Andreia Martins Rosa

Background/Objectives: Fungal keratitis (FK) is a current challenge in ophthalmology due to its association with severe visual impairment and the limitations of current antifungal therapies. We aim to evaluate the antifungal activity of essential oils (EOs) from the aromatic and medicinal plants Cymbopogon citratus and Lavandula pedunculata against selected FK pathogens collected from FK patients in two Portuguese hospitals. Methods: The antifungal activity of the EOs was tested at concentrations of 25%, 50%, 75%, and 100% for up to 7 days using the solid-phase disk diffusion in vitro assay. Results: Candida albicans was the most prevalent pathogen (28.6%), followed by Candida parapsilosis (21.4%) and Dicyma olivacea (14.2%). The other identified species were Aspergillus fumigatus and Scedosporium boydii (7.1%). Clinical diagnostic methodologies showed agreement with the molecular identification. Cymbopogon citratus EO showed higher antifungal activity than Lavandula pedunculata EO. The highest antifungal activity was observed against Aspergillus fumigatus and Scedosporium boydii (inhibition zone diameter, IZD = 90.0 mm) after 7 (Cymbopogon citratus EO) or 3 days of incubation (Lavandula pedunculata EO). While the antifungal activity of Cymbopogon citratus EO was maintained during the study (for Aspergillus fumigatus, Candida albicans, and Scedosporium boydii), the antifungal activity of Lavandula pedunculata EO decreased with time. Conclusions: Cymbopogon citratus EO and Lavandula pedunculata EO showed optimal antifungal activity against molds (Aspergillus fumigatus and Scedosporium boydii) after 3 days of incubation. Against yeasts (Candida albicans and Candida parapsilosis), the EOs showed lower activity. Our study sheds light on the development of new pharmacological strategies for FK based on EOs extracted from aromatic and medicinal plants.

Purpose: To assess current prescription patterns in Descemet membrane endothelial keratoplasty (DMEK) in Europe. Setting: Countries affiliated with the European Cornea and Cell Transplantation Registry and the European Vision Institute Clinical Research Network. Design: Cross-sectional study (European survey). Methods: An electronic survey was distributed to 16 national societies to gather data on prescription patterns for DMEK. Responses were categorized by 3 clinical goals: prevention of postoperative endophthalmitis, graft rejection, and pupillary block and glaucoma. Results: Responses from 136 surgeons revealed that medication protocols mainly came from departmental protocols (54%) or personal experiences (48%) rather than national guidelines (22%) (multiple answers were allowed). Infection prevention primarily relied on intraoperative (72%) and postoperative (92%) antibiotics, with preoperative use less common (18%). Steroids were the mainstay for rejection prevention, used intraoperatively (59%), postoperatively (100%), and occasionally preoperatively (13%). Steroids were typically tapered to once daily after 6 months (46%) and discontinued after varying durations (65%). Dexamethasone was the preferred steroid. For high-risk DMEK, the most common approach was adding another topical (30%) or systemic immunosuppressive drug (24%), such as cyclosporine or mycophenolate. For graft rejection, most respondents increased topical steroid frequency (85%) or added (peri)bulbar steroid injections (42%). Pupillary block and glaucoma prophylaxis mainly involved intraoperative mydriatics (34%); intraocular pressure–lowering agents were rarely used (0.7% to 2.2%). For steroid-induced ocular hypertension, the common approach was switching to a lower-potency steroid (40%) or reducing steroid frequency (43%). Conclusions: Current prescription patterns in routine and high-risk DMEK vary significantly, reflecting the lack of standardized guidelines.

Purpose: The aim of this study was to perform a systematic review of diagnostic test accuracy of the criteria used to define keratoconus progression. Methods: A systematic search of MEDLINE/PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials (CENTRAL) databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines, from inception to December 31, 2024. The study protocol was preregistered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023391880). Risk of bias was assessed with the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Eligible references included randomized controlled trials, cohort studies, cross-sectional studies, and case-control studies assessing the diagnostic accuracy of criteria used to define keratoconus progression, calculating sensitivity, specificity, and diagnostic odds ratio. Results: Fifteen studies (2 prospective and 13 retrospective) were included, comprising 3547 eyes from 2654 individual patients. Overall, best-performing diagnostic tests for keratoconus progression were Belin/Ambrósio Enhanced Ectasia Display (BAD-D); ABCD 1 criteria >95 confidence interval; and anterior best-fit sphere radius, with maximum mean sensitivity/specificity values of 0.82/0.98, 0.81/1.00, and 0.86/0.94, respectively. In 2 studies, maximum keratometry (Kmax) had high specificity (0.91 and 1.00), but low sensitivity (0.70 and 0.49). Image criteria were poorer discriminators: deep learning of color-coded maps showed very low specificity (below 0.60) while anterior segment optical coherence tomography lacked sensitivity (below 0.68). Conclusions: Composite indexes combining multiple data such as BAD-D and ABCD, or global measurements of the corneal surfaces, such as best-fit sphere radius, might be ideal criteria to define disease progression, instead of single-point measurements.

Background/Objectives: Fungal keratitis (FK) is a current challenge in ophthalmology, due to its association with severe visual impairment and limitations of current antifungal therapies. We aim to evaluate the antifungal activity of essential oils (EOs) from aromatic and medicinal plants Cymbopogon citratus and Lavandula pedunculata against selected FK pathogens collected from FK patients in two Portuguese hospitals. Methods: The antifungal activity of EOs was tested at concentration of 25%, 50%, 75%, and 100%, up to 7 days, through solid-phase disk diffusion testing in vitro assay. Results: Candida albicans were the more prevalent (28.6%), followed by Candida parapsilosis (21.4%) and Dicyma olivacea (14.2%). Other species identified were Aspergillus fumigatus and Scedosporium boydii (7.1%). Clinical diagnostic methodologies showed agreement with the molecular identification (data not shown). Cymbopogon citratus EO showed higher antifungal activity than Lavandula pedunculata EO. Highest antifungal activity was observed against Aspergillus fumigatus and Scedosporium boydii (inhibition zone diameter, IZD=90.0mm), up to 7 (Cymbopogon citratus EO) or 3 days of incubation (Lavandula pedunculata EO). While the antifungal activity of Cymbopogon citratus EO was maintained during the study (for Aspergillus fumigatus, Candida albicans and Scedosporium boydii), it decreases with time with Lavandula pedunculata EO. Conclusions: Cymbopogon citratus EO and Lavandula pedunculata EO showed optimal antifungal activity against molds (Aspergillus fumigatus and Scedosporium boydii), up to 3 days of incubation. Against yeasts (Candida albicans and Candida parapsilosis), the EOs showed lower activity. Our study shed light on developing new pharmacological strategies for FK based on EOs extracted from aromatic and medicinal plants.

To assess if cone location and phenotype have an impact on the risk of keratoconus progression. Retrospective multi-centric cohort study. The baseline visit was used to classify cases according to cone location (based on thinnest pachymetry and maximum keratometry, Kmax) and phenotype. Cases were further labeled as stable or progressive depending on whether they fulfilled criteria for progression throughout the follow-up. Time from baseline to progression was noted. Univariate and multivariate mixed-effects models accounted for correlations between both eyes of the same patient and adjusted for Kmax and age at baseline. A total of 423 eyes from 250 patients was included, 48.0% (n = 203) labeled as progressive. Based on the location of thinnest pachymetry and Kmax, 72.1% (n = 305) and 60.8% (n = 257) respectively were classified as central. In univariate analysis, there were significant differences between groups (p < 0.001), with central keratoconus more frequently associated with progression. However, after adjusting for Kmax and age at baseline in multivariate analysis, this association lost its statistical significance. Results were similar for cone location based on thinnest pachymetry adjusted for Kmax and age. In univariate analysis, there were significant differences between groups (p < 0.001) in the proportion of each phenotype in the stable and progressive groups, with central "nipple" keratoconus more frequently associated with progression. This was lost after adjusting for Kmax and age in multivariate analysis. Kaplan-Meier survival analysis showed significant differences between phenotypes (p < 0.001), with central nipple cones progressing more rapidly. Central keratoconus and central "nipple" phenotype are more frequently associated with progression, and at a higher rate, but are not independent predictors for progression beyond keratometry and age.

The study aimed to evaluate the precision of different Pentacam indices in diagnosing keratoconus (KC) in pediatric patients with and without Down Syndrome (DS) and determine suitable cutoff values. This prospective multicenter cross-sectional study evaluated 216 eyes of 131 patients aged 6–18 years (mean age 12.5 ± 3.2 years) using Pentacam. Patients were categorized into four groups: KC, forme fruste keratoconus (FK), DS, and control, excluding DS patients with topographic KC. Receiver operating characteristic curves were generated to determine the optimal cutoff points and compare the accuracy in identifying KC and FK in patients with and without DS. In DS patients, corneal morphology resembled KC features. The most effective indices for distinguishing KC in DS patients were the average pachymetric progression index (AUC = 0.961), higher-order aberration of the anterior cornea (AUC = 0.953), anterior elevation (AUC = 0.946), posterior elevation (AUC = 0.947), index of vertical asymmetry (AUC = 0.943), and Belin/Ambrosio enhanced ectasia total derivation value (AUC = 0.941). None of the indices showed good accuracy for distinguishing FK in DS patients. The thresholds of these indices differed significantly from non-DS patients. The results highlighted the need for DS-specific cutoff values to avoid false-positive or false-negative diagnoses in this population.

Kabuki syndrome (KS) is a multiple congenital anomaly syndrome with diversified ophthalmological manifestations. We report a case of a boy with bilateral features of Salzmann nodular degeneration (SND) associated with KS. An 18-year-old Caucasian man with KS presented for a second opinion regarding incapacitating photophobia in his right eye, refractory to medical therapy. Biomicroscopy revealed bilateral subepithelial nodules in the midperiphery of the cornea, less extensive in the left eye, consistent with SND. Symptomatic improvement was achieved after superficial keratectomy, manually performed with a blade and adjuvant application of mitomycin C. We report a rare case of a KS patient with SND. Since KS manifestations may vary widely, it is important to perform an early ophthalmological examination for prompt detection and treatment of ocular abnormalities and thus improve life quality in these patients.

We report a case of a 41-year-old woman, wearer of contact lenses who was presented to the emergency room with a 2-month history of pain and red eye. She presented with a severe keratitis refractory to quinolones, fortified antibiotics and clotrimazole. Due to the risk of perforation, a tectonic penetrating keratoplasty (PK) was performed. Clinical signs of keratitis recurrence were observed and cultures were positive for Purpureocillium lilacinum (former Paecilomyces lilacinus). The patient did not improve on topical amphotericin B and intracameral voriconazole. Worsening of clinical condition required a new PK. Oral posaconazole was initiated postoperatively and suspended at the fourth postoperative month. The cornea remains clear until the last follow-up visit, 12 months after the second graft. To our knowledge, this is the second case report that documents the effectiveness of oral posaconazole in a refractory P. lilacinus keratitis, resistant to other second-generation triazoles and conventional antifungals.

Purpose: To investigate the relation between optical properties, population receptive fields (pRFs), visual function, and subjectively perceived quality of vision after cataract surgery. Methods: The study includes 30 patients who had recently undergone bilateral sequential cataract surgery. We used functional magnetic resonance imaging and pRF modelling methods to assess pRF sizes across visual cortical regions (V1–V3). Subjects also performed a complete ophthalmologic and psychophysical examination and answered a quality of vision questionnaire. Results: Subjects with worse optical properties had, as predicted, larger pRF sizes. In addition, analysis in the primary visual cortex revealed significantly larger mean pRF sizes for operated subjects with worse contrast sensitivity (P = 0.038). In contrast, patients who scored high in the subjective “bothersome” dimension induced by dysphotic symptoms had surprisingly lower pRF size fitting interception (P = 0.012) and pRF size fitting slopes (P = 0.020), suggesting a dissociation between objective quality of vision and subjective appraisal. Conclusions: Optical properties of the eye influence pRF size. In particular, visual aberrations have a negative impact on visual cortical processing. A novel dissociation between subjective reports of quality of vision and pRF sizes was further identified. This suggests that patients with better cortical resolution may have a negative subjective response possibly because of improved perception of dysphotic phenomena. pRF properties represent a valuable quantitative measure to objectively evaluate quality of vision but do not necessarily predict subjective complaints.