Slow coagulation versus micropulse transscleral cyclophotocoagulation for refractory childhood glaucoma.

PURPOSE: To compare the safety and efficacy of micropulse laser (MP-TSCP) and slow coagulation transscleral cyclophotocoagulation (TSCP) with a diode laser for reducing intraocular pressure (IOP) in patients with refractory childhood glaucoma (CG). METHODS: Patients with CG and at least 12 months of medical chart data were included. Data on preoperative and postoperative outcomes were analyzed. The primary outcomes were an IOP of 6-21 mmHg and/or ≥ 20% reduction in the baseline value. RESULTS: A total of 17 eyes were included. The preoperative mean IOP was 28 mmHg in the MP-TSCP and 29.9 mmHg in the TSCP. The mean IOP decreased significantly to 17.26 ± 3.27 mmHg in the MP-TSCP and 14.68 ± 5.79 mmHg TSCP at the last medical record. Three anti-glaucoma meds were administered to the eyes preoperatively in both groups. A mean of 1.02 eye drops was administered to the MP-TSCP and 2.06 to the TSCP. The number of medications decreased by 2.38 ± 1.55 in the MP-TSCP and 0.82 ± 1.68 in the TSCP. The median preoperative visual acuity (logMAR) was 1.51 ± 1.06 in the MP-TSCP and 1.87 ± 0.74 in the TSCP. The variation in mean visual acuity (logMAR) was -0.027 ± 0.05 in the MP-TSCP and -0.40 ± 0.58 in the TSCP. The most frequent complication was corneal decompensation (one - MP-TSCP and two - TSCP). CONCLUSION: Both techniques were effective and relatively safe for reducing IOP. These techniques appear to extend the indications of cyclophotocoagulation in CG eyes and improve the functional prognosis.

Lost to follow-up of patients who received intravitreal anti-vascular endothelial growth factor therapy to treat four different retina disorders in an individual center in Brazil.

Objectives: To identify risk factors for loss to follow-up in periodic intravitreal anti-vascular endothelial growth factor injections for the treatment patients with diabetic macular edema, subretinal neovascularization, age-related macular degeneration, and retinal vein occlusion in a single eye center in São Paulo, Brazil. Methods: This was a retrospective longitudinal study that gathered information from 992 patients who required intravitreal anti-vascular endothelial growth factor drugs over 6 months. The authors included age, eye disease, laterality, monthly income, distance, and payment mode as risk factors. Results: Two hundred and seventy patients (29.93%) were lost to follow-up. Multivariate analysis showed age, monthly income, eye involvement, and type of medical assistance independently associated with loss to follow-up. The odds of loss to follow-up were greater among older patients than those less than 50 years (reference), p < 0.001. The odds of loss to follow-up were greater among patients who received unilateral treatment than those who received bilateral injections (p = 0.013). Concerning gross monthly income, there were no differences in the odds of the four salary strata; the data also indicate an absence of difference in the three strata of patients' distance to the clinic. Considering the diagnosis, only age-related macular degeneration showed greater odds of loss to follow-up (p = 0.016). Finally, the data suggest greater odds of loss to follow-up in private patients than in those on a health care plan (p < 0.001). Conclusion: Loss to follow-up is paramount because many patients may remain unassisted concerning their eye diseases. Identifying the risk factors is crucial to enforcing measures to increase adherence and the long-term success of the treatment.

A Retrospective Comparison of Ahmed Glaucoma Valve Implants with or without Ologen Collagen Matrix.

Purpose: To study the effects of Ologen collagen matrix on the outcomes of the Ahmed glaucoma valve implant. Study Design: Retrospective case-control multicenter study, conducted at four centers, comparing the 6-month outcomes of Ahmed valve implants with or without Ologen. Participants: The study included 125 eyes in a 4:1 pairing (25 patients with Ologen matched to 100 patients without Ologen). Intervention: Ologen was placed over the Ahmed plate in the study group. Success was defined as an intraocular pressure (IOP) ≤ 21 mmHg either with no medication (complete success) or regardless of medications (qualified success). Other outcomes included IOP variation, eye drop use, and surgical complications. Results: Overall, the IOP decreased from 30.72 ± 9.08 to 16.14 ± 4.79 mmHg (p=0.0001). Of the 125 eyes, 26 achieved complete success and 94 achieved qualified success. There was no difference in complete success between the groups (p=0.12); however, there was a difference in qualified success (p=0.01), with better results in the no-Ologen group (80% vs 56%). There were no differences in the decrease in medications (p=0.06), as well as the incidence of complications (p=0.69). Although the need for postoperative surgical reintervention was higher in the no-Ologen group (13% vs 4%), the difference was not significant (p=0.2). Conclusion: The reductions in IOP and number of medications were similar in both groups after 6 months, with similar complication rates. The qualified success rate was lower in the Ologen group, but further studies are needed to clarify the role of Ologen in Ahmed valve implants.

The use of Ologen Collagen Matrix implants to treat ocular hypotony developing after trabeculectomy: A case series.

PURPOSE: Late hypotony is an undesirable and challenging complication of glaucoma surgery. We describe our use of the Ologen Collagen Matrix to treat late hypotony developing after trabeculectomy. STUDY DESIGN: A retrospective study performed at three eye surgery centers in Brazil. PARTICIPANTS: Eighteen patients who underwent 19 eye surgeries. INTERVENTION: Subconjunctival Ologen was implanted at the trabeculectomy sites to treat over-filtering or leaking blebs in patients experiencing late hypotony after trabeculectomy (obtained 6 months after glaucoma surgery). The primary outcome was the intraocular pressure (IOP); we gathered preoperative data records from 19 Ologen treated eyes and days 1, 7, 30, 60, and 180 postoperatively. The secondary outcomes included visual acuity and macular thickness measured via optical coherence tomography; we compared preoperative data to subsequent ones up to sixth-month-evolution. RESULTS: Over the 6-month period, the IOP rose from 2.89 ± 1.59 mmHg preoperatively to 8.21 ± 3.46 mmHg (p = 0.0001). Visual acuity improved from 0.33 ± 0.29 to 0.21 ± 0.31 LogMar (p = 0.0013). Macular thickness fell from 325.62 ± 58.7 to 283.08 ± 47.35 µm (p = 0.0097). We encountered two complications: one related to suture dehiscence following an ocular trauma and one instance of transitory choroidal detachment. CONCLUSION: Subconjunctival Ologen implants preserved bleb function and successfully treated post-trabeculectomy hypotony as revealed by data collected at the 6-month follow-up. Longer follow-up is necessary to confirm long-term efficacy and safety. There are no financial conflicts of interest to disclose.

Mid-Term Evaluation of iStent Inject® Trabecular Micro-Bypass Stent Implantation with or without Phacoemulsification: A Retrospective Study.

INTRODUCTION: This study evaluated the 6-month performance and safety of micro-invasive glaucoma surgery (MIGS) with iStent inject either with or without cataract surgery. MATERIAL AND METHODS: Longitudinal retrospective study of 86 surgeries in 49 patients with inadequately controlled open-angle glaucoma (OAG) or ocular hypertension who underwent iStent inject trabecular micro-bypass implantation either alone (isolated group) or combined with cataract surgery (combined group). The two primary outcomes included an intraocular pressure (IOP) drop of ≥20% versus preoperative values (adequate drop) and IOP maintenance between 6 and 18 mmHg (adequate Range). For both outcomes, we determined "complete" and "qualified" success if patients did not require or did require glaucoma medications, respectively, at the end of follow-up. Safety outcomes included best-corrected visual acuity, adverse events, and secondary surgeries. RESULTS: In the adequate drop analysis, 30.2% achieved "complete success," and 37.2% achieved "qualified success." For adequate range, 40.7% achieved "complete success" and 39.5% achieved "qualified success." There was no difference in medication decrease (p=0.77) nor IOP reduction (p=0.46) between the isolated and combined groups. Safety was generally favorable and similar between groups, with mild transient adverse events that resulted in no sequelae. DISCUSSION/CONCLUSION: iStent inject implantation either with or without cataract surgery was able to safely decrease IOP and medication requirements through 6 months after surgery.

Perioperative management of anticoagulant users scheduled for glaucoma surgery: a survey among the Brazilian Glaucoma Society members / Condução de pacientes usuários de anticoagulantes no perioperatório de cirurgia antiglaucomatosa: uma pesquisa entre os membros da Sociedade Brasileira de Glaucoma

PURPOSE: To investigate and describe, among the members of the Brazilian Glaucoma Society (BGS), the practices regarding the perioperative management of anticoagulants (warfarin and aspirin) use in patients scheduled for glaucoma surgery. METHODS: The active members of the Brazilian Glaucoma Society answered a questionnaire evaluating different aspects of their current perioperative management of glaucomatous patients taking warfarin or aspirin. RESULTS: A total of 52 participants returned a complete questionnaire. Warfarin or aspirin was routinely interrupted prior to glaucoma surgery by 82.7% of the respondents. The majority of the surgeons who discontinued these medications reported doing so 7 days prior to surgery and resumed their use the day after the procedure. Almost half of our interviewees reported hemorrhagic complications that could be related to anticoagulant therapy. A large number of the surgeons (86.5%) preferred a particular surgical technique for anticoagulated patients; however, most of them (88.5%) do not change the anesthetic planning in such patients. Finally, the majority of the participants (90.4%) refer their anticoagulated patients to a preoperative appointment with a cardiologist or a general practitioner before the surgery. CONCLUSIONS: The majority of Brazilian Glaucoma Society members participating in this study interrupt either warfarin or aspirin prior to glaucoma surgery. Although there is scant information available in the literature to offer definitive guidance, most participants from the Brazilian Glaucoma Society seem to share the same opinion when it comes to perioperative management of anticoagulant users.

OBJETIVO: Investigar e descrever, entre os membros da Sociedade Brasileira de Glaucoma (SBG), as práticas relativas ao manejo de anticoagulantes (varfarina e aspirina) em pacientes agendados para cirurgia antiglaucomatosa. MÉTODOS: Foi enviado um questionário objetivo aos membros ativos da Sociedade Brasileira de Glaucoma avaliando diferentes aspectos da forma como conduzem seus pacientes em uso de varfarina ou aspirina durante o período perioperatório de uma cirurgia antiglaucomatosa. RESULTADOS: Cinquenta e dois participantes retornaram o questionário preenchido adequadamente. O uso de varfarina ou aspirina foi rotineiramente interrompido antes da cirurgia antiglaucomatosa por 82,7% dos entrevistados. A maior parte dos cirurgiões, quando interromperam o uso destes medicamentos, o fez sete dias antes da cirurgia e os reintroduziram no dia seguinte ao procedimento. Aproximadamente metade dos entrevistados disse ter observado complicações hemorrágicas que poderiam ser relacionados à terapia anticoagulante. Embora a maioria dos cirurgiões (86,5%) referiu utilizar alguma técnica cirúrgica em particular para esses pacientes anticoagulados, quase todos (88,5%) não alteram seu planejamento anestésico de rotina nesses mesmos casos. Finalmente, a maior parte dos participantes (90,4%) relatou referir seus pacientes anticoagulados para uma avaliação pré-operatória com um cardiologista ou um clínico geral. CONCLUSÃO: A maior parte dos membros da Sociedade Brasileira de Glaucoma que participou desse estudo refere interromper o uso de anticoagulantes (varfarina ou aspirina) antes de uma cirurgia antiglaucomatosa. Embora existam poucas informações disponíveis na literatura para oferecer uma orientação definitiva, a maioria dos participantes parece compartilhar da mesma opinião quando se trata do manejo perioperatório de anticoagulantes.

Perioperative management of anticoagulant users scheduled for glaucoma surgery: a survey among the Brazilian Glaucoma Society members.

PURPOSE: To investigate and describe, among the members of the Brazilian Glaucoma Society (BGS), the practices regarding the perioperative management of anticoagulants (warfarin and aspirin) use in patients scheduled for glaucoma surgery. METHODS: The active members of the Brazilian Glaucoma Society answered a questionnaire evaluating different aspects of their current perioperative management of glaucomatous patients taking warfarin or aspirin. RESULTS: A total of 52 participants returned a complete questionnaire. Warfarin or aspirin was routinely interrupted prior to glaucoma surgery by 82.7% of the respondents. The majority of the surgeons who discontinued these medications reported doing so 7 days prior to surgery and resumed their use the day after the procedure. Almost half of our interviewees reported hemorrhagic complications that could be related to anticoagulant therapy. A large number of the surgeons (86.5%) preferred a particular surgical technique for anticoagulated patients; however, most of them (88.5%) do not change the anesthetic planning in such patients. Finally, the majority of the participants (90.4%) refer their anticoagulated patients to a preoperative appointment with a cardiologist or a general practitioner before the surgery. CONCLUSIONS: The majority of Brazilian Glaucoma Society members participating in this study interrupt either warfarin or aspirin prior to glaucoma surgery. Although there is scant information available in the literature to offer definitive guidance, most participants from the Brazilian Glaucoma Society seem to share the same opinion when it comes to perioperative management of anticoagulant users.

Anafilaxia com convulsões após angiografia com fluoresceína em paciente ambulatorial / Anaphylaxis with convulsions following intravenous fluorescein angiography at an outpatient clinic

A fluoresceína endovenosa é associada a pequenos efeitos adversos durante a angiografia da retina, a maioria deles sem gravidade e não relacionada a mecanismos imunológicos. Entretanto, em raras ocasiões, pode ocorrer reação anafilactoide; fatalidades envolvendo o uso de fluoresceína têm sido descritas. Complicações graves após injeção endovenosa de fluoresceína requerem ação imediata da equipe envolvida, assim como treinamento regular para padronizar o tratamento.

Fluorescein is associated with minor adverse effects during retinal angiography, and most of these effects are not severe and not related to immunological mechanism. However, on rare occasions, anaphylatoid reaction can occur, and fatalities involving fluorescein have been described. Life threatening complications after intravenous injection of sodium fluorescein require immediate intervention. Trainings for professionals are needed to standardize treatment for this event.

Anaphylaxis with convulsions following intravenous fluorescein angiography at an outpatient clinic.

Fluorescein is associated with minor adverse effects during retinal angiography, and most of these effects are not severe and not related to immunological mechanism. However, on rare occasions, anaphylatoid reaction can occur, and fatalities involving fluorescein have been described. Life threatening complications after intravenous injection of sodium fluorescein require immediate intervention. Trainings for professionals are needed to standardize treatment for this event.

Fluid resuscitation with isotonic or hypertonic saline solution avoids intraneural calcium influx after traumatic brain injury associated with hemorrhagic shock.

BACKGROUND: Calcium is one of the triggers involved in ischemic neuronal death. Because hypotension is a strong predictor of outcome in traumatic brain injury (TBI), we tested the hypothesis that early fluid resuscitation blunts calcium influx in hemorrhagic shock associated to TBI. METHODS: Fifteen ketamine-halothane anesthetized mongrel dogs (18.7 kg +/- 1.4 kg) underwent unilateral cryogenic brain injury. Blood was shed in 5 minutes to a target mean arterial pressure of 40 mm Hg to 45 mm Hg and maintained at these levels for 20 minutes (shed blood volume = 26 mL/kg +/- 7 mL/kg). Animals were then randomized into three groups: CT (controls, no fluid resuscitation), HS (7.5% NaCl, 4 mL/kg, in 5 minutes), and LR (lactate Ringer's, 33 mL/kg, in 15 minutes). Twenty minutes later, a craniotomy was performed and cerebral biopsies were obtained next to the lesion ("clinical penumbra") and from the corresponding contralateral side ("lesion's mirror") to determine intracellular calcium by fluorescence signals of Fura-2-loaded cells. RESULTS: Controls remained hypotensive and in a low-flow state, whereas fluid resuscitation improved hemodynamic profile. There was a significant increase in intracellular calcium in the injured hemisphere in CT (1035 nM +/- 782 nM), compared with both HS (457 nM +/- 149 nM, p = 0.028) and LR (392 nM +/- 178 nM, p = 0.017), with no differences between HS and LR (p = 0.38). Intracellular calcium at the contralateral, uninjured hemisphere was 438 nM +/- 192 nM in CT, 510 nM +/- 196 nM in HS, and 311 nM +/- 51 nM in LR, with no significant differences between them. CONCLUSION: Both small volume hypertonic saline and large volume lactated Ringer's blunts calcium influx in early stages of TBI associated to hemorrhagic shock. No fluid resuscitation strategy promotes calcium influx and further neural damage.

O paciente hipertenso em cirurgia eletiva: consideraçöes clínicas pré-operatórias / Hypertensive patient in elective surgery: preoperative considerations

Arterial hypertension is a common disease, the most frequent cardiovascular pathology in the United States, and still is an important cause of welfare benefits in Brazil. These patients are always a challenge that anesthetists have to rise to. Either by target-organ involvment, or adverse effect due to antihypertensives, they need special care, monitoring and observation each minute in perioperative period. We present a review with pathophysiological features, including new concepts about left ventricular hypertrophy and preanesthetic emphasis. The intention is not only try to understand the clinical changes in these patients, but also - and more important - give to the medical practitioner the basis to deal with this particular side of preanesthetic evaluation.