M.Phil. / Cataracts have been identified as one of the leading causes of blindness, especially in the developing world. The only presently known effective treatment for this growing problem is surgical removal of the opaque lens followed by replacement with an artificial intra ocular lens. Newer methods have brought greater success, and greater costs. For people in the developing world, these newer methods are not always an option. Together with the increased cost, there is a growing demand because of this worldwide problem. This increased need for surgery has lead to the development of waiting lists in the state funded hospitals. To qualify for a cataract extraction in most state funded hospitals, a best visual acuity of 6/60 is required, compared to the 6/12 to 6/24 levels required in the industrial countries and private practices. With these levels of visual impairment in the developing world, many patients are left functionally blind for long periods of time until cataract extraction can be performed. Older methods such as extra-capsular cataract extraction are still being used in the developing world. This is mostly due to the increased density of the cataracts at the time when the extraction can be performed because of the long waiting time leading to further maturation of the cataract. This method requires a large corneal incision, which is normally closed with nylon sutures. With this method of surgery meticulous wound closure is very important, and in many cases surgically induced astigmatism is one of the unwanted consequences. It was therefore decided, for the purpose of this study, to use autokeratometric data to explore the refractive effects of two different methods of corneal wound closure following planned extra-capsular cataract extraction (ECCE). Astigmatism is a major problem associated with extra capsular cataract extraction, especially when the wound is closed by means of sutures. Studies by Minassian et al. (2001), Jacobi (2003) and Dowler et al. (2000) all show that newer methods of cataract extraction making use of smaller incisions and therefore fewer sutures show faster recovery and less astigmatism. These methods are however mostly restricted to private practice, and therefore potentially unsuited for use in developing countries. The type of material used for wound closure is another very important factor. Depending on the method of suturing wound gape and wound compression can cause increased amounts of astigmatism. Using a method of wound closure that would cause less traction on the cornea could therefore cause less of a problem postoperatively. Tissue adhesives such as Tisseel® fibrin glue could be such an alternative. Studies by Henrick et al. (1987), Kim and Kharod (2007) and Bhatia (2006) show that fibrin glue forms a watertight, non irritating wound while promoting the healing process by the cross linking of collagen fibres.

Orientador: Newton Kara-Jose / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-13T21:12:46Z (GMT). No. of bitstreams: 1 Costa_DacioCarvalho_D.pdf: 11382661 bytes, checksum: a5c3e2c591c002085753bfe5397e34f3 (MD5) Previous issue date: 2009 / Resumo: Objetivo: Comparar a eficácia da injeção subconjuntival de 20 mg de triancinolona associada a prednisolona 1% tópica com a injeção intravenosa de 500 mg de metilprednisolona associada a prednisolona 1% tópica no tratamento da rejeição endotelial de transplante de córnea. Métodos: Estudo caso-controle realizado no Hospital das Clínicas da UNICAMP. Os pacientes submetidos a transplante penetrante de córnea que apresentaram primeiro episódio de rejeição endotelial com até 15 dias do início dos sintomas durante o período de novembro de 2005 a outubro de 2006 foram tratados com injeção subconjuntival de 20 mg de acetonido de triancinolona associado a acetato de prednisolona 1% tópico. Estes pacientes foram pareados por idade e diagnóstico com pacientes submetidos a tratamento com injeção intravenosa de 500 mg de succinato sódico de metilprednisolona associado a acetato de prednisolona 1% tópico e analisados quanto à capacidade de reversão do episódio de rejeição, pressão intraocular aos 30 dias e acuidade visual ao final de 1 ano. Resultados: 16 pacientes foram tratados com 20 mg de triancinolona subconjuntival e prednisolona 1% tópica durante o período de recrutamento e foram pareados com 16 pacientes tratados com 500 mg de metilprednisolona intravenosa e prednisolona 1% tópica. Ao final de 1 ano, o grupo tratado com triancinolona obteve melhores resultados do que o grupo tratado com metilprednisolona (p=0,025), obtendo 15 pacientes com córnea transparente enquanto o grupo tratado com metilprednisolona obteve 10 pacientes. 3 pacientes do grupo tratado com triancinolona apresentaram segundo episódio de rejeição durante o seguimento e foram retratados com sucesso enquanto no grupo da metilprednisolona, 4 pacientes apresentaram segunda rejeição, com 2 pacientes apresentando falência com o retratamento e 2 obtendo sucesso. A pressão intraocular subiu nos dois grupos (p=0,002) após 30 dias, porém não houve diferença entre os grupos (p=0,433). A acuidade visual melhorou após 1 ano em ambos os grupos (p=0,049) e o grupo tratado com triancinolona obteve melhor acuidade visual (p=0,002). Conclusão: A injeção subconjuntival de 20 mg de triancinolona combinada com prednisolona 1% tópica mostrou-se mais eficaz em reverter episódios de rejeição de transplante de córnea neste estudo caso-controle do que a aplicação intravenosa de 500 mg de metilprednisolona. Estudos adicionais necessitam ser realizados para verificar a segurança e eficácia deste tratamento em grandes populações / Abstract: Purpose: To compare the efficacy of 20 mg subconjunctival triamcinolone in association with topical prednisolone 1% to 500 mg intravenous methylprednisolone in association with topical prednisolone 1% in the treatment of cornea endothelial graft rejection. Methods: Case-control study carried out at State University of Campinas Hospital. Patients submitted to penetrating keratoplasty that presented first episode of corneal endothelial rejection within 15 days of symptoms onset between November 2005 and October 2006 were treated with 20 mg subconjunctival injection of triamcinolone acetate in association with topical prednisolone acetate 1%. These patients were matched for age and diagnosis to patients that were submitted to a single 500 mg intravenous injection of methylprednisolone sodium succinate in association with topical prednisolone acetate 1% and analyzed regarding the reversion of the rejection episode, intraocular pressure at day 30 and visual acuity at the end of 1 year. Results: 16 patients were treated with 20 mg subconjunctival triamcinolone and topical prednisolone 1% during the period of recruitment and were matched to 16 patients treated with 500 mg intravenous methylprednisolone and topical prednisolone 1%. At the end of 1 year, the group treated with triamcinolone had a better outcome than the group treated with methylprednisolone (p=0.025), having 15 patients with clear grafts as the group treated with methylprednisolone had 10 patients. 3 patients from the group treated with triamcinolone had new rejection episodes during follow-up and were retreated successfully as in the group treated with methylprednisolone 4 patients had a new rejection episode, with 2 progressing to failure and 2 to success with retreatment. Intraocular pressure rose in both groups (p=0.002) at day 30 but there were no statistically significant differences between the groups (p=0.433). Visual acuity improved after 1 year in both groups (p=0.049) and the group treated with triamcinolone had better visual acuities (p=0.002). Conclusions: 20 mg subconjunctival injection of triamcinolone acetonide associated with topical prednisolone acetate 1% showed to be more effective than 500 mg intravenous methylprednisolone associated with prednisolone acetate 1% in this case-control study. Further studies need to be accomplished to verify its safety and effectiveness in larger populations / Doutorado / Oftalmologia / Doutor em Ciências Médicas