Assuntos
Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Oftalmologia/métodos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Betacoronavirus/isolamento & purificação , COVID-19 , Infecções por Coronavirus/epidemiologia , Humanos , Controle de Infecções/métodos , Controle de Infecções/normas , Oftalmologistas , Oftalmologia/organização & administração , Oftalmologia/normas , Pneumonia Viral/epidemiologia , SARS-CoV-2RESUMO
BACKGROUND: Much has been written on infection control and clinical measures for ophthalmic institutions and departments to cope with the COVID-19 pandemic. However, few articles have detailed implementation plans to manage lockdowns and subsequent re-openings. In this article, specific operational responses and their outcomes in a large tertiary ophthalmology centre are described. METHOD: Through a concerted effort led by a dedicated task force, the Singapore National Eye Centre (SNEC) planned and executed an operational transformation to respond to the restrictions imposed on healthcare delivery during a national lock down. A carefully calibrated re-starting of services was carried out with the subsequent phased reopening of the country, taking into consideration unique constraints faced at that time. Strategies for operating in the new normal environment were also developed. RESULTS: Outpatient attendances were safely and expediently reduced by 70% (8749 vs. 29,311) and 82% (5164 vs. 29,342) in April and May 2020, respectively, compared to the corresponding months in 2019. A correspondingly large reduction in surgical load was also achieved through a similar triaging and prioritization system. Through optimizing the center's use of space and time, as well as expanding on new models of care, a return to pre-pandemic patient load was achieved 3 months into the phased reopening of the country, and subsequently exceeded in the following months. CONCLUSION: The lessons gleaned from SNEC's experience may be useful for institutions currently facing the same challenges, and for future responses to COVID-19 resurgences or other pandemics.
Assuntos
COVID-19 , Oftalmologia , COVID-19/epidemiologia , Humanos , Controle de Infecções , Pandemias/prevenção & controle , SARS-CoV-2 , Singapura/epidemiologiaRESUMO
BACKGROUND: Human pluripotent stem cells (hPSCs) provide a promising cell source for retinal cell replacement therapy but often lack standardized cell production and live-cell shipment logistics as well as rigorous analyses of surgical procedures for cell transplantation in the delicate macula area. We have previously established a xeno- and feeder cell-free production system for hPSC differentiated retinal pigment epithelial (RPE) cells, and herein, a novel immunosuppressed non-human primate (NHP) model with a disrupted ocular immune privilege is presented for transplanting human embryonic stem cell (hESC)-derived RPE on a scaffold, and the safety and submacular graft integration are assessed. Furthermore, the feasibility of intercontinental shipment of live hESC-RPE is examined. METHODS: Cynomolgus monkeys were systemically immunosuppressed and implanted with a hESC-RPE monolayer on a permeable polyester-terephthalate (PET) scaffold. Microscope-integrated intraoperative optical coherence tomography (miOCT)-guided surgery, postoperative follow-up incorporated scanning laser ophthalmoscopy, spectral domain (SD-) OCT, and full-field electroretinography (ERG) were used as outcome measures. In addition, histology was performed after a 28-day follow-up. RESULTS: Intercontinental cell shipment, which took >30 h from the manufacturing to the transplantation site, did not alter the hESC-RPE quality. The submacular hESC-RPE xenotransplantation was performed in 11 macaques. The miOCT typically revealed foveal disruption. ERG showed amplitude and peak time preservation in cases with favorable surgical outcomes. Histology confirmed photoreceptor preservation above the grafts and in vivo phagocytosis by hESC-RPE, albeit evidence of cytoplasmic redistribution of opsin in photoreceptors and glia hypertrophy. The immunosuppression protocol efficiently suppressed retinal T cell infiltration and microglia activation. CONCLUSION: These results suggest both structural and functional submacular integrations of hESC-RPE xenografts. It is anticipated that surgical technique refinement will further improve the engraftment of macular cell therapeutics with significant translational relevance to improve future clinical trials.
Assuntos
Células-Tronco Embrionárias Humanas , Animais , Diferenciação Celular , Linhagem Celular , Xenoenxertos , Humanos , Primatas , Epitélio Pigmentado da Retina , Transplante HeterólogoRESUMO
PURPOSE: To describe the 12-month outcomes of treatment-naïve eyes with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) after initiation of intravitreal anti-vascular endothelial growth factor (VEGF) monotherapy or combination therapy with verteporfin photodynamic therapy (PDT). DESIGN: A 12-month single-center, retrospective, comparative, nonrandomized cohort study. PARTICIPANTS: Patients with AMD or PCV who initiated intravitreal anti-VEGF therapy during 2015. METHODS: Demographics, visual outcomes, OCT, and treatment data were collected at baseline and months 1, 3, 6, and 12 after treatment initiation. Multivariate analysis was performed to identify baseline features predictive of visual maintenance and improvement after 12 months of treatment. MAIN OUTCOME MEASURES: Primary end point was visual acuity (VA) change from baseline to month 12. Secondary end points were treatment exposure and change in central subfield thickness on OCT. RESULTS: A total of 364 patients (165 AMD and 199 PCV) were included. Baseline vision was 41 and 43 logarithm of the minimum angle of resolution (logMAR) letters for AMD and PCV patients, respectively. Patients with AMD and PCV received 5.5 and 5.3 injections (5.0 monotherapy vs. 5.6 combination therapy; mean, 1.2 PDT sessions), respectively. Patients with AMD gained 4.7 logMAR letters after 12 months (P = 0.002), whereas PCV patients gained 6.6 logMAR letters (P = 0.001) and 10.8 logMAR letters (P < 0.001) for monotherapy and combination therapy, respectively. Only patients with presenting VA of fewer than 35 letters (Snellen equivalent, 6/60) achieved significant visual improvement (10.4 letters for AMD, 17.1 letters for PCV with monotherapy, and 35.5 letters for PCV with combination therapy). Predictors of VA gain included number of intravitreal injections (AMD and PCV adjusted odds ratio, 12.1 [P = 0.001] and 12.5 [P = 0.004] for ≥7 injections, respectively) and baseline VA of 20 logMAR letters or fewer (adjusted odds ratio, 3.8 and 10.6 for AMD and PCV, respectively). Age, gender, race, use of PDT or focal laser therapy, and central subfield thickness were not predictive of significant visual gain at 12 months. CONCLUSIONS: In Asian patients, treatment of AMD with anti-VEGF therapy yielded 12-month visual outcomes comparable with those of other real-world studies from Western populations but poorer than those of controlled trials. In contrast, for PCV eyes, anti-VEGF monotherapy and combination therapy with PDT yielded comparable outcomes as those of controlled clinical trials.
Assuntos
Doenças da Coroide/tratamento farmacológico , Corioide/irrigação sanguínea , Degeneração Macular/tratamento farmacológico , Fotoquimioterapia/métodos , Pólipos/tratamento farmacológico , Ranibizumab/administração & dosagem , Acuidade Visual , Inibidores da Angiogênese/administração & dosagem , Doenças da Coroide/diagnóstico , Doenças da Coroide/epidemiologia , Angiofluoresceinografia , Seguimentos , Humanos , Incidência , Injeções Intravítreas , Degeneração Macular/diagnóstico , Degeneração Macular/epidemiologia , Fármacos Fotossensibilizantes/uso terapêutico , Pólipos/diagnóstico , Estudos Retrospectivos , Singapura/epidemiologia , Tomografia de Coerência Óptica , Resultado do Tratamento , Fator A de Crescimento do Endotélio Vascular/antagonistas & inibidoresRESUMO
To describe the 25-year surgical trends, long-term outcomes and risk factors affecting the outcomes of giant retinal tear-related rhegmatogenous retinal detachments (GRT-RRD). Patients' demographics, pre-operative characteristics, risk factors, operative procedures and post-operative outcomes were collected and divided into three groups - Group A: 1991 to 2015 (overall); Group B: 1991 to 2005, and Group C: 2006 to 2015. Functional and anatomical successes were monitored over a 5-year period. Multivariate logistic regression analysis was performed to identify the risk factors related to functional and anatomical success.127 eyes of 127 patients were included in the study. At 5th year, 69.4% patients had visual acuity (VA) < logMAR 1.0 with 87.5% primary anatomical success rate. While the functional outcome remained the same between group B and C, there was an increase in the anatomical success from 89.7% to 100%, albeit not statistically significant. Patients with worse presenting VA, 150 degrees or more of giant retina tear, macula-detached status and presence of PVR were associated with VA of> logMAR 1.0 (all p < 0.05). The types of surgery (TPPV vs combined SB/TPPV), number of breaks, lens extraction and additional cryotherapy were not associated with the functional or anatomical success. In conclusion, the GRT-RRD functional and structural outcomes were comparable between 1991-2005 and 2006-2015, albeit a statistically insignificant improvement of anatomical outcome over the past 25 years. Worse presenting VA, 150 degrees or more of giant retinal tear, detached macula and presence of PVR were associated with poorer visual outcome.
Assuntos
Descolamento Retiniano/cirurgia , Perfurações Retinianas/cirurgia , Estudos de Coortes , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Recidiva , Análise de Regressão , Descolamento Retiniano/fisiopatologia , Perfurações Retinianas/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Recurvamento da Esclera/métodos , Fatores de Tempo , Resultado do Tratamento , Acuidade Visual , Vitrectomia/métodos , Vitreorretinopatia Proliferativa/etiologiaRESUMO
A case of late spontaneous dislocation of the lens capsular bag (CB) with foldable acrylic intraocular lens (IOL) and endocapsular tension ring (CTR) and its surgical management is reported in a 52-year-old man. The dislocation occurred 2 years 3 months after phacoemulsification cataract surgery in which a CTR was used for zonular instability. A 3-port pars plana vitrectomy was performed. Because it was not possible to grasp the IOL-CTR-CB complex, perfluorocarbon liquid was used to attempt to float it up. This was unsuccessful, so a scleral indenter was used to apply external pressure on the sclera to tilt the IOL-CTR-CB complex into a position where it could be grasped with a forceps and removed through a corneal section. A scleral-fixated IOL was placed, and the patient achieved a best corrected visual acuity of 6/9. The procedure was safe and effective without intraocular complications.
Assuntos
Migração de Corpo Estranho/cirurgia , Cápsula do Cristalino , Lentes Intraoculares , Próteses e Implantes , Retina/cirurgia , Humanos , Implante de Lente Intraocular/métodos , Masculino , Pessoa de Meia-Idade , Polimetil Metacrilato , Técnicas de Sutura , Vitrectomia/métodosRESUMO
OBJECTIVES: To describe the safety and efficacy of goniotomy in medically uncontrolled glaucoma complicating chronic uveitis and the factors affecting its outcome. METHODS: All goniotomies performed by a single surgeon for refractory childhood uveitic glaucoma were retrospectively reviewed. Success was defined as final intraocular pressure (IOP) of no greater than 21 mm Hg without medications and qualified success as IOP of no greater than 21 mm Hg with medications. Unless otherwise indicated, data are expressed as mean +/- SD. RESULTS: Fifty-four goniotomies were performed in 40 eyes of 31 patients. Juvenile rheumatoid arthritis-associated uveitis was the diagnosis in 30 eyes (75%). Eleven eyes (28%) were aphakic. Mean follow-up was 98.9 months (range, 2-324 months). Mean age at surgery was 10.3 +/- 4.7 years (range, 4-22 years). Mean preoperative IOP was 36.7 +/- 6.4 mm Hg while receiving a mean of 2.9 +/- 1.1 medications. Overall surgical success was achieved in 29 eyes (72%), including success in 22 (55%) and qualified success in 7 (18%) while receiving a mean of 1.6 +/- 1.1 medications. Mean postoperative IOP in the success and qualified-success groups were 14.3 +/- 2.8 and 15.7 +/- 3.1 mm Hg, respectively. Kaplan-Meier survival probabilities (95% confidence interval) at 1, 5, and 10 years were 0.92 (0.82-1.00), 0.81 (0.65-0.97), and 0.71 (0.49-0.92), respectively. Phakic eyes, eyes with fewer peripheral anterior synechiae, patients younger than 10 years, and eyes with no prior surgery had significantly better outcomes. Hyphema, typically mild and transient, occurred in 43 procedures (80%). CONCLUSIONS: Goniosurgery is low risk and effective for refractory glaucoma complicating chronic childhood uveitis. It should be considered the surgical procedure of choice for this condition. Surgical outcome is adversely affected by increased age, peripheral anterior synechiae, prior surgeries, and aphakia.
Assuntos
Glaucoma/cirurgia , Procedimentos Cirúrgicos Oftalmológicos , Malha Trabecular/cirurgia , Uveíte/complicações , Adolescente , Adulto , Artrite Juvenil/complicações , Criança , Pré-Escolar , Doença Crônica , Glaucoma/etiologia , Gonioscopia , Humanos , Pressão Intraocular , Estudos Retrospectivos , Segurança , Resultado do TratamentoRESUMO
PURPOSE: To investigate the risk of acute angle closure (AAC), changes in intraocular pressure (IOP), and factors associated with these outcomes after routine pupil dilation in a cohort of Asian subjects with diabetes mellitus. METHODS: The study was a prospective observational case series of 1910 consecutive Asian subjects newly referred for assessment of diabetic retinopathy at a tertiary clinic. All subjects underwent routine pupil dilation unless there was a prior history of angle-closure glaucoma. Noncontact air-puff tonometry was used to assess IOP, which was measured by the same observer before and 1 hour after pupil dilation. Subjects were assessed for signs and symptoms of AAC before leaving the clinic, and their charts were also subsequently reviewed for revisits with AAC. RESULTS: Of the 1910 subjects who participated, none developed AAC. Sixty-nine subjects (3.6%, 95% CI: 2.8%-4.5%) showed an increase in IOP of >or=5 mm Hg in the either eye, 37 subjects (1.9%, 95% CI: 1.4%-2.6%) had a postdilation IOP >25 mm Hg in either eye, and only 10 subjects (0.52%, 95% CI: 0.25%-0.96%) had an increase in IOP >or=5 mm Hg and had a postdilation IOP >25 mm Hg in either eye. The level of predilation IOP and a known history of glaucoma were significant risk factors for a postdilation IOP >or=25 mm Hg. CONCLUSIONS: In this cohort of Asian persons with diabetes, the risk of AAC was insignificant after routine dilation of pupils for fundus examination. These data substantiate the safety of routine dilation of pupils in Asian patients with diabetes.
Assuntos
Povo Asiático , Retinopatia Diabética/diagnóstico , Midriáticos/administração & dosagem , Pupila/efeitos dos fármacos , Combinação de Medicamentos , Feminino , Glaucoma de Ângulo Fechado/induzido quimicamente , Humanos , Pressão Intraocular/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Midriáticos/efeitos adversos , Fenilefrina/administração & dosagem , Fenilefrina/efeitos adversos , Estudos Prospectivos , Fatores de Risco , Singapura/etnologia , Tonometria Ocular , Tropicamida/administração & dosagem , Tropicamida/efeitos adversosRESUMO
New neurons are produced continually in the dentate gyrus of the hippocampus. Numerous factors modulate the rate of neuron production. One of the most important is the adrenal-derived corticoids. Raised levels of corticoids suppress proliferation of progenitor cells, while removal of corticoids by adrenalectomy reverses this. The exact mechanisms by which corticoids mediate such regulation are unknown, but corticoids are believed to act through the receptors for mineralocorticoids (MR) and glucocorticoids (GR). Previous reports regarding the roles of these receptors in regulating cell proliferation came to contrasting conclusions. Here we use both agonists and antagonists to these receptors in adult male rats to investigate and clarify their roles. Blockade of MR with spironolactone in adrenalectomised male rats implanted with a corticosterone pellet to reproduce basal levels enhanced proliferation, whereas treatment with the GR antagonist mifepristone had no effect. However, mifepristone reversed the suppressive effect of additional corticosterone in intact rats. Both aldosterone and RU362, agonists of MR and GR, respectively, reduced proliferation in adrenalectomised rats, and combined treatment with both agonists had an additional suppressive action. These results clearly show that occupancies of both receptors act in the same direction on progenitor proliferation. The existence of two receptors with different affinities for corticoids may ensure that proliferation of progenitor cells in the adult dentate gyrus is regulated across the range of adrenal corticoid activity, including both basal and stressful contexts. Although a small proportion of newly formed cells may express GR and MR, corticosterone probably regulates proliferation indirectly through other local cells.
Assuntos
Proliferação de Células/ética , Hipocampo/citologia , Neurônios/fisiologia , Receptores de Glucocorticoides/fisiologia , Receptores de Mineralocorticoides/fisiologia , Células-Tronco/fisiologia , Adrenalectomia/métodos , Análise de Variância , Animais , Bromodesoxiuridina/metabolismo , Contagem de Células/métodos , Corticosterona/sangue , Corticosterona/farmacologia , Interações Medicamentosas , Hipocampo/fisiologia , Antagonistas de Hormônios/farmacologia , Imuno-Histoquímica/métodos , Antígeno Ki-67/metabolismo , Masculino , Mifepristona/farmacologia , Tamanho do Órgão/efeitos dos fármacos , Ratos , Espironolactona/farmacologia , Estatística como Assunto , TimoRESUMO
New neurons continue to be generated in the adult dentate gyrus of the hippocampus. Corticosterone (CORT), a steroid secreted by the adrenal glands, had been shown to regulate progenitor proliferation. High levels of CORT suppress proliferation while low levels of the steroid stimulate it. Here we present an investigation into the regulation of survival by corticoids, with emphasis on the differential effects of the pre-mitotic and post-mitotic corticoid environments. Post-mitotic adrenalectomy increased subsequent survival of progenitors at 28 days, while additional CORT administered during the post-mitotic period decreased survival. In contrast, a corticoid-free environment prior to progenitor division resulted in a reduced survival rate of new cells and, similarly, high levels of CORT before proliferation reduced subsequent survival. In addition, phased treatment with CORT during a 27-day post-mitotic interval showed that newly formed cells lose their sensitivity to administered CORT after about 18 days. These results are the first to show that the corticoid environment both before and after cell division regulates survival.
Assuntos
Corticosteroides/fisiologia , Divisão Celular/fisiologia , Giro Denteado/citologia , Neurônios/fisiologia , Células-Tronco/fisiologia , Adrenalectomia/métodos , Análise de Variância , Animais , Bromodesoxiuridina/metabolismo , Contagem de Células/métodos , Divisão Celular/efeitos dos fármacos , Sobrevivência Celular/efeitos dos fármacos , Sobrevivência Celular/fisiologia , Corticosterona/farmacologia , Esquema de Medicação , Imuno-Histoquímica/métodos , Masculino , Neurônios/efeitos dos fármacos , Ratos , Fatores de TempoRESUMO
PURPOSE: To evaluate the efficacy of diode laser contact transscleral pars plana photocoagulation (CTPPP) for intraocular pressure (IOP) control in glaucoma and its clinical application. METHOD: A prospective, non-randomized hospital-based pilot study was conducted. Fourteen patients with poor visual acuity (VA worse than 6/60) and medically uncontrolled, refractory glaucoma were recruited, and CTPPP was performed after informed consent. RESULTS: Mean preoperative IOP was 41.0 mmHg (SD 12.6, range 27-70, n = 14). At 1 week postoperatively, IOP was reduced in 12 of 14 (86%) patients to a mean of 28.6 mmHg (SD 15.8, range 3-55, n = 14). This represented a mean decrease of 12.4 mmHg. Mean IOP was 34.0 mmHg (SD 17.4, range 5-71, n = 14) and 31.6 mmHg (SD 13.4, range 5-22, n = 12) at 4 and 12 weeks, respectively. The IOP reduction was significant at 1 week (P = 0.001, paired t-test) and at 12 weeks (P = 0.04, paired t-test). The two patients with preoperative pain reported abolition of pain after the procedure. Seven of 13 patients on preoperative antiglaucoma eye drops did not require eye drops postoperatively. CONCLUSION: Diode laser CTPPP was found to significantly reduce IOP in the majority of patients at 1 week postoperatively, with less but still significant effect at 12 weeks. Its potential application as a procedure for short-term IOP reduction in medically uncontrolled glaucoma requiring filtering surgery needs to be further investigated.