Дисертації з теми "Vitrector"

orionpizango@gmail.com
Case report: A 43-year-old female presented with decreased visual acuity in the right eye.“Snowball-like” retinal lesions were found in both eyes on examination. Due to a lackof improvement with intravitreal antifungal empirical treatment, vitreous culture wasperformed and Candida glabrata was isolated. The patient then received intravitreal ampho-tericin B, as well as systemic treatment with caspofungin and amphotericin B lipid complex.Discussion: Endogenous fungal endophthalmitis is a sight-threatening condition. There arefew reports of C. glabrata endogenous endophthalmitis. Treatment regimens for Candidaendophthalmitis include combinations of systemic and/or intravitreal antifungals, as wellas vitrectomy.

Background: Vitrectomy is a well-accomplished method for treatment of vitreomacular traction. In 2013, a new approach for treating symptomatic vitreomacular traction was presented, ocriplasmin (Jetrea®), that could perform enzymatic vitreolysis. In this study ocriplasmin was studied to compare the treatment results with the standard method vitrectomy. Aim: The purpose of this study was to compare vitrectomy to ocriplasmin-injection for treatment of vitreomacular traction performed between 2013 and 2016. Materials and methods: The medical records of 16 patients were reviewed. Eight of them were treated with ocriplasmin and the other eight underwent vitrectomy due to vitreomacular traction. All patients who received ocriplasmin at the clinic were included, and vitrectomy-patients were matched to these according to sex, age and visual acuity. Preoperative and postoperative symptoms, visual acuity and optical coherence tomography findings were analyzed. Results: Vitreomacular traction resolved in every eye treated with vitrectomy compared to four of eight eyes treated with ocriplasmin. With one exception, every patient´s visual acuity in the vitrectomy group improved, with a mean value of +0,223 Snellen. Three of eight patients in the ocriplasmin group had improved visual acuity, while three worsened and two remained the same. Visual acuity in this group altered with a mean value of +0,071 Snellen. Conclusions: Enzymatic vitreolysis is a good idea, but according to our and other international studies, it only achieves good results in half of the cases, while vitrectomy almost always succeeds. Although vitrectomy can lead to certain complications, for example cataract, it is a well functioning and relatively moderate surgical procedure and its complications can be managed.

The purpose of this project is to study the risk of cataract development in patients who had undergone pars plana vitrectomy, scleral buckle, or both. A retrospective study was performed of phakic patients who underwent pars plana vitrectomy, scleral buckle, or both at Yale University Eye Center from 1998 to 2005. Mild postoperative cataract, defined as a change in severity of 1+, developed in 32 of 53 (60%) eyes following vitrectomy, 2 of 19 (11%) post scleral buckle, and 14 of 16 (88%) after both. Moderate postoperative cataract, defined as a change in severity of 2+, developed in 14 of 53 (26%) eyes post vitrectomy, 1 of 19 (5%) post scleral buckle, and 11 of 16 (69%) after both procedures. In eyes that underwent vitrectomy, a lens change of at least 2+ occurred in 8% at 3 months, 15% at 6 months, 21% at 12 months, and 26% at 36 months. In eyes status post scleral buckle surgery, one eye (5%) experienced a 2+ change at 36 months. In eyes that underwent both vitrectomy and scleral buckle, a lens change of at least 2+ occurred in 44% at 3 months, 50% at 6 months, 63% at 12 months, and 69% at 36 months. Cataract extraction surgery was performed in 15% of eyes post vitrectomy, 0% post scleral buckling, and 50% after both. The most common type of cataract to develop was nuclear sclerotic, which accounted for 61% of cataracts after vitrectomy, 50% after scleral buckling, and 50% after combined vitrectomy and scleral buckling. Scleral buckling surgery is associated with a low risk of cataract formation. Pars plana vitrectomy and combined vitrectomy and buckle have a higher risk of cataract development.

Includes abstract.
Includes bibliographical references (leaves 38-43).
The purpose of this study was to determine the visual function and quality of life of patients 6 months after undergoing pars plana vitrectomy for diabetic retinopathy complications at the Groote Schuur Hospital. The study also investigated the association between quality of life and the indications for surgery, the type of procedure performed, pan-retinal photocoagulation before surgery, the duration of complications, age, gender, the presence systemic disease and best-corrected visual acuity (BCVA).

Objetivos
Estudiar el papel de la extracción de la membrana limitante interna (MLI) durante la vitrectomía posterior por vía pars plana (VPP), en el tratamiento quirúrgico de lo agujero macular (AM) y de lo edema macular crónico diabético (EMCD). Hemos estudiado las tasas de éxito clínico de la extracción de la MLI durante la VPP. Además hemos analizado el procedimiento técnico de extracción de la MLI, el aporte de la extracción de la MLI en la resolución clínica del EMCD después de la VPP y el valor de la tomografía de coherencia óptica (TCO) en el seguimiento de pacientes con EMCD y AM.
El objetivo secundario consistía en establecer una correlación clínico-patológica mediante el examen histológico de la MLI. Este estudio abarcaba los descubrimientos histológicos y las diferencias de la MLI observadas mediante microscopia electrónica de transmisión (MET) y microscopia óptica (MO).
Material y Métodos
Estudio prospectivo de un año de 28 pacientes, no randomizado, no comparativo, con dos grupos de pacientes: 1) grupo con AM; 2) grupo con EMCD resistente al tratamiento láser.
Los pacientes habían sido sometidos, antes y después de la VPP, a un examen oftalmológico: refracción objetiva, mejor agudeza visual (AV) corregida con teste de Snellen, medición de la presión intraocular, biomicroscopia, examen del fondo ocular y oftalmoscopia indirecta. El seguimiento postoperatorio fue efectuado durante el primer año a un día, una semana, 1, 3, 6 y 12 meses del postoperatorio. Los pacientes fueron sometidos a angiografía fluoresceínica digital, fotografía del fondo de ojo y mapado macular con TCO, como exámenes diagnósticos complementarios.
Todos los pacientes fueron sometidos a la VPP y el objetivo principal era la disección epiretiniana y extracción de la MLI. Las MLIs fueron preparadas para un análisis con MO y MET.
Resultados
En el grupo con AM formado por diez ojos, seis tenían AM de tipo 2 y 3 y cuatro de tipo 4 (clasificación de Gass). Cinco pacientes presentan AM idiopáticos. Todos, salvo uno, mantuvieron o mejoraron la mejor AV corregida al final del estudio. La mejora de la VA era significativa estadísticamente sólo después del tercer mes del postoperatorio. El seguimiento mediante OCT demostró que el cierre del los AM fue alcanzado en nueve de ellos. La TCO pudo acompañar la evolución anatómica del cierre del agujero.
En los 18 pacientes con EMCD, trece ojos mejoraron la AV, en dos no se produjo ningún cambio y tres empeoraron la AV, al final del seguimiento. La mejora de la AV comenzó a ser significativa entre el tercer y sexto mes del postoperatorio. El espesor foveal postoperatorio se redujo de manera significativa y progresiva respecto al observada en el preoperatorio. Hemos observado una disminución graduada y evidente del espesor macular paralelamente con una mejora progresiva de la AV: cuanto menos espessa era la fovea (TCO), mayor resultaba la mejor AV corregida.
Hemos analizado las características ultraestructurales de la MLI normal en las retinas extraídas de dos donadores de ojos y comparado la MLI obtenida de los ojos sometidos a la VPP.
Hemos realizado el examen histopatológico en 10 muestras del grupo con AM. Hemos podido observar la presencia de la MLI en 9 muestras. Hemos encontrado residuos de retina neurosensorial asociada con la superficie retinal de la MLI en 3 muestras. Pocas MLI presentaban un componente celular asociado con la superficie vítrea. En algunas MLI, hemos observado la presencia de fragmentos condensados de la hialoides posterior, a veces asociado con componente celular. Hemos llevado a cabo 75 mediciones correspondientes a distintos segmentos de la MLI. Los resultados han demostrado una significativa diferencia (p = 0.00011) entre el promedio del espesor de la MLI en el grupo con AM y en máculas normales. Al comparar el promedio de espesor observado en el grupo con AM con los obtenidos en el grupo con EMCD (2.2 ± 0.78 µm), la diferencia era siempre significativa (p = 0.03).
En las muestras diabéticas examinadas mediante MET, hemos podido observar la presencia de la MLI en 7 muestras sobre 10. En 3 muestras sobre 10 no había ninguna MLI y la membrana epiretiniana presentaba una gran cantidad de matriz extracelular (colágeno y una gran variabilidad de células). El único descubrimiento histopatológico observado en 5 muestras mediante MET consistía en segmentos de MLI sin componentes fibrilares o celulares. Cuatro muestras presentaban una abundante disposición de colágeno compatible con el espesoramiento de la membrana hialoides o MER. Distintos tipos que rodeaban el colágeno extracelular componen la población celular asociada al tejido diabético: a) células glials; b) células fibroblásticas; c) células epiteloides; d) células plasmáticas macrófagas. En la MET hemos podido demostrar la presencia de componentes retinales neurosensoriales asociadas con la superficie retiniana de la MLI en 3 muestras.
Conclusiones
Grupo de Agujeros Maculares:
1. La VPP asociada a la extracción de la MLI es un procedimiento de utilidad para el tratamiento quirúrgico de los AM. En el presente estudio prospectivo de un año, la tasa de cierre anatómico fue de un 90% y la mejor media de la AV final corregida se obtuvo en los ojos con éxito anatómico.
2. La TCO contribuyó para el diagnóstico, se presentó como una alternativa no invasiva para la evaluación del estado foveal y permitió documentar y analizar la evolución del cierre anatómico de los AM.
Grupo de Edema Macular Diabético:
1. El presente estudio clínico prospectivo de un año demostró los beneficios de la extracción de la MLI, mediante VPP, como tratamiento quirúrgico del EMCD. La extracción de la MLI conllevó a una disminución del engrosamiento de la retina, a la resolución clínica del edema macular y a una mejor AV.
2. La TCO permitió un seguimiento cualitativo del perfil de la retina y un análisis cuantitativo de las pequeñas variaciones del espesor macular. El espesor de la macula ha disminuido significativamente al final del primer mes del postoperatorio (p = 0,00016) comparado con una mejoría significativa de la AV corregida a partir del sexto mes de seguimiento clínico (p = 0,05).
3. Mediante MO y MET, el estudio histológico mostró la ausencia de fragmentos de MLI en algunos de los especimenes analizados. Algunas piezas histológicas eran membranas epirretinianas o la hialoides posterior engrosada.
Ambos Grupos:
1. La correlación clínico-patológica indicó que la presencia de elementos de la retina neurosensorial observados en la cara retiniana de algunos especimenes de MLI fue extraída de ojos que presentarían una peor AV final corregida.
2. El espesor de la MLI observado en el grupo de AM fue mayor que el observado en el grupo de EMCD (p = 0,03) que, a su vez, fue mayor que el espesor observado en la MLI de la retina normal (p = 0,00003).

Objetivo: A partir das medidas anatômicas isoladas (altura, diâmetro externo e interno) do BMI construir um novo índice prognóstico para a cirurgia de correção do Buraco Macular Idiopático (IPBM). Tipo de estudo: intervencional, série de casos. Pacientes e Métodos: Estudo realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e no Instituto Suel Abujamra, São Paulo-SP, entre outubro de 2005 e outubro de 2007. Foram incluídos 36 olhos de 36 pacientes com BMI, que foram avaliados segundo as medidas apresentadas ao exame de TCO (Stratus - Zeiss, versão 4.01) antes da cirurgia do BMI. Utilizando o compasso do TCO, obteve-se a medida dos maiores diâmetros externo e interno e da altura dos BMI. Por meio dessas medidas, foi criado o IPBM. Após vitrectomia posterior com retirada de Membrana Limitante Interna (MLI), sem utilização de corantes, os pacientes foram acompanhados por seis meses. Após a cirurgia, os pacientes foram avaliados no primeiro e sétimo dias, duas semanas, um, três e seis meses. Ao final do seguimento, o IBPM e outras variáveis (sexo, idade, raça, estádio do BMI pela classificação biomicroscópica de Gass, tempo decorrido desde a piora da acuidade visual informada pelo paciente e a acuidade visual pré-operatória), foram correlacionadas com o resultado anatômico e a acuidade visual pós-operatória. Resultados: Vinte e nove (80,6%) dos 36 olhos com BMI obtiveram fechamento anatômico ao final de seis meses de acompanhamento (8,86 ± 4,23 meses). Dezenove (52,7%) dos BMI eram do estádio IV de Gass, com tempo de duração maior que um ano em 21 pacientes (58,3%). A AV LogMAR corrigida pré-operatória média foi de 1,10 (0,60 a 1,62) e a pós-operatória média foi de 0,69 (0,0 a 1,60). A média de melhora da AV foi de 3,94 linhas. Em relação ao fechamento anatômico, não houve significância em relação ao tempo de história da doença entre os grupos aberto (grupo 1) e fechado (grupo 2) (Teste t-Student, p=0,072). O diâmetro da base interna foi maior no grupo 1 em relação ao grupo 2 (Teste t-Student, p=0,007). Na análise do índice IPBM, houve diferença significativa entre o grupo 1 (média 0,49) e o grupo 2 (média 0,91). (Teste t-Student, p< 0,001) A análise de regressão logística apontou que BMIs com IPBM maior que 0,53 apresentam chance de fechamento anatômico 9,6 vezes maior (Odds Ratio= 9,6, p = 0,018). Pacientes com IPBM > 0,53 apresentaram AV pós-operatória ao final do sexto mês significativamente melhor do que pacientes com IPBM < 0,53 (Mann-Whitney, p=0,005). O ganho percentual da AV foi de 41,93% nos pacientes com IBPM>0,53, quando comparado com os 7,14% do grupo com IPBM <0,53 (p=0,002). No que diz respeito à AV final LogMAR, todas as variáveis estudadas anteriormente foram submetidas ao teste de correlação de Pearson. Observou-se que o IPBM tem uma correlação negativa significante com a AV, e foi selecionado juntamente com a AV pré-operatória através de regressão linear como os melhores preditores de AV final (p<0,001 e p=0,005, respectivamente). O modelo aponta que 58,4% da AV pós-operatória está sendo explicada pelo IPBM e AV pré-operatória. Conclusões: Foi construído um novo índice Prognóstico do Buraco Macular Idiopático (IPBM) representado pela razão altura / diâmetro interno do BMI. Verificou-se que o IPBM pode ser utilizado como fator prognóstico de fechamento anatômico do BMI. O IPBM e a AV pré-operatória foram os fatores prognósticos com melhor relação para a AV no sexto mês após o tratamento cirúrgico do BMI.
Purpose: To create a new prognostic index for IMH surgery based on anatomical values of IMH height, external and internal diameters (MHPI). Type of Study: Prospective, interventional, case of series. Patients and Methods: 36 eyes with IMH of 36 patients followed at Hospital das Clinicas, University of São Paulo Medical School (HC-FMUSP) and Suel Abujamra Institute (ISA), São Paulo-SP, between October 2006 and October 2007, were included. IMH OCT measurements were obtained before surgery (Stratus - Zeiss version 4.01) Values of the larger external and internal diameters, and the IMH height were obtained using the OCT compass. The prognostic index of IMH (MHPI) was defined as the index height / internal base. MHPI was defined by using those OCT measurements. Patients underwent pars plana vitrectomy with ILM peeling without dye and were followed by 6 months. Patients were seen at days 1, 7, 14, and months 1, 2, 3, and 6 after surgery. At the end of the follow-up period, MHPI and, other variables (sex, age, ethnic group, stage of IMH following the biomicroscopic classification of Gass, the time of visual loss reported by the patient, and pre surgical visual acuity) were correlated with anatomical results and post-surgical visual acuity. Results: Twenty nine eyes (80.6%) of thirty six patients with IMH had anatomical closure at the end of the six-month follow-up (8.86 ± 4.23 months). Nineteen (52.7%) IMH were stage IV of Gass with more than one year duration in twenty one patients. Pre-surgical medium LogMAR VA was 1.10 (0.60 to 1.62) and post-surgical was 0.69 (0.0 to 1.60). Medium VA improvement was 3.94 lines. The internal base diameter (BINT) was larger in group 1 than in group 2 (t-Student Test, p=0.373). MHPI analisys showed significant difference between group 1 (average 0.49) and group 2 (average 0.91) (t-Student Test, p> 0.001). Logistical regression showed that IMH with MHPI higher than 0.53 present 9.6 times more risk of failure than those with MHPI lower than 0.53 (Mann-Whitney, p=0.005). The percentage gain of VA was 41.93% in patients with MHPI > 0.53, and 7.14% in patients with MHPI lower than 0.53 (p=0.002). In regards to the final LogMAR VA, all studied variables above submitted to Pearson correlation test. MHPI is inversely correlated with VA by linear regression with gradient procedure as best predictor of final VA (p< 0.001 and p= 0.005 respectively). The sample shows that 58.4% of post-surgery VA is being explained by the MHPI and pre-surgery VA. Conclusions: A new prognostic index for IMH surgery was defined as IMH height/internal diameter. We concluded that MHPI may be used as a prognostic factor for IMH anatomical closure after surgical treatment. MHPI and preoperatory VA were the best correlated prognostic factors for 6-month VA.

Dissertação de Mestrado Integrado em Medicina Veterinária
A uveíte recorrente equina (URE) é frequentemente citada como a causa mais comum de cegueira em cavalos, apresentando prevalências entre 8 a 10% na Europa e entre 2% a 25% nos Estados Unidos. É caracterizada por episódios recorrentes de inflamação intraocular, separados por períodos de remissão, nos quais não há sinais de inflamação intraocular ativa. Evidências recentes correlacionam-na com uma forte resposta autoimune, despoletada após infeção por Leptospira. Embora a terapêutica médica anti-inflamatória seja eficaz no controlo da maioria dos casos de uveíte recorrente equina, alguns casos requerem abordagem cirúrgica, por exemplo, vitrectomia. Neste estudo foram revistos os dados referentes às vitrectomias realizadas entre Janeiro de 2012 e Janeiro de 2013, na Clínica de Equinos da Faculdade de Medicina Veterinária de Hannover. Durante a vitrectomia foram recolhidas amostras de vítreo, que foram analisadas por reação da polimerase em cadeia (PCR) e teste de aglutinação microscópica (TAM). O PCR foi positivo para 46,7% dos cavalos testados enquanto 53,3% dos cavalos apresentavam anticorpos anti-Leptospira. No total dos dois testes, 56,7% dos cavalos mostraram reação positiva para Leptospira. Foram detetados anticorpos contra o serovar Grippotyphosa em 81,3% dos cavalos positivos ao TAM. Foi encontrada uma diferença estatisticamente significativa entre a idade dos animais positivos para Leptospira e a idade dos animais negativos. A análise das lesões oculares existentes confirmou uma correlação positiva entre a gravidade das lesões e a positividade para Leptospira. Este estudo suporta a hipótese da relação entre a URE e a infeção por Leptospira no equino. Os resultados obtidos estão de acordo com os trabalhos que sugerem que a seropositividade para Leptospira está correlacionada com uma maior probabilidade do desenvolvimento de cegueira. À medida que prosseguem os estudos na procura de terapêuticas eficazes, para melhor compreensão da patogénese e dos fatores de risco da URE, a necessidade de investigação desta doença no nosso país é cada vez mais premente.
ABSTRACT - Equine Recurrent Uveitis and Leptospirosis: a study of variables in horses that underwent vitrectomy in the region of Hannover - Equine recurrent uveitis is often cited as the most common cause of blindness in horses, with prevalence of 8 to 10% in Europe and 2% to 25% in the United States. It is characterized by recurrent bouts of intraocular inflammation separated by periods of remission, in which there are no signs of active inflammation. Recent research shows it has positive correlation with strong autoimmune response, triggered by infection with Leptospira. Although anti-inflammatory medical therapy is effective in controlling most cases of equine recurrent uveitis, some cases require surgical approach, such as vitrectomy. This study reviewed the data of the horses that underwent vitrectomy between January 2012 and January 2013 in the Equine Clinic of the Faculty of Veterinary Medicine of Hannover. Vitreous samples collected during vitrectomy were analyzed by Polymerase Chain Reaction (PCR) and microscopic agglutination test (MAT). The PCR was positive in 46.7% of the horses, whereas 53.3% of the horses presented antibodies anti-Leptospira. Altogether, 56.7% of the horses showed positive reaction for Leptospira. Antibodies for serovar Grippotyphosa were detected in 81.3% of horses positive for MAT. There was a significant difference between the age of the animals positive for Leptospira and the age of the negative animals. The analysis of the ocular lesions confirmed an association between the severity of the lesions and positivity for Leptospira. This study supports the hypothesis of the link between URE and Leptospira infection in horses. The results are also in agreement with studies suggesting that Leptospira seropositive is correlated with a higher probability of developing blindness. As studies proceed in the search for effective therapies for a better understanding of the pathogenesis and the risk factors of ERU, research into this disease in our country is increasingly needed.

Orientador: Keila Miriam Monteiro de Carvalho
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: Introdução: O tratamento cirúrgico das doenças retinianas sofreu grandes mudanças nas últimas décadas. Na vitrectomia posterior via pars plana (VVPP) realizada com o sistema 20 gauge são utilizados instrumentos com 0.9 mm de diâmetro. Em 2002 foi proposto um novo sistema de vitrectomia posterior composto por instrumentos de 0.5 mm de diâmetro denominado sistema 25 gauge. Objetivo: O objetivo desse estudo é comparar os aspectos per e pós-operatórios das VVPP realizadas com os sistemas 20 e 25 gauge. Metodologia: Foram selecionados prospectivamente pacientes com indicação de vitrectomia apresentando as seguintes doenças retinianas: Buraco Macular idiopático (26 casos), Membrana Epiretiniana Idiopática (28 casos) e Hemorragia Vítrea secundária à Retinopatia Diabética (26 casos), totalizando 80 olhos de 79 pacientes. Após o exame pré-operatório inicial, os pacientes foram distribuídos aleatoriamente e igualitariamente em 2 grupos de acordo com a doença retiniana. O primeiro grupo foi submetido a VVPP com o sistema 20 gauge, enquanto o segundo grupo foi submetido a VVPP com o sistema 25 gauge . Os parâmetros analisados nos dois grupos foram: pressão intra-ocular, tempo cirúrgico, queixa do paciente no pós-operatório através de questionário objetivo sobre dor ocular, desconforto ocular, lacrimejamento, fotofobia e hiperemia ocular, e complicações per e pós-operatórias. O seguimento dos pacientes foi de 6 meses. Resultados: Em relação à presença de queixas pós-operatórias houve diferença entre as seguintes variáveis: dor (p= 0,008), hiperemia ocular (p = 0,014) e lacrimejamento (p= 0,034), com maior queixa para os pacientes submetidos à cirurgia com o sistema 20 gauge. A cirurgia com o sistema 20 gauge ocorreu em um tempo médio de procedimento igual a 39,3 (± 5,4) min enquanto a cirurgia com o sistema 25 gauge ocorreu em um tempo médio de procedimento igual a 23,7 (±7,9) min (p<0,001). Não houve diferença significativa da média da PIO em relação ao tipo de cirurgia realizada e o período de observação. Foram observados 3 casos de formação de bolha conjuntival no per operatório e um caso de endoftalmite no pós-operatório em pacientes submetidos ao sistema 25 gauge. Conclusão: Não foram observadas diferenças estatísticas entre as médias da PIO e o índice de complicações per e pós-operatório sendo o procedimento com o sistema 25 gauge realizado em menor tempo cirúrgico e oferecido maior conforto aos pacientes no pós-operatório
Abstract: Introduction: In the last decades, great improvement has been achieved on the surgical treatment of retinal disease using smaller diameter instruments. Nowadays, pars plana vitrectomy (PPV) is usually executed using the 20 gauge system, in which the instrument's diameter is 0,9mm. In 2002, a new posterior victrectomy system was proposed, using 25 gauge (0,5mm) diameter instruments. Purpose: To compare intra and post operative parameters of the PPV technique with 20 and 25 gauge. Methods: Patients presenting retinal disease, including idiopathic macular hole (26 cases), idiopathic epiretinal membrane (28 cases), and vitreous hemorrhage due to diabetic retinopathy (26 cases) with PPV indication were selected, with a total of 80 patients. After the initial evaluation, patients were randomly assigned to one of the two groups, according to the retinal disease. The first group was submitted to the 20 gauge system surgery and the second group, to the 25 gauge technique. Parameters observed were: intraocular pressure (IOP), surgery time, patients¿ complains on post surgical days through an objective questionnaire about ocular pain, ocular discomfort, tearing, photophobia, ocular redness and intra and post-operative complications. The follow-up of these patients was 6 months. Results: On post operative complains, difference was observed on the following parameters: ocular pain (p= 0,008), ocular redness (p= 0,014) and tearing (p= 0,034), with greatest complains between patients of the 20 gauge group. Median surgery time of the 20 gauge surgery was 39,3 (± 5,4) min; the 25 gauge system was executed in about 23,7 (± 7,9) min (p < 0,001). No significant differences were observed on median post-operative IOP measurements. Bubble conjuntival formation was observed in 3 cases in 25 gauge system. Endophthalmitis was observed in one case in the the group of 25 gauge system. Conclusion: The surgical procedures are equivalent when comparing the median intraocular pressure and the intra and post operative complications, but the 25 gauge system has the advantage of being less time consuming and offering the patient more comfort during the post operative period
Mestrado
Oftalmologia
Mestre em Ciências Médicas

Introduction A full-thickness macular hole (FTMH) is a round deformity in the fovea that involve alllayers of the neurosensory retina. The condition is usually symptomatic and is associatedwith a decreased visual acuity (VA). Large FTMHs are associated to a larger decrease in VA.To treat FTMH pars plana vitrectomy (PPV) is performed to repair the hole. There aredifferent dimensions of instruments in PPV but limited information on the outcome usingeach dimension. Aim This study aims to assess the healing rate of large FTMHs after 25-gauge vitrectomy. Methods The study is a retrospective record review. Patients were identified through the surgicalintervention registry at the Department of Ophthalmology, USÖ. The study included largeFTMHs (diameter > 400 μm) who underwent 25-gauge PPV at USÖ between 2015-2017. Results After 25-gauge PPV 19 (82.6%) out of 23 included eyes healed. No significant difference inhealing rate between subgroups of different sized FTMHs was discovered. Out of 4 eyes thatfailed to heal, 1 patient underwent a reoperation and the other 3 either chose not to or it wasdeemed not indicated. A statistically significant increase in mean VA postoperatively wasobserved. The most reported complications postoperatively were gas cataract and atemporary increase in intraocular pressure. In 7 cases the PPV led to an accelerateddevelopment of cataract and cataract surgery. Conclusion The majority of FTMHs healed after 25-gauge PPV and the mean VA increased after surgery.The most common complications were secondary cataract and temporary increase in IOP.

Introducció: No existeix formació tutoritzada en retina a Espanya. No hi ha cap mètode d'avaluació de la corba d'aprenentatge en cirurgia de retina, sent el més habitual l'anàlisi de casos successius de complicacions quirúrgiques. És necessari el desenvolupament d'un sistema d'autoavaluació de la corba d'aprenentatge en vitrectomia per assegurar el seu correcte progrés amb seguretat fins la seva aquisició. Objectiu: Avaluar la utilitat de les gràfiques de suma acumulada (CUSUM) per analitzar l'evolució de la corba d'aprenentatge en vitrectomia. Mètodes: Es van revisar els primers pacients intervinguts de vitrectomia per un cirurgià principiant. Es van recollir les següents dades: el diagnòstic principal, el temps d'aprenentatge, la tècnica quirúrgica i les complicacions intraoperatòries i postoperatòries. Es va realitzar una anàlisi de casos successius de l'evolució de les complicacions quirúrgiques i es van crear gràfiques CUSUM per a 5 variables: retinotomía, hipertensió i hipotonia postoperatòries, cataracta secundària i redesprendimiento de retina. Resultats: Es van incloure 237 vitrectomies. L'anàlisi de casos successius va determinar un canvi de tècnica a favor de la vitrectomia transconjuntival a partir de les 80 vitrectomies, amb un increment de les complicacions en el següent trimestre. Les gràfiques CUSUM mostren un bon rendiment, adquirint la competència en moments diferents per a cada variable; així com períodes de baix rendiment, coincident amb l'increment en les complicacions. La competència completa es va aconseguir en el cas 236. Conclusions: L'anàlisi de la corba d'aprenentatge mostra que el temps d'aprenentatge és més gran que la percepció del cirurgià. L'anàlisi de casos successius es confirma subjectiu i tardà, mentre que l'anàlisi CUSUM es proposa com un mètode objectiu, prospectiu i precís, amb capacitat per preveure un pobre rendiment.
Introducción: No existe ningún método de evaluación de la curva de aprendizaje en cirugía de retina, siendo el más habitual el análisis de casos sucesivos de complicaciones quirúrgicas. No existe formación tutorizada en retina en España, por lo que es necesario el desarrollo de un sistema de autoevaluación de la curva de aprendizaje en vitrectomía para asegurar su correcto progreso con seguridad hasta su adquisición. Objetivo: Evaluar la utilidad de las gráficas de suma acumulada (CUSUM) para analizar la evolución de la curva de aprendizaje en vitrectomía. Métodos: Se revisaron los primeros pacientes intervenidos de vitrectomía por un cirujano principiante. Se recogieron los siguientes datos: el diagnóstico principal, el tiempo de aprendizaje, la técnica quirúrgica y las complicaciones intraoperatorias y postoperatorias. Se realizó un análisis de casos sucesivos de la evolución de las complicaciones quirúrgicas y se crearon gráficas CUSUM para 5 variables: retinotomía, hipertensión e hipotonía postoperatorias, catarata secundaria y redesprendimiento de retina. Resultados: Se incluyeron 237 vitrectomías. El análisis de casos sucesivos determinó un cambio de técnica a favor de la vitrectomía transconjuntival a partir de las 80 vitrectomías, con un incremento de las complicaciones en el siguiente trimestre. Las gráficas CUSUM muestran un buen rendimiento, adquiriendo la competencia en momentos distintos para cada variable; así como períodos de bajo rendimiento, coincidente con el incremento en las complicaciones. La competencia completa se consiguió en el caso 236. Conclusiones: El análisis de la curva de aprendizaje muestra que el tiempo de aprendizaje es mayor que la percepción del cirujano. El análisis de casos sucesivos se confirma subjetivo y tardío, mientras que el análisis CUSUM se propone como un método objetivo, prospectivo y preciso, con capacidad para prever un pobre rendimiento.
Introduction: There is no method for learning curve assessment in vitrectomy, the most common being the sequential case analysis of surgical complications. There are no tutorized retina fellowships in Spain, so it is necessary to develop a self-assessment system of the vitrectomy learning curve, to ensure safe progress until it is achieved. Objective: To assess cumulative sum analysis (CUSUM) capability to analyze learning curve in vitrectomy. Methods: A single ophthalmologist trainee’s first vitrectomy cases were evaluated. Following data was collected: diagnosis, learning time, surgical technique, intraoperative and postoperative complications. Sequential case analysis was carried out to assess the evolution of surgical complications over time and CUSUM charts were created for 5 variables: retinotomy, ocular hypertension, hypotony, secondary cataract and retinal redetachment. Results: 237 vitrectomies were included. Sequential case analysis detected a change in surgical technique towards transconjunctival vitrectomy around the 80th case, with surgical complications increasing in the following trimester. CUSUM charts show good performances, achieving competence at a different learning time for each variable, as well as periods of an unsatisfactory performance, coincident with an increase in surgical complications. Full vitrectomy competence was achieved following 236 procedures. Conclusions: Learning curve analysis indicates that time to achieve competence takes longer than the surgical trainee thinks. Sequential case analysis is proved to be a subjective and late system for learning curve assessment, while CUSUM analysis is proposed as an objective, prospective and precise method, that also provides the ability to anticipate an unsatisfactory performance.

Objetivos: Avaliar a função e estrutura da retina de pacientes com membrana epirretiniana (MER) ou buraco macular (BM) antes e após a cirurgia, e determinar suas relações e os valores preditivos para a acuidade visual após tratamento com vitrectomia associada a peeling da membrana limitante interna. Casuística e Métodos: Foram incluídos 51 olhos de 50 pacientes com indicação de tratamento cirúrgico de MER ou BM idiopáticos. Foi realizada avaliação oftalmológica completa, incluindo melhor acuidade visual corrigida (MAVC) no pré-operatório e nas semanas 1, 3, 8, 24 e 48 após a cirurgia, enquanto que eletrorretinografia multifocal (mfERG) e tomografia de coerência óptica (OCT) foram realizadas antes da cirurgia e dois e doze meses após o procedimento. Os resultados da mfERG serão apresentados na forma da razão entre os valores encontrados nos dois anéis centrais, normalizados pelas médias dos três anéis periféricos (denominada razão P1), para minimizar a variabilidade interpessoal desse teste e ressaltar as alterações encontradas nos anéis centrais. A OCT foi usada para calcular o quociente entre medidas da altura e base do BM (IBM). Resultados: Quarenta e cinco pacientes (46 olhos; n = 30 BM e 16 MER) completaram as 48 semanas de seguimento. No pré-operatório, a média ± SE da MAVC (logMAR) para os grupos BM e MER, respectivamente, foi: 0,93 ± 0,22 (20/170; ou 0,12 decimal) e 0,58 ± 0,11 (20/76; ou 0,26 decimal), com melhora significativa após 48 semanas de seguimento (média ± EP da diferença entre as acuidades visuais medidas em logMAR em 48 semanas e a basal) -0,25 ± 0,07 para o grupo BM e -0,29 ± 0,06 para o grupo MER. O mfERG mostrou-se alterado antes da cirurgia para BM, com melhora da razão P1 após a cirurgia. Para o BM, houve correlação entre a razão P1 no pré-operatório e o ganho da MAVC na semana 8 após a cirurgia (r = -0,42; p = 0,033), mas essa correlação não foi observada para o grupo MER. Também não houve correlação entre o IBM e a acuidade visual após a cirurgia. Conclusões: Os resultados indicam que pacientes com BM apresentando mfERG com baixa razão P1 têm menor probabilidade de ganho de visão após a cirurgia, mas essa afirmativa não é válida para a MER.
Purpose: To evaluate retinal structure and function in eyes with macular hole (MH) or epiretinal membrane (ERM) before and after pars-plana vitrectomy with internal limitant membrane (ILM) peeling, to determine function/structural interrelations and predictive values of postoperative visual acuity. Casuistic and Methods: Fifty-one eyes of 50 patients with idiopathic MH or ERM were included. Comprehensive ophthalmologic evaluation including best-corrected visual acuity (BCVA) was performe date baseline, 1, 3, 8, 24 e 48 weeks after surgery, while optical coherence tomography (OCT) and multifocal ERG was performed before and at 2 and 12 months after surgery. mfERG results are show using the ratio between the amplitude averages of the 2 central rings and the 3 peripheral rings (P1 ratio) and OCT was used to calculate the macular hole index (MHI) defined by the quotient between hole height/base. Results: Forty-five patients (46 eyes; n = 30 MH and 16 ERM) finished follow-up. Mean ± SE (logMAR) preoperative BCVA was 0.93 ± 0.22 and 0.58 ± 0.11 for MH and ERM respectively, and improved in -0.25 ± 0.07 logMAR for MH and -0.29 ± 0.06 logMAR for ERM. mfERG P1 ratio was reduced in BM, and increased significantly after surgery. There was significant correlation between preoperative P1 ratio and BCVA gainat week 8 for MH group (r = -0,42; p = 0,033), but not for ERM group. There was no correlation between preoperative MHI and postoperative BCVA. Conclusion: This data indicates that patients with MH and poor mfERG amplitudes have worse prognoses for BCVA improvement, but does not apply for ERM.

Objetivo: Estudar e comparar a acuidade visual, metamorfopsia, espessura foveal, camada limitante externa e zona elipsoide por meio da Tomografia de Coerência Óptica (OCT), e a taxa de recorrência dos pacientes operados de remoção de membrana epirretiniana, com e sem a retirada da membrana limitante interna. Métodos: Pacientes com MER operados por um único cirurgião e randomizados, aleatoriamente, em dois grupos. Todos os pacientes tiveram a retirada da membrana epirretiniana: 35 pacientes do Grupo 01, sem a adicional retirada de membrana limitante interna, e 28 pacientes do Grupo 02, com a retirada dessa membrana. Os pacientes foram seguidos e avaliados no primeiro, terceiro e sexto mês. Resultados: Setenta pacientes operados no total, sendo sete excluídos por perda de seguimento. Os pacientes de ambos os grupos evoluíram com melhora gradativa da visão ao longo do tempo. No Grupo 01, a média de acuidade visual inicial foi 0,60 logMAR (±0,3 desvio padrão - DP), no primeiro mês foi 0,49 logMAR (±0,26 DP), no terceiro mês, 0,39 logMAR (±0,30 DP) e no sexto mês, 0,27 logMAR (±0,25 DP). No Grupo 02, a média de acuidade visual inicial foi 0,63 logMAR (±0,25 DP), no primeiro mês foi 0,44 logMAR (±0,26 DP), no terceiro mês, 0,41 logMAR (±0,35 DP), e no sexto mês, 0,43 logMAR (0,44 DP). Não houve diferença estatisticamente significante quanto à melhora da acuidade visual entre os dois grupos. Não foi encontrada diferença estatisticamente significante em relação às alterações na OCT entre os grupos. O Grupo 02 apresentou maior taxa de recidiva (17%) quando comparada com o Grupo 01 (3,6%), embora esta diferença não foi estatisticamente significante (p=0,09). Conclusão: Ambos os grupos apresentaram melhora funcional e anatômica semelhantes, mas o grupo no qual não se removeu a membrana limitante interna mostrou uma possível tendência à maior taxa de recidiva
Objective: To study and compare the visual acuity, metamorphosis, foveal thickness, the outer limiting layer and the ellipsoid zone, studied by Optic Coherence Tomography (OCT), and the recurrence rate of patients undergoing removal of epiretinal membrane with and without the removal of the internal limiting membrane. Methods: Seventy patients undergoing removal of epiretinal membrane, by a single surgeon and randomly assigned into two groups. Group 1, without additional removal of internal limiting membrane, 35 patients, and group 2 with the removal of the internal limiting membrane, 28 patients. Both groups were followed and evaluated in the first, third and sixth month. Results: Patients of both groups developed with a gradual improvement of vision over time. In group 1, the mean initial visual acuity was 0.60 logMAR (±0.3 standard deviation - SD), the average visual acuity of the first month was 0.49 logMAR (±0.26 SD), in the third month 0.39 logMAR (±0.30 DP), and in the sixth month logMAR 0.27 (±0.25 SD). In group 2, the mean initial visual acuity was 0.63 logMAR (±0.25 SD), average visual acuity of the first month was 0.44 (±0.26 DP) logMAR, in the third month 0.41 logMAR (±0.35 DP), and in the sixth month 0.43 logMAR (±0.44 DP). There was no statistical difference in improvement in visual acuity between the two groups, there was no statistically significant differences related to tomographic alterations between the groups, but the group 2 showed a higher relapse rate (17%) compared to the group 1 (3.6%). Although the difference is not statistically significant (p=0.09). Conclusion: Both groups showed similar functional and anatomical improvement, but the group which the internal limiting membrane was not removed showed a higher recurrence rate

The paper introduces briefly topics of retinal detachment, vitrectomy and applicable postoperative care. A system for increasing patient comfort is described, which continuously records and signalizes head tilt. The software part of aforementioned system is implemented, using C++ Builder programming environment and helper libraries supplied by system's hardware component vendors. This software application allows user to analyze recorded data and manage the system. Application's user interface and usage is described in detail, as well as implementation details concerning internal functions and organization.

The goal of all vitreous surgery is to perform the desired intraoperative intervention with minimum collateral damage in the most efficient way possible. The primary purpose of the vitreous cutter is to remove vitreous gel from the eye with minimal retinal traction. The consequences of uncontrolled vitreoretinal traction and inflow/outflow mismatch can be very severe. The advancement of vitrectomy surgery instrumentation has been motivated by smaller tools and greater practicability since the introduction of pars plana vitrectomy approximately 40 years ago. During the past 2 decades, engineering development has focused on evaluating different gauge instrumentation in an attempt to make the vitrectomy surgery less invasive and faster, lessening patient discomfort and postoperative inflammation. Our study has consisted in a preliminary study in order to develop an instrument capable of performing vitrectomy using ultrasound. In the first phase of the study (ex-vivo testing) our aim was to study the behavior of the flow obtainable using the instrument considering some modifiable variables (testing vitrector tips with new geometries, new shapes and new holes). This first phase was essential for obtaining the useful work window for the following developments. Furthermore, the vitreous is a non-newtonian fluid with uneven viscosity and fibril structure, and its removal through small-gauge probes is technically challenging and potentially dangerous because of the presence of unpredictable, localized retinal adhesion. An accurate comprehension of vitreous perturbation in response to suction and ultrasonic exposure was essential for the improvement of vitrectomy probes. In the second phase of the study (invivo testing) we performed the experimental in-vivo vitrectomies using the hypersonic vitrector prototype in order to evaluate the macroscopic and ultrastructural effects of the ultrasound on the vitreous and retina. In the first phase of our study we evaluated vitreous flow rates during experimental vitrectomies using an ultrasoundbased prototype vitreous cutter. Thanks to an experimental setup, developed by engineers of the University of Pisa, we measured vitreous flow rates in different experimental conditions. In particular we tested different tips (Conic hole, Cylindric hole, Eccentric Cylindric hole, End Milled hole). The experimental vitrectomies were performed on vitreous obtained from porcine cadaveric eyes (manually dissected). After our flow rate analysis, we observed that it was possible to liquefy vitreous using ultrasound. Furthermore, we can assume that, in general, vitreous flow rates increased with increasing aspiration levels and with increasing % of US power. In particular, using 20% US power we registered probe occlusions or, when it was possible to register a flow, very low levels of flow rates. The greatest increase in flow rates was registered between 20% and 40/50% of US power. Enhancing US power over 40/50% we noticed a minor increase, or in some cases even a reduction, of flow rates. This phenomenon is probably due to the cavitation phenomenon (which becomes significant at high % of US) and to the physical limits of the small (0,2 mm) hole of the instrument, which cannot carry out flows above a certain limit. These general considerations are valid for all the tips we tested, in particular, the most regular behaviour was obtained using the Conic hole tip. The advantages of an ultrasound-based vitrector may be the following: small size of the probe and the hole; aspiration hole always open (continuous flow, less retinal traction); higher flow rates with lower aspiration levels. In the second phase of the study we have evaluated the in-vivo efficacy and safety of an ultrasound vitrector prototype comparing the fragmentation capacity with a traditional guillotine vitrector and observing the microscopic effect on the retinal surface: we did not observe macroscopic harmful effects during US vitrectomy and the ultrastructural evaluation of the vitreous allowed us to observe an excellent fragmentation using the ultrasound vitrector; more specifically the longitudinal modality resulted more efficient than the torsional: the fibril fragments obtained using a standard guillotine vitrectomy and 50% US power in longitudinal mode were shorter in the examined vitreous (ROI), compared to the other experimental sets. Regarding the microscopic findings, no differences in the retina after the use of both types of vitrectors (guillotine and ultrasound vitrector) and no clear/direct correlation between US vitrector use and retinal damage were detected. Vitreoretinal diseases include a multitude of disorders of varying gravity. Most often the only therapeutic approach is a surgical approach which is the vitrectomy. Recently, vitrectomy has seen remarkable technological advances that have revolutionized the management of vitreo-retinal diseases. However, some limits cannot be overcome with the current technique: the presence of the guillotine and the cutting mechanism. Ultrasound-based vitrectomy represents a possible alternative: a tool capable of liquefying and excising the vitreous body using ultrasound could encompass all limits of the guillotine-based technique. Furthermore, initial studies have shown promising results with no macroscopic and microscopic retinal defects. This technique has enormous potential that, thanks to future developments, could be used to treat ocular pathologies

Surgical vitreous removal (vitrectomy) is increasingly advocated to diminish the undesired consequences of retinal damage, which frequently arises from disease or injury to the vitreous. Current surgical techniques for vitrectomy use mechanical or ultrasonic devices that fragment and aspirate the vitreous from the eye. Because of the close proximity and attachment of the vitreous to the retina, this procedure itself incurs a high risk of inflicting retinal damage. Therefore, a less hazardous procedure for total vitrectomy is clinically desirable. This project primarily focuses on the use of enzymes as an adjunct to vitrectomy. Injected into the vitreous a few minutes prior to vitrectomy, the enzymes disrupt the structural integrity of the vitreous macromolecules and vitreo-retinal junction, making vitrectomy a less hazardous procedure. To investigate the effect of the enzymes on the vitreous, it was necessary to quantify changes in the rheological properties of the vitreous resulting from enzyme action. Three experimental schemes were devised for this purpose: firstly, a modified capillary viscometer was built in our laboratory. Secondly, vitrectomy instrumentation was used, and the time for total vitrectomy was measured in enzyme or control eyes. Lastly, a fluids rheometer was used to measure the elastic and viscous moduli and dynamic viscosity of enzyme or control eyes. The incidence of retinal damage caused by the enzymes was also estimated. The results showed that the most effective enzymes were chymopapain and chondroitinase ABC, which required short pretreatment times (20 minutes) and relatively low dose levels (10 and 0.6 mg/ml respectively). Both reduced the vitrectomy time by up to 61% of the controls and neither enzyme produced significant numbers of retinal detachments. Indeed, it was observed that chymopapain effected a clean detachment of the vitreous from the retina. Fluids rheometer experiments revealed that the mechanism by which these two enzymes assist vitrectomy is different.

Idiopathic macular hole is a disease of the eye with unknown cause, but a pathology that, over the course of several decades of investigation by clinicians and researchers alike, has become readily treatable with surgical intervention at a very high rate of successful repair. The current study presents a retrospective case series exploring surgical outcomes for treatment of recurrent macular holes. The study additionally provides a window into the past, present, and future of macular holes across all clinical considerations, and importantly performs a supplementary statistical meta analysis of reoperation success rates in the relevant field of published data- the first of its kind. The introductory background of the present study establishes a natural history of idiopathic macular holes in clinical discovery, classification, and management. The study's case series data specifically focuses on the phenomenon of macular hole recurrence, offering surgical outcome measures of patients undergoing primary and secondary repair operations in a single-center, single-surgeon design. The findings of the retrospective series support the hypothesis that macular hole reoperation does achieve successful anatomical closure in a majority of cases. A meta analysis performed on the current field of published clinical research pertaining to recurrent macular holes established cumulative success rates across a variety of surgical conditions. The present study's findings were then compared to the corresponding measures across the landscape of recurrent macular hole literature, to help inform a niche of clinical research that continues to be an area of investigation and discovery. In presenting a cohesive, synthesized narrative of recurrent macular holes, the study provides a foundation wherein ongoing collaborative efforts in the field can continue to build upon a blueprint currently set in place, and work towards finding a cause behind an otherwise idiopathic disease.

PURPOSE: This study examined the surgical outcomes after pars plana vitrectomy in patients with proliferative diabetic retinopathy at various stages of posterior vitreous detachment. The investigation assessed the changes in visual acuity and the frequency of complications associated with each stage of detachment. METHODS: This retrospective, single-site, single-surgeon study reviewed 328 medical records of patients at Beth Israel Deaconess Medical Center (Boston, MA) requiring pars plana vitrectomy (PPV) for complications of proliferative diabetic retinopathy between 2000 and 2017. The 328 patients were separated into 4 groups based on their vitreous status (Stages 0 and 1, Stage 2, Stage 3, and Stage 4). Preoperative characteristics were collected, including best-corrected visual acuity (BCVA) and diabetes duration. Complications, visual acuity, and reoperation data were collected postoperatively. RESULTS: Sixty-one percent of the patients in the combined group (Stages 0 and 1), 56% in Stage 2, 67% in Stage 3, and 77% in Stage 4 did not require a revision PPV. Thirteen percent of the patients in the combined group, 13% in Stage 2, 5% in Stage 3, and 0% in Stage 4 required a revision PPV for retinal detachment. This represented a statistically significant difference between the groups (p = 0.0254). The combined group had a postoperative change in BCVA of 0.31 compared with 0.29 for Stage 2, 0.67 for Stage 3, and 0.90 for Stage 4. These BCVA changes represented a statistically significant difference (p = 0.0001) between the groups. CONCLUSIONS: This study shows that having a preoperative posterior vitreous detachment leads to improved visual acuity postoperatively and decreased chance of developing a postoperative retinal detachment. The study also indicates that increased vitreoretinal traction results in less change in visual acuity and an increase in complications. Further research is needed to validate these findings.

PURPOSE: To study the long-term anatomic and visual outcomes after pars plana vitrectomy (PPV) with and without internal limiting membrane (ILM) peeling in patients with symptomatic vitreomacular traction (VMT). This study assesses the frequency of complications, changes in visual acuity, and changes in anatomical central macular thickness after macular surgery. METHODS: This retrospective, single-site, single-surgeon study reviewed 40 medical records (45 eyes) of patients at the Beth Israel Deaconess Medical Center requiring PPV with ILM peeling (n=27) or without ILM peeling (n=18) for VMT between the years of 2003 and 2016. Successful surgery was defined as the relief of anatomical traction, and the absence of a second surgery, or any post-operative complications (n=42). Visual acuity was documented for each eye prior to surgery and post surgery. RESULTS: All 27 (100%) eyes that had ILM peeling had successfully resolved macular traction following a single surgery, and 15 of the 18 (83.3%) eyes without ILM peel were successful. None of 27 (0%) eyes that had ILM peeling required a second surgery, nor did they have complications. 3 of the 18 (16.7%) eyes without ILM peeling required a second surgery. Best corrected visual acuity (BCVA, logMAR) improved significantly in both groups: BCVA improved from 0.59 ± 0.29 preoperatively to 0.37 ± 0.25 postoperatively in eyes receiving ILM peeling and from 0.77 ± 0.37 to 0.53 ± 0.37 in eyes with PPV only. Mean change in CMT pre-operatively to post-operatively was found to be greater in eyes with PPV alone, but this difference was not statistically significant. CONCLUSIONS: Our case series shows that PPV with ILM peeling for VMT relieved macular traction better than PPV alone, although there was no significant difference in visual acuity outcomes or central macular thickness between the two groups. Further research is required to validate these findings.
2019-07-11T00:00:00Z

The purpose of this study was to quantify the effects of phacoemulsification and posterior segment chamber lens placement on vitreous inflammatory and neovascular growth factors. More specifically, the effect of immediately preceding cataract surgery was compared to a history of cataract surgery. This study involved a retrospective review and analysis of vitreous samples from a total of twenty seven patients separated into three groups. Group 1, seven patients who underwent a pars plana vitrectomy with macular surgery, group 2, fourteen patients who underwent a combined cataracts and pars plana vitrectomy procedure and group 3, six patients with a history of cataract surgery who underwent a pars plana vitrectomy. The twenty seven patients were picked from a pool of 100 patients who all received pars plana vitrectomy at Beth Israel Deaconess Medical Center with surgeon Dr. Jorge Arroyo. Exclusion factors included active ocular pathologies such as vitreous hemorrhage and retinal detachment. Undiluted vitreous samples from each group were taken before beginning the pars plana vitrectomy. The vitreous samples were analyzed for concentrations of fourteen specific vitreous cytokines and neovascular growth factors including but not limited to TNF Alpha; and SCD40L. These fourteen cytokines and growth factors were chosen through a literature review on the post-surgery ocular inflammatory response. Statistical analysis was done on the average means of the cytokine levels for each group using SPSS 20 for windows. A comparison of means analysis found no significant difference in the means of the fourteen cytokines for group 1 and group 2. A second comparison of means with a pooled control group of both group 1 and group 2 patients versus group 3 was also run. In this analysis, only SCD40L or soluble CD40 ligand was shown to have a significant difference between groups. SCD40L levels were significantly higher (significance level of .038) in group 3, the history of cataract group with a mean of (9.50±4.76) than in the control group with a mean of (5.50±3.35). The findings of this study indicate that the protein SCD40L may play an important role in mediating the inflammatory response seen post cataract surgery and may be useful as a target for novel therapies against the inflammatory response.

PURPOSE: To investigate the outcomes and success rate of surgical intervention for patients diagnosed with primary rhegmatogenous retinal detachment. We investigate the most common and current procedures: pneumatic retinopexy (PR), pars plana vitrectomy(PPV), scleral buckle(SB), and combined vitrectomy and scleral buckle(SB+PPV). METHODS: This nonrandomized, retrospective case series was conducted using data from a single retina surgeon at Beth Israel Deaconess Medical Center. Patient data was collected from September 1999 - October 2017. The main inclusion criteria were diagnosis with a primary (meaning it is a first RD experienced by the eye) RRD and subsequent treatment with scleral buckle, vitrectomy, pneumatic retinopexy, or a combination of scleral buckle and vitrectomy (SBV). Patients who have experienced a prior RD, trational RD, or RD due to trauma were excluded from this study. Preoperative and postoperative VA was compared using a logarithm of the minimum angle of resolution (logMAR) score. sixty patients underwent PR treatment (n=60), sixty patients were treated with a combination of SB+PPV (n=60), fifty-two were treated with PPV (n=52) alone, and fifty-four had SB (n=54) treatment. A successful outcome was a complete reattachment of the retina in subsequent follow-up appointments based on comprehensive fundus exams and ocular coherence tomography (OCT) scan. RESULTS: Our study showed significant success rates across all four potential surgeries. PR having a success rate of 48/60 (72%), SB+PPV with 53/60 (88%), PPV at 41/52 (77%), and SB showing 41/54 (79%). Starting visual acuity for PR was .67, Combined SB+PPV patients started with 1.4, PPV patients had a 1.84 logMAR score, and SB patients had a starting visual of 1.82. Patients undergoing PR treatment had a lower occurrence of mac-off RRD at 55%. While patients who underwent combined SB+PPV, vitrectomy alone, and SB had higher rates of mac-off RRD at 67%, 60%, and 58% respectively. CONCLUSIONS: Our study demonstrated good outcomes for all surgical procedures used. While the type of surgery performed will depend on a case-by-case determination. The results of our study showed improvement in visual acuity in patients after treatment for primary rhegmatogenous retinal detachment (RRD). Overall, the results of our study demonstrate very good outcomes for patients treated with PR, vitrectomy, SB, and combine SB+PPV.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
INTRODUÇÃO: A membrana epirretiniana (MER) define-se como uma proliferação fibrocelular da superfície interna da retina. Com o recurso à tomografia de coerência ótica, diversos parâmetros estruturais e sistemas de classificação das MER foram descritos com potencial impacto prognóstico, anatómico e funcional.OBJETIVO: Este trabalho propõe caracterizar o impacto prognóstico de biomarcadores avaliados através da tomografia de coerência ótica de domínio spectral (SD-OCT) - camada interna ectópica foveal (EIFL), espessura macular central (EMC), sinal de cotton ball, integridade da camada elipsoide, presença de líquido intraretiniano ou subretiniano e esquisis – em olhos submetidos a vitrectomia pars plana (VPP) por MER e pelagem membrana limitante interna. MÉTODOS: Trata-se de um estudo retrospetivo, longitudinal, de coorte. Foram incluídos, de forma consecutiva, olhos com diagnóstico de MER idiopática, submetidos a VPP 23/25-gauge, com tempo mínimo de follow-up pós-cirúrgico de 12 meses. Foram avaliadas imagens de SD-OCT (Spectralis, Heidelberg Engineering, Heidelberg, Germany), preoperatoriamente, aos 6 e 12 meses pós-operatório, por 2 médicos especialistas independentes. Com o recurso à função de “caliper”, foi registada a espessura EIFL medida na vertical e horizontal, em b-scans centrados na fóvea. A associação entre a espessura da EIFL e de outros biomarcadores do SD-OCT, previamente descritos, com a melhor acuidade visual corrigida (MAVC) foi avaliada. O nível de significância estabelecido foi p<0.05.RESULTADOS: Foram incluídos cento e dezoito olhos, de 108 doentes (idade média 76,52±7,09; 65% do sexo masculino). Pré-operativamente, a MAVC média foi 55,52±12,44 letras e, 70,00±13,34 letras aos 12 meses pós-operatório, a evolução média da MAVC foi de 13,45±14,15 letras (p<0,001). Pré-operativamente, a EIFL estava presente em 59 olhos (50%). A espessura média da EIFL, medida na horizontal e vertical, foi 239,31±89,27µm e 228,48±85,67 µm, respetivamente. A medição na vertical e horizontal está correlacionada, pré-operativamente, com a CFT (rho=0,63 e rho=0,55; p<0,001, respetivamente). No entanto, apenas a camada ectópica medida na vertical demonstrou ter impacto prognóstico na MAVC final, independentemente da CFT pré-operatória (ß=-0,12±0,05; p=0,01). De facto, a espessura da EIFL medida na vertical demonstrou ser o marcador individual de prognóstico visual mais sensível (ß=-0,07±0,01; p<0,001). CONCLUSÃO: Este estudo revela que a camada ectópica medida na vertical pode ser um importante preditor da evolução da acuidade visual pós-cirurgia. Isto é, um aumento na espessura da EIFL medida na vertical, antes da cirurgia, esteve relacionada com pior prognóstico funcional final. Este parâmetro parece ser um biomarcador mais sensível e melhor preditor do outcome visual, prevalecendo sobre outros biomarcadores previamente descritos.
INTRODUCTION: Epiretinal membrane (ERM) is a fibrocellular proliferation above the inner surface of the retina. Optical coherence tomography (OCT) structural features and new classifications schemes have been proposed as prognostic biomarkers for anatomical and functional postoperative improvement.PURPOSE: To characterize the prognostic impact of baseline spectral domain optical coherence tomography (SD-OCT) biomarkers - ectopic inner foveal layer (EIFL), cotton ball sign, ellipsoid disruption, intra and subretinal fluid - in eyes with idiopathic ERM who underwent pars plana vitrectomy (PPV) with ERM and internal limiting membrane peeling.METHODS: Retrospective longitudinal cohort study. Consecutive eyes with idiopathic ERM that underwent 23- or 25-gauge PPV and had a minimum follow-up of 12 months after surgery were included. SD-OCT (Spectralis, Heidelberg Engineering, Heidelberg, Germany) scans were graded at baseline (preoperatively), and at 6 and at 12 months postoperatively by two independent medical graders (JPM and MR). Two EIFL thickness measures were manually obtained using the caliper function: a horizontal EIFL based on a horizontal b-scan centered at the fovea and a vertical EIFL based on a vertical b-scan also centered at the fovea. The association of EIFL thickness and others SD-OCT biomarkers (cotton ball sing, ellipsoid sone disruption, intraretinal and subretinal fluid, macular retinal schisis and CFT) with best corrected visual acuity (BCVA) change was evaluated. Significance was considered at p<0.05.RESULTS: One-hundred and eighteen eyes of 108 patients (mean age 76.52 ± 7.09; 65% males) were included. Preoperatively, mean BCVA was 55.52 ± 12.44 letters and a mean BCVA change of 13.45 ± 14.15 letters was observed at 12 months (p<0.001). EIFL was present in 59 eyes (50%) preoperatively. Horizontal mean EIFL thickness was 239.31 ± 89.27 µm and vertical mean EIFL thickness was 228.48 ± 85.67 µm. Both were correlated with preoperative central foveal thickness (CFT) (rho=0.63 and rho=0.55; p<0.001, respectively). Nonetheless, only vertical EIFL thickness demonstrated a prognostic impact on final BVCA, independent of preoperative CFT (ß= -0.12 ± 0.05; p=0.01). Indeed, vertical EIFL thickness was the most important visual individual prognostic biomarker (ß= -0.07 ± 0.01; p-<0.001)CONCLUSION: Our study revealed that vertical EIFL thickness may reflect the true impact of this ectopic layer on visual prognosis. That is, an increased preoperative vertical EIFL thickness predicted worst anatomical and functional outcomes. This parameter seems to be a reliable biomarker to predict final visual outcome, surpassing other common OCT biomarkers.

PURPOSE: To investigate relationships between preoperative and intraoperative characteristics with outcome variables in patients suffering from primary rhegmatogenous retinal detachment (RRD) or traction retinal detachment (TRD) complicated by serous choroidal detachment (CD). Choroidal detachment is a rare complication of retinal detachment and the current literature cites generally poor visual outcome variables. By investigating a retrospective case series, we hope to elucidate new relationships and embolden existing ones so that future physicians can make more educated decisions regarding the care for these complicated patients. METHODS: A retrospective case series analyzed 18 patient’s medical records (18 eyes) who had been diagnosed and surgically treated for RRD or TRD associated with a CD at the Longwood Medical Eye Center at Beth Israel Deaconess Medical Center. Patients with RDCD who had undergone 23-gauge pars plana vitrectomy with silicone oil tamponade were selected. Exclusionary criteria included ocular complications such as phthisis bulbi and open globe trauma. Patients experienced a variety of surgical procedures including by not limited to relaxing retinotomy (n=12 eyes), choroidal drainage (n=10 eyes), endoscopy-assisted PPV (n=10 eyes), and ERM peeling (n=8 eyes). Primary outcome variables tabulated were primary and final anatomic success, defined as successful reattachment of the retina to the underlying choroid, and final visual acuity. RESULTS: The mean age of the sample group was 69 with 8 patients (44%) diagnosed with preoperative hypotony (IOP <= 6 mmHg). A total of 12 patients were pseudophakic (67%). With a mean follow-up of 21.6 months, patients exhibited expected visual outcomes with 6 patients (33%) improving visual acuity and 7 patients (39%) decreasing visual acuity. Final anatomic success was seen in 17 cases (94%). A significant correlation was found between decreased number of previous surgeries and better visual outcomes (change in BCVA). Another significant relationship correlates choroidal drainage with worse visual outcomes (change in BCVA). Finally, patients who received ERM peeling had better rates of primary anatomic success. CONCLUSION: The advanced age of the sample lends itself to increased risk for cataracts and thus pseudophakia. In addition, high rates of diabetes and macular degeneration follow. The pathophysiology of RDCD in relation to the risk factors of hypotony and macular holes is possibly based on the Starling forces and favorable fluid transudation into the suprachoroidal space. Although the outcomes of this study were similar to previous literature, the visual outcomes are still poor at best. Reducing the number of previous, invasive, ocular surgeries was seen to be correlated with better visual outcomes. In addition, performing ERM peels is seen to be correlated with improved rates of primary anatomic success. More research is required on the etiology of the disease process and a case-controlled longitudinal study may be helpful in determining more relationships with outcome variables.

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2019
Resumo: Introdução: Como conceito, Catarata define-se como uma opacidade da lente. Entre as idades pediátricas, particularmente nos mais jovens, essa opacidade provoca uma privação de estímulo que tem a capacidade de causar ambliopia irreversível. Aliada ao facto de que o olho pediátrico não corresponde morfologicamente ao olho adulto por ainda continuar seu crescimento e maturação, ainda existem vários desafios relativos às soluções cirúrgicas disponíveis e seus respectivos efeitos secundários. Tendo a grande maioria dos casos com catarata pediátrica nenhum tratamento médico possível, a opção cirúrgica é vista como a única maneira de restaurar o desenvolvimento biológico necessário para obter uma acuidade visual bilateral adequada. No entanto, ainda não estão claros todos os aspectos fundamentais da tomada de decisão na hora de escolher a abordagem cirúrgica correta. A lateralidade, a idade da criança, o tipo de catarata e a técnica cirúrgica devem ser consideradas em conjunto para alcançar o melhor resultado visual, nunca esquecendo as complicações pós-operatórias importantes e frequentes que podem comprometer o objetivo inicial. A cirurgia de catarata pediátrica está associada a várias complicações intra e pós-operatórias. Nos últimos anos, como resultado da melhoria da técnica cirúrgica e do management pós-operatório, a taxa de complicações diminuiu. Complicações associadas incluem: opacificação da cápsula posterior, glaucoma, complicações inflamatórias, hemorragia, edema corneano, má posição da lente intra-ocular (LIO), descolamento da retina, infecção, astigmatismo, myopic shift, ambliopia e estrabismo. A opacificação da cápsula posterior (PCO) é a complicação pós-operatória mais comum na idade pediátrica. Desenvolve-se devido à intensa resposta do olho jovem, criando uma resposta inflamatória que leva à formação de membranas fibrosas na superfície anterior do vítreo. Em crianças menores de 5 anos, praticamente ocorre em 100% dos pacientes sem capsulorrexia posterior e vitrectomia anterior. São por isso, hoje em dia, aplicadas globalmente como um procedimento padrão. Na cirurgia de catarata pediátrica, a capsulotomia posterior e a vitrectomia anterior são procedimentos standards nas idades mais jovens. No entanto, atualmente não existe evidência definitiva relativamente superioridade da técnica por via limbar ou pars plana. Métodos: Realizou-se um resumo teórico sobre o tema da cirurgia de catarata em idade pediátrica. Adicionalmente, foi realizada uma pesquisa da literatura utilizando pesquisa eletrónica na PubMed (MEDLINE) e Cochrane Central Register of Controlled Trials (CENTRAL) desde sempre até Março de 2019, incluindo todos os estudos comparativos da cirurgia de catarata pediátrica por via limbar vs pars plana. As palavras-chave para pesquisa incluíram “limbar”, “transcorneal”, “pars plana”, “vitrectomia anterior”, “capsulotomia posterior / capsulorrexia”, “comparação de estudo”, “catarata congénita”, “catarata pediátrica”, além de outras expressões relacionadas que foram utilizadas nesta pesquisa, com diferentes combinações, a fim de obter o máximo de artigos disponíveis. Os estudos foram inicialmente selecionados pelo título e resumo e submetidos à avaliação de texto completo se elegíveis. Muitos artigos foram encontrados, todavia a maioria usou apenas uma técnica e tirou conclusões disso. Só foram possíveis reunir três estudos heterogéneos que abordaram a questão pretendida. Resultados: Foram encontrados 3 estudos comparativos: “Comparison between Limbal and Pars Plana Approaches Using Microincision Vitrectomy for Removal of Congenital Cataracts with Primary Intraocular Lens Implantation” - by Ahmadieh, H. et al; “Comparison of Transcorneal and Pars Plana Routes in Pediatric Cataract Surgery in Infants Using a 25-Gauge Vitrectomy System” - by Raina, U. et al; “Comparison between Limbal and Pars Plana Approaches Using Microincision Vitrectomy for Removal of Congenital Cataracts with Primary Intraocular Lens Implantation” - by Liu, X. et al. Tanto a via limbar quanto a pars plana alcançaram bons resultados quanto à acuidade visual. Em termos de acuidade visual, os dois estudos que usaram uma LIO primária, Ahmadieh, H. et al e Liu, X. et al chegaram à mesma conclusão, usando diferentes escalas de medida. Ambas as abordagens relatam boa melhoria da acuidade visual após a cirurgia e nenhuma delas, VCL e VPP, obteve superioridade mensurável da abordagem. Liu, X. et al não revelou diferença estatística directa entre a abordagem VCL e VPP. No estudo de Ahmadieh, H. et al, houve um sistema de classificação para os resultados VA pré e pós-operatórios, de acordo com os grupos, sendo que nenhuma diferença entre a abordagem limbal e pars plana foi encontrada. O estudo de Raina, U. et al não apresentou resultados em relação à acuidade visual pós-operatória. No entanto, é relatado que todos os pacientes em ambos os grupos tinham um eixo visual claro após 12 meses de acompanhamento. No entanto, a taxa de complicações cirúrgicas quando utilizada a via limbar corneano foi superior. Em termos de complicações intra-operatórias: Ahmadieh, H. et al relataram que a capsulotomia inadequada foi três vezes mais frequente com a abordagem limbal em comparação com a pars plana, embora não tenha encontrado uma diferença estatisticamente significativa. Houve também um caso de captura de íris no grupo VPP. Liu, X. et al revelaram uma diferença substancial entre a frequência de complicações intra-operatórias. Entre a aspiração da íris, o prolapso da íris, a lesão na íris e a existência de fragmentos do cristalino no vítreo, 42,5% dos pacientes do grupo VCL apresentaram pelo menos uma complicação em comparação aos 14,6% do grupo VPP. Por outro lado, em 2 dos 12 pacientes do grupo pars plana, relataram ruptura acidental da cápsula posterior antes da conclusão da aspiração da substância, enquanto nenhum foi relatado no grupo limbo. Raina, U. et al não relataram nenhuma complicação durante a operação cirúrgica. No entanto, no grupo VPP, 16,7% dos olhos sofreram acidentalmente ruptura. Em termos de complicações pós-operatórias: Em Liu, X. e cols., também mais pacientes do grupo VCL tiveram complicações pós-operatórias em comparação com a via pars plana (17,5% vs 7,3%). Os autores explicaram isso com a manipulação mais difícil do instrumento com o uso dessa via. A curta câmara anterior tornou a técnica desafiante, levando à falsa manipulação da íris durante a lensectomia e capsulotomia, ainda mais em olhos com pupilas menores. Ahmadieh, H. et al não relataram qualquer complicação como CME, glaucoma, rotura da retina ou luxação da LIO. No entanto, obtiveram um caso em cada grupo de formação de sinéquias posteriores. Raina, U. et al não tiveram complicações pós-operatórias em nenhum dos dois grupos. Em termos de técnica, a abordagem limbar tem a principal vantagem de uma curva de aprendizagem, mais curta, enquanto que através da pars plana é possível realizar uma lensectomia, capsulorréxis posterior e a vitrectomia anterior mais precisas. Conclusão: É sem dúvida verdade que, sem fortes evidências científicas, todas as decisões no mundo médico moderno não se sustentam apenas por si. Não obstante, o caminho para a evidência científica só pode ser feito passo a passo. O mesmo se aplica ao dilema da preferência entre as vias pars plana e limbar. Embora não seja possível chegar a uma conclusão definitiva, devido à grande heterogeneidade obtida nos estudos encontrados, com este trabalho é possível reconhecer alguma superioridade, apesar de limitada, da abordagem pars plana em relação à abordagem límbar de acordo com os resultados cirúrgicos e as avaliações cirúrgicas de especialistas, embora vários cirurgiões prefiram mais frequentemente a via anterior. As PCC e AV, fundamentais para o correto manuseamento de crianças mais novas, feitas através da via pars plana, parecem oferecer ótima execução técnica, manuseio intraoperatório mais seguro e menos complicações futuras. Para ser possível comprovar a conclusão deste trabalho, estudos prospetivos randomizados e metanálises posteriores devem ser realizados.
Abstract: Introduction: In pediatric cataract surgery, primary posterior capsulotomy and anterior vitrectomy are common practice in the youngest children. Whether this should be done through the limbal or pars plana route, no strongly evidence-based conclusion has been taken. Methods: A summary of the current standards for pediatric cataract surgery was conducted. Additionally a literature review was performed using an electronic database search on PubMed (MEDLINE) and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to March 2019, including all comparative studies of pars plana versus corneal approach for posterior capsulotomy and anterior vitrectomy. Results: Three comparative studies of both approaches were found. Both the limbal and pars plana achieved good results concerning visual acuity. However, the corneal limbus approach presented more intra and post-operative complications when compared to the pars plana route. In terms of technique, the limbal approach had the main advantage of a shorter learning curve, whereas through the pars plana more precise lensectomy, posterior capsulorrhexis and anterior vitrectomy can be achieved. Conclusion: Although no conclusion can be taken due to the high level of heterogeneity, it seems that the pars plana via offered better optimal technical execution, safer intraoperative handling and fewer postoperative complications.

Idiopathic Epiretinal membrane is a proliferation of contractile cells on the surface of the retina that typically occurs after posterior vitreous detachment. Though many questions have been raised on the causes of this condition, a greater debate has been on the treatment of this pathology. The literature suggest the potential benefit in peeling ILM, due to its inherent proliferative characteristics, along with the ERM, during the surgery, however sufficient data has yet to been found. Due to the lack of consensus in treatment of iERM, this study set forth to provide some insight on the surgical outcomes of patients that undergo combined peeling as well attempting to contribute to a potential surgical protocol in treating iERM. This was a retrospective case series study looking at 140 eyes from 126 iERM patients that underwent ERM surgical treatment at Beth Israel Deaconess Medical Center between 1998 and 2015. Pre- and post- operative visual acuities, lens status (phakic, aphakic, pseudophakic), type (kenalog with or without ICG) and duration (0.5min, 1 min, 1.5 min) of the stains used in the procedure, and any prior or successive surgeries were recorded and analyzed. Overall, ERM surgeries demonstrated a significant (p<0.0001) improvement in visual acuity. Furthermore, the combined peel patients demonstrated a significantly (p<0.0467) greater mean change in logMAR score when compared to ERM-only peel procedures. In addition, the combined peel group showed a smaller rate of recurrence. Lastly, simultaneous cataract surgery and the use of ILM stains did not have an impact on the outcome of ERM surgery. The study found that combined (ERM and ILM) peeling along with simultaneous cataract surgery, if a cataract was present, along with the utilization of ILM stains is cost-effective, safe, and effective approach in treating iERM and decreasing its recurrence.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
INTRODUCTION: Pediatric cataract is one of the leading preventable causes of blindness worldwide. Timely diagnosis and treatment of the cataract are crucial to avoid irreversible visual effects. The visual axis opacification (VAO) is the most frequent complication arising from pediatric cataract surgery. According to most scientific evidence, an anterior and posterior continuous curvilinear capsulorhexis with anterior vitrectomy (AV) is recommended to prevent VAO. The necessity of its inclusion in the treatment of pediatric cataracts, however, is still questioned. Secondary glaucoma, one of the most feared complications, can occur at any moment after surgery, demanding a life-long follow-up. PURPOSE: To describe a large Portuguese pediatric cataract cohort and determine whether the VAO is prevented by AV and access glaucoma development. METHODS: A review of 340 eyes from 245 individuals of pediatric age who underwent pediatric cataract surgery at Centro Hospitalar e Universitário de Coimbra (CHUC) between 1990 and 2019. A retrospective, non-interventional statistical analysis was carried. For sub-analysis of the impact of AV in OEV, need for reoperation or YAG-laser due to it, and occurance of inflammatory membranes, the sample was divided into 3 groups regarding age at surgery: < 2 years; 2 to 5 years; and >5 years. For sub-analysis of the association of glaucoma with age at surgery we considered 4 groups regarding age at surgery: <1 month, 1 to 12 months, 1 to 5 years, and >5 years; and 3 groups to study the association with follow-up duration: <1 year, 1 to 5 years, and >5 years; respectively. The association of glaucoma with primary intraocular lens implantation (pIOL) was studied. RESULTS: The median age at surgery was 39,33 months, with a mean follow-up time of 66,44 months. Most patients had congenital cataract (67,7% n=157) and 51,9 % were bilateral (n=123). Primary IOL implantation was performed in 55,7% (n=206) and was associated with lower glaucoma rates (1,1% vs 9,0%, p=0,001). Patients who underwent AV (76,5% of eyes, n=235) had lower postoperative complications and VAO rates (39,3% vs 65,3%, p=0,001 and 4,7% vs 16,8%, p=0,001, respectively) and less reoperation or YAG-laser rates due to VAO (3,4% vs 15,3%, p=0,001). Glaucoma (total incidence of 5,3%, n=18) was associated with premature surgery (p=0,005) - higher on the first month - and longer follow-up (p<0,001) – higher with 5 or more years of follow-up. CONCLUSION: The inclusion of anterior vitrectomy has proven to be a better approach to prevent postoperative complications, visual axis opacification, and the need for reoperation or YAG-laser due to this complication. A lifelong follow-up is crucial to evaluate the long-term outcomes and late complications, namely glaucoma.
INTRODUÇÃO: A catarata pediátrica constitui uma das principais causas de cegueira prevenível a nível mundial. Um diagnóstico e tratamento atempados são cruciais para evitar defeitos visuais irreversíveis. A opacificação do eixo visual (OEV) é a complicação mais frequente da cirurgia de catarata pediátrica. Atualmente e de acordo com a maioria da evidência científica, recomenda-se a realização de capsulorrexis circular curvilínea posterior com vitrectomia anterior (VA), até aos 5 anos, por prevenir a OEV. No entanto, a necessidade da sua inclusão no tratamento ainda é questionada. O glaucoma, é uma das complicações mais temidas e pode surgir a qualquer momento após a cirurgia exigindo vigilância a longo prazo. OBJETIVO: Descrever uma coorte portuguesa em idade pediátrica submetida a cirurgia de catarata, e determinar se a VA previne a OEV e avaliar o desenvolvimento de glaucoma. MÉTODOS: Foram avaliados 340 olhos de 245 indivíduos em idade pediátrica submetidos a cirurgia de catarata pediátrica no CHUC entre 1990 e 2019. A amostra foi alvo de uma análise estatística retrospetiva, não intervencional. Para análise do impacto da VA na OEV, consequente necessidade de reoperação ou YAG-laser, e desenvolvimento de membranas inflamatórias, a amostra foi dividida em 3 grupos de acordo com a idade na cirurgia: <2 anos; 2 a 5 anos; e >5 anos. Foi estudada a associação de glaucoma com a idade na cirurgia tendo em conta 4 grupos: <1 mês, 1 a 12 meses, 1 a 5 anos, e >5 anos; e com a duração do follow-up tendo em conta 3 grupos: <1 ano, 1 a 5 anos, e >5 anos. A associação de glaucoma com a implantação primária de lente intraocular foi estudada. RESULTADOS: A mediana da idade aquando da cirurgia foi 39,22 meses e a média do follow-up 66,44 meses. A etiologia foi maioritariamente congénita (67,7% n=157) e 51,9 % tinha catarata bilateral (n=123). Foi implantada lente intraocular primária em 55,7% (n=206), estabelecendo-se a sua associação com menor incidência de glaucoma (1,1% vs 9,0%, p=0,001). Verificou-se a associação de VA (76,5% dos olhos, n=235) com menor incidência de complicações pós-operatórias e OEV (39,3% vs 65,3%, p=0,001 e 4,7% vs 16,8%, p=0,001, respetivamente) e menor necessidade de reoperação ou YAG-laser devido a OEV (3,4% vs 15,3%, p=0,001). A ocorrência de glaucoma está associada à realização de cirurgia mais cedo na vida (p=0,005), sendo mais elevada no primeiro mês de vida, e a maior duração do follow-up (p<0,001) – maior no grupo seguido por 5 ou mais anos. CONCLUSÃO: A realização de VA provou ser uma melhor abordagem para prevenção de complicações pós-operatórias, OEV, e diminuição da reoperação ou YAG-laser devido a esta complicação. A cirurgia da catarata pediátrica exige um follow-up continuo para avaliar os resultados a longo-prazo e as complicações tardias, nomeadamente o glaucoma.

Univerzita Karlova 1. lékařská fakulta Studijní program: Zobrazovací metody v lékařství (P5150) Studijní obor: Zobrazovací metody v lékařství (5103V000) MUDr. Adam Kopecký Změny na předním segmentu po 25G+ PPV Changes in the Anterior Segment after 25G+ PPV Abstract Vedoucí závěrečné práce/Školitel: doc. MUDr. Jiří Pašta, CSc., FEBO Praha, 2019 Abstract: Pars plana vitrectomy is a dominant surgical method in posterior segment surgery of the eye. The principle of this method is the surgical approach via the pars plana anatomical region. With this approach, surgeon performs the posterior segment surgery without directly affecting the anterior segment of the eye. Short-term effect of pars plana vitrectomy on the anterior segment of the eye has been repeatedly proven. That might be an important factor both in assessing the complications of this method and planning the surgery in complicated patients. Generally, it is presumed that we do not observe long-term effects on anterior segment after pars plana vitrectomy. The aim of our work is to evaluate the long-term changes in the anterior segment after the uncomplicated 25G + PPV with gas tamponde. The group of 20 patients was selected according to strict indication criteria. Using a series of examinations, we examined specific parameters such as: intraocular...

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Introdução: Caracterizar os resultados anatómicos e funcionais a longo prazo após cirurgia de buraco macular (BM).Métodos: Revisão retrospectiva de 44 olhos de 44 pacientes com diagnóstico de buraco macular submetidos a cirurgia de BM num centro de referência terciário. Foi realizada vitrectomia via pars plana com pelagem simples da membrana limitante interna, tamponamento com gás e posicionamento de face para baixo. A cirurgia de catarata foi feita simultaneamente com a cirurgia do buraco macular ou durante o acompanhamento, se uma catarata visualmente significativa se desenvolvesse. Os critérios de exclusão incluíram vitrectomia prévia, BMs traumáticos, descolamento de retina ou BMs associados a alta miopia. Os exames de linha de base e de seguimento aos 6 meses e 5 anos incluíram a avaliação da melhor acuidade visual corrigida (BCVA) nas letras ETDRS e imagens de OCT em série, avaliadas por dois avaliadores independentes.Resultados: Foram incluídos 44 olhos de 44 pacientes (59,1% do sexo feminino, idade 66,9 ± 9,8 anos) no estudo. A média do score da BCVA da amostra foi de 36,2 ± 13,4 letras no início do estudo. O tamanho médio do BM (diâmetro mínimo) foi de 515,0 ± 194,2 µm e 4,5% eram BMs pequenos (<250 µm), 27,3% eram BMs médios (250-400 µm) e 68,2% eram BMs grandes (> 400 µm ). O encerramento do BM no final do seguimento foi de 90,9% (40/44 olhos). Os casos sem encerramento (4/44) foram todos buracos maculares grandes. A média da melhoria individual da BCVA, comparada com a linha de base, foi de +21,2 ± 16,1 letras aos 6 meses (p <0,001) e +25,4 ± 18,5 letras aos 5 anos (p <0,001). Em comparação com o período de 6 meses, a acuidade visual melhorou significativamente aos 5 anos (+ 5,0 ± 12,1 letras, p = 0,024). No geral, 86,4% (38/44) melhoraram a BCVA em mais de 5 letras, 9,1% (4/44) mantiveram a BCVA dentro de 5 letras e apenas 4,6% (2/44) perderam mais de 5 letras no final do seguimento. A melhoria da acuidade visual aos 5 anos não diferiu pelo status do cristalino (pseudofáquico + 24,3 ± 16,4 letras vs fáquico + 27,9 ± 23,4 letras, p = 0,563). A espessura macular central (CMT) diminuiu significativamente com o acompanhamento, com uma redução de -37,1 ± 83,9 µm aos 6 meses (p = 0,037) e -50,0 ± 80,3 µm aos 5 anos (p <0,001).Conclusão: Até onde sabemos, apresentamos o maior coorte a longo prazo sobre os resultados funcionais e estruturais após a cirurgia ao BM. A alta taxa de encerramento do BM foi alcançada neste coorte. A acuidade visual não só permaneceu estável em 5 anos de seguimento, mas também aparentemente melhorou a partir do início do período pós-operatório de 6 meses.
Introduction: To characterize anatomical and functional long-term outcomes following macular hole (MH) surgery.Methods: Retrospective chart review of forty-four eyes of 44 patients diagnosed with macular hole (MH) who underwent MH surgery at a tertiary referral center. Standard pars plana vitrectomy with simple ILM peeling, gas tamponade and face-down positioning was performed. Cataract surgery was done simultaneously with macular hole surgery or during follow-up if a visually significant cataract developed. Exclusion criteria included previous vitrectomy, traumatic MHs, retinal detachment or MHs associated with high myopia. Baseline and follow-up examinations at 6 months and 5 years included evaluation of best-corrected visual acuity (BCVA) in ETDRS letters and serial OCT imaging, assessed by two independent graders.Results: We included 44 eyes from 44 patients (59.1% female, age 66.9±9.8 years) in the study. Mean sample BCVA letter score was 36.2±13.4 letters at baseline. Mean MH size (minimum linear diameter) was 515,0±194,2 µm and 4.5% were small MHs (<250 µm), 27.3% were medium MHs (250-400 µm) and 68.2% were large MHs (> 400 µm). MH closure at the end of follow-up was 90.9% (40/44 eyes). Non-closure cases (4/44) were all large macular holes. Mean individual BCVA improvement, compared to baseline, was +21.2±16.1 letters at 6 months (p<0.001) and +25.4±18.5 letters at 5 years (p<0.001). Compared to the 6 months timepoint, visual acuity significantly improved at 5 years (+5.0±12.1 letters, p=0.024). Overall, 86.4% (38/44) improved BCVA more than 5 letters, 9.1% (4/44) maintained BCVA within 5 letters and only 4.6% (2/44) lost more than 5 letters at the end of follow-up. Visual acuity improvement at 5 years did not differ by lens status (pseudophakic +24.3±16.4 letters vs phakic +27.9±23.4 letters, p=0.563). Central macular thickness (CMT) significantly decreased with follow-up, with a reduction of -37.1±83.9 µm at 6 months (p=0.037) and -50.0±80.3 µm at 5 years (p<0.001).Conclusion: To the best of our knowledge, we present the largest long-term cohort on functional and structural outcomes following MH surgery. A high MH closure rate was achieved in this cohort. Visual acuity not only remained stable at 5 years of follow-up, but also seemingly improved from the early 6 months post-operative period.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Introdução: As cataratas congénitas constituem a principal causa tratável de cegueira a nível mundial, uma vez que provocam ambliopia irreversível na ausência de tratamento adequado e atempado. Apesar dos avanços na sua abordagem, continua a ser uma cirurgia marcada por uma elevada taxa de complicações pós-operatórias. A opacificação do eixo visual é uma complicação major desta cirurgia. A capsulorrexis circular contínua posterior e a vitrectomia anterior são duas técnicas usadas para a prevenção desta complicação, mas o seu impacto não se encontra devidamente esclarecido e é questionado por alguns autores.Objectivo: Avaliar o impacto da inclusão de capsulorrexis circular contínua posterior e de vitrectomia anterior na prevenção da opacificação do eixo visual na cirurgia da catarata congénita.Materiais e métodos: A partir de uma população de doentes operados no Centro Hospitalar da Universidade de Coimbra (n=143), e aplicando critérios de exclusão, obteve-se o grupo de estudo (n=79). Procedeu-se a uma análise retrospectiva não intervencional do grupo. Foi feita a sua caracterização, tendo em conta o sexo, idade aquando da cirurgia, lateralidade, morfologia das cataratas e complicações registadas no seguimento pós-operatório. Os doentes foram, posteriormente, distribuídos por 3 faixas etárias e de acordo com a técnica cirúrgica realizada. Comparou-se a incidência de complicações pós-operatórias, nomeadamente de opacificação do eixo visual e formação de membranas inflamatórias pós-operatórias, entre os subgrupos.Resultados: A complicação cirúrgica registada mais frequentemente foi a opacificação do eixo visual, que ocorreu em 16,5% (n=13) dos doentes, seguida de estrabismo (15,2%; n=12), formação de membrana inflamatória pós-operatória (11,4%; n=9) e glaucoma (7,6%; n=6). A incidência das complicações pós-operatórias descritas foi significativamente superior em doentes que realizaram capsulorrexis posterior sem vitrectomia anterior, face aos doentes que realizaram capsulorrexis posterior com vitrectomia anterior (p=0,011). Não foi estabelecida nenhuma relação entre a idade aquando da operação e a probabilidade de desenvolver complicações pós-operatórias.A incidência de opacificação do eixo visual foi significativamente inferior (p<0,001) no grupo de doentes que realizou capsulorrexis posterior com vitrectomia anterior (10,5%; n=4), do que no grupo de doentes que realizou capsulorrexis posterior sem vitrectomia anterior (100%; n=7), mesmo em doentes com idade superior a 5 anos.A formação de membrana inflamatória pós-operatória não foi influenciada pela realização, ou não, de vitrectomia anterior.A realização de capsulorrexis posterior com vitrectomia anterior diminuiu de forma estatisticamente significativa (p<0,001) o número de doentes submetidos a re-operação para correção da opacificação secundária do eixo visual.Conclusão: A realização de capsulorrexis posterior com vitrectomia anterior é superior à capsulorrexis posterior sem vitrectomia anterior na prevenção de complicações pós-operatórias na cirurgia da catarata congénita, nomeadamente a ocorrência de opacificação do eixo visual, e diminui a necessidade de re-operação para correção de opacidade do eixo visual, independentemente da idade da criança operada.
Introduction: Congenital cataracts are the world’s main cause of treatable blindness, since they cause irreversible amblyopia if the treatment is not performed correctly and on time. Despite the big advances in its management, the development of post-operative complications remains common. Visual axis opacification is one of the major complications of this surgery. Surgical techniques used to prevent it include posterior continuous curvilinear capsulorhexis and anterior vitrectomy, but their effectiveness is not properly clarified and is questioned by some authors.Objective: To evaluate the impact of the inclusion of posterior continuous curvilinear capsulorhexis and anterior vitrectomy preventing the development of visual axis opacification, in the surgery of congenital cataracts.Materials and Methods: A population of 143 patients was operated in Coimbra University Hospital Center. After applying exclusion criteria, a study group of 79 patients was obtained. A retrospective non interventional study was carried. The group was characterized taking into account the sex and the age of the patients, the laterality and morphology of the cataracts and the occurrence of post-operative complications during the follow-up period. Then, the patients were divided in 3 different age groups and classified according to the surgical techniques performed. The incidence of post-operative complications, in particular visual axis opacification, was compared between the subgroups.Results: The most common complication was visual axis opacification, which occurred in 16,5% (n=13) of the patients. The second most common was strabismus (15,2%; n=12), followed by the development of an inflammatory membrane (11,4%; n=9) and glaucoma (7,6%; n=6). The incidence of those post-operative complications was significantly higher on patients who underwent through posterior capsulorhexis without anterior vitrectomy, compared to the patients who underwent through posterior capsulorhexis with anterior vitrectomy (p=0,011). There was no correlation between the age of the patients during surgery and the development of post-operative complications.The incidence of visual axis opacification was significantly lower (p<0,0001) on patients who underwent through posterior capsulorhexis with anterior vitrectomy (10,5%; n=4), compared to the group of patients who underwent through posterior capsulorhexis without anterior vitrectomy (100%; n=7), even in patients older than 5.The formation of post-operative inflammatory membrane was not related to the execution or anterior vitrectomy.Patients undergoing posterior capsulorhexis and anterior vitrectomy are less likely to undergo through additional surgeries to correct the secondary visual axis opacification (p<0,001).Conclusion: Posterior capsulorhexis with anterior vitrectomy is better than posterior capsulorhexis without anterior vitrectomy regarding the prevention of post-operative complications, in the surgery of congenital cataracts, particularly preventing the development of visual axis opacification across all age groups. Patients undergoing through posterior capsulorhexis and anterior vitrectomy are less likely to undergo through additional surgeries to correct the secondary visual axis opacification.