Objetivos Valorar la eficacia preoperatoria de suplementos orales con inmunonutrientes frente a la preparación prequirúrgica habitual en cirugía colorrectal oncológica programada en el servicio de Cirugía General del Hospital General Universitario de Ciudad Real, en términos de reducción de la incidencia de complicaciones infecciosas postquirúrgicas. Material y Métodos Estudio experimental y randomizado, donde se incluyeron 84 pacientes susceptibles de cirugía programada por cáncer colorrectal resecable. Se randomizaron en el grupo SÍ IN, que recibió inmunonutrición preoperatoria (Impact© Oral) durante 8 días y el grupo control (NO IN), que no la recibió. Se determinaron parámetros antropométricos, nutricionales e inmunológicos en la primera consulta, preoperatorio, 2º y 5º días postquirúrgicos. Se registraron las complicaciones postquirúrgicas (y el subgrupo específico de las complicaciones infecciosas). Resultados Un 40,5 % (17) de los pacientes no inmunonutridos sufrieron complicaciones infecciosas frente a un 33,3 % (14) de los inmunonutridos. En los pacientes con cáncer rectal NO IN, un 50 % (8) sufrió complicaciones infecciosas menores (p=0,028). Conclusiones Los pacientes no inmunonutridos sufrieron con mayor frecuencia complicaciones infecciosas postquirúrgicas, sobre todo el subgrupo de pacientes con cáncer rectal. / Aim To evaluate the effectiveness of preoperative oral supplementation with immunonutrients compared with the usual preoperative preparation for programmed oncologic colorectal surgery in the Department of General Surgery at the University General Hospital of Ciudad Real, in terms of reducing the incidence of postoperative infectious complications. Materials and Methods An randomized, experimental study was conducted. 84 patients who were candidates for programmed surgery for resectable colorectal cancer. They were randomly into group SI IN that received preoperative immunonutrition (IMPACT®) for eight days and group NO IN with no preoperative immunonutrition. Anthropometric parameters were determined, nutritional parameters and immunologic parameters at the first consultation, in the preoperative period and on the second and fifth postoperative days. Postoperative complications (and the specific infectious complications subgroup) were registered. Results 40.5% (17) of the no immunonutrition patients had infectious complications compared with 33.3% (14) of the immunonutrition patients. 50% (8) of the patients with rectal cancer in group NO IN had minor infectious complications (P = 0.028). Conclusions The no immunonutrition patients had postoperative infectious complications more frequently, specially the subgroup of patients with rectal cancer.

El implante coclear (IC) se define como un dispositivo electrónico que sustituye al oído externo, medio e interno, capaz de recoger los sonidos, transformarlos en estímulos eléctricos para transmitirlos al nervio auditivo, y restablecer el flujo de información auditiva que llega al cerebro. El Programa de Implantes Cocleares del Hospital Clínico Universitario Virgen de la Arrixaca (PIC-HCUVA) comenzó en el año 2003. Surge de la necesidad de dar respuesta en forma de tratamiento global a las demandas surgidas del Programa Regional de screening de Hipoacusias implantado dos años antes. Una vez iniciado el programa, en concreto 4 años más tarde, diversas asociaciones de padres de niños sordos cuestionaron los resultados del PIC-HCUVA. Dicha inquietud provocó que desde diversas instancias incluido el propio Servicio de Otorrinolaringología (ORL) del HCUVA se planteara una evaluación externa de los resultados de nuestro programa. Desde la Secretaria Autonómica de Atención al Ciudadano se creó un comité de evaluación. Una vez ya asentado el PIC-HCUVA, analizamos los resultados del programa, tras 10 años de implantación, con los siguientes objetivos: En primer lugar mostrar los resultados iniciales a fin de comprobar que estos son acordes a la literatura; en segundo lugar, servir de modelo, a partir de nuestra experiencia, para todos aquellos grupos con interés en poner en marcha un programa propio de implantes cocleares.; y finalmente, y en base al segundo de los objetivos, elaborar una curva de aprendizaje que permita identificar un número mínimo total, y un número mínimo por año de pacientes implantados a partir de los que los resultados obtenidos sean acordes a los estándares mundiales. La serie consta de 64 pacientes, todos ellos sometidos a un implante coclear entre Enero de 2003 y Diciembre de 2010. Treinta y dos de los casos eran mujeres (50%). La edad media fue de 5,56 años con un rango de edad de 1-64 años. Sólo en 8 casos (12,5%) existieron antecedentes familiares de interés. El implante coclear se efectuó sobre el oído derecho en 49 casos (76,6%), mientras que en 15 pacientes (23,4%) el implante fue sobre el oído izquierdo. El tipo de implante colocado fue el Freedom® en 32 casos (50%), el Contour® 24 en 17 casos (26,6%), y el Nucleus 5® en los restantes 15 casos (23,4%). La estancia hospitalaria media de de 5,56 días, con un rango de 2-9 días y una moda de 5 días (20 casos, 20,3%). El 51,6% de los casos tuvo una estancia inferior a los 5 días, y el 90% por debajo de la semana. El 87,5% de los casos (56 casos) no presentaron complicación postquirúrgica alguna, presentándose éstas sólo en 8 casos (13,5%): 4 casos de dehiscencias de piel (6,3%), 1 fístula de LCR (1,6%), 1 necrosis dérmica (1,6%), 1 hemorragia (1,6%) y 1 caso de seroma postoperatorio. Respecto de los resultados funcionales, basados en las audiometrías efectuadas de forma postoperatoria, los dividiremos por frecuencias. Así, en el nivel de los 250Hz, el 87,5% de los casos oía a 35dB, con una media de 29,5dB y una moda de 25dB (14 casos, 21,9%). A 500Hz, el 89,3% oía a 40dB, con una media de 32,2 dB y una moda de 30dB (17 casos, 26,6%). A 1000Hz, el 91,1% de los casos oía a 45dB, con una media de 35,5dB y una moda de 30dB (15 casos, 23,4%). A 2000Hz, el 91,1% oía a 45 dB, con una media de 33,4dB y una moda de 25dB (17 casos, 26,6%). Finalmente, a 4000Hz, el 91,1% oía a 40dB, con una media de 32,2dB y una moda de 25dB (17 casos, 26,6%). Por otra parte, y por lo que respecta al test de respuesta neural, éste, que se efectuó en el 100% de los casos, fue positivo en 63 de los 64 casos (98,4%), pues sólo en 1 caso fue negativo. En conclusión: 1.- El modelo de creación, puesto en marcha y funcionamiento de nuestro programa de IC queda avalado por los resultados iníciales obtenidos al ser estos acordes a lo publicado en la literatura internacional. 2.-Al igual que en otros tipos de intervención quirúrgica, existe una curva de aprendizaje en la cirugía del implante coclear. 3.- La experiencia obtenida en las fases iníciales de este programa puede ser de gran utilidad a la hora de exportar e implantar un modelo semejante de Programa de Implantes Cocleares en otros Hospitales. / Cochlear implants are electronic devices which replace the function of the outer, medium and inner ear, able to turn sounds into electric stimuli to be transmitted through the auditory nerve, and restore the flow of hearing information that reaches the brain. The Cochlear Implant Program from the Clinical University Virgen de la Arrixaca Hospital (PIC-HCUVA) was started in 2003. It comes up from the need of global treatment for all those cases appeared after the Hearing Impairment Screening, which was started up two years earlier. Once the program started, several associations of parents of deaf children questioned the results of the PIC-HCUVA. This concern made several institutions set out an external evaluation of the result of the program From the Autonomous Secretary of Citizen-Help a evaluation committee was created. Ten years after being settled, we analyzed the program outcomes with the next goals. First, show the initial results in order to verify that they are consistent with the literature; Secondly, serve as a model, based on our experience, for groups with an interest in starting a cochlear implants program up; and finally, according to the second objective, develop a learning curve which allows to identify a minimum number, and a minimum number of implanted patients annually from which the results are in compliance with world standards. The series is made up of 64 patients, all of them with a cochlear implant made between January of 2003 and December of 2010. 32 of them were female (50%). The average age was 5.56 years with a range from 1 to 64 years. Only 8 of them (12.5%) had remarkable family history. The implant was made in the right ear in 49 cases (76.6%) while in the left one in 15 patients (23.4%). The model used for the implant was Freedom® in 32 cases (50%), Contour®24 in 17 patients (26.6%) and Nucleus 5® for the remaining 15 cases (23.4%). The average length of stay in hospital was 5.56 days ranged from 2 to 9 days and the mode was 5 days (20 cases, 20.3%). 51.6% of the patients stayed for less than 5 days, and 90% stayed for less than one week. In 87.5% of them (56 cases) post-surgery complications did not occur, they did occur just in 8 cases (13.5%): 4 skin dehiscences (6.5%), 1 case of cerebrospinal fluid fistula (1.6%), 1 of skin necrosis (1.6%) and 1 post-surgery seroma (1.6%). Regarding the functional outcomes, based on post-surgery audiometries, we shall divide them up into different frequencies. Thus, 87.5% of the patients could hear 35 dB sounds at 250 Hz level frequencies, with an average of 29.5 dB and the mode was 25 dB (14 cases, 21.9%). At 500 Hz level, 89.3% could hear 40 dB sounds, with an average of 32.2 dB and the mode was 30 dB (15 cases, 23.4%). At 2000 Hz level, 91.1% could hear 45 dB sounds, with an average of 33.4 dB and the mode was 25 dB (17 cases, 26.6%). Finally, at 4000 Hz level, 91.1% could hear 40 dB sounds, the average was 32.2 dB and the mode was 25 dB (17 cases, 26.6%). On the other hand, and according to the neural response test, which was performed in 100% of the cases, it had a positive result in 63 cases (98.4%) and just one negative result. In conclusion: 1. The creative model and performance of our cochlear implant program are endorsed by the initial results as they are in accordance with worldwide literature. 2. As well as in other specific kinds of surgery, there is a learning curve for the cochlear implant surgery. 3. The experience gathered after the initial phases of this program can be very useful for starting new cochlear implant programs up, similar to ours, in some other hospitals.

La electrorretinografía es una técnica que permite evaluar de forma objetiva, la función retinal durante el proceso de transformación de un estímulo luminoso en una respuesta eléctrica. En nuestro estudio, se reproduce un biomodelo de glaucoma crónico humano de ángulo abierto en Göttingen minipig. Este biomodelo de glaucoma se consigue mediante la cauterización de las venas epiesclerales de uno de sus ojos, estando ya previamente validado en cerdo. Nuestros objetivos comprenden primeramente, la valoración de la evolución de la presión intraocular a lo largo de un periodo cercano al año (50 semanas), la estandarización de un protocolo electrorretinográfico en el Göttinger minipig y mediante el mismo, analizar los cambios producidos en el electrorretinograma como consecuencia del aumento sostenido de la presión intraocular. Esto nos permitirá crear un modelo de neurodegeneración producido por el glaucoma experimental. Por último, se analizará el modelo de neurodegeneración para encontrar patrones electrofisiológicos tempranos de dicho proceso. Todos estos datos se compararán con la bibliografía existente tanto a nivel de estudios realizados en humanos, como en otros biomodelos. Este estudio fue realizado en los ojos de 5 cerdos Göttingen minipig con edades en torno a los 5 meses. Tras confirmar la aptitud de los ojos para el estudio, a cada uno de los animales se les realizó un estudio clínico electrorretinográfico inicial, basado en las recomendaciones descritas por el ECVO y el ISCEV. El Test electroretinográfico se divide en tres pruebas, donde son recogidas las respuestas de la retina a estímulos de alta frecuencia (30Hz) y estímulos de baja frecuencia (4HZ) en condiciones fotópicas y en escotópicas. Una vez obtenidos los registros electrorretinográficos basales, se procede a la cauterización de las venas epiesclerales dorsales y ventrales de ojo izquierdo de cada animal. Este diseño experimental posibilita obtener en el mismo individuo un ojo control y un ojo experimental. Dicha cirugía permitió obtener una presión intraocular por encima de los valores normales, con un rango comprendido entre los 25 y 40 mmHg y mantenido a lo largo de todas las semanas de estudio. Nuevos estudios electrorretinográficos se repitieron posteriormente a los 2 y 4 meses tras la cirugía. El análisis de los resultados electrorretinográficos obtenidos, permitió mostrar una relación estadísticamente significativa entre el aumento de presión intraocular conseguida en el ojo a estudio, y el descenso de los valores de las ondas del electrorretinograma en dichos ojos. La comparativa realizada entre los valores electrorretinográficos basales y el ojo derecho control, con los datos obtenidos en el ojo izquierdo intervenido, evidencian la existencia de alteraciones en las ondas electrorretinográficas. Estas alteraciones quedan reflejadas primeramente en los valores de la onda-b, la onda-i y el PhNR del electrorretinograma y posteriormente se extienden al resto de los componentes electrorretinográficos. Estas ondas muestran un decrecimiento en su amplitud y latencia conforme avanza el tiempo de estudio y la presión intraocular elevada es mantenida. Dicho decrecimiento muestra un patrón, afectando primero a los componentes electrorretinográficos encargados de evaluar la función de las células ganglionares, así como también cuanto mayor es el tiempo de adaptación a condiciones escotópicas. Esta misma progresión de los valores electrorretinográficos de las ondas, ha sido ya descrita tanto en otros biomodelos de glaucoma experimental, como en personas afectadas por glaucoma crónico de ángulo abierto. Los hallazgos encontrados en nuestro estudio son homólogos a los que describe la bibliografía existente. Dentro de los parámetros cuyos valores muestran afectación debido al aumento sostenido de la presión intraocular, el componente PhNR presenta evidencias de una mayor precocidad en la detección los efectos producidos por dicha presión, en la respuesta de la retina. Los resultados obtenidos en nuestro estudio muestran que, en los ojos intervenidos, este componente posee un mayor número de valores fuera del rango normalidad desde el inicio del estudio electrorretinográfico y así mismo, no presenta alteración en el ojo control. Otros componentes como la onda-i y los valores de onda-b en condiciones escotópicas, presentan valores similares al PhNR pero no de forma tan precoz. Se representa así pues al componente PhNR como un importante marcador que permite el estudio y evaluación de los efectos que produce un aumento de presión intraocular sostenido, en la función electrofisiológica de la retina. / The electroretinography is a technique that allows us, in an objective way, to test the function of the retina during the transformation process of a light stimulus into an electrical response. In this study, a biomodel of human chronic open-angle glaucoma is reproduced in Gottinguen minipigs. This glaucoma biomodel is made by the cauterization of episcleral veins in one of their eyes, this was previously described for pigs. Our main objectives include: Firstly, the evaluation of the intraocular pressure evolution throughout a period of nearly a year (50 weeks). Secondly, the standardization of an electroretinographic protocol in the Gottinguer minipig and, by means of it, the analysis of the changes produced in the electroretinogram after a sustained increase of the intraocular pressure. This will allow us to generate a model of neurodegeneration produced by the experimental glaucoma. And lastly, we will analyse the model of neurodegeneration in order to find early electrofisiological patterns in the mentioned process. All these data will be compared with the current bibliography about studies done in humans as well as in other biomodels. This test was done in the eyes of five gottinguen minipigs aged around five months. After verifying the suitability of the eyes for the study, a first electroretinografic clinic study was done to each animal, based on the detailed recommendations of the ECVO and ISCEV. The electroretinographic Test is divided into three different tests, in which we gather the responses of the retine to high(30Hz) and low (4HZ) frequency stimuli in photopic and scotopic conditions. Once we have obtained the basal electroretinographic values, we continue by cauterizing the dorsal and ventral episcleral veins in the left eye of each animal. This experimental design gives us the possibility of obtaining in the same individual a control eye and an experimental eye. Such surgery gave a result of an intraocular pressure above the standard values, with a rank of values between 25 and 40 mmHg, and were maintained all over the test period. New electroretinographic studies were repeated later, two and four months after the surgery. The analysis of the obtained electroretinographic results, gave us the possibility of showing a statistically significant relation between the increase of the intraocular pressure achieved in the eyes tested and the decrease of the electroretinogram wave values in those eyes. This comparison made between the basal electroretinographic values and the control right eye to the obtained data from the operated left eye, showed the presence of alterations in the electroretinographic waves. These alterations are showed first in the b-wave, the i-wave and the PhNR values of the electroretinogram and are later reflected on the rest of electroretinographic components. These waves show a decrease in their amplitude and latency as the time of the study progresses and the high intraocular pressure is maintained. Such a decrease shows a pattern: it first affects the electroretinographic components in charge of evaluating the ganglion cells function, and even more when the adaptation time to scotopic conditions is higher. This same progression of the wave electroretinographic values, has been already described in other biomodels of experimental glaucoma as well as in people affected by chronic open-angle glaucoma. The discoveries found in our study are a counterpart of what it is described in the current bibliography. Among the parameters whose values show affectation because of the sustained increase of intraocular pressure, the PhNR component gives evidence of a higher precocity in the detection of the effects produced by such pressure, in the retine response. The results obtained in our study show that, in the operated eyes, this component has a higher number of values out of the normal rank from the beginning of the electroretinographic study, and besides, there is no alteration in the control eye. Other components as the i-wave and the b-wave values in scotopic conditions, show values similar to the PhNR but not in such an early way. The PhNR is then presented as an important sign for allowing the study and evaluation of the effects produced by an increase of a sustained intraocular pressure in the electrophysiological function of the retine.

Objetivos: Trabajos previos muestran que la corrección astigmática mediante cirugía láser en sujetos con grandes cantidades de astigmatismo interno (AI) es menos predecible. La influencia exacta del AI en los resultados de la cirugía refractiva, así como la exactitud en su medida o su relación con el resto de estructuras ópticas del ojo se desconoce. Ésta tesis pretende estudiar y analizar la epidemiología del AI y su influencia en los resultados de la cirugía refractiva. Si aumentamos el conocimiento sobre el AI, podremos conocer las fuentes de error que influyen en la cirugía refractiva y corregirlas. Material y Métodos: Estudio retrospectivo de series de casos de pacientes intervenidos de cirugía refractiva corneal con un astigmatismo subjetivo ≥1,00D. El AI es la diferencia vectorial entre el astigmatismo total (AT) y el astigmatismo corneal anterior (ACA). El análisis vectorial se ha realizado mediante el análisis de Fourier (power vectors). El AI se ha relacionado con características demográficas (sexo y edad), topográficas (ángulo Kappa, queratometría, asfericidad y paquimetría), refractivas (esfera, cilindro y eje preoperatorio) y con el resto de componentes astigmáticos (AT, ACA, diferencias de potencia y eje entre AT y ACA). Se han propuesto 3 métodos de clasificación para detectar los ojos a los que más les influye el AI en sus resultados quirúrgicos. Los resultados de la cirugía se han valorado en función del perfil de ablación realizado, mediante los índices de seguridad, eficacia, predictibilidad, éxito y corrección y se han correlacionado con el AI. En análisis estadístico se ha realizado mediante el software SPSS v.19, considerando p≤0,05 estadísticamente significativo. Resultados: Analizamos 567 ojos. El AI medio es -0,78x93º (media vectorial) con una contribución interna media en el AT del 36%. Sin embargo, 1 de cada 5 ojos presenta una contribución interna superior a la corneal. La magnitud del AI es mayor en las mujeres (p=0,034). La magnitud del AI es independiente a la edad, el ángulo Kappa, la paquimetría, la queratometría, el astigmatismo topográfico, la esfera y el cilindro preoperatorio (p<0,05), solo presenta una ligera correlación con la asfericidad (r=-0,138, p=0,020), clínicamente poco relevante. Los ojos con astigmatismos inversos presentan un mayor valor de AI (p=0,001). Las diferencias de potencia y eje entre el AT y el ACA presentan una fuerte correlación con la magnitud del AI (r=-0,640, p<0,001 y r=-0,472, p<0,001, respectivamente). Los resultados de la cirugía varían en cada perfil de ablación. En las ablaciones astigmáticas hipermetrópicas (AH), a mayor contribución interna menor cilindro residual (r=0,231; p=0,015). En las ablaciones astigmáticas miópicas (AM), a mayor AI, mayor cilindro residual (r=0,184; p=0,001) y mayor hipercorrección astigmática (r=-0,122; p=0,032). En las ablaciones astigmáticas miópicas con asfericidad programada (AMAsf), los ojos con mayores diferencias de eje entre el AT y el ACA presentan una menor agudeza visual postoperatoria y una peor seguridad de la cirugía. Conclusiones: El astigmatismo interno es un componente del astigmatismo total presente en toda nuestra muestra. Las diferencias de potencia y eje entre el AT y el ACA son una fuerte herramienta de predicción y clasificación del AI. El AI tiende a inducir hipercorrección, mejorando los resultados quirúrgicos de las ablaciones AH y empeorando los resultados de las ablaciones AM y AMAsf. Los peores resultados quirúrgicos los encontramos en los ojos con un AT superior al ACA y en los ojos con diferencias de eje superiores a 13º. / Purpose: Previous works have shown that the astigmatic correction by refractive surgery is less predictable in eyes with high amount of internal astigmatism (IA). To our knowledge, the exact influence of IA on the refractive surgery results, as well as its exact measurement or its relation with other optical structures of the eye is not clear. The purpose of this thesis is to study and to analyze the epidemiology of IA, and its influence on the results of the refractive surgery. Understanding only the internal astigmatism, we could know the error source on the astigmatic correction by refractive surgery and correct them. Materials and methods: Retrospective case series study of patients with manifest astigmatism of 1.00D or greater who underwent corneal refractive surgery. IA is the vector difference between total astigmatism (AT) and anterior corneal astigmatism (ACA). The vector analysis was performed by the Fourier analysis (power vectors). The IA was correlated with demographic (sex and age), topographic (Kappa angle, keratometry, asphericity, pachymetry) and refractive (sphere, cylinder and axis) characteristics and with others astigmatic components (AT, ACA and the power and axis differences between AT and ACA). We have proposed 3 classification methods to detect the eyes most influenced by IA on its surgery results. According to the profile of ablation performed, the surgery results have been valued by the following indexes: safety, efficacy, predictability, success and correction. The results were correlated with IA. Statistical analysis was performed by software SPSS v.19. For all statistics, a p-value of ≤0.05 was considered significant. Results: Five hundred sixty-seven eyes have been analyzed. The mean IA is -0.78x93º (vectorial mean) and the mean internal contribution on TA is 36%. However, 1 of every 5 eyes presents an internal contribution greater than corneal contribution. Females have a greater IA (p=0.034). IA is independent of age, Kappa angle, pachymetry, keratometry, topographic astigmatism, and preoperative manifest sphere and cylinder (p>0.05) and only presents a slight correlation with asphericity (r=-0.138, p=0.020), with minimal clinical relevance. Eyes with against-the-rule astigmatism shows greater IA (p=0.001). The power and axis differences between TA and ACA presents a strong correlation with IA (r=-0.640, p<0.001 and r=-0.472, p<0.001, respectively). The results of the surgery depend on the ablation profile. On hyperopic astigmatic ablations (HA), the greater internal contributions have greater residual astigmatisms (r=0.231; p=0.015). On myopic astigmatic ablations (MA), the greater internal astigmatisms present greater residual astigmatism (r=0.184; p=0.001) and bigger hypercorrections (r=-0,122; p=0,032). On the myopic astigmatic ablations with asphericity programmation (MAasf), the eyes with bigger differences between TA and ACA show less postoperative visual acuity and lower index security. Conclusions: The internal astigmatism (IA) is a component of the total astigmatism (TA) presents on all our sample. The power and axis differences between TA and ACA are a good tool for predict and classify the IA. The IA induces hypercorrection. This improves the surgery results of HA ablations and worsens the surgery results of MA and MAasf ablations. The worst results are on eyes with TA bigger than ACA and on eyes with axis differences between TA and ACA bigger than 13º.

La distrofia endotelial de Fuchs es una enfermedad común, que se caracteriza por la pérdida progresiva de células endoteliales y edema estromal. La cirugía “Descemet Stripping Automated Endothelial Keratoplasty” (DSAEK) es la técnica elegida por muchos cirujanos para tratar dicha enfermedad. Esta técnica se basa en la sustitución selectiva del endotelio enfermo por un tejido donante sano. Dicha técnica tiene la ventaja de una rápida recuperación visual. Sin embargo, tras la cirugía, los pacientes suelen presentar un aumento de la luz dispersada por la córnea y degradación óptica producida por un incremento en las aberraciones oculares. Las aberraciones son el principal condicionante de la calidad de imagen. Debido al cambio en el contorno corneal asociado a la adición del lentículo donante en ojos intervenidos de DSAEK, no es sorprendente que las aberraciones derivadas de la superficie posterior estén incrementadas, aunque no hay que olvidar que la superficie anterior puede presentar irregularidades por la larga duración de la enfermedad corneal. Dicha irregularidad junto con la cicatrización corneal resultante tras la cirugía, puede provocar un aumento en la dispersión de la luz por la pérdida de transparencia de la superficie anterior corneal, que la cirugía DSAEK no es capaz de solucionar. Por lo tanto, el propósito de este estudio es analizar el dioptrio corneal de pacientes diagnosticados de distrofia endotelial de Fuchs e intervenidos de cirugía DSAEK y compararlo con las córneas de un grupo control formado por pacientes intervenidos de cirugía de catarata. Para ello, se han analizado 33 ojos de 24 pacientes, todos ellos diagnosticados de distrofia endotelial de Fuchs y tratados con DSAEK. Se han realizado exámenes de agudeza visual, refracción subjetiva, biomicroscopía, exploración de fondo de ojo, análisis de aberraciones con Pentacam, medición del espesor corneal con Pentacam y OCT y evaluación de la dispersión intraocular mediante C-Quant. Los resultados obtenidos muestran como la máxima agudeza visual corregida aumenta tras la cirugía DSAEK y el equivalente esférico sufre un cambio miópico, aunque dicho cambio no es significativo. Las aberraciones oculares permanecen prácticamente sin cambios salvo las de la superficie posterior corneal. Los valores de espesor corneal son significativamente mayores con respecto al grupo control y el lentículo endotelial presenta diferente espesor entre el centro y la periferia. Por último, la dispersión intraocular es significativamente mayor con respecto al grupo control, con un pico de mayor densitometría, medida mediante Pentacam en la superficie anterior corneal. A la vista de los resultados obtenidos, la cirugía DSAEK es eficaz para el tratamiento de la distrofia endotelial de Fuchs, aunque diversos parámetros ópticos no retornan a sus valores normales tras la cirugía. / Fuchs endothelial dystrophy is a common progressive disease, characterized by progressive loss of endothelial cells and stromal edema. Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) is the technique of choice for many surgeons to remove this disease. The technique is based on the selective replacement of diseased endothelium replaced by a healthy donor tissue. This technique has the advantage of a fast visual recovery. However, after the surgery, patients usually present increased light scattered by the cornea and optical degradation caused by increased ocular aberrations. The ocular aberrations are the primary determinant of image quality. Due to the change in the corneal shape associated with the addition of the lenticule donor in eyes with DSAEK surgery, it is not surprising that aberrations arising from the posterior surface are increased, although we must not forget that the anterior surface can be slightly different due to the long-term corneal disease. Such irregularity, with the resulting corneal scarring after surgery, can cause an increase in light scattering by the loss of transparency of the corneal anterior surface that even DSAEK surgery cannot solve. Therefore, the purpose of this study is to analyze the corneal diopter of patients diagnosed with Fuchs endothelial dystrophy that underwent DSAEK and compare to the corneas of a control group of patients undergoing cataract surgery. To make this, we analyzed 33 eyes of 24 patients, all diagnosed with Fuchs endothelial dystrophy and treated with DSAEK. They have conducted tests of visual acuity, subjective refraction, biomicroscopy, fundus examination, analysis of aberrations by Pentacam, corneal thickness measurement by Pentacam and OCT and evaluation of the intraocular Straylight measured by C-Quant. The results show that the maximum corrected visual acuity increases after surgery and a myopic change in the spherical equivalent is made, but this change is not significant. Ocular aberrations remain unchanged except for the posterior corneal surface. Corneal thickness values are significantly higher compared to the control group and the endothelial lenticule presents variation in thickness between the center and the periphery. Finally, intraocular Straylight is significantly higher compared to the control group, with a higher peak of densitometry in the anterior corneal surface measured by Pentacam. In light of the obtained results, DSAEK surgery is an effective treatment for Fuchs endothelial dystrophy, although several optical parameters do not return to normal after surgery.

El objetivo de esta tesis es evaluar si las lentes ajustables por luz permiten corregir los defectos refractivos residuales tras la cirugía de catarata de forma eficaz, reproducible, estable y segura. Para ello, hemos estudiado su eficacia para corregir los defectos refractivos tras la cirugía de la catarata, la predictibilidad de los tratamientos aplicados, la seguridad de los mismos y su estabilidad a largo plazo. Se han seguido 77 ojos implantados con lentes ajustables por luz mediante técnica de facoemulsificación habitual. A los 15 días de la implantación, se realizaron tratamientos para el ajuste refractivo en función de la graduación residual tras la cirugía de catarata (tratamientos neutros, miópicos, hipermetrópicos, astigmático-miópicos y astigmático-hipemetrópicos), y para el bloqueo final de las lentes. Hemos medido la agudeza visual con y sin corrección, los defectos refractivos expresados tanto en esfera, cilindro y eje como en M, J0, J45. Hemos examinado el fondo de ojo de los pacientes mediante funduscopía y tomografía de coherencia óptica, así como revisado otras estructuras oculares, como el endotelio corneal, a fin de detectar posibles efectos adversos secundarios al implante de la lente o a los tratamientos realizados. Se ha realizado un seguimiento de los pacientes durante 4 años con el objetivo de evaluar cambios en el comportamiento de la lente a lo largo del tiempo. La cirugía se realizó de manera similar a otras lentes intraoculares no registrándose complicaciones. La agudeza visual media sin corrección al mes de los tratamientos fue de 0,93±0,20, siendo esta superior a la obtenida con lentes monofocales, alcanzando con corrección una agudeza visual de 1,03±0,19. El 76,62% de los pacientes presentó una agudeza visual sin corrección tras los tratamientos mejor o igual a la que tenían con la mejor corrección previa a realizar el tratamiento de ajuste. El 25,97% de los pacientes mejoró en una o más líneas su mejor agudeza visual postquirúrgica. El 67,99% de los pacientes presentó un equivalente estérico residual entre ±0,5D. Los índices de seguridad y eficacia fueron de 1,10 y 0,99 respectivamente. No se han registrado complicaciones significativas en nuestros pacientes. El porcentaje de opacidad capsular posterior ha sido similar al de otras series publicadas. En conclusión, las lentes intraoculares ajustables por luz son capaces de corregir errores refractivos tras la cirugía de la catarata en un rango de ±2 dioptrías tanto esféricas como cilíndricas, siendo esta tecnología segura, y sus resultados altamente predecibles y estables en el tiempo. / The purpose of this thesis is to evaluate if the light adjustable lenses allow to correct residual refractive errors after cataract surgery effectively, reproducibly, safely and stably. We have studied their effectiveness to correct refractive defects after cataract surgery, the predictability of the treatments applied, safety and long-term stability. We have followed 77 eyes implanted with light adjustable lenses by using a standard phacoemulsification technique. At 15 days after implantation, we performed different treatments for adjusting the residual refractive errors (neutral treatments, myopic, hyperopic, astigmatic-myopic and astigmatic-hyperopic) and finally the lock-in treatments. We have measured both corrected and uncorrected visual acuity, refractive errors expressed as sphere, cylinder and M, J0, J45. We examined the retina of patients by ophthalmoscopy and optical coherence tomography and revised other ocular structures such as the corneal endothelium in order to detect possible adverse events secondary to lens implantation or the applied treatment. Patients were followed during 4 years with the intention to evaluate changes in the behaviour of the lens over time. Surgery was performed similarly to other intraocular lenses, not registering complications. The average uncorrected visual acuity at one month after treatment was 0.93 ± 0.20, higher than that obtained with monofocal intraocular lenses, reaching corrected visual acuity of 1.03 ± 0.19. A 76.62%of patients had uncorrected visual acuity after treatment equal or better than they best previous to the adjustments. A 25.97% of patients improved one or more lines their best postoperative visual acuity. The 67,99% of the patients had a residual spherical equivalent between a range of ± 0.5D. The safety and efficacy rates were 1.10 and 0.99 respectively. There have been no significant complications in any of the patients. The posterior capsular opacity percentage was similar to other published series. In conclusion, the light adjustable intraocular lenses are able to correct refractive errors after cataract surgery in a range of ± 2 diopters both spherical and cylindrical. It is a safe technology, providing highly predictable results stable over time.

Made available in DSpace on 2013-08-07T19:04:32Z (GMT). No. of bitstreams: 1 000401332-Texto+Completo-0.pdf: 1214979 bytes, checksum: 7e4437b8356d96791833f8997a3a2bdb (MD5) Previous issue date: 2008 / Objectives - This study analysed a group of postoperative congenital clubfeet children from PUCRS Hospital, concerning on Simons talonavicular articular congruation and Laaveg and Ponseti functional system. We tried a radiographic-functional parameters association. Metodology - A transversal retrospective study involving 71 postoperative congenital clubfeet in 50 children, 34 male (48 feet) and 16 female (23 feet) was carried out in the São Lucas Hospital of PUCRS from January 1986 to December 2002. Simons Classification was used by radiographic analysis and Laaveg and Ponseti scores by the functional evaluation. The children`s ages varies from 6 to 16 months on the time of surgery, average 13,76 and 4,97 standard deviation (sd); 82% were white and 52,11 were right feet. Results - The feet evaluation by Simons criteria showed 38 centrated feet (53,5%), 25 small complicated feet (35,2%) and 8 tall complicated (11,3%) on AP radiographics evaluation. The P radiographics evaluation showed 31 centrated feet (43,7%), 27 small complicated feet(38%) and 13 tall complicated feet (18,3%). The Laaveg and Ponseti functional scores varied from 47 to 100 points, average 86,86 and sd 11,08, median 97 points and mode 88 points. Conclusion - The Simons talonavicular radiographic parameters on AP and P did not showed significant statistic association to Laaveg and Ponseti functional scores in our study. / Objetivo - Descrever a amostra de indivíduos com pé torto congênito idiopático tratados cirurgicamente de 1986 a 2002 no Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (HSL-PUCRS). Verificar associação entre os achados radiográficos da articulação talonavicular e o escore funcional de pés tortos congênitos idiopáticos tratados cirurgicamente de maneira uniforme. Metodologia – Cinqüenta crianças (71 pés) que realizaram cirurgia para correção de pé torto congênito idiopático no período de 1986 a 2002 no HSL-PUCRS, participaram deste estudo. Para desenvolvimento deste trabalho foi realizada revisão dos prontuários hospitalares visando a criação de um banco de dados com variáveis de interesse relacionadas à avaliação pós-operatória. Foi realizada análise descritiva dos dados e, posteriormente, de associação. Resultados – A amostra foi composta por 34 pacientes do sexo masculino (48 pés) e 16 do sexo feminino (23 pés) submetidos a tratamento cirúrgico no HSL-PUCRS. A avaliação dos pés pelos critérios de Simons mostrou 38 pés centrados (53,5%), 25 pés com complicações menores (35,2%) e 8 pés com complicações maiores (11,3%) nas radiografias em ântero-posterior (AP). Nas radiografias em perfil (P), encontramos 31 pés centrados (43,7%), 27 complicações menores (38%) e 13 complicações maiores (18,3%). Os resultados funcionais, segundo a tabela de Laaveg e Ponseti, mostraram escores variando de 47 a 100 pontos (pts), com média de 86,86 pts e desvio padrão (dp) 11,08, mediana de 88 pts e moda de 97 pts. Conclusão – As variações encontradas nas radiografias em AP e P da articulação talonavicular dos pés pelos critérios de Simons, não mostraram associação estatisticamente significativa com os escores de função avaliados pela tabela de Laaveg e Ponseti.

Made available in DSpace on 2014-06-11T19:31:09Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-07-14Bitstream added on 2014-06-13T20:01:42Z : No. of bitstreams: 1 dias_lggg_dr_jabo.pdf: 2151686 bytes, checksum: 192fc332d876bb868c167e3bd4402379 (MD5) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / As fraturas de tíbia em cães representam 20% das que ocorrem em ossos longos. Vários métodos são utilizados nas osteossínteses desse osso, contudo, atualmente as hastes bloqueadas vêm ganhando espaço, especialmente por suas vantagens biomecânicas quando comparadas às demais técnicas. O presente trabalho teve por objetivo desenvolver e avaliar o uso de haste intramedular bloqueada angulada para fraturas tibiais em cães, visando minimizar erros de bloqueio de parafusos e consequentemente problemas na consolidação óssea. Hastes anguladas, de aço inoxidável da série 316L, foram confeccionadas nos diâmetros de 5, 6, 7 e 8 mm, com comprimentos variados. Num período de 17 meses, ocorreu a implantação destas em 15 cães com fratura de tíbia. As avaliações clínica e radiográfica ocorreram no pré e pós-operatório imediato e a cada 30 dias até completar quatro meses. Clinicamente, a recuperação da função do membro se deu no período médio de 10 dias após a cirurgia. Em três animais, utilizou-se além da haste angulada e parafusos, pinos de Schanz como bloqueio (fixador externo), que posteriormente foram retirados. Radiograficamente verificou-se consolidação óssea em média de 70 dias de pós-operatório. A haste intramedular bloqueada angulada mostrou-se eficaz como método de osteossíntese em fraturas tibiais de cães. / In dogs, tibial fractures account for approximately 20% of all long bone fractures. Different methods of fracture repair are used in this bone; however, interlocking nails have gained popularity in recent years owing to its biomechanical advantages when compared to other techniques. The present study aimed to develop and to evaluate the usefulness of an angulated interlocking nail model in tibial fractures of dogs to minimize blocking errors arising from inaccurate bolt stabilization, responsible for generation osseous consolidation. Angulated stainless steel pins from series 316L were manufactured with 5, 6, 7 and 8 mm of diameter, and variable length. During 17 months, pins were implanted in 15 dogs with tibial fracture. Clinical and radiographic findings were recorded on preoperative and on the immediate postoperative period, and every 30 days, until the last recheck, 4 months latter. Clinically, animals recovered the hind function on an average of 10 days after surgery. In three dogs, in addition to the angulated interlocking nail and bolts, scat pins (external fixator) were used. Radiographically, bone consolidation was evident on an average of 70 days of postoperative period. The angulated interlocking nail is a feasible method to repair tibial fractures of dogs.

Made available in DSpace on 2014-06-11T19:31:10Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-06-06Bitstream added on 2014-06-13T19:41:05Z : No. of bitstreams: 1 fonseca_bpa_dr_botfmvz.pdf: 1506158 bytes, checksum: 39cabcc02dac5441d02e67e6a944f006 (MD5) / A lombalgia é reflexo de uma desordem estrutural ou funcional na coluna vertebral dos eqüinos e seu diagnóstico e tratamento são associados a um impacto na indústria eqüina, tanto em termos de queda do desempenho atlético quanto ao reflexo econômico direto. A terapia por ondas de choque extracorpóreas representa uma nova modalidade no tratamento de algumas lesões ortopédicas em eqüinos e está ganhando crescente interesse e aceitação por parte de veterinários, treinadores e proprietários. Foram utilizados 14 animais da raça Quarto de Milha, com queixa de queda de desempenho atlético associada à lombalgia, nos quais foi realizado o exame físico da região toracolombar na seguinte seqüência: Inspeção com o animal parado, palpação, execução dos testes de mobilidade e exame do animal em movimento, seguido do exame ultra-sonográfico da região toracolombar. Após a localização e caracterização das lesões, foi realizado o tratamento por ondas de choque. Foi observada uma evidente redução na soma dos escores do exame físico em todos os animais entre o dia 0 e 120 dias após a última sessão, com redução nos escores de ecogenicidade e irregularidade de superfície articular e aumento nos escores de paralelismo nos diferentes momentos. Pôde-se observar uma relação positiva entre os escores na escala de intensidade e a evolução da aparência ultra-sonográfica das lesões. Sendo assim, o protocolo proposto para a aplicação das ondas de choque extracorpóreas focais induziu melhora funcional e morfológica nos animais tratados, demonstrando ser um tratamento eficiente para as enfermidades toracolombares estudadas neste estudo. / Back pain is a reflex of a structural or functional dysfunction in the vertebral column of horses and its diagnosis and treatment are associated to an impact in the equine industry, in terms of decrease of athletic performance and direct economic affect. The extracorporal shock wave therapy represents a new modality in the treatment of some orthopedics injuries in equine and has been increasing interest and acceptance on veterinarians, trainers and owners. Fourteen Quarter of Mile Horses were used, with complaint of fall of athletic performance associated with back pain, in which the physical exam for the thoracolumbar area was performed in the following sequence: Inspection, palpation, mobility tests and exam in motion, followed of the ultrasonographic examination of the thoracolumbar spine. After the localization and characterization of the injuries, the shock waves treatment was performed. An evident reduction in the scores of the physical exam was observed in all the animals between day 0 and day 120 after the last session of shock waves, with reduction in the scores of echogenicity and irregularity of surface of the articular processes and increase in the scores of parallelism at the different moments. A positive relation between the scale of intensity and the evolution of the ultrasonographic appearance of the injuries could be observed. Being thus, the protocol used for the application of the focal extracorporal shock waves induced functional and morphologic improvement in the treated horses, demonstrating to be an efficient treatment for the injuries of the thoracolumbar spine in this study.

Submitted by GUILHERME SEMBENELLI null (guilhermesembenelli@hotmail.com) on 2017-08-09T01:53:10Z No. of bitstreams: 1 Dissertação_Guilherme_Sembenelli.pdf: 2565740 bytes, checksum: d9b68e8304088478cada8ab56efa1c00 (MD5) / Rejected by LUIZA DE MENEZES ROMANETTO (luizamenezes@reitoria.unesp.br), reason: Solicitamos que realize uma nova submissão seguindo as orientações abaixo: No campo “Versão a ser disponibilizada online imediatamente” foi informado que seria disponibilizado o texto completo porém no campo “Data para a disponibilização do texto completo” foi informado que o texto completo deverá ser disponibilizado apenas 12 meses após a defesa. Caso opte pela disponibilização do texto completo apenas 12 meses após a defesa selecione no campo “Versão a ser disponibilizada online imediatamente” a opção “Texto parcial”. Esta opção é utilizada caso você tenha planos de publicar seu trabalho em periódicos científicos ou em formato de livro, por exemplo e fará com que apenas as páginas pré-textuais, introdução, considerações e referências sejam disponibilizadas. Se optar por disponibilizar o texto completo de seu trabalho imediatamente selecione no campo “Data para a disponibilização do texto completo” a opção “Não se aplica (texto completo)”. Isso fará com que seu trabalho seja disponibilizado na íntegra no Repositório Institucional UNESP. Por favor, corrija esta informação realizando uma nova submissão. Agradecemos a compreensão. on 2017-08-11T16:51:15Z (GMT) / Submitted by GUILHERME SEMBENELLI null (guilhermesembenelli@hotmail.com) on 2017-08-17T19:38:24Z No. of bitstreams: 1 Dissertação_Guilherme_Sembenelli.pdf: 2565740 bytes, checksum: d9b68e8304088478cada8ab56efa1c00 (MD5) / Approved for entry into archive by Luiz Galeffi (luizgaleffi@gmail.com) on 2017-08-23T14:17:33Z (GMT) No. of bitstreams: 1 sembenelli_g_me_jabo.pdf: 2565740 bytes, checksum: d9b68e8304088478cada8ab56efa1c00 (MD5) / Made available in DSpace on 2017-08-23T14:17:33Z (GMT). No. of bitstreams: 1 sembenelli_g_me_jabo.pdf: 2565740 bytes, checksum: d9b68e8304088478cada8ab56efa1c00 (MD5) Previous issue date: 2017-05-30 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / O objetivo do presente estudo foi desenvolver placa de TPLO bloqueada modificada e avaliar a eficácia da estabilização óssea proporcionada pelo implante desenvolvido comparativamente a outros dois métodos convencionais de fixação óssea (placa bloqueada e placa bloqueada associada a pino intramedular). Por meio de estudos biomecânicos, avaliaram-se as construções às forças de torção, flexão craniocaudal, flexão mediolateral e compressão axial. Foram utilizadas sessenta tíbias sintéticas dividas em três grupos. O Grupo 1 (placa TPLO modificada), o Grupo 2 (placa bloqueada) e o Grupo 3 (placa bloqueada associada a pino intramedular) foram qsubdivididos em quatro grupos de cinco tíbias. Os ensaios foram realizados até a falha da montagem (implantes e/ou tíbia) e os resultados obtidos comparados entre os grupos. As variáveis estudadas foram analisadas sob delineamento inteiramente casualizado no esquema fatorial 3 por 4 com 5 repetições para cada combinação do esquema fatorial. Os resultados foram submetidos à análise de variância e as médias comparadas entre si pelo teste de Tukey a 5% de probabilidade. No ensaio de compressão axial houve diferença significativa em relação a variável força máxima em que o Grupo 3 obteve maior média, não havendo diferença significativa entre os Grupos 1 e 2. Todas as montagens falharam devido à flexão da placa na região de falha no corpo de prova. No ensaio de flexão em três pontos craniocaudal houve diferença significativa em relação às três variáveis estudas. Na variável força máxima G2>G3=G1, na variável deflexão G3>G1=G2 e na variável rigidez G3=G2, G2=G1 G3>G1. Todas as montagens falharam devido à quebra do corpo de prova. No ensaio de flexão mediolateral houve diferença significativa em relação a variável rigidez em que G3>G2=G1. Todas as montagens falharam devido à flexão da placa na região de falha no corpo de prova. No ensaio de torção houve diferença significativa em relação às variáveis ângulo no pico de torque e rigidez. Na variável ângulo no pico de torque G2>G1=G3. Na variável rigidez G1=G3>G2. Todas as montagens falharam devido à quebra do corpo de prova distal a placa. Conclui-se a placa de TPLO modificada apresentou semelhança biomecânica com a placa reta convencional na maioria das variáveis estudadas. O grupo, da associação placa e pino, obtive maiores índices de rigidez comparativamente aos outros dois grupos, exceto no teste de torção em que o grupo da placa de TPLO modificada apresentou o mesmo índice de rigidez que o da associação placa e pino. / The aim of this study was to develop modified TPLO locked plate and to evaluate the effectiveness of stabilization provided by the implant developed compared to two other conventional methods of stabilization (locked plate and plate-rod). Through biomechanical studies the constructions were evaluated to craniocaudal and mediolateral bending, axial compression and torsional forces. Sixty synthetic tibias were used divided into three groups. Group 1 (modified TPLO plate), Group 2 (locked plate) and Group 3 (plate-rod) were subdivided into four groups of five tibiae. The tests were perfomed until failure of the construction (implants / tibia) and the results compared between the groups. The variables studied were analyzed under a completely randomized design in the factorial scheme 3 by 4 with 5 replicates for each combination of the factorial scheme. The results were submitted to analysis of variance and the means compared to each other by the Tukey test at 5% probability. In the axial compression test there was a significant difference in relation to the variable maximum force in which Group 3 obtained higher mean, not having significant difference between Groups 1 and 2. All constructions failed due to plate bending in the gap region of the synthetic tibia. In the three-point craniocaudal flexion test there was a significant difference in relation to the three variables studied. In the variable force maximum G2> G3 = G1, in the variable deflection G3> G1 = G2 and in the variable stiffness G3 = G2, G2 = G1 G3> G1. All constructions failed because of the breaking of the synthetic tibia. In the three-point craniocaudal flexion test there was a significant difference in relation to the three variables studied. In the variable force maximum G2> G3 = G1, in the variable deflection G3> G1 = G2 and in the variable stiffness G3 = G2, G2 = G1 G3> G1. All constructions failed because of the breaking of the synthetic tibia. In the mediolateral flexion test there was a significant difference in relation to the stiffness variable in which G3> G2 = G1. All constructions failed due to plate bending in the gap region of the synthetic tibia. In the torsion test there was a significant difference in relation to the variables angle at peak torque and stiffness. In the variable angle at the torque peak G2> G1 = G3. In the stiffness variable G1 = G3> G2. All constructs failed due to the breaking of the synthetic tibia distally to the plate. It is concluded that the modified TPLO plate presented biomechanical similarity with the conventional plate in most of the studied variables. The groups of locking plate an plate-rod constructions obtained higher stiffness indices compared to the other two groups, except for the torsion test in which the modified TPLO plate group had the same stiffness index as the plate and plate-rod. / FAPESP: 2015/14602-8