supine position and then a new dial in 180 and zero degrees respectively from right and left eye were made. Results: The current study demonstrated that patients submitted to cataract surgery with implantation of toriclens under local anesthesia showed approximately 6.89 degrees of incyclotorsion (82 eyes) and 6.93 degrees of excyclotorsion (38 eyes) and a mean of cyclotorsion of 6.91 degrees. Patients undergoing peribulbar block showed 5.68 degrees of incyclotorsion (73 eyes) and 4.81 degrees of excyclotorsion (47 eyes) and a mean of cyclotorsion of 4.92 degrees. Conclusion:Through the study we can see that the movement of incyclotorsion in patients undergoing peribulbar anesthesia was lower when compared to topical anesthesia. This is relevant since the greater the incyclotorsion, the lower the predictability of the surgery and the lower the chance of obtaining excellent results in the final refractometric. Kewords:Eye movements; Torsion abnormality; Patient positioning;peribulbar block;anesthesia, local; Administration, topical RESUMO Objetivo: Avaliar a magnitude da ciclotorção durante a cirurgia de catarata em pacientes com indicação de lentes intraoculares tóricas comparando os resultados após o bloqueio peribulbar e após a anestesia tópica. Métodos: Esse estudo prospectivo compreende 112 olhos que foram submetidos à cirurgia de catarata com implante de lente intraocular tórica por meio de anestesia tópica ou bloqueio peribulbar. Foram estimados quantos graus de ciclotorção ocorreu após a anestesia tópica e após o bloqueio peribulbar, com o paciente em posição supina.foi realizada uma marcação na posição de 180 graus do olho direito e zero grau do olho esquerdo, com o paciente sentado, em seguida,houve uma mudançade posição para decúbito dorsal, sendo realizadas novas marcações em 180 e zero graus dos olhos direito e esquerdo, respectivamente. Resultados: O presente estudo demonstrou que pacientes submetidos à facoemulsificação com implante de lente tórica com anestesia tópica apresentaram aproximadamente 6.89 graus de inciclotorção (82 olhos) e 6,93 graus de exciclotorção (38 olhos) com uma média de ciclotorção de 6.91 graus. Já os pacientes submetidos à anestesia peribulbar apresentaram 5.68 graus de inciclotorção(73 olhos) e 4,81 graus de exciclotorção (47 olhos) com uma média de ciclotorção de 4,92. Conclusão: Através do estudo podemos observar que o movimento de inciclotorção em pacientes submetidos à anestesia peribulbar foi menor quando comparado ao da anestesia tópica. Isso se torna relevante uma vez que, quanto maior for a inciclotorção, menor a previsibilidade da cirurgia e menor a chance de obtenção de excelência nos resultados refratométricos finais. Descritores: Movimentos oculares; Anormalidade torsional; Posição do paciente; Anestesia local; Administração tópica 1 Universidade de São Paulo, São Paulo, (SP), Brazil; 2 Hospital Naval Marcílio Dias, Rio de Janeiro (RJ), Brazil; 3 Hospital Federal Bonsucesso, Rio de Janeiro (RJ), Brazil; Study carried out at Departament of Oftalmology, Universidade de São Paulo, São Paulo (SP), Brazil There are no conflicts of interest. Received for publication 16/03/ Accepted for publication 14/04/2014. Rev Bras Oftalmol. 2014; 73 (4):

10 200 Kara-Junior N, Mourad PC, Moraes RLB, Piva C, Santhiago MR INTRODUCTION Cyclotorsions are movements of cyclorotation of the eyes (1). The cyclotorsion of the human eye occurs with movement of the head and body, changing the original position of the corneal axis. A significant different range of cyclotorsion between a lie and a supine position was previously reported as varying from 2 to 7 degrees (2).The measurement of the rotation raised concern among refractive and cataract surgeons especially regarding astigmatism correction where a mistake in the position of the axis will lead to a significant impact in patients visual acuity. Peribulbar block is one of the techniques for anesthesia for cataract surgery and is one of the most popular throughout the world because it is a safe procedure and it s able to warrant a cataract surgery with no pain (3). The objective is not only the analgesia but also ocular akinesia during the surgical procedure. It is believed that after the peribulbar block, the torsional motion of the eye suffers distortions, which could result in consequences if not evaluated prior to surgery procedure (4,5). Toric intraocular lenses (IOLs) are spherocylindrical and correct for corneal astigmatism after cataract surgery. The orientation of the toric IOL in the capsular bag is critical because misalignment negates the desired effect of correcting astigmatism. If, for instance, a toric IOL rotates 30 degrees off the prescribed axis of alignment, there is virtually no correction of astigmatism; if it rotates more than 45 degrees from the prescribed axis, the IOL augments the preoperative ocular cylinder (6). The aim of this prospective study is to determine the amount of ocular cyclotorsion in lie positions after topical anethesia and peribulbar block. METHODS This prospective series of cases included 112 eyes of 112 patients. The study was approved by the ethical committee of University of São Paulo. Exclusion criteria were patients who showed any alteration in ocular extrinsic motility and patients with very shallow or deep orbit, abnormalities of their visual system and their stereopsis less than 40 seconds of arc. Strabismus (especially dissociated vertical divergence, DVD) and any organic eye disease were excluded by thorough ophthalmological examination including biomicroscopy, indirect ophthalmoscopy, refractometry or retinoscopy in cycloplegia, cover test, assessment of ocular motility, prism and cover test, verification of stable, central fixation by using the so called Haidinger Büschel and after image, determination of stereopsis by the Lang stereotest and the Titmus test. The nature of the study had been clearly explained and informed consent was obtained from all subjects before testing. The study follows the tenets of declaration of Helsinki. Perilimbar mark was performed in the position of 180 degrees in right eye and zero degrees of left eye, with the patient seat down, in the immediately sequence requested that the patient lie down, and then a new dial in 180 and zero degrees respectively from right and left eye were made. The angle of rotation of the original mark was recorded after topical anesthesia. After that, the block was performed with peribulbar infiltration of 5mL of anesthetics in access inferotemporal. New measures were taken in lying down position, always with reference to the initial marking in the supine position. Statistical analysis was performed using SPSS for Windows (version 115, SPSS, Inc.). For statistical analysis of visual acuity, LogMAR values were used. Normality was checked using the Kolmogorov-Smirnov test. When parametric analysis was not possible the non-parametric Mann Whitney U test was used to compare data between the two IOL groups. The analysis of primary outcome measures was based on a non-normal distribution of the data. When parametric analysis was possible, the Student s t-test was used to compare the outcomes. All the statistical tests have been conducted at an alpha level of RESULTS This study evaluated 112 eyes of 112 patients and the measured cyclotorsional deviation in supine position, in patients with topical anesthesia was located around 6.89 degrees (82 eyes) of incyclotorsion and 6.93 (38 eyes) degrees of excyclotorsion, with a mean of cyclotorsion located around 6.91 degrees. In patients with peribulbar block, the deviation were located around 5.68 degrees (73 eyes) of incyclotorsion and 4.81 degrees (47 eyes) of excyclotorsion and a mean of cyclotorsion of 4.92 degrees. (p=0.002). Statistical analysis of the different test positions and anesthesia showed less positionaly induced incyclotorsion on patients with peribulbar block. There were also no statistically significant difference between the topical anesthesia and peribulbar block on excyclotorsion (p=0.120). DISCUSSION In this prospective series of 112 consecutive cases we observed that the range of cyclotorsion (incyclotorsion) previously the block, in lie positions was 6.91±2.36 degrees. After the peribulbar block there was a decrease in the cyclotorsion, for 4.92±2.91degrees (p=0.002). These results lead us to suggest that, despite the apparent akinesia achieved with the peribulbar block, the cyclotorsion persists and presents significant different values when compared to topical anesthesia. It is known that a rotation of 6 degrees can reduce the effect of an astigmatic correction by approximately 20% (2,5). Positional induced inexcyclotorsion could be an important factor concerning of astigmatism in refractive surgery. Before performing refractive and cataract surgery correcting astigmatism, the axis of astigmatism is usually measured in seated position, while the procedure of correction itself takes place in a supine position. Positional induced inexcyclotorsion could be an important factor in the outcome of cataract and refractive surgery. Two possible mistakes with clinical significance may occur. Firstly, a simple difference of the axis of astigmatism between the sitting and supine position will lead not only to an erroneous correction of the astigmatism itself, but the whole spherocylindrical correction could be false (7). The refractive outcome of the cylinder correction depends on the accuracy of the axis treatment. For example, a 10-degree Rev Bras Oftalmol. 2014; 73 (4):

11 Analysis of ocular cyclotorsion in lying position after peribulbar block and topical anesthesia 201 axis shift decreases the efficiency of the desired cylinder correction by more than 30%. Even minimal meridional errors can have significant negative refractive consequences, particularly in cases of moderate to high astigmatism (8). Febbraro et al. also evaluated cyclorotationand found that the mean static of cyclotorsionin their study was / degrees, which was statistically significant greater than 0 degrees.the cyclotorsion was less than 5 degrees in 53 eyes (71%), 5 to 9 degrees in 19 eyes (26%) and 10 degrees or more in 2 eyes (3%).Incyclotorsion appeared in 22 eyes (31%) and the mean of rotation was 2.9 degrees. Excyclotorsion ocurred in 42 eyes (60%) and the mean was 3.6 degrees. There were no cyclotorsion in 6 eyes (9). Postural changes, such as moving from an upright to a supine position, can induce a mean ocular cyclotorsional effect of 0.4 to 4.2 degrees (range 0 to 16 de- grees) (10,11),and this effect can be incyclotorsional or excylcotorsional (10). However, keratometry is typically recorded with the patient upright, whereas ocular surgery is performed with the patient supine. As a consequence, it has been recommended that preoperative corneal markings of the 0- to 180-degree meridian using specifically designed instruments should be made with the patient upright and that the markings should then be aligned with the 0- to 180-degree meridian of a fixation ring with the patient supine, from which the meridian of the toric IOL to be implanted is marked with a meridian marker. In conclusion, cyclotorsion represents another potential source of residual refractive errors that subsequently will lead to a reduced visual quality postoperatively. Therefore should be carefully taken into account in the preoperative analyses. REFERENCES 1. Spielmann A. [Cyclotorsions]. J Fr Ophtalmol. 2002;25(9): French. 2. Kim H, Joo CK. Ocular cyclotorsion according to body position and flap creation before laser in situ keratomileusis. J Cataract Refract Surg. 2008;34(4): Clausel H, Touffet L, Havaux M, Lamard M, Savean J, Cochener B, et al. [Peribulbar anesthesia: efficacy of a single injection with a limited local anesthetic volume]. J Fr Ophtalmol. 2008;31(8): French. 4. Swami AU, Steinert RF, Osborne WE, White AA. Rotational malposition during laser in situ keratomileusis. Am J Ophthalmol. 2002;133(4): Chang J. Cyclotorsion during laser in situ keratomileusis. J Cataract Refract Surg. 2008;34(10): Novis C. Astigmatism and toric intraocular lenses. CurrOpinOphthalmol. 2000;11(1): Review. 7. Becker R, Krzizok TH, Wassill H. Use of preoperative assessment of positionally induced cyclotorsion: a video-oculographic study. Br J Ophthalmol. 2004;88(3): Febbraro JL, Aron-Rosa D, Gross M, Aron B, Brémond-Gignac D. One year clinical results of photoastigmatic refractive keratectomy for compound myopic astigmatism. J Cataract Refract Surg. 1999;25(7): Febbraro JL, Koch DD, Khan HN, Saad A, Gatinel D. Detection of static cyclotorsion and compensation for dynamic cyclotorsion in laser in situ keratomileusis. J Cataract Refract Surg. 2010;36(10): Swami AU, Steinert RF, Osborne WE, White AA. Rotational malposition during laser in situ keratomileusis. Am J Ophthalmol. 2002;133(4): Smith EM Jr, Talamo JH, Assil KK, Petashnick DE. Comparison of astigmatic axis in the seated and supine positions. J Refract Corneal Surg. 1994;10(6): Rev Bras Oftalmol. 2014; 73 (4):

12 202 ORIGINAL ARTICLE Surgical treatment of congenital blepharoptosis Tratamento cirúrgico da blefaroptose congênita Suzana Matayoshi 1, Ivana Cardoso Pereira 2, Luiz Angelo Rossato 2 ABSTRACT The blepharoptosis is the improper positioning of the upper eyelid, being below its normal position in primary gaze, which is 0.5-2mm below the superior corneal limbus. It may block partially or completely the upper visual field, and lead to aesthetic commitment. The causes are categorized as congenital or acquired. It is considered congenital if present at birth or diagnosed during the first year of life. The main techniques used for the treatment of congenital ptosis are the resection of the levator muscle aponeurosis and the frontalis suspension. The function of the levator muscle is the most important parameter to define the surgical technique. When the function is weak, the frontalis suspension is more appropriate; the supra-maximal resection of the levator muscle may also be employed. With function above 4 or 5mm, the resection of the aponeurosis is preferred. For the frontalis suspension surgery, various materials can be used, so we present a comparison of the most relevant studies. We also discuss some characteristics in more complicated cases, such as the Blepharophimosis syndrome and the Marcus-Gunn syndrome, and surgical techniques less performed and complications reported. Keywords: Blepharoptosis/congenital; Blepharoptosis/surgery; Blepharoptosis/ complications; Eyelid/pathology RESUMO A blefaroptose é o posicionamento inadequado da pálpebra superior, estando abaixo de sua posição normal na posição primária do olhar, a qual seria 0,5 2mm abaixo do limbo superior. Pode causar bloqueio parcial ou completo do campo visual superior, além do comprometimento estético. As causas são categorizadas em congênitas ou adquiridas. É considerada congênita se presente ao nascimento ou diagnosticada no primeiro ano de vida. As principais técnicas utilizadas para o tratamento da ptose congênita são a ressecção da aponeurose do músculo levantador da pálpebra superior (MLPS) e a suspensão frontal. A medida da função do MLPS é o parâmetro mais importante na escolha da técnica cirúrgica. Quando a função é fraca, a suspensão frontal é mais indicada; a ressecção supramáxima do MLPS também pode ser empregada. Acima de 4 ou 5mm de função do MLPS, prefere-se a ressecção da aponeurose. Para a cirurgia de suspensão frontal, vários são os materiais utilizados, portanto apresentamos uma comparação entre os estudos mais relevantes. Discutiremos também particularidades em casos mais complicados, como as Síndromes da Blefarofimose e de Marcus-Gunn, além de técnicas cirúrgicas menos utilizadas e as complicações relatadas. Descritores: Blefaroptose/congênito; Blefaroptose/cirurgia; Blefaroptose/complicações; Pálpebra/patologia 1 Oculoplastic Surgery Unit, Medical School, São Paulo University, São Paulo/SP, Brazil. 2 Postgraduate Programme, Department of Ophthalmology, Medical School, São Paulo University, São Paulo/SP, Brazil. Work conducted at the University Hospital of the São Paulo University, São Paulo/SP, Brazil. The authors declare no conflict of interest. Received for publication 03/02/ Accepted for publicatin 23/03/2014. Rev Bras Oftalmol. 2014; 73 (4): 202-9

13 Surgical treatment of congenital blepharoptosis 203 INTRODUCTION Blepharoptosis is characterised by improper positioning of the upper eyelid below its normal position, 0.5-2mm below the superior limbus in the primary position of gaze (PPG). (1) The lowered eyelid margin can partially or completely block the upper visual field in the PPG and in downgaze, and it can also cause cosmetic problems. The difference between the position of the upper eyelid margin with ptosis and the position of a normal eyelid (covering the corneal limbus by 2 mm at the 12 o clock position) was one of the first parameters taken into consideration in the semiology of ptosis by Beard (2), who classified the condition into mild (1.5-2 mm), moderate (3 mm), and severe (ee4 mm). Because this measurement can be inaccurate as the examiner needs to manually lift the eyelid, Sarver and Putterman (3) suggested using the marginal reflex distance (MRD-1), which is the distance between the upper eyelid margin and the centre of the pupil. A normal MRD-1 is between mm, with lower values characterising ptosis. (4) Nonetheless, other factors should also be taken into account, such as presence of facial and/or eyelid asymmetry, the patient s facial proportions, and ethnicity. The patient unconsciously tries to compensate for the ptosis by contracting the frontalis and corrugator muscles, changing head position by raising the chin, or even lifting the eyelids and/ or eyebrows with his/her fingers. Constant stimulation of facial muscles can cause tension. The prevalence of ptosis is similar for both genders and across different races. The risk factors for the condition are: age, diabetes, myasthenia gravis, and brain tumour, all of which can affect neural or muscle responses. (5) Ptosis can be classified as congenital or acquired. It is considered to be congenital when present at birth or when diagnosed within the first year of life. Acquired ptosis is further divided into anatomical, neurogenic, mechanical, traumatic, and myogenic. (6,7) The anatomical structures involved in upper eyelid elevation include three muscles: the levator palpebrae superioris (LPS) (the main muscle, innervated by the oculomotor nerve), Müller s smooth muscle (sympathetic innervation, responsible for up to 2 mm of elevation), and the frontalis muscle (which is innervated by the facial nerve and has a secondary function in eyelid elevation). Eyelid ptosis is treated surgically, and the procedure is based on the three above-mentioned muscles. Surgery can be indicated for functional or cosmetic reasons. It is an elective procedure that needs to be planned taking into account its risks and benefits. The preferred technique and its outcomes depend on the type of ptosis, LPS function, age, laterality, the presence of additional ophthalmic or neurological abnormalities, and the surgeon s preference. The three most common procedures are: levator aponeurosis resection-reinsertion; Müller s muscle resection (conjunctival mullerectomy or tarsal-conjunctival mullerectomy); and frontalis suspension. (5,6) These techniques will be presented and discussed throughout this paper. Clinical features of congenital ptosis Congenital ptosis often results from a failure in the embryonic development of the LPS muscle. This muscle is initially formed from the superior rectus muscle during embryogenesis and reaches its normal position around the fourth month of pregnancy. The first abnormalities appear during this period. Müller s muscle is also formed at this stage. In congenital myogenic ptosis LPS fibres are dystrophic and replaced by fibrous tissue. (8) Unlike acquired ptosis, congenital ptosis has different characteristics depending on the position of gaze: it is accentuated in upgaze, while in downgaze it shows lid lag (the muscle does not relax normally), and the eyelid crease is absent in most cases. (9) The initial evaluation of children with congenital ptosis includes an assessment of marginal reflex distance (MRD-1), LPS excursion, height of the upper eyelid crease, Bell s phenomenon, and the presence of conditions such as Marcus Gunn syndrome and associated vertical strabismus. (1) A significant decrease in LPS function (4 mm or less) is usually observed. Although ptosis is not considered a progressive condition, children with ptosis have a higher incidence of amblyopia (14-23%) and other developmental visual disorders such as myopia, astigmatism, anisometropia, torticollis, and strabismus. (10) Ptosis is unilateral in 70% of cases and can be associated with changes in one or more extraocular muscles and/or systemic diseases. More severe cases involve hypoplasia of the LPS or its aponeurosis, with an absent or attenuated eyelid crease. (6) Measurement of LPS function, i.e. eyelid excursion, is the most important parameter when choosing the surgical technique. Child cooperation is required for an accurate measurement. Surgical treatment of congenital ptosis Reports from the 19 th century already described the surgical treatment of congenital ptosis. Bowman first reported on LPS resection in 1857, and Dransart described the first frontalis suspension in In 1909, Payr introduced the use of autologous fascia lata, which was later reintroduced by Wright in In 1966, Tillet and Tillet first described the use of silicone in frontalis suspension to correct ptosis. In the mid-20 th century, authors such as Berk, Jones and Beard systematised surgical techniques and concepts. (11) Currently, the most common techniques are LPS resection and frontalis suspension. When there is no risk or sign of amblyopia, surgical correction can be performed at the age of 3-5 years, when eyelid structures are well developed and the fascia lata can be removed. If amblyopia is present, however, ptosis correction should be performed at an early age, and an alloplastic material can be used as a temporary sling until the patient is old enough for autologous fascia lata grafting. Resection of LPS aponeurosis In the traditional approach to aponeurosis resection, a horizontal incision measuring approximately mm is made on the skin, the orbicularis muscle is dissected, the septum is opened, and the aponeurosis is identified as the pink-white structure underneath the eyelid fat. It is then resected at the intended height and subsequently advanced up to the middle third of the tarsal plate with three U-shaped sutures positioned in the central, medial and lateral regions. (1) In order to better identify and individualise the aponeurosis, 2% lidocaine with a vasoconstrictor (1: adrenaline) can Rev Bras Oftalmol. 2014; 73 (4): 202-9

14 204 Matayoshi S, Pereira IC, Rossato LA be injected in the subconjunctival space, allowing the surgeon to easily separate the LPS aponeurosis from the conjunctiva-müller s muscle complex. A small horizontal incision of the aponeurosis in the upper third of the tarsus followed by medial and lateral extension helps disconnect the aponeurosis from the tarsus. Oblique cuts made vertically along the medial and lateral horns of the aponeurosis help move it anteriorly. A Berke forceps can be used to manipulate the aponeurosis (Figure 1). Figure 1. LPS aponeurosis resection using a Berke forceps. Non-absorbable sutures should be used, as absorbable sutures can lead to late surgical failure. (12) An eyelid crease or fold can be created by suturing the upper margin of the skin, the aponeurosis and the skin in the lower incision margin. Three to four sutures are usually applied. The major question in this kind of procedure is the amount of aponeurosis to be resected, which is highly dependent on surgeon s experience. The resection can be small (10-13 mm), medium (14-20 mm), or large (e 21 mm); LPS function and the degree of ptosis should be used as parameters. The resection table proposed by Beard (1) can be used to determine resection size (Table 1). Table 1 Degree of ptosis and amount of LPS aponeurosis resection Degree of LPS Procedure ptose (mm) Function (mm) Mild (1,5-2,0) Good ( 8 ) Ressecção 10-13mm 8 Ressecção 14-17mm Moderate (3,0) 5-7 Ressecção 18-22mm 4 Ressecção 23mm Severe ( 4) 4 Ressecção 23mm 5-7 Ressecção 23mm This technique has two variants: 1) Whitnall s ligament suspension: the aponeurosis is resected up to Whitnall s ligament and the tarsus is sutured directly to the ligament. This procedure is indicated when LPS function is between 4-5 mm. Its drawback is that Whitnall s ligament works as a mobile sleeve for the LPS muscle, turning its horizontal force into a vertical force for the upper eyelid. Dissecting the medial and lateral pillars of the ligament can compromise its supporting role. (13) The eyelid can evert if the suture is placed too close to the lower border of the tarsus. 2) Supramaximal resection of the aponeurosis: more than 30 mm of tissue are resected, including the aponeurosis and the LPS muscle. In order to release the posterior part of the ligament, its adhesion is resected medially and laterally. The dissection should not damage the superior rectus muscle. (14) This is an alternative to frontalis suspension that avoids the risk of infection and extrusion and does not require removal of the fascia lata, thus avoiding an additional scar and reducing the duration of surgery. Frontalis suspension Frontalis suspension is widely used to repair ptosis with poor LPS function and good frontalis muscle function. It is used primarily for congenital ptosis, but also for blepharophimosis syndrome and neurogenic ptosis (third cranial nerve palsy and Marcus Gunn syndrome). (10,15) The procedure connects the motor unit (frontalis muscle) to the upper eyelid (Figure 2). Most techniques use skin incisions at the tarsus and eyebrow levels to insert the sling material in the suborbicularis Figure 2. Frontalis suspension. The arrow indicates the point where the sling material ends are joined together at the head of the eyebrow. plane. (10) The material is placed anteriorly to the orbital septum plane, so that the eyelid is raised towards the eyebrow instead of along the eye surface, decreasing the interaction between the eyelid and the cornea. A hood can also be formed under the pre-tarsal and pre-septal skin, delaying eyelid lowering in downgaze. (6) The sling material may become loose, which reduces its function and effectiveness. Asian patients are more prone to eyelid inversion following frontalis suspension surgery. (16) Endogenous versus exogenous materials The most commonly used materials are preserved or nonpreserved fascia lata or temporal fascia, the palmaris longus tendon, and the umbilical vein. Different exogenous materials have been used for suspension, such as silicone, nylon, collagen, silk, and stainless steel sutures and Mersilene (Ethicon, Blue Ash, OH, EUA.), Supramid (nylon polyfilament, S. Jackson, Alexandria, VA, EUA) and Gore-Tex (polytetrafluorethylene W.L. Gore and Associates, Newark, DE, EUA) mesh. (17) Autologous fascia lata has a minimal risk of infection, extrusion or rupture, and also a greater viability time and compatibility, although it requires a second surgical incision. (16) The patient should be at least 3 years old, so that their leg size is Rev Bras Oftalmol. 2014; 73 (4): 202-9

15 Surgical treatment of congenital blepharoptosis 205 sufficient for removing an appropriate fascia. (16,18) A fascia lata allograft is another option, but it shows higher (8-63.2%) rates of recurrence compared to autologous fascia lata (0.8-5%), especially in the long term. (10,13,19) Preserved fascia lata can be replaced by a fibrous tissue, producing a permanent effect, but it can also be absorbed prematurely, and it involves the risk of transmitting infectious diseases. While several authors consider the fascia lata to be the best material for frontalis suspension (10), others prefer silicone. (20) Silicone is a readily accessible, adjustable and elastic material, which makes it convenient for frontalis suspension in conditions coursing with mild Bell s phenomenon such as chronic progressive external ophthalmoplegia, myasthenia gravis, and third cranial nerve palsy. (20) A silicone suture on the tarsus has the benefits of lower migration and thus lower recurrence rates, and is also important for creating an eyelid crease. (21) Table 2 shows a summary of studies comparing the different materials used in frontalis suspension. Note that the results are highly variable for the rates of recurrence and complications. Until 2005, the fascia lata was almost unanimously considered the best material, but more recent studies tend to prefer silicone due to its superior cosmetic outcomes and lower recurrence rates. (21) Still, prospective randomised trials are required to confirm the superiority of silicone over the fascia lata (21) and to compare silicone with other materials. Studies have shown that nylon, Mersilene and polytetrafluorethylene (PTFE or Gore-tex ) also have good acceptance, but show varying rates of extrusion, infection, and granuloma formation. (17,19,22) Autologous fascia lata remains the preferred material for most surgeons and is considered the gold-standard procedure. (7,10,16,18,23) Preserved fascia lata is the second-best option. (23) Even though eyelid height, contour, and creasing seem to be satisfactory in the early postoperative period, the cosmetic outcome can change over time, mainly as regards the symmetry of eyelid height in unilateral cases and eyelid creasing in unilateral and bilateral cases, even when the functional outcome remains good. Other authors, however, report good long-term functional outcomes, with preserved eyelid height and creasing. (16) Sling Design Various suture designs can be used, including: single triangle, double triangle, single rhomboid (Friedenwald-Guyton procedure), double rhomboid (Iliff procedure), double Table 2 Comparison of different materials used for frontalis suspension N Follow-up (months) Recorrence rate (%) Complications (%) Wasserman (2001) (17) 34 Autologous fascia 30 4,2 8,3 Preserved fascia ,7 Polypropylene 24 12,5 0 Nylon ,7 Mersilene ,1 Polytetrafluorethylene Lee (2009) (21) Preserved fascia Silicone Ben Simon (2005) (22) 27 Autologous fascia > Nylon Silicone > Polytetrafluorethylene Wagner (1984) (24) 42 Preserved fascia lata 20,8 8,3 0 Nylon Berry-Brincat (2009) (25) Mersilene Mehta (2004) (26) Mersilene Juncedo-Moreno (2005) (27) 12 Autologous fascia 18 5 Preserved fascia 23 Silicone 15 Polytetrafluorethylene Rev Bras Oftalmol. 2014; 73 (4): 202-9

16 206 Matayoshi S, Pereira IC, Rossato LA trapezoid (Wright procedure), single pentagon (Fox procedure), and double pentagon (Crawford procedure). (16,23) Some authors believe the single triangle procedure is preferred for pointed eyebrows and the pentagonal or rhomboid procedures are preferred for diffusely elevated eyebrows. Other, however, recommend the single triangle procedure (modified Fox procedure) for children and the double triangle (modified Crawford procedure) for adults. (23) There are also authors who recommend the single rhomboid procedure for small children, as it prevents postoperative eyelid folds. (10) Ben Simon et al. found no differences in terms of recurrence rates, function, or cosmetics between the single rhomboid loop and the double pentagon. (22) The Crawford procedure is recommended for fascia lata grafting, and the Fox procedure is recommended for alloplastic material. Crease incisions showed better outcomes regarding eyelid contour and crease symmetry than supraciliary incisions. (22) Bilateral versus unilateral surgery in severe unilateral ptosis Some authors recommend bilateral frontalis suspension for the treatment of unilateral congenital ptosis, claiming that it results in improved symmetry when closing the eyes, blinking, and gazing downward. (16,18) However, bilateral surgery puts both eyes at risk of postoperative complications such as lagophthalmos, exposure keratitis, upper eyelid entropion, eyelash ptosis, absent eyelid crease, excess skin, and superior oblique muscle palsy. Other authors suggest that unilateral surgery preserving the healthy side is more likely to be accepted by parents, as well as being a shorter procedure with lower risks. The presence of spontaneous eyebrow elevation on the affected side preoperatively can be predictive of successful unilateral frontalis suspension. Unilateral surgery is recommended for unilateral congenital ptosis with poor LPS function and without amblyopia. (28) Patients with amblyopia are at risk of under-correction when subjected to unilateral surgery, therefore bilateral frontalis suspension is the procedure of choice in these cases. (16) Other less commonly used techniques Tarsectomy According to Reifler (29), tarsectomy was first described by Gillet de Grandmont in It has become popular over the past twenty years because it can be flexibly combined with either posterior resection of LPS aponeurosis (30,31) or posterior Müller s muscle resection (Fasanella-Servat, 1961). (32) It has also been described as a technique for correcting recurrent ptosis and ptosis unresponsive to other usual techniques. (31) Tarsectomy involves vertical eyelid shortening, which elevates the eyelid margin. Tarsal resection should preserve at least 3 mm from the eyelid margin in order to maintain eyelid stability. (32) Frontalis transfer This technique involves a dynamic flap of the frontalis muscle tunneled to the upper eyelid and sutured to the tarsal plate; it is used in cases of congenital and/or acquired ptosis which recurs after correction using other procedures and whose LPS function is under 4 mm. (6,7,19) The frontalis muscle is dissected from the periosteum and from the orbicularis muscle, the orbital septum is separated from the orbital margin, and a semielastic pulley is created to accommodate the flap. (19) The LPS muscle is advanced and folded over the aponeurosis for a distance of mm. The flap is sutured to the tarsal plate using non-absorbable 6-0 or 7-0 sutures (three stitches: centre of pupil, lateral limbus and medial limbus). The eyelid margin is adjusted so it remains at the level of the upper limbus, and patients need to learn how to position their eyelid in a functional and cosmetic fashion. Reported complications include reduced eyelid excursion on extreme upgaze and downgaze (primarily in the immediate postoperative period), bleeding due to frontalis muscle dissection, denervation, donor site deformities with eyebrow asymmetry, supraciliary scar, and lagophthalmos. There are no reports of corneal exposure. Eyelid symmetry is more frequently achieved in bilateral procedures. (7,19) This procedure can be performed in younger children, as the frontalis muscle is adequately developed by the age of two. (6) Indications for surgical techniques Current recommendations for congenital ptosis correction vary, but frontalis suspension is recommended for children younger than 3-4 years of age with poor LPS function. The options for children with LPS function under 3 mm include frontalis suspension, frontalis muscle flap, and Whitnall s ligament suspension. The LPS muscle can be resected or advanced in patients whose LPS function is over 5 mm. Whitnall s ligament suspension (with or without tarsectomy) can be performed in cases of relapse after frontalis suspension, and vice versa. The greatest difficulties occur when indicating surgery for cases with LPS function between 5 and 7 mm, since resection of the LPS aponeurosis may not be sufficient. Alternatives include frontalis suspension, maximal LPS resection, and Whitnall s ligament suspension alone or combined with superior tarsectomy. (20,30) Surgery for blepharophimosis syndrome Patients with blepharophimosis syndrome usually present with epicanthus inversus, horizontal and vertical narrowing of the palpebral fissures, telecanthus, and severe ptosis (LPS hypoplasia). Other associated changes include strabismus, amblyopia, high-arched eyebrows, ear deformities, hypogonadism, and infertility. (33) Where possible, correction of telecanthus and epicanthus should precede ptosis correction because the palpebral fissure height can decrease with surgical manipulation (34) (Figure 3). Frontalis suspension with fascia lata grafting is the most indicated procedure. (33) Some authors report good experiences with supramaximal LPS resection. (14) Even in successful cases, blepharophimosis patients retain a typical facies with narrower palpebral fissures. Figure 3. Blepharophimosis. Note the marks of epicanthus inversus correction. Severe ptosis with arched eyebrows, reduced horizontal fissure, and euryblepharon. Rev Bras Oftalmol. 2014; 73 (4): 202-9

17 Surgical treatment of congenital blepharoptosis 207 Marcus Gunn syndrome Marcus Gunn syndrome is a trigeminal-oculomotor synkinesis consisting of unilateral congenital ptosis in which the eyelid retracts when the ipsilateral pterygoid muscle is stimulated. This stimulation can occur when the patient opens his/her mouth, chews, sucks, smiles, moves the jaw laterally to the affected and/or unaffected site, protrudes the tongue or jaw, and contracts the sternocleidomastoid muscle. (35) Although bilateral cases exist, they are rare. The condition s prevalence is similar for both genders and sides of the face, being observed in 2-13% of patients with congenital ptosis. It is believed to be caused by a deviation of one branch of the fifth cranial nerve to the third cranial nerve, but other cranial nerves can also be involved. Some patients learn how to control the position and excursion of the affected eyelid. (15) It is classified according to upper eyelid excursion during mouth stimulation, measured in millimetres: mild (<2 mm), moderate (2-5 mm), and severe (>5 mm). When the syndrome results in functional or cosmetic impairment, surgical treatment should be considered, such as LPS excision (aponeurosis and terminal muscle) in the affected site and weakening or excision of the contralateral LPS, followed by bilateral frontalis suspension. (15,36) For patients who do not want to undergo bilateral surgery or non-amblyogenic patients, the procedure can be performed only in the affected side, although it can result in eyelid asymmetry in downgaze. Patients submitted to bilateral surgery show better upper eyelid symmetry in the primary position of gaze. (36) Associated changes such as treatable amblyopia (23-59% of patients), vertical strabismus (23-48%) and horizontal strabismus (34%) should be resolved beforehand. (36) If the jawwinking synkinesis causes only minor cosmetic problems it can be ignored, and ptosis treatment should be done by simply using the appropriate techniques for each degree of LPS function. If the synkinesis is moderate to severe and causes problems to the patient, it should be taken into account in the choice of surgical treatment. For mild synkinesis, treatment includes observation, LPS resection, or the Fasanella-Servat procedure. (15) The LPS aponeurosis has a number of connections underneath Whitnall s ligament and divides the lacrimal gland into its orbital and palpebral sections. Therefore, LPS excision is not always complete, and the connections between the LPS and the eyelid can be restored. This is why some authors recommend excising the aponeurosis and the terminal LPS associated with bilateral frontalis suspension. This would lead to a better outcome due to the symmetrical weakness of upper eyelids, symmetrical frontalis suspension, and the use of the frontalis muscle to elevate both upper eyelids. (36) Complications of ptosis surgery The most common complication is under-correction (10-15% of cases), which can result from improper resection, incorrect identification of structures, excessive scarring, or improper suturing (6,7) (Figure 4). Over-correction results in incomplete eyelid occlusion and is a rare complication of congenital ptosis correction, but it can occur when the eyelid is sutured to Whitnall s ligament or when the orbital septum is excessively shortened. (7) Although it is desirable postoperatively, symmetrical eyelid height can expose the cornea, therefore it is recommended that a Frost Figure 4. Under-correction of left ptosis 15 days after resection of the LPS aponeurosis. suture is made at the end of surgery and removed after 48 hours. Other complications include transient or permanent diplopia in cases of residual third cranial nerve palsy, adverse reaction to anaesthetics, intra- or postoperative bleeding, infectious processes, mild keratitis and corneal abrasion secondary to improper suturing, reactions to alloplastic materials (Figure 5), or suture abscess. Absent or low eyelid creasing can be secondary to an improper incision or a failure in crease formation, and eyelid margin distortions can be secondary to asymmetric aponeurosis advancement. (6) Late complications include eyelid asymmetry and foreign-body sensation. Eyelash ptosis, entropion and excessive skin folding can also occur. Fixation of the fascia to the lower tarsus creates an anterior torque on the eyelid margin and reduces the risk of entropion, but it can lead to a euryblepharon-like opening of the margin. Creating an eyelid crease is also important. In order to prevent skin folding, excessive skin should be removed as appropriate. (16) Figure 5. Reaction to silicone with a local inflammatory process and partial exposure of the material. CONCLUSION The major techniques used in the treatment of congenital ptosis are resection of the LPS aponeurosis and frontalis suspension. When amblyopia is present the ptosis needs to be corrected early; otherwise, it can be corrected after three years of age. Measurement of LPS function, i.e. eyelid excursion, is the most important parameter when choosing the surgical technique. Frontalis suspension is indicated when LPS function is poor; alternatively, supramaximal resection of the LPS muscle can also be employed. Aponeurosis resection is the preferred technique in patients whose LPS function is around 4-5 mm. Outcomes are less effective in patients with Rev Bras Oftalmol. 2014; 73 (4): 202-9

18 208 Matayoshi S, Pereira IC, Rossato LA blepharophimosis syndrome than in simple congenital ptosis. Bilateral frontalis suspension is still the most used technique, although supramaximal resection of the LPS can also be considered for such cases. For Marcus Gunn syndrome, maximal resection of the LPS in combination with frontalis suspension produces the best results. Under-correction is the most frequent complication, followed by crease deformities, lagophthalmos, keratopathy, implant extrusion, and granuloma formation (associated with alloplastic materials in frontalis suspension). Even though the literature on the subject is vast, the lack of controlled randomised studies on the different surgical techniques and alloplastic or homologous materials hinder a more objective analysis and the selection of the best approach in the treatment of congenital ptosis. REFERENCES 1. Callahan MA, Beard C. Beard s ptosis. 4a ed. Birmingham: Aesculapius; Beard C, Sullivan JH. Ptosis current concepts. Int Ophthalmol Clin. 1978;18(3): Review. 3. Sarver BL, Putterman AM. Margin limbal distance to determine amount of levator resection. Arch Ophthalmol. 1985;103(3): Frueh BR. Graves eye disease: orbital compliance and other physical measurements. Trans Am Ophthalmol Soc. 1984;82: Review. 5. Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27(3): Review. 6. Allard FD, Durairaj VD. Current techniques in surgical correction of congenital ptosis. Middle East Afr J Ophthalmol. 2010;17(2): Baroody M, Holds JB, Vick VL. Advances in the diagnosis and treatment of ptosis. Curr Opin Ophthalmol. 2005;16(6): Review. 8. Baldwin HC, Manners RM. Congenital blepharoptosis: a literature review of the histology of levator palpebrae superioris muscle. Ophthal Plast Reconstr Surg. 2002;18(4): Review. 9. Meyer DR, Rheeman CH. Downgaze eyelid position in patients with blepharoptosis. Ophthalmology. 1995;102(10): Takahashi Y, Leibovitch I, Kakizaki H. Frontalis suspension surgery in upper eyelid blepharoptosis. Open Ophthalmol J. 2010;4: Gonzalez MO, Durairaj VD. The history of ptosis surgery. In: Cohen AJ, Weinberg DA. Evaluation and management of blepharoptosis. New York: Springer; Frueh BR, Musch DC, McDonald HM. Efficacy and efficiency of a small-incision, minimal dissection procedure versus a traditional approach for correcting aponeurotic ptosis. Ophthalmology. 2004;111(12): Review. 13. Holmström H, Bernström-Lundberg C, Oldfors A. Anatomical study of the structures at the roof of the orbit with special reference to the check ligament of the superior fornix. Scand J Plast Reconstr Surg Hand Surg. 2002;36(3): Epstein GA, Putterman AM. Super-maximum levator resection for severe unilateral congenital blepharoptosis. Ophthalmic Surg. 1984;15(12): Demirci H, Frueh BR, Nelson CC. Marcus Gunn jaw-winking synkinesis: clinical features and management. Ophthalmology. 2010;117(7): Yoon JS, Lee SY. Long-term functional and cosmetic outcomes after frontalis suspension using autogenous fascia lata for pediatric congenital ptosis. Ophthalmology. 2009;116(7): Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol. 2001;119(5): Bernardini FP, Devoto MH, Priolo E. Treatment of unilateral congenital ptosis. Ophthalmology. 2007;114(3): Ramirez OM, Peña G. Frontalis muscle advancement: a dynamic structure for the treatment of severe congenital eyelid ptosis. Plast Reconstr Surg. 2004;113(6):1841-9; discussion Lee V, Konrad H, Bunce C, Nelson C, Collin JR. Aetiology and surgical treatment of childhood blepharoptosis. Br J Ophthalmol. 2002;86(11): Lee MJ, Oh JY, Choung HK, Kim NJ, Sung MS, Khwarg SI. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis a three-year follow-up study. Ophthalmology. 2009;116(1): Ben Simon GJ, Macedo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005;140(5): Bagheri A, Aletaha M, Saloor H, Yazdani S. A randomized clinical trial of two methods of fascia lata suspension in congenital ptosis. Ophthal Plast Reconstr Surg. 2007;23(3): Wagner RS, Mauriello JA Jr, Nelson LB, Calhoun JH, Flanagan JC, Harley RD. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmology. 1984;91(3): Berry-Brincat A, Willshaw H. Paediatric blepharoptosis: a 10- year review. Eye. 2009;23(7): Mehta P, Patel P, Olver JM. Functional results and complications of Mersilene mesh use for frontalis suspension ptosis surgery. Br J Ophthalmol. 2004;88(3): Junceda-Moreno J, Suárez-Suárez E, Dos-Santos-Bernardo V. Treatment of palpebral ptosis with frontal suspension: a comparative study of different materials. Arch Soc Esp Oftalmol. 2005;80(8): Kersten RC, Bernardini FP, Khouri L, Moin M, Roumeliotis AA, Kulwin DR. Unilateral frontalis sling for the surgical correction of unilateral poor-function ptosis. Ophthal Plast Reconstr Surg. 2005;21(6):412-6; discussion Reifler DM. The tarsectomy operation of A.P.L. Gillet de Grandmont ( ) and its periodic rediscovery. Doc Ophthalmol. 1995;89(1-2): Patel SM, Linberg JV, Sivak-Callcott JA, Gunel E. Modified tarsal resection operation for congenital ptosis with fair levator function. Ophthal Plast Reconstr Surg. 2008;24(1): Bassin RE, Putterman AM. Full-thickness eyelid resection in the treatment of secondary ptosis. Ophthal Plast Reconstr Surg. 2009;25(2): Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified operation. Arch Ophthalmol. 1961;65: Tyers A, Meyer-Rüsenberg HW. [Blepharophimosis ptosis epicanthus inversus syndrome (BPES) (corrected)]. Klin Monbl Augenheilkd. 2012;229(1): Review. German. Erratum in: Klin Monbl Augenheilkd. 2012;229(1):E1. Rev Bras Oftalmol. 2014; 73 (4): 202-9

19 Surgical treatment of congenital blepharoptosis Li H, Li D, Jie Y, Qin Y. Multistage correction of blepharophimosis: our rationale for 18 cases. Aesthetic Plast Surg. 2009;33(4): Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, Marcet MM, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011;118(12): Khwarg SI, Tarbet KJ, Dortzbach RK, Lucarelli MJ. Management of moderate-to-severe Marcus-Gunn jaw-winking ptosis. Ophthalmology. 1999;106(6): Corresponding author: Luiz Angelo Rossato Rua Cruzeiro do Sul, 220, Londrina/PR, Brazil - CEP:

20 210ORIGINAL ARTICLE Increased intercellular adhesion molecule-1 immunoreactivity in the sclera-choroid complex in hypercholesterolemia experimental model Aumento da imunorreatividade da molécula de adesão intercelular-1 na esclera e coroide em modelo experimental de hipercolesterolemia Rogil José de Almeida Torres 1, Lucia de Noronha 2, Regiane do Rocio de Almeida Torres 3, Seigo Nagashima 4, Caroline Luzia de Almeida Torres 5, Andréa Luchini 6, Robson Antônio de Almeida Torres 5, Leonardo Brandão Précoma 7, Dalton Bertolim Précoma 8 ABSTRACT Objective: The aim of this study is to investigate the expression of the intercellular adhesion molecule 1 (ICAM-1) in the sclera and choroid of hypercholesterolemic rabbits. Methods: New Zealand rabbits were divided into two groups: the normal diet group (NG), with 8 rabbits (8 eyes), was fed a standard rabbit diet for 4 weeks; the hypercholesterolemic group (HG), with 13 rabbits (13 eyes), was fed a 1% cholesterol- enriched diet for 8 weeks. Total serum cholesterol, triglyceride, HDL cholesterol and fasting blood glucose exams were performed at the start of the experiment and at the euthanasia time. HG and NG animals were euthanized after 8th week and 4th week, respectively. Their eyes were stained with hematoxylin-eosin and underwent histological, histomorphometric and immunohistochemical analyses with ICAM-1 antibody. Results: The diet has induced a significant increase in total cholesterol and triglyceride levels in HG when compared with NG (p<0.001). The histological analysis with hematoxylin-eosin revealed a large number of macrophages in the HG sclera-choroid complex. Moreover, a significant increase in the HG sclera and choroid thickness was observed in relation to NG (p<0.001). There was a significant increase in the ICAM-1 expression in HG sclera and choroid in relation to NG. Conclusion: This study has revealed that the hypercholesterolemic diet induces an increase in the ICAM-1 expression in the rabbits sclera and choroid. Keywords: Cholesterol;Cell adhesion molecules; Macrophages; Choroid; Sclera; Macular degeneration RESUMO Objetivo: O objetivo deste trabalho é avaliar a expressão da molécula de adesão intercelular-1 (ICAM-1) na esclera e coroide de coelhos hipercolesterolêmicos. Métodos: Coelhos New Zealand foram organizados em dois grupos: GN (grupo dieta normal), composto por 8 coelhos (8 olhos), recebeu ração padrão para coelhos, durante 4 semanas; GH (grupo hipercolesterolêmico), composto por 13 coelhos (13 olhos), recebeu dieta rica em colesterol a 1% por 8 semanas. Foi realizada a dosagem sérica de colesterol total, triglicerídeos, HDL colesterol, glicemia de jejum no início do experimento e no momento da eutanásia. Ao final da 4ª semana para o GN e 8ª semana para o GH foi realizada a eutanásia dos animais. Os olhos foram corados com hematoxilina-eosina e submetidos à análise histológica, histomorfométrica e imunohistoquímica com o anticorpo ICAM-1. Resultados: Observou-se significativo aumento do colesterol total e triglicerídeos do GH em relação ao GN (p<0,001). A avaliação histológica com hematoxilina eosina revelou grande quantidade de macrófagos no complexo esclero-coroidal do GH. No GH constatou-se significativo aumento da espessura da esclera e coroide em relação ao GN (p<0,001). Houve significativo aumento da expressão da ICAM-1 na esclera e coroide dos animais do GH em relação ao GN (p<0,001). Conclusão: Este estudo demonstra que a dieta hipercolesterolêmica induz ao aumento da expressão da ICAM-1 na esclera e coroide de coelhos. Descritores: Colesterol; Moléculas de adesão celular; Macrófagos; Coroide; Esclera; Degeneração macular 1 Postdoctoral Programme, Pontifical Catholic University of Paraná, Curitiba/PR, Brazil; 2 Pontifical Catholic University of Paraná, Curitiba/PR, Brazil; 3,4 Medical School of the Pontifical Catholic University of Paraná, Curitiba/PR, Brazil; 5 Positivo University, Curitiba/PR, Brazil; 6 Curitiba Ophthalmic Centre, Curitiba/PR, Brazil; 7 Angelina Caron Hospital, Campina Grande do Sul/PR, Brazil; 8 Pontifical Catholic University of Paraná, Curitiba/PR, Brazil; Study conducted in the postgraduate unit of the Pontifical Catholic University of Paraná and the Angelina Caron Hospital (Campina Grande do Sul/PR). The authors declare no conflict of interest. Received for publication 17/12/ Aceppted for 26/02/2014. Rev Bras Oftalmol. 2014; 73 (4): 210-5

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