Cancelamento de cirurgias de catarata em um hospital público de referência

OBJETIVO: Analisar a incidência e causas de cancelamento de cirurgias de catarata em um hospital público de referência. MÉTODOS: Trata-se de um estudo retrospectivo em que foram analisados o número de cancelamentos de facectomias durante o ano de 2009. Foram analisados sexo, idade, tipo de procedimento suspenso (facoemulsificação ou extração extracapsular do cristalino), tipo de anestesia, convênio (Sistema Único de Saúde ou convênio/particular) e motivo de suspensão da cirurgia (causas clínicas, institucionais ou pessoais). RESULTADOS: Foram agendadas no período 2.965 cirurgias de catarata, havendo 650 cancelamentos (21,92%). Dentre as principais razões para a suspensão do procedimento destacaram-se as causas clínicas (86,90%). Os meses de inverno apresentaram os maiores índices de suspensão de cirurgias de catarata. CONCLUSÃO: A taxa de cancelamento de cirurgia de catarata em serviços públicos parece ser a mesma que há 10 anos. A principal causa de suspensão deve-se por condições clínicas (hipertensão, diabetes, falta de exames, etc.).

Facoemulsificação versus extração extracapsular no sistema público de saúde: análise de custos para o hospital, para o governo e para a sociedade

OBJETIVO: Comparar custos da cirurgia de catarata em larga escala para um hospital público, para o governo e para a sociedade, pelas técnicas de facoemulsificação (FACO) e extração extracapsular (EECP). MÉTODOS: Foi realizada revisão baseada principalmente em diversos estudos clínicos realizados entre 2002 e 2010, no Centro Cirúrgico Ambulatorial do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. RESULTADOS: Os gastos estimados com os insumos utilizados para as cirurgias foram de R$ 468,92 no grupo FACO e R$ 259,96 no grupo EECP. As despesas hospitalares com o acompanhamento pós-operatório foram em média de R$ 16,40 (42%) menores no grupo FACO. Com relação ao gasto estimado para a Previdência Social, o grupo EECP custou em média, US$ 44,58 por paciente a mais que o grupo FACO. CONCLUSÃO: O incentivo e o investimento governamental para a realização da FACO no SUS são socialmente justificados, deve-se considerar também a economia dos pacientes e do sistema empresarial, bem como as vantagens clínicas para os pacientes e vantagens econômicas para os hospitais.

A clinical comparison between DisCoVisc and 2% hydroxypropylmethylcellulose in phacoemulsification: a fellow eye study

OBJECTIVE: This study sought to compare the effects and outcomes of two ophthalmic viscosurgical devices, 1.6% hyaluronic acid/4.0% chondroitin sulfate and 2.0% hydroxypropylmethylcellulose, during phacoemulsification. METHODS: This prospective, randomized clinical trial comprised 78 eyes (39 patients) that received phacoemulsification performed by the same surgeon using a standardized technique. Patients were randomly assigned to receive either 1.6% hyaluronic acid/4.0% chondroitin sulfate or 2.0% hydroxypropylmethylcellulose on the first eye. The other eye was treated later and received the other viscoelastic agent. Preoperative and postoperative examinations (5, 24 and 48 hours; 7 and 14 days; 3 and 6 months) included measurements of the total volume of the ophthalmic viscosurgical device, ultrasound and washout times to completely remove the ophthalmic viscosurgical device, intraocular pressure, central corneal thickness and best-corrected visual acuity. The corneal endothelial cell count was measured at baseline and at six months postoperatively. ClinicalTrials.gov: NCT01387620. RESULTS: There were no statistically significant differences between groups in terms of cataract density or ultrasound time. However, it took longer to remove 2.0% hydroxypropylmethylcellulose than 1.6% hyaluronic acid/ 4.0% chondroitin sulfate, and the amount of viscoelastic material used was greater in the 2.0% hydroxypropylmethylcellulose group. In addition, the best-corrected visual acuity was significantly better in the hyaluronic acid/ chondroitin sulfate group, but this preferable outcome was only observed at 24 hours after the operation. There were no statistically significant differences between the two ophthalmic viscosurgical devices regarding the central corneal thickness or intraocular pressure measurements at any point in time. The corneal endothelial cell count was significantly higher in the hyaluronic acid/chondroitin sulfate group. CONCLUSION: The ophthalmic viscosurgical device consisting of 1.6% hyaluronic acid/4.0% chondroitin sulfate was more efficient during phacoemulsification and was easier to remove after IOL implantation than 2.0% hydroxypropylmethylcellulose. In addition, the corneal endothelial cell count was significantly higher following the use of hyaluronic acid/chondroitin sulfate than with hydroxypropylmethylcellulose, which promoted an improved level of corneal endothelium protection.

Pathogenic mechanisms in mitochondrial optic neuropathies

Leber’s hereditary optic neuropathy (LHON) and Autosomal Dominant Optic Atrophy (ADOA) are the two most common inherited optic neuropathies and both are the result of mitochondrial dysfunctions. Despite the primary mutations causing these disorders are different, being an mtDNA mutation in subunits of complex I in LHON and defects in the nuclear gene encoding the mitochondrial protein OPA1 in ADOA, both pathologies share some peculiar features, such a variable penetrance and tissue-specificity of the pathological processes. Probably, one of the most interesting and unclear aspect of LHON is the variable penetrance. This phenomenon is common in LHON families, most of them being homoplasmic mutant. Inter-family variability of penetrance may be caused by nuclear or mitochondrial ‘secondary’ genetic determinants or other predisposing triggering factors. We identified a compensatory mechanism in LHON patients, able to distinguish affected individuals from unaffected mutation carriers. In fact, carrier individuals resulted more efficient than affected subjects in increasing the mitochondrial biogenesis to compensate for the energetic defect. Thus, the activation of the mitochondrial biogenesis may be a crucial factor in modulating penetrance, determining the fate of subjects harbouring LHON mutations. Furthermore, mtDNA content can be used as a molecular biomarker which, for the first time, clearly differentiates LHON affected from LHON carrier individuals, providing a valid mechanism that may be exploited for development of therapeutic strategies. Although the mitochondrial biogenesis gained a relevant role in LHON pathogenesis, we failed to identify a genetic modifying factor for the variable penetrance in a set of candidate genes involved in the regulation of this process. A more systematic high-throughput approach will be necessary to select the genetic variants responsible for the different efficiency in activating mitochondrial biogenesis. A genetic modifying factor was instead identified in the MnSOD gene. The SNP Ala16Val in this gene seems to modulate LHON penetrance, since the Ala allele in this position significantly predisposes to be affected. Thus, we propose that high MnSOD activity in mitochondria of LHON subjects may produce an overload of H2O2 for the antioxidant machinery, leading to release from mitochondria of this radical and promoting a severe cell damage and death ADOA is due to mutation in the OPA1 gene in the large majority of cases. The causative nuclear defects in the remaining families with DOA have not been identified yet, but a small number of families have been mapped to other chromosomal loci (OPA3, OPA4, OPA5, OPA7, OPA8). Recently, a form of DOA and premature cataract (ADOAC) has been associated to pathogenic mutations of the OPA3 gene, encoding a mitochondrial protein. In the last year OPA3 has been investigated by two different groups, but a clear function for this protein and the pathogenic mechanism leading to ADOAC are still unclear. Our study on OPA3 provides new information about the pattern of expression of the two isoforms OPA3V1 and OPA3V2, and, moreover, suggests that OPA3 may have a different function in mitochondria from OPA1, the major site for ADOA mutations. In fact, based on our results, we propose that OPA3 is not involved in the mitochondrial fusion process, but, on the contrary, it may regulate mitochondrial fission. Furthermore, at difference from OPA1, we excluded a role for OPA3 in mtDNA maintenance and we failed to identify a direct interaction between OPA3 and OPA1. Considering the results from overexpression and silencing of OPA3, we can conclude that the overexpression has more drastic consequences on the cells than silencing, suggesting that OPA3 may cause optic atrophy via a gain-of-function mechanism. These data provide a new starting point for future investigations aimed at identifying the exact function of OPA3 and the pathogenic mechanism causing ADOAC.

Studio caso-controllo multicentrico su distacco di retina e movimentazione manuale di carichi

Obiettivo Valutare l’ipotesi secondo cui la movimentazione manuale di carichi possa essere un fattore di rischio per il di distacco di retina. Metodi Si è condotto uno studio caso-controllo ospedaliero multicentrico, a Bologna, (reparto di Oculistica del policlinico S. Orsola Malpighi, Prof. Campos), e a Brescia (reparto di oculistica “Spedali Civili” Prof. Semeraro). I casi sono 104 pazienti operati per distacco di retina. I controlli sono 173 pazienti reclutati tra l’utenza degli ambulatori del medesimo reparto di provenienza dei casi. Sia i casi che i controlli (all’oscuro dall’ipotesi in studio) sono stati sottoposti ad un’intervista, attraverso un questionario strutturato concernente caratteristiche individuali, patologie pregresse e fattori di rischio professionali (e non) relativi al distacco di retina. I dati relativi alla movimentazione manuale di carichi sono stati utilizzati per creare un “indice di sollevamento cumulativo―ICS” (peso del carico sollevato x numero di sollevamenti/ora x numero di anni di sollevamento). Sono stati calcolati mediante un modello di regressione logistica unconditional (aggiustato per età e sesso) gli Odds Ratio (OR) relativi all’associazione tra distacco di retina e vari fattori di rischio, tra cui la movimentazione manuale di carichi. Risultati Oltre alla chirurgia oculare e alla miopia (fattori di rischio noti), si evidenzia un trend positivo tra l’aumento dell’ICS e il rischio di distacco della retina. Il rischio maggiore si osserva per la categoria di sollevamento severo (OR 3.6, IC 95%, 1.5–9.0). Conclusione I risultati, mostrano un maggiore rischio di sviluppare distacco di retina per coloro che svolgono attività lavorative che comportino la movimentazione manuale di carichi e, a conferma di quanto riportato in letteratura, anche per i soggetti miopi e per coloro che sono stati sottoposti ad intervento di cataratta. Si rende quindi evidente l’importanza degli interventi di prevenzione in soggetti addetti alla movimentazione manuale di carichi, in particolare se miopi.

Identifizierung und Charakterisierung von Protein-Biomarkern beim Glaukom

Das Glaukom ist, nach dem Katarakt, die zweithäufigste Ursache für Erblindungen weltweit mit Milionen von Betroffenen, die von dieser zunächst weitgehend symptomfreien neurodegenerativen Erkrankung heimgesucht werden. Die Möglichkeiten auf dem Feld der Diagnose beschränken sich bislang weitestgehend auf die Messung des Augeninnendrucks und der Beurteilung des Augenhintergrundes durch einen erfahrenen Augenarzt. Eine labordiagnostische Prophylaxe ist bis heute nicht verfügbar, die Zahl unerkannter Erkrankungen dementsprechend hoch. Hierdurch geht wertvolle Zeit verloren, die man für eine effektive Therapie nutzen könnte.rnBezüglich der Pathogenese des Glaukoms geht man heute von mehreren, miteinander wechselwirkenden Pathomechanismen aus, zu denen neben mechanischen Einflüssen durch einen erhöhten IOD auch Hypoxie, verminderte Neutrophinversorgung, Exzitotoxizität, oxidativer Stress und eine Beteiligung autoimmuner Prozesse gezählt werden. Unabhängig vom Pathomechanismus folgt stets die Etablierung umfangreicher degenerativer Prozesse im Sehnervenkopf, den retinalen Ganglienzellen und den Axonen des Sehnerven, die letztlich im irreversiblen Untergang dieser Neuronen münden. Diese pathologischen Prozesse im ZNS hinterlassen auf Proteomebene Spuren, die mithilfe moderner massenspektrometrischer Methoden in Kombination mit multivariaten statistischen Methoden detektierbar und als sogenannte Biomarker-Kandidaten mit definiertem Molekulargewicht darstellbar sind. In dieser Arbeit wurde ein „Workflow“ entwickelt, der es ermöglicht, diese Biomarker-Kandidaten im Blutserum und in der Tränenflüssigkeit in einfachen, reproduzierbaren Schritten zu identifizieren und zu charakterisieren. Abweichend von der etablierten Methotik der Bottom-Up-Proteomics musste hierfür eine Methode entsprechend einer Top-Down-Philosophie entwickelt werden, die es erlaubt, die Spuren des Glaukoms im Proteom zu detektieren und zu charakterisieren.rnDies erfolgte in dieser Arbeit durch sowohl massenspektroskopischen Methoden wie SELDI-TOF® und MALDI-Tof-Tof als auch durch Bead-, Gel- und Flüssigkeits-chromatographisch-basierte Separations und Fraktionierungstechniken.rnDie erfolgreiche Kombination dieser Methoden führte zu Identifikationen einer ganzen Reihe von Biomarker-Kandidaten. Unter den identifizierten Proteinen, die bezüglich ihres korrespondierenden SELDI-Peaks im Massenbereich von Biomarker-Kandidaten liegen, finden sich Zytokine und Effektormoleküle der angeborernen Immunität, stressinduzierbare Kinasen, Faktoren, die zum Schutz der Telomeren dienen, Proliferationsmarker, neuronale Antigene und Transportproteine. Darüber hinaus wurden Komponenten identifiziert, die an der neuronalen Neutrophinversorgung beteiligt sind, neuronale Rezeptoren und Antigene, Komponenten des Komplementsystems und des MHC-I-Komplexes. All diese identifizierten Proteine sind bezüglich ihrer Funktion und möglichen Rolle innerhalb der Pathogenese des Glaukoms detailliert beschrieben und charakterisiert. Dies erlaubt einen umfassenden Einblick in alle Pathomechanismen, denen nach heutigem Kenntnisstand, eine Rolle an der Pathogenese des Glaukoms unterstellt wird.rn

Simple and objective method for routine detection of the macular pigment xanthophyll

A new simple method for two-dimensional determination of optical density of macular pigment xanthophyll (ODx) in clinical routine is based on a single blue-reflection fundus image. Individual different vignetting is corrected by a shading function. For its construction, nodes are automatically found in structureless image regions. The influence of stray light in elderly crystalline lenses is compensated by a correction function that depends on age. The reproducibility of parameters in a one-wavelength reflection method determined for three subjects (47, 61, and 78 years old) was: maxODx = 6.3%, meanODx = 4.6%, volume = 6%, and area = 6% already before stray-light correction. ODx was comparable in pseudophakic and in an eye with a crystalline lens of the same 11 subjects after stray-light correction. Significant correlation in ODx was found between the one-wavelength reflection method and the two-wavelength autofluorescence method for pseudophakic and cataract eyes of 19 patients suffering from dry age-related macular degeneration (AMD) (R(2) = 0.855). In pseudophakic eyes, maxODx was significantly lower for dry AMD (n = 45) (ODx = 0.491±0.102 ODU) than in eyes with healthy fundus (n = 22) (ODx = 0.615±0.103 ODU) (p = 0.000033). Also in eyes with crystalline lens, maxODx was lower in AMD (n = 125) (ODx = 0.610±0.093 ODU) than in healthy subjects (n = 45) (ODx = 0.674±0.098 ODU) (p = 0.00019). No dependence on age was found in the pseudophakic eyes both of healthy subjects and AMD patients.

Effect of topical anesthetic agents and ethanol on corneoepithelial wound healing in an ex vivo whole-globe porcine model

To assess the impact of topical anesthetic agents and ethanol on ocular surface wound healing using an ex vivo whole-globe porcine model.

Ten Years after the Chernobyl Accident: Long-Term Immunological Consequences; Prognosis of Autoimmune Disorders

The Chernobyl tragedy was the biggest accident since the beginning of the nuclear power industry. The aim of this study was to determine the role of immunological mechanisms in the development of autoimmune disorders (thyroiditis and cataract) and cancers among those workers who participated in clean-up operations in 1986. Blood samples from 165 clean-up workers aged 30-65 from Minsk and Kiev who underwent prophylactic medical examinations and from 80 healthy donors were investigated for the presence of autoimmune reactions and the appearance of onco-foetal antigens. The sera of clean-up workers were found to include the thyroid gland antigen, auto-antibodies to thyroid gland and eye antigens, and immune complexes which are normally absent or found in much lower quantities. The appearance of the clinically unmanifested thyroid gland antigen made it possible to generate a concept describing the mechanism for induction and long-term maintenance of auto-antibody production in an organism after irradiation. Lymphocytes from clean-up workers showed normally absent onco-foetal antigens (PSG and CEA). The data obtained indicate that clean-up workers represent a high risk group for autoimmune and cancer diseases. Immunological findings reveal the long-lasting effects of low doses of irradiation and may be used in prognosis and monitoring of human health.

Ocular toxicity during adjuvant chemoendocrine therapy for early breast cancer: results from International Breast Cancer Study Group trials

BACKGROUND: Others have reported ocular toxicity after adjuvant chemoendocrine therapy, but this study looked at ocular toxicity in similarly treated patients from large randomized clinical trials. METHODS: Information was retrieved on incidence and timing of ocular toxicity from the International Breast Cancer Study Group (IBCSG) database of 4948 eligible patients randomized to receive tamoxifen or toremifene alone or in combination with chemotherapy (either concurrently or sequentially). Case reports of patients with ocular toxicity were evaluated to determine whether ocular toxicity occurred during chemotherapy and/or hormonal therapy. Additional information was obtained from participating institutions for patients in whom ocular toxicity occurred after chemotherapy but during administration of tamoxifen or toremifene. RESULTS: Ocular toxicity was reported in 538 of 4948 (10.9%) patients during adjuvant treatment, mainly during chemotherapy. Forty-five of 4948 (0.9%) patients had ocular toxicity during hormone therapy alone, but only 30 (0.6%) patients had ocular toxicity reported either without receiving any chemotherapy or beyond 3 months after completing chemotherapy and, thus, possibly related to tamoxifen or toremifene. In 3 cases, retinal alterations, without typical aspects of tamoxifen toxicity, were reported; 4 patients had cataract (2 bilateral), 12 impaired visual acuity, 10 ocular irritation, 1 optical neuritis, and the rest had other symptoms. CONCLUSION: Ocular toxicity during adjuvant therapy is a common side effect mainly represented by irritative symptoms due to chemotherapy. By contrast, ocular toxicity during hormonal therapy is rare and does not appear to justify a regular program of ocular examination. However, patients should be informed of this rare side effect so that they may seek prompt ophthalmic evaluation for ocular complaints.

Determinants of reduced walking speed in people with musculoskeletal pain

OBJECTIVE: Maintenance of good walking speed is essential to independent living. People with musculoskeletal disease often have reduced walking speed. We investigated determinants of slower walking, other than musculoskeletal disease, that might provide valuable additional targets for therapy. METHODS: We analyzed data from the Somerset and Avon Survey of Health, a community based survey of people aged over 35 years. A total of 2703 participants who reported hip or knee pain at baseline (1994/1995) were studied, and reassessed in 2002-2003; 1696 were available for followup, and walking speed was tested in 1074. Walking speed (m/s) was used as outcome measure. Baseline characteristics, including comorbidities and socioeconomic factors, were tested for their ability to predict reduced walking speed using multiple linear regression analysis. RESULTS: Age, female sex, and immobility at baseline were predictive of slower walking speed. Other independent risk factors included the presence of cataract, low socioeconomic status, intermittent claudication, and other cardiovascular conditions. Having a cataract was associated with a decrease of 0.10 m/s (95% CI 0.03, 0.16). Those in social class V had a walking speed 0.22 m/s (95% CI 0.126, 0.31) slower than those in social class I. CONCLUSION: Comorbidities, age, female sex, and lower socioeconomic position determine walking speed in people with joint pain. Issues such as poor vision and social-economic disadvantage may add to the effect of musculoskeletal disease, suggesting the need for a holistic approach to management of these patients.

Is pseudophakia a risk factor for neovascular age-related macular degeneration?

PURPOSE: To examine the possible association between pseudophakia and neovascular age-related macular degeneration (AMD). METHODS: Reports of all patients undergoing fluorescein angiography in the authors' department over a 6-year period were retrospectively reviewed. Four hundred ninety-nine patients with recent onset of neovascular AMD in one eye and early age-related maculopathy (ARM) in the fellow eye were included in the study. Lens status (phakic or pseudophakic) in both eyes at the time of onset of neovascular AMD and the time between cataract surgeries (if performed) and onset of neovascular AMD were determined. RESULTS: There was no significant difference in lens status between eyes with neovascular AMD and fellow eyes with early ARM (115/499 [23.0%] vs. 112/499 [22.4%] pseudophakic; P = 0.88, odds ratio 1.035, 95% CI 0.770-1.391). Subgroup analysis revealed no difference between the groups with large drusen, small drusen, or pigmentary changes only (respectively, 20.3% vs. 19.6% pseudophakic, P = 0.92; 20.5% vs. 23.3% pseudophakic, P = 0.84; 33.3% vs. 31.7% pseudophakic, P = 1.0). Pseudophakic eyes with neovascular AMD had not been pseudophakic for a significantly longer period at the time of onset of neovascular AMD than their pseudophakic fellow eyes at the same time point (225.9 +/- 170.4 vs. 209.9 +/- 158.2 weeks, P = 0.27). CONCLUSIONS: The results do not support the hypothesis that pseudophakia is a major risk factor for the development of neovascular AMD.

Radiation exposure to the surgeon during fluoroscopically assisted percutaneous vertebroplasty: a prospective study

STUDY DESIGN: A prospective case control study design was conducted. OBJECTIVES: The purpose of the current study was to determine the intraoperative radiation hazard to spine surgeons by occupational radiation exposure during percutaneous vertebroplasty and possible consequences with respect to radiation protection. SUMMARY OF BACKGROUND DATA: The development of minimally invasive surgery techniques has led to an increasing number of fluoroscopically guided procedures being done percutaneously such as vertebroplasty, which is the percutaneous cement augmentation of vertebral bodies. METHODS: Three months of occupational dose data for two spine surgeons was evaluated measuring the radiation doses to the thyroid gland, the upper extremities, and the eyes during vertebroplasty. RESULTS: The annual risk of developing a fatal cancer of the thyroid is 0.0025%, which means a very small to small risk. The annual morbidity (the risk of developing a cancer including nonfatal ones) is 0.025%, which already means a small to medium risk. The dose for the eye lens was about 8% of the threshold dose to develop a radiation induced cataract (150 mSv); therefore, the risk is very low but not negligible. The doses measured for the skin are 10% of the annual effective dose limit (500 mSv) recommended by the ICRP (International Commission on Radiologic Protection); therefore, the annual risk for developing a fatal skin cancer is very low. CONCLUSION: While performing percutaneous vertebroplasty, the surgeon is exposed to a significant amount of radiation. Proper surgical technique and shielding devices to decrease potentially high morbidity are mandatory. Training in radiation protection should be an integral part of the education for all surgeons using minimally invasive radiologic-guided interventional techniques.

Outcome indicators for vitrectomy in Terson syndrome

PURPOSE: There is no general agreement on the best indication and timing of vitrectomy in patients suffering from Terson syndrome. Therefore, we reviewed our cases in order to assess factors interfering with the functional outcome and complication rates after vitrectomy. METHODS: In this retrospective consecutive case series, the records from all patients undergoing vitrectomy for Terson syndrome between 1975 and 2005 were evaluated. RESULTS: Thirty-seven patients (45 eyes) were identified, 36 of whom (44 corresponding eyes) were eligible. The best-corrected visual acuity (BCVA) at first and last presentation was 0.07 +/- 0.12 and 0.72 +/- 0.31, respectively. Thirty-five eyes (79.5%) achieved a postoperative BCVA of > or = 0.5; 26 (59.1%) eyes achieved a postoperative BCVA of > or = 0.8. Patients operated on within 90 days of vitreous haemorrhage achieved a better final BCVA than those with a longer latency (BCVA of 0.87 +/- 0.27 compared to 0.66 +/- 0.31; P = 0.03). Patients younger than 45 years of age achieved a better final BCVA than older patients (0.85 +/- 0.24 compared to 0.60 +/- 0.33; P = 0.006). Retinal detachment developed in four patients between 6 and 27 months after surgery. Seven patients (16%) required epiretinal membrane peeling and seven cataract surgery. CONCLUSION: Ninety-eight per cent of our patients experienced a rapid and persisting visual recovery after removal of a vitreous haemorrhage caused by Terson syndrome. A shorter time between occurrence of vitreous haemorrhage and surgery as well as a younger patient age are predictive of a better outcome. Generally, the surgical risk is low, but complications (namely retinal detachment) may occur late after surgery.