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The Cogan's sign is indicative of myasthenia gravis. This is the first report of neurological signs in a patient with post-COVID-19 vaccine-associated myasthenia gravis in Brazil. In this case, a previously healthy 68-year-old woman presented with proximal limb weakness, left ptosis, and diplopia 1 month after receiving her fourth dose of the COVID-19 vaccine. Neurological examination revealed the presence of Cogan's sign, and she recovered rapidly after treatment. To our knowledge, this is the first reported case of myasthenia gravis associated with the COVID-19 vaccine in Brazil.

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OBJECTIVES: To determine the age at onset of amblyopia, the response to occlusion therapy, and the association with systemic disorders in children with congenital eyelid ptosis. STUDY DESIGN: Retrospective chart review of children seen at Seattle Children's Hospital with moderate or severe congenital ptosis. Assessments were longitudinal visual acuity development using objective methods, definition of ptosis severity by eyelid margin to pupillary light reflex distance (margin reflex distance [MRD]), age at amblyopia diagnosis, correlation between amblyopia and MRD, and associated systemic disorders. RESULTS: Eighty-four children with moderate-to-severe congenital ptosis met inclusion criteria; the mean longitudinal follow-up was 49.1 months. Fifteen (18%) of these children had amblyopia, of which 9 had deprivation amblyopia (mean age 17.3 months ± 11.2) and 6 had anisometropic or strabismic amblyopia (mean age 60 months ± 11.8). Eleven (73%) of the children with amblyopia were successfully treated with occlusion therapy. Amblyopia was not correlated with MRD. A systemic disorder was identified in 29 (35%) of the children, the most common being genetic, chromosomal, or neurologic conditions. Patients with systemic disorders and developmental delay have significantly lower visual acuity bilaterally compared with patients without systemic disorders (P ≤ .003). CONCLUSIONS: Using longitudinal and objective visual acuity assessments, the incidence of amblyopia was 18% in children with moderate to severe congenital ptosis. Visual deprivation was the predominant risk factor that was reliably distinguished by its earlier onset in young children. The best indicator of amblyopia in children is visual acuity rather than MRD measurements. Systemic disorders are frequent in children with moderate to severe congenital ptosis.

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A blefaroplastia tem sido realizada com grande frequência devido à valorização da cirurgia estética. As complicações relacionadas a este procedimento são raras. Este relato de caso tem como objetivo enfatizar um tipo de complicação que pode ocorrer. T.J.S.P., 45 anos de idade, sexo feminino, branca, procedente de Botucatu, apresentava dermatocálase bilateral. Optou-se pela realização de blefaroplastia superior bilateral, realizada removendo-se pele e gordura da pálpebra superior. No pós-operatório foi observado ptose palpebral à esquerda. Optou-se pela cirurgia para reinserção do músculo levantador da pálpebra superior à esquerda. Um mês após a reinserção, observou-se retração palpebral superior nos dois olhos. A paciente foi, então, submetida à cirurgia para a correção de retração palpebral por desinserção do músculo de Müller. Dois meses após esta última cirurgia, a paciente apresentava ptose palpebral à direita e piora da retração palpebral à esquerda. Nova cirurgia para correção da retração palpebral foi feita, colocando-se enxerto livre de esclera para alongamento do levantador da pálpebra superior esquerda, com bom resultado. Foi apresentada uma paciente submetida à blefaroplastia e que desenvolveu no pós-operatório quadro de ptose, seguida de retração palpebral. Estes dois quadros podem ocorrer como complicação de blefaroplastia e o cirurgião deve estar atento para manejar de forma apropriada, a fim de obter o resultado que a paciente espera ter.

The blepharoplasty has been performed with great frequency due to the appreciation of aesthetic surgery. The complications related to this procedure are rare. This case report aims to emphasize complications that can occur. T.J.S.P., 45 years old, female, white, resident of Botucatu City, presented dermatocalase bilaterally. We opted to perform upper blepharoplasty bilateral, by removing skin and fat of the upper eyelid. In the postoperative period was observed left eyelid ptosis. We decided to reinsert the levator muscle of the left upper eyelid. One month after the ptosis correction, retraction was observed in both upper eyelid. The patient was then submitted to surgery for the correction of eyelid retraction by disinsertion of the muscle of Muller. Two months after this last surgery, the patient presented right eyelid ptosis and worsening of eyelid retraction to the left. New surgery for correction of the eyelid retraction was made, using free graft sclera for elongation of the left eyelid levator muscle, with good results. The authors presented a patient who underwent a blepharoplasty and developed ptosis in the post-operative period, followed by eyelid retraction. These two possibilities may occur as a complication of blepharoplasty and the surgeon must be careful to handle in an appropriate way, in order to get the result that the patient expects to have.

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INTRODUCTION: Congenital ptosis is malpositioning of the eyelids that, when moderate or severe, can negatively affect visual development during its critical period, resulting in amblyopia: diminished visual acuity with no apparent organic cause. Early diagnosis and timely treatment are essential for preventing amblyopia. Congenital ptosis is uncommon but poses a challenge to any ophthalmologist; the only treatment is surgical. Among these patients in Cuba, those with the most complex clinical characteristics are generally referred to the Ramón Pando Ferrer Ophthalmology Institute in Havana. OBJECTIVE: Characterize visual acuity outcomes obtained in patients seen at this Institute who received surgery for simple congenital ptosis using the frontalis sling procedure. METHOD: A descriptive prospective longitudinal study was conducted to describe visual acuity outcomes in 11 patients with a diagnosis of isolated congenital ptosis seen in the Oculoplastic Service of the Ramón Pando Ferrer Ophthalmology Institute between January and July 2009 and operated on using the frontalis sling procedure. The majority exhibited severe visual acuity impairment (0.1-0.5) prior to surgery. Variables employed were age, sex, degree of ptosis, degree of ptosis correction, visual acuity, and complications during surgery and postoperatively. RESULTS: Male patients aged 1-4 years predominated. Visual acuity improved in 100% of patients, to varying degrees. Prior to surgery, 72% had visual acuity of 0.1-0.5. Six months post-surgery, with visual rehabilitation, 90.9% exhibited visual acuity of >0.5. In 81.8% of patients, palpebral ptosis was fully corrected. Complications were minimal: injury to the palpebral tarsus and undercorrection were the most common and did not affect final surgical outcome or interfere with rehabilitation. CONCLUSIONS: Correction of congenital ptosis using the frontalis sling technique yielded satisfactory visual acuity outcomes, contributing to visual rehabilitation of the affected patients.

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Resumo: Introduçäo: A paresia ou paralisia que atinge o reto superior e eo oblíquo inferior do mesmo olho é, também, denominada paralisia dupla de elevadores (PDE). A maioria dos casos requer tratamento e este é cirúrgico na quase totalidade dos pacientes. Säo discutidas as vantagens e desvantagens das diferentes condutas, bem como o modo de distribui-las ao longo do tempo. Quadro clinico: O ângulo de desvio na posiçäo primária é variável. Alguns pacientes têm visäo binocular. O olho afetado pode ser usado para fixaçäo. O paciente pode ter ptose palpebral verdadeira ou pseudo-ptose. Posiçäo viciosa de cabeça pode ser observada. O fenômeno de Bell pode estar preservado ou ausente. O teste das duçöes forçadas é usualmente normal, mas às vezes revela certa limitaçäo na elevaçäo. Etinologia: A maioria dos autores admite uma lesäo supranuclear, atingindo as fibras cruzadas destinadas ao reto superior e as näo-cruzadas que se dirigem ao oblíquo inferior. Pode haver comprometimento do sub-núcleo contralateral do reto superior. Tratamento: A cirurgia convencional, de debilitamento e/ ou reforço de musculos com açäo vertical, é ineficaz. Pode haver comprometimento do sub-núcleo contralateral do reto superior. Tratamento: A cirurgia convencional, de debilitamento e/ ou reforço de músculos com açäo vertical, é ineficaz. A transposiçäo dos retos horizontais para a inserçäo do reto superior é o procediemnto de escolha. Conclusäo: A PDE é um quadro multiforme que responde bem à transposiçäo dos retos horizontais (au)

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INTRODUCTION: Mirror movements (MM) are involuntary shudders which occur at the same time as voluntary movements of the homologous contralateral muscles. They may occur alone or associated with other pathology. CLINICAL CASES: We present three new cases of congenital MM (CMM) and discuss their clinical, physiopathological and genetic aspects. Case 1. A four year old boy was brought to the clinic because he dropped things held in one hand when he tried to take things with the other. On examination it was seen that when he made a voluntary movement with one hand, the other hand made a similar movement simultaneously and involuntarily. This phenomenon had been observed since he was a few months old. Apart from this, the rest of the neurological examination was normal. Cerebral MR was also normal. Neuropsychological assessment showed borderline intellectual function. Case 2. The first patient's father, who was 26 years old, knew no details of his own family history. Since childhood he had noticed that he himself had made similar movements to those of his son. However, with time, he had managed to partially control and even inhibit these movements. His cerebral MR scan was normal. Case 3. An 11 year old boy consulted for MM, non-fluctuating congenital palpebral ptosis and nocturnal enuresis. The neurological examination and his intelligence were found to be normal. One of his sisters had palpebral ptosis and nocturnal enuresis without MM. His cerebral MR, X-ray of his spine, EMG, electroretinogram, CPK, blood lactate, glucemia, urine and urological examination were normal. CONCLUSIONS: MM may be another manifestation within the clinical spectrum of diverse encephalopathies; may be associated with different syndromes (Kallman, Klippel-Feil and Usher amongst others) or may present alone. Both familial and sporadic cases have been described. We consider our cases 1 and 2 to be of the familial CMM condition, with autosomal dominant inheritance, in which MM was the only finding. The association observed in case 3 has not previously been described. It may possibly be a condition transmitted by autosomal recessive inheritance.

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O caso descrito apresentava uma hipotropia pouco severa com acuidade visual normal e binocularidade em infra-versäo; além de uma hipotonia muscular generalizada, ao contrário da severa hipotropia e ambliopia encontrada nessa afecçäo. O procedimento cirúrgico levou estes fatos em consideraçäo, tendo-se optado por um retrocesso pequeno do reto inferior para que se corrigisse o torcicolo sem interferir na posiçäo de leitura. Os resultados pós-operatórios foram satisfatórios.

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OBJECTIVE: This study used image processing techniques to quantify the upper eyelid contour of patients with Graves upper eyelid retraction and congenital blepharoptosis. DESIGN: The study design was a cross-sectional study. PARTICIPANTS: A total of 29 patients with Graves disease, 22 patients with congenital blepharoptosis, and 50 patients with no history of eye disease participated. INTERVENTION: The images of the palpebral fissure of all participants were transferred to a personal computer and processed with NIH Image 1.55 software. MAIN OUTCOME MEASURES: The following parameters were analyzed: the curvature of the upper eyelid contour, the position of the contour peak relative to the midline, and the ratio between the temporal and nasal upper quadrant areas of the palpebral fissure. RESULTS: All upper eyelid contours could be fitted with second-degree polynomial functions. The mean temporal/nasal area ratio was 1.33 mm in patients with Graves disease, 0.92 mm in patients with blepharoptosis, and 1.04 mm in control subjects. The peak of the upper eyelid contour was found to be lateral to the midline in control subjects (1.05 mm) and in patients with Graves disease (2.09 mm). In patients with blepharoptosis, the peak was 0.69 mm medial to the midline. Overall, the distance between the midpupil and the upper eyelid margin was correlated with several factors: the degree of curvature, the position of the peak of the eyelid contour, and the temporal/nasal area ratio. CONCLUSIONS: In Graves eyelid retraction, the curvature of the upper eyelid is enhanced, the peak of the contour is displaced laterally, and the temporal upper quadrant area is increased. Conversely, in congenital blepharoptosis, the eyelid is almost flat, the peak of the contour is displaced medially, and the upper quadrant area is diminished. The lateral segment of the upper eyelid is more involved than the nasal segment in both Graves upper eyelid retraction and congenital blepharoptosis.

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O presente trabalho apresenta um estudo clínico prospectivo de 39 pacientes submetidos a blefaroplastia estética na 38ª Enfermaria da Santa Casa de Misericórdia do Rio de Janeiro, com o objetivo de determinar as modificações anatômicas da fenda palpebral e sua relação com o aparecimento dos sintomas de "olho seco" no pós-operatório. Para melhor compreensão destas alterações e de suas conseqüencias, os autores descrevem a anatomia da fenda palpebral, a fisiologia do sistema lacrimal e a síndrome de olho seco, ressaltando a importância da história clínica e da avaliação criteriosa da morfologia orbital e periorbital, na identificação de fatores predisponentes no pré-operatório.

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