Transient retinal artery occlusion after phacoemulsification under local anesthetic block / Oclusão arterial retiniana transitória após facoemulsificação sob bloqueio anestésico

ABSTRACT We here in report the case of a patient subjected to cataract surgery through phacoemulsification under local anesthetic block, without intra-operative complications. The patient presented important visual impairment in the first post-operative day. Fundoscopy showed pallor resembling cherry-red spots at the macula. Fluorescein angiography did not depict signs of vascular occlusion and the spectral-domain optical coherence tomography showed increased reflectivity in the inner layers of the retina, thus suggesting local thickening and edema. The current case led to the diagnostic hypothesis of transient retinal arterial occlusion.

RESUMO Relatamos um caso de um paciente submetido a facectomia por facoemulsificação sob bloqueio anestésico peribulbar, sem intercorrências per-operatória, que apresentou no primeiro dia de pós-operatório baixa visual significativa. À fundoscopia observou-se palidez em aspecto de mácula em cereja. A angiofluoresceinografia não demonstrou sinais de oclusão vascular e a tomografia de coerência óptica mostrou aumento da refletividade das camadas internas da retina, sugerindo espessamento e edema local. No caso descrito foi aventada hipótese diagnóstica de oclusão arterial retiniana transitória.

Cerebral Angiographic Findings of Cosmetic Facial Filler-related Ophthalmic and Retinal Artery Occlusion

Cosmetic facial filler-related ophthalmic artery occlusion is rare but is a devastating complication, while the exact pathophysiology is still elusive. Cerebral angiography provides more detailed information on blood flow of ophthalmic artery as well as surrounding orbital area which cannot be covered by fundus fluorescein angiography. This study aimed to evaluate cerebral angiographic features of cosmetic facial filler-related ophthalmic artery occlusion patients. We retrospectively reviewed cerebral angiography of 7 patients (4 hyaluronic acid [HA] and 3 autologous fat-injected cases) showing ophthalmic artery and its branches occlusion after cosmetic facial filler injections, and underwent intra-arterial thrombolysis. On selective ophthalmic artery angiograms, all fat-injected patients showed a large filling defect on the proximal ophthalmic artery, whereas the HA-injected patients showed occlusion of the distal branches of the ophthalmic artery. Three HA-injected patients revealed diminished distal runoff of the internal maxillary and facial arteries, which clinically corresponded with skin necrosis. However, all fat-injected patients and one HA-injected patient who were immediately treated with subcutaneous hyaluronidase injection showed preserved distal runoff of the internal maxillary and facial arteries and mild skin problems. The size difference between injected materials seems to be associated with different angiographic findings. Autologous fat is more prone to obstruct proximal part of ophthalmic artery, whereas HA obstructs distal branches. In addition, hydrophilic and volume-expansion property of HA might exacerbate blood flow on injected area, which is also related to skin necrosis. Intra-arterial thrombolysis has a limited role in reconstituting blood flow or regaining vision in cosmetic facial filler-associated ophthalmic artery occlusions.

Verrucous carcinoma in association with oral submucous fibrosis.

Oral verrucous carcinoma is a form of well differentiated squamous cell carcinoma characterized by exophytic over growth. It is slow growing and locally invasive tumor occurring in 6 th and 7 th decade of life. Smoking and chewing tobacco is found to be the most common etiological factor of verrucous carcinoma although oral leukoplakia may act as a predisposing factor. This is a rare case of oral varrucous Carcinoma seen in association with oral submucous fibrosis in a younger patient with long standing history of chewing tobacco.

Evaluation of oral submucous fibrosis using ultrasonographic technique: A new diagnostic tool.

Aim: The aim of this study is to evaluate oral submucous fibrosis (OSMF) by clinical and histopathological examination, and compare the results with those from ultrasonographic technique. Materials and Methods: 30 clinically diagnosed OSMF patients were subjected to both ultrasonographic and histopathological evaluation before treatment. Later, only ultrasonographical examination was done during 4 th and 8 th week of treatment. Prognosis of the lesion for the treatment was evaluated. Peak systolic velocity (PSV) of blood in the lesional area was statistically analyzed. 10 normal individuals without any mucosal lesions were considered as the control group. Results: In normal individuals, ultrasonography delineates normal mucosa with uniform fine mottled appearance with interspersed hypoechoic areas. Color Doppler and spectral Doppler depicts uniform distribution of blood vessels and normal peak systolic velocity of blood respectively. All OSMF patients were diagnosed upon clinical and histopathological examination. Clinical examination revealed 14 individuals with unilateral palpable fibrotic bands and 16 individuals with bilateral fibrotic bands whereas, ultrasonographic evaluation revealed 6 individuals with unilateral fibrotic bands and 24 individuals were with bilateral fibrotic bands, which was statistically significant. Ultrasonography demonstrated number, length and thickness of the fibrotic bands. Color Doppler and spectral Doppler showed decreased vascularity and PSV in lesional area. Prognosis evaluation revealed 25 cases of good prognosis and 5 cases were showed poor prognosis. Wilcoxon Signed Ranks Test revealed no significant difference of PSV was seen in poor prognosis patients. Conclusion: Ultrasonography is a non-invasive diagnostic tool for OSMF. It could be a better diagnostic tool compared to clinical and histopathological examination.

Topical betamethasone and hyaluronidase in the treatment of phimosis in boys: a double-blind, randomized, placebo-controlled trial

PURPOSE: To compare the efficacy of three different formulations containing Betamethasone Valerate versus placebo in the topical treatment of phimosis. As a secondary goal, we compared the outcomes after 30 and 60 days of treatment. MATERIALS AND METHODS: Two hundred twenty boys aged 3 to 10 years old with clinical diagnosis of phimosis were enrolled. Patients were randomized to one of the following groups: Group 1: Betamethasone Valerate 0.2 percent plus Hyaluronidase; Group 2: Betamethasone Valerate 0.2 percent; Group 3: Betamethasone Valerate 0.1 percent or Group 4: placebo. Parents were instructed to apply the formula twice a day for 60 days and follow-up evaluations were scheduled at 30, 60 and 240 days after the first consultation. Success was defined as complete and easy foreskin retraction. RESULTS: One hundred ninety-five patients were included at our final analysis. Group 1 (N = 54), 2 (N = 51) and 3 (N = 52) had similar success and improvement rates, all treatment groups had higher success rates than placebo(N = 38). After 60 days of treatment, total and partial response rates for Groups 1, 2 and 3 were 54.8 percent and 40.1 percent, respectively, while placebo had a success rate of 29 percent. Success and improvement rates were significantly better in 60 days when compared to 30 days. CONCLUSIONS: Betamethasone Valerate 0.1 percent, 0.2 percent and 0.2 percent in combination with Hyaluronidase had equally higher results than placebo in the treatment of phimosis in boys from three to ten years-old. Patients initially with partial or no response can reach complete response after 60 days of treatment.

Efficacy of hydrocortisone acetate/hyaluronidase vs triamcinolone acetonide/hyaluronidase in the treatment of oral submucous fibrosis.

Background & objective: Oral submucous fibrosis is a common premalignant condition caused by chewing arecanut and other irritants in various forms. Its medical treatment is not yet fully standardized, although the optimal doses of its medical treatment is in the form of hydrocortisone acetate combined with hyaluronidase. The problem with the prevailing treatment was injections at weekly interval. In this study we compared the efficacy of hydrocortisone acetate and hyaluronidase at weekly interval versus triamcinolone acetonide and hyaluronidase at 15 days interval. Methods: Patients of OSMF (100) were randomly divided into two groups A and B. Group A patients received combination of hydrocortisone acetate (1.5 ml)/hyaluronidase (1500 IU) at weekly interval submucosally in pterygomandibular raphe, half dose on each side for 22 wk. Group B patients received combination of triamcinolone acetonide (10 mg/ml)/ hyaluronidase (1500 IU) at 15 days interval for 22 wk. Treatment outcome was evaluated on the basis of improvement in symptom score, sign score and histopathological improvement. Student’s ‘t’ test was applied for comparing the results. Results: No statistically significant difference in symptom score, sign score and histopathological improvement was seen between the two groups. Interpretation & conclusion: Treatment regimen of group B was more convenient to the patients because less number of visits required and cheap. No side effects were seen. A follow up study is required to see long term effects.

To circ or not to circ: clinical and pharmacoeconomic outcomes of a prospective trial of topical steroid versus primary circumcision

Purpose: To compare the efficacy and costs of circumcision versus topical treatment using a prospective pharmacoeconomic protocol. Materials and methods: We treated 59 patients (3-10 years of age) randomized into two groups: 29 underwent an 8-week course of topical treatment with 0.2 percent betamethasone-hyaluronidase cream twice a day; and 30 underwent circumcision. Topical treatment success was defined as complete exposure of the glans. In cases of treatment failure, circumcision was performed and its cost imputed to that of the initial treatment. The pharmacoeconomic aspects were defined according to the Brazilian National Public Health System database and the Brazilian Community Pharmacies Index. Results: The two groups were statistically similar for all clinical parameters evaluated. Topical treatment resulted in complete exposure of the glans in 52 percent of the patients. Topical treatment was associated with preputial pain and hyperemia. However, treatment suspension was unnecessary. Minor complications were observed in 16.6 percent of the surgical group patients. The mean cost per patient was US$ 53.70 and US$ 125.20, respectively, for topical steroid treatment (including the costs related to treatment failure) and circumcision. The total costs were US$ 2,825.32 and US$ 3,885.73 for topical treatment and circumcision, respectively. Conclusions: Topical treatment of phimosis can reduce costs by 27.3 percent in comparison with circumcision. Therefore, topical treatment of phimosis should be considered prior to the decision to perform surgery.

O efeito das enzimas hialuronidase e tripsina na liquefação do sêmen de macacos pregos (Cebus apella) / The effect of hyaluronidase and trypsin ensymes on liquefaction of semen in capuchin monkey (Cebus apella)

Os efeitos das enzimas hialuronidase e tripsina foram avaliados quanto à liquefação, motilidade, vigor e integridade do acrossoma, no sêmen de seis macacos pregos (Cebus apeiia), mantidos na Fundação Parque Zoológico de São Paulo. O sêmen foi colhido por eletroejaculação, após anestesia geral, e a fração líquida foi imediatamente avaliada. A fração coagulada do sêmen foi tratada com as enzimas hialuronidase e tripsina, na dose de 1mg/ml, diluídas em meio 199 (Nutricel, Campinas/SP, Brasil), na proporção 1:4 e examinada após 5 e 15 minutos. Test t de Student foi utilizado para comparar os tratamentos. Não houve diferença significativa quanto a motilidade, vigor e integridade de acrossoma (p > 0.05), entre a fração de sêmen coagulado diluído em hialuronidase e tripsina, após cinco ou quinze minutos. No entanto, houve diferença significativa quanto a motilidade e vigor entre a fração líquida e a coagulada do sêmen (p < 0.05), após quinze minutos. Não houve diferença significativa com relação à integridade de acrossoma (p > 0.05) entre a fração líquida e coagulada do sêmen, após 15 minutos. De acordo com os resultados, podemos concluir que não houve efeito aparente na fração coagulada do sêmen tratado com as enzimas hialuronidase e tripsina com relação a motilidade, vigor e integridade do acrossoma. No entanto, houve diferença significativa entre a fração líquida e coagulada do sêmen com relação a motilidade e vigor, porém não quanto à integridade do acrossoma. De maneira geral, em ambos os tratamentos, não houve a completa dissolução do coágulo.

The effect of the enzymes hyaluronidase and trypsin were recorded on the motility, vigor and acrosome integrity in the semen of capuchin monkey (Cebus apella). The animals (n=6) were maintained at Fundação Parque Zoológico de São Paulo. Under anesthesia semen samples were collected by electroejaculation. Immediately after the ejaculation, the semen liquid fraction was analyzed for volume (ml), pH, motility (%), vigor (0-5), concentration (cells/ml), defects (%) and percentage of intact acrosome (%). The coagulated fraction was treated with a solution of hyaluronidase or trypsin, 1mg/ml in commercial medium (199-Nutricel, Campinas/SP, Brazil) in a proportion of 1:4 and the samples were examined after 5 and 15 minutes. The Student T Test (95%) was used to compare the treatments. There was no significant difference in the motility, vigor or acrossome integrity (p > 0.05) between coagulated fraction diluted either in trypsin or in hyaluronidase, after 5 or 15 minutes. However, there was significant difference in motility and vigor between liquid and coagulated fraction, after 15 minutes, for both treatments (p<0.05), but there were no difference in acrosome integrity (p > 0.05). In conclusion, there were no apparent effects in the coagulum for both treatments regarding motility, vigor and acrosome integrity. There were significant differences between liquid and coagulated fractions regarding motility and vigor, but not for acrosome integrity. In both enzyme treatments there were no complete dissolution of the coagulum.

Peribulbar anaesthesia for penetrating keratoplasty. A case series.

PURPOSE: To prospectively analyse the efficacy and safety of peribulbar anaesthesia for penetrating keratoplasty through a noncomparative, consecutive series. METHODS: One hundred twenty-four (91.1%) of 136 patients undergoing penetrating keratoplasty (PK) from January 1997 to December 2001, were administered peribulbar anaesthesia. The anaesthetic mixture consisted 5 ml of lignocaine, bupivacaine, and hyaluronidase (to avoid evaluation bias) in the peribulbar space. A repeat injection of 3 ml was used if the primary injection was inadequate. Digital ocular compression was done for 10-15 minutes after the first injection. Each patient was analysed for degree of akinesia, subjective patient comfort, analgesia, subjective surgeon comfort, and types of surgical conditions. RESULTS: The age ranged from 19 to 86 years. Forty-nine of 124 patients (39.5%) received PK only and remaining 75 patients (60.5%) received additional procedures. A single injection was sufficient to achieve adequate akinesia (grade II and III) in 114 (92%) patients and 120 (97%) of patients were satisfied (graded pain as < or = grade II). During surgery, 6 (5%) phakic eyes developed episodes of positive intraocular pressure and 5 eyes (4%) developed chemosis. There were no other local or systemic adverse events. The surgeon level comfort was (grade II or more) 98% (122 of 124). CONCLUSION: One-point, low volume, peribulbar anaesthesia for penetrating keratoplasty is safe and efficacions.

Bloqueio peribulbar com ropivacaina: influência da hialuronidase sobre a qualidade do bloqueio e a pressäo intra-ocular / Peribulbar block with ropivacaine: effects of hyaluronidase on blockade quality and intraocular pressure

Justificativa e objetivos - Alguns estudos têm relatado melhoria da qualidade do bloqueio peribulbar com o emprego de hialuronidase, enquanto outros concluem pela ausência de efeito. O objetivo deste estudo foi investigar a influência da hialuronidase sobre a pressão intra-ocular (PIO) e a qualidade do bloqueio peribulbar com ropivacaína a 1 por cento. Método - Quarenta pacientes submetidos à cirurgia de catarata foram distribuídos de forma aleatória em dois grupos e submetidos a bloqueio peribulbar com 7ml de ropivacaína a 1 por cento em técnica de dupla punção, com hialuronidase 50UI.ml-1 no Grupo A(n=20) e sem hialuronidase no Grupo B(n=20). As medidas de PIO foram realizadas com tonômetro de aplanação de Perkins em quatro momentos: MO=antes do bloqueio (controle); M1=1 min após o bloqueio; M2=5 min após o bloqueio; M3=15 min após o bloqueio. A qualidade foi avaliada pelo médico Nicoll, baseado na redução da motilidade do globo ocular. Resultados - As médias de PIO (mmHg) antes do bloqueio foram semelhantes nos dois grupos: 16ñ2,1 (A) vs 16,4ñ3,3 (B). Após o bloqueio, as médias de PIO foram significativamente menores no Grupo A em relação ao Grupo B nos três momentos: M1=11,7ñ2,4 vs 17,9ñ3,6; M2=8,2ñ1,9 vs 14,1ñ4,0; M3=5,3ñ2,1 vs 10,2ñ3,1. O comportamento intragrupos também foi diferente. No Grupo A, as médias de PIO foram significativamente menores em relação ao controle nos três momentos após o bloqueio; no Grupo B a média de PIO elevou-se em M1 e foi significativamente inferior ao controle em M2 e M3. As médias para os índices de motilidade do globo ocular (Nicoll) foram significativamente menores no Grupo A em relação ao B nos três momentos: M1=2,55 vs 3,65; M2=0,25 vs 2,2; M3=0,00 vs 1,00. Conclusões - Quando se emprega solução de ropivacaína a 1 por cento adicionada de hialuronidase 50Ui.ml-1 em bloqueio peribulbar, os valores da PIO são menores e a qualidade do bloqueio é melhor do que se utiliza ropivacaína a 1 por cento sem hialuronidase

Sodium bicarbonate--an alternative to hyaluronidase in ocular anaesthesia for cataract surgery.

PURPOSE: To evaluate and compare the safety, efficacy and cost-effectiveness of 7.5% sodium bicarbonate buffered lidocaine (pH 7.2) with hyaluronidase mixed lidocaine (pH 4.6) for local anaesthesia in cataract surgery. METHODS: This prospective study comprised two parts. Part I: We evaluated the ocular and systematic anaesthetic safety and efficacy of 7.5% sodium bicarbonate buffered lidocaine on 112 consecutive patients undergoing cataract extraction with intraocular lens (IOL) implantation. At 12-week postoperative follow up final visual acuity and detailed fundus examination was done. Part II: It was conducted as a double blind, randomized comparative clinical trial involving 120 patients undergoing cataract surgery under retrobulbar anaesthesia. Patients were randomly assigned to one of the two groups: 60 eyes received 2 ml of 2% lidocaine with 1:200,000 epinephrine and 1 ml of 7.5% sodium bicarbonate, (0.299 mmol/ml); the remaining 60 eyes received 2 ml of 2% lidocaine with 1:200,000 epinephrine and 450 units of hyaluronidase (15 U/ml). In the event of incomplete akinesia, retrobulbar blocks were supplemented at 10 minutes. Onset and duration of anaesthesia and akinesia were assessed and compared in both groups. RESULTS: The pH-adjusted lidocaine group did not show any demonstrable variation in blood pressure (BP) or other systemic reaction. No anaesthesia-related adverse ocular effects were observed either during or after surgery. Thirty-one eyes (51.6%) achieved complete anaesthesia and akinesia within 5 minutes compared to 13 eyes (21.6%) in the hyaluronidase group. However, the overall mean onset time of anaesthesia and akinesia, repeat block rate and the duration of the anaesthesia were comparable in both the groups--p: 0.14). Twelve weeks postoperatively 88.39% of patients showed a best corrected visual acuity of 6/18 or better (73.21%-6/12 or better). CONCLUSION: In this study, sodium bicarbonate buffered 2% lidocaine was found to be a safe and effective local anaesthetic, with reduced time of onset, and improved quality of both anaesthesia and akinesia. Sodium bicarbonate (7.5%) may be used as an alternative to hyaluronidase in ocular anaesthesia. It is readily available and is cost effective.

pH-adjusted periocular anaesthesia for primary vitreoretinal surgery.

PURPOSE: To evaluate the efficacy of pH-adjusted bupivacaine in conjunction with medial orbital periconal block (periocular anaesthesia). METHODS: Sixty consecutive patients undergoing primary vitreoretinal surgery were enrolled prospectively. RESULTS: Adequate anaesthesia and akinesia with no intraoperative supplementation was achieved in 53 eyes (88.3%). Factors influencing intraoperative supplementation were combined vitrectomy with scleral buckling (p = 0.005) and duration of surgery of more than 2 hours (p = 0.001). No ocular or systemic complication resulted. CONCLUSION: pH-adjusted periocular anaesthesia is safe and effective in patients undergoing primary vitreoretinal surgery.

Ropivacaína em bloqueio peribulbar: estudo comparativo com bupivacaína / Ropivacaine in peribulbar block: a comparative study with bupivacaine

Justificativa e objetivos - O presente estudo tem por finalidade avaliar a eficácia da ropivacaína - um novo anestésico local com menor oxicidade sistêmica - em bloqueio peribulbar para cirurgias intra-oculares, comparandoa com a bupivacaína. Método - participaram do estudo oitenta pacientes com idade entre 45 e 92 anos, estado físico I, II ou III (ASA), divididos em dois grupos. No grupo A (n=40) receberam ropivacaína a 1 por cento e no Grupo B bupivacína a 0,75 por cento, ambas adicionadas de hialuronidase 50 UL.ml elevado a menos 1, pela técnica de bloqueio peribulbar com duas punçöes. A qualidade do bloqueio foi avaliada através de método que quantifica a reduçäo da motilidade do globo ocular. Resultados - O percentual de pacientes com índice de motilidade ocular demonstrativo de sucesso de bloqueio foi maior no grupo A no 1º e no 5º minutos após a injeçäo. O índice de motilidade ocular no 5º minuto foi significativamente menor no grupo A. Aos 10 minutos näo houve diferença significativa entre os grupos quanto ao índice de motilidade ocular e 100 por cento dos pacientes em ambos os grupos apresentaram índice de motilidade demonstrativo de sucesso de bloqueio. Conclusöes - Embora tenha se evidenciado tendência para instalaçäo mais rápida do bloqueio com a ropivacaína, ambos os anestésicos locais mostraram-se igualmente eficazes em bloqueio peribulbar para a realizaçäo de cirurgias intra-oculares

Effects of intracervical injection of hyaluronidase in primigravidae during labour.

A study was conducted on 75 primigravidae in labour of which 50 were injected with intracervical injection of hyaluronidase and 25 were taken as control. Labour could be accelerated and shortened by an average of 1.95 hours (p < .01) after intracervical injection of hyaluronidase. Its effect was insignificant on the latent phase of labour while it significantly shortened the active phase of labour by 2.09 hours (p < .001). Its effect on maximum rate of cervical dilatation (0.85 cm/hour) was also found to be statistically significant ie, p < .001. Hyaluronidase had no effect on uterine contractions, duration of 2nd and 3rd stages of labour and on involution of the uterus. There was no incidence of cervical tear in any of the cases.

Hialuronidase em anestesiologia: atualizaçäo / Hyaluronidase in anesthesiology: atualization

A hialuronidase (HYA) hidrolisa o ácido hialurônico (cimento intercelular), e é empregada em Anestesiologia e em outras condiçöes clínicas como para acelerar a absorçäo de líquidos infiltrados nos tecidos. Os autores descrevem diversos aspectos da farmacodinâmica deste fermento e das atuais aplicaçöes em Anestesiologia

Anestesia local en procedimientos ano rectales / Local anesthesia in anorectal surgery

Se trata de un estudio prospectivo de 62 pacientes con patología ano rectal, en los cuales se utilizó anestesia local, Lidocaína al 5% con una solución de Epinefrina al 1 x 200.000 y 1-2 cc de Hialuronidasa. Estudiamos la analgesia y relajación, las molestias producidas por el procedimiento anestésico y su tolerancia en el enfermo