Subconjunctival lidocaine before laser treatment: a randomized trial.

PURPOSE: The aim of the study was to determine whether subconjunctival anesthesia is effective at reducing pain associated with laser retinopexy. DESIGN: This was a single-center, prospective, patient-masked, randomized, controlled trial. PARTICIPANTS: In the primary study group, 65 patients were recruited. Thirty-two patients (32 eyes) received anesthetic injection, and 33 patients (33 eyes) received the sham injection. The crossover study group consisted of 28 patients (56 eyes). METHODS: Between February 2008 and April 2008, all patients who were consecutively booked to undergo panretinal photocoagulation (PRP) or peripheral laser retinopexy (PLR) were invited to participate in the study. Patients were randomized to receive subconjunctival lidocaine injection or a sham injection before their intended laser retinal treatment. These patients were defined as our primary study group. Patients who required a second laser treatment received the opposite injection in a masked fashion before laser retinal treatment. These patients were defined as our crossover group. Patients in both the primary study group and the crossover group were masked to the treatment given. After the laser treatment, patients completed a pain questionnaire. MAIN OUTCOME MEASURES: The primary outcome was incidence of pain. The secondary outcome was severity of pain. RESULTS: Primary study group: In the anesthetic treatment group, 19 patients (59%) experienced pain compared with 32 patients (97%) in the sham treatment group (P<0.001). Among the patients who did experience pain, the average pain score was 3.6 in the anesthetic treatment group and 4.1 in the sham treatment group (P=0.55). Crossover study group: In the anesthetic treatment group, 12 patients (43%) experienced pain compared with 28 patients (100%) in the sham treatment group (P<0.001). In patients who did experience pain, the average pain score was 3.3 in the anesthetic treatment group and 4.6 in the sham treatment group. Twenty patients (71%) preferred anesthetic to sham treatments, 1 patient (4%) preferred sham over anesthetic, and 7 patients (25%) thought both laser treatments were the same. CONCLUSIONS: Subconjunctival 2% lidocaine significantly reduces the incidence of pain in patients who receive PRP or PLR.

Morphologic and clinical effects of subretinal injection of indocyanine green and infracyanine green in rabbits.

PURPOSE: The aim of this study was to determine the effects of subretinal injection of indocyanine green (ICG), infracyanine (IfCG), and balanced salt solution (BSS) in rabbits. METHODS: Ten (10) animals were subjected to a subretinal injection of 0.05% ICG (279 mOsm), 0.5% IfCG (276 mOsm), and BSS (300 mOsm) used as a control. Animals were examined at 6, 12, and 24 h and 14 days following the surgical procedure by indirect binocular ophthalmoscopy, fluorescein angiography (FA), and light and transmission electron microscopy. RESULTS: The subretinal injection of ICG caused damage to all retinal layers and retinal pigment epithelium (RPE) during the entire follow-up. Subretinal injection of IfCG resulted in abnormalities of the photoreceptor outer segments (POSs) during the entire follow-up; however, abnormalities of the photoreceptor inner segments (PISs) and outer nuclear layer (ONL) were observed only 24 h and 14 days after surgery; no RPE damage was observed. FA showed that window defects were more prominent in the subretinal ICG bleb position than the IfCG-related area. BSS caused only abnormalities of the POS layer and no RPE alterations. CONCLUSIONS: Subretinal injection of 0.05% ICG results in more significant retinal damage than 0.5% IfCG. In this model, iodine-free IfCG demonstrates a safer profile than a tenfold lower concentration of ICG, which contains iodine in its composition.

Subretinal injection of preservative-free triamcinolone acetonide and supernatant vehicle in rabbits: an electron microscopy study.

BACKGROUND: To evaluate the effect of injections of benzyl alcohol (BA)-free triamcinolone acetonide (TA) solution (MTA-PF) and the supernatant vehicle of TA (STA) containing BA into the subretinal space of rabbit eyes. METHODS: Sixteen rabbits underwent vitrectomy and subretinal injection of 0.02 ml of either 40 mg/ml MTA-PF, 40 mg/ml STA, or balanced salt solution (BSS). The animals were examined 6, 12, and 24 hours and 14 days after the procedure by fundus examination and fluorescein angiography (FA), as well as histological studies by light and transmission electron microscopy. The histological injury was classified in four stages: (1) stage 1, photoreceptor outer segment injury, (2) stage 2, stage 1 + photoreceptor inner segment injury, (3) stage 3, stage 2 + outer nuclear layer damage, and (4) stage 4, stage 3 + retinal pigment epithelium (RPE) damage. RESULTS: FA showed no window defects in areas where MTA-PF, STA, or BSS have been injected. Histological examination revealed that subretinal BSS-injection resulted in stage 1 damage during entire follow-up. Subretinal injection of MTA-PF resulted in damage stage 2 at 24 h and 14 days after surgery. However, at the STA position, stage 3 damage was noted 24 h and 14 days postoperatively. No RPE or choroidal damage was observed. CONCLUSIONS: The histological lesions induced by subretinal STA were more relevant than the damage induced by MTA-PF. The vehicle BA may be involved in these abnormalities. The data indicate that care must be taken when using TA during internal limiting membrane peeling in macular hole surgery, due to the possibility of unintentional subretinal migration and for retinal pharmacotherapy.

Effects of subretinal injection of patent blue and trypan blue in rabbits.

PURPOSE: To investigate the histologic and clinical effects of subretinal injection of patent blue (PB) and trypan blue (TB) in rabbits. METHODS: Dutch-belted rabbits (n=8) were vitrectomized followed by subretinal injection of 2.4 mg/ml PB (285 mOsm) and 1.5 mg/ml TB (312 mOsm); balanced salt solution (BSS) (300 mOsm) served as the control. Animals were examined 6, 12, and 24 hr and 14 days after the procedure by fluorescein angiography (FA) and indirect ophthalmoscopy; for retinal toxicity, histologic evaluation studies were performed by light and transmission electron microscopy. RESULTS: FA examination demonstrated window defects suggestive of retinal pigment epithelium (RPE) atrophy in positions of subretinal TB injection, but this was not observed after subretinal injection of PB or BSS. Histologic evaluation disclosed only minimal abnormalities on the photoreceptor outer segment (POS) after subretinal injection of BSS during all follow-up. Subretinal injection of PB caused POS and photoreceptor inner segment (PIS) abnormalities 12 and 24 hr after surgery as well as outer nuclear layer (ONL) damage 14 days after surgery. Subretinal TB injection resulted in POS and PIS damage at 12 hr follow-up. The ONL damage was observed 24 hr after surgery; additionally, POS, PIS, ONL, and RPE abnormalities were observed 14 days after surgery after TB injection. CONCLUSIONS: Subretinal injection of TB induced more significant clinical and histologic damage of neurosensory retina/RPE than did PB or BSS. Future human studies are necessary to access the clinical relevance of these in vivo experiments.

Effects of subretinal injections of indocyanine green, trypan blue, and glucose in rabbit eyes.

PURPOSE: To evaluate the effects of subretinal injections of indocyanine green (ICG), trypan blue, glucose (GL), and balanced salt solution (BSS) in rabbits. DESIGN: Experimental study. PARTICIPANTS: Twenty Dutch-belted rabbits. METHODS: Ten animals underwent vitrectomy and subretinal injection of 0.02 ml of either 0.05% ICG (279 milliosmoles [mOsm]), 0.15% trypan blue (312 mOsm), 5% GL (280 mOsm), or BSS (300 mOsm), which was tested as a control. Ten additional animals underwent subretinal injection of 0.02 ml of 0.046% ICG (251 mOsm), 0.13% trypan blue (260 mOsm), 4.6% GL (253 mOsm), or BSS (300 mOsm). Animals were examined 6, 12, and 24 hours and 14 days after the procedure by fluorescein angiography and fundus evaluation; histologic studies were performed by light and transmission electron microscopy. MAIN OUTCOME MEASURES: Clinical outcome, fluorescein angiography, and histopathologic results. RESULTS: All subretinal blebs were flat 24 hours after the procedure. Fluorescein angiography showed window defects where ICG and trypan blue had been injected. Subretinal BSS and GL resulted in minimal abnormalities of the photoreceptor outer segments (POS) during follow-up. Hypo-osmolar GL caused edema in all retinal layers; pyknosis of the outer nuclear layer (ONL) was observed 24 hours after injection. Subretinal injection of trypan blue resulted in histologic abnormalities 24 hours and 14 days after surgery. Hypo-osmolar trypan blue caused edema of the POS and the photoreceptor inner segments and pyknosis of the ONL 6 and 12 hours after surgery; the retinal pigment epithelium also was affected 24 hours and 14 days after surgery. Subretinal injection of iso-osmolar and hypo-osmolar ICG caused severe damage of all retinal layers during the entire follow-up. CONCLUSIONS: Subretinal injection of 0.05% ICG results in more substantial retinal damage than that associated with the 0.15% trypan blue subretinal injection. The damage induced by hypo-osmolar solutions was more important than that caused by the iso-osmolar solutions. These findings emphasize that care must be taken regarding the solution osmolarity and that subretinal migration of these substances should be avoided during macular hole surgery.

Síndrome de Wolfram: relato de caso / Wolfram syndrome: case report

A síndrome de Wolfram consiste na associação de diabetes mellitus e atrofia óptica. Outros achados comuns são surdez neurossensorial, alterações do trato urinário e distúrbios neurológicos. Tem padrão de herança autossômico recessivo com penetrância incompleta e expressividade variável. O objetivo deste relato é apresentar paciente que apresenta todas as características da síndrome de Wolfram (ou síndrome DIDMOAD). JFP, negro, 23 anos, apresenta diabetes mellitus e insipidus, atrofia óptica, surdez neurossensorial, polineuropatia periférica, neuropatia autonômica, bexiga neurogênica, dilatação do trato urinário, infecções repetidas do trato urinário e azoospermia. Os exames clínico-oftalmológico, retinografia, angiografia fluoresceínica, eletrorretinografia (ERG) e potencial visual evocado (PVE) mostram padrão de normalidade retiniana e de atrofia de nervos ópticos. A síndrome de Wolfram deve ser lembrada em casos de atrofia óptica associados a diabetes, poliúria, polidipsia ou a qualquer uma das alterações apresentadas.

Effect of chronic systemic use of trimethoprim-sulfamethoxazole in the conjunctival bacterial flora of patients with HIV infection.

PURPOSE: To investigate the effect of orally administered trimethoprim-sulfamethoxazole (TMP-SMZ) on the prevalence, species distribution, and resistance of the conjunctival bacterial flora in adults with human immunodeficiency virus (HIV) infection. DESIGN: Cross-sectional study, with clinical and experimental laboratory investigation. METHODS: Samples from the inferior conjunctival fornix were collected and submitted for culture to evaluate aerobic flora. RESULTS: Sixty samples were collected. Negative cultures were found in 17 (56.7%) eyes of the TMP-SMZ group and in 10 (33%) of the control group (P = .036). All Staphylococcus species isolates in the TMP-SMZ group were resistant to the drug, whereas 50% of the control group presented this finding (P = .025). In the study group, all bacteria were resistant to TMP-SMZ, compared with only 47% of the microorganisms in the control group. CONCLUSION: Orally administered TMP-SMZ in patients with HIV infection seems to exert a selection pressure in the microorganisms present on the conjunctiva.

Seguimento ambulatorial de pacientes vítimas de trauma ocular aberto / Ambulatorial follow-up of ocular open trauma

Objetivo: Avaliar as causas e fatores associados ao trauma ocular aberto, bem como o resultado de intervenções terapêuticas na evolução da função visual em pacientes acompanhados em um ambulatório especializado. Métodos: Análise retrospectiva dos prontuários de 100 pacientes atendidos no pronto-socorro de oftalmologia do Hospital São Paulo no período de janeiro de 2002 a fevereiro de 2003, com quadro de trauma ocular aberto. Os mesmos foram posteriormente acompanhados pelo ambulatório de Trauma Ocular do Departamento de Oftalmologia da Universidade Federal de São Paulo - Escola Paulista de Medicina. Resultados: Entre os pacientes atendidos neste período, 80 por cento eram do sexo masculino, com idade variando de 2 a 85 anos, tendo a maior parte (61 por cento) recebido atendimento médico prévio. Apenas 40 por cento dos pacientes chegaram ao pronto-socorro dentro das primeiras 12 horas após o acidente. A sutura de córnea foi o procedimento cirúrgico mais realizado. Foram observadas lesões que comprometeram o prognóstico visual em 80 por cento dos pacientes dentro de um período de seguimento mínimo de três semanas e máximo de 10 meses. Conclusão: Apesar do aperfeiçoamento e melhor treinamento dos profissionais médicos e da disponibilidade de equipamentos de altas tecnologias e complexidade, o trauma ocular penetrante continua sendo uma importante causa de debilidade e perda visual, devendo os esforços serem dirigidos para sua prevenção.