Glaucoma e óleo de silicone / Glaucoma and silicone oils

RESUMO O óleo de silicone é um importante tampão utilizado na retinopexia cirúrgica de casos graves de descolamento de retina. O aumento da pressão intraocular e o desenvolvimento de glaucoma secundário são frequentes complicações da sua utilização. A depender do período de aparecimento, diversos mecanismos justificam a ocorrência de tais complicações. Compreender os fatores de riscos e a patogênese do aumento da pressão intraocular associada a aplicação de óleo de silicone em cirurgia retiniana ajuda a orientar o tratamento adequado para cada paciente. O objetivo deste artigo é revisar a literatura sobre a patogenia, a incidência, os fatores de risco e o tratamento desta condição clínica.

ABSTRACT Silicone oil has been an important intraocular tamponade in retinopexy in cases of complicated retinal detachment surgery. The increase of intraocular pressure and development of secondary glaucoma are a known complication of its use. A variety of mechanisms have been proposed for the pathogenesis, depending on the onset. This article aims to review the literature about pathogenesis, the incidence and risk factors, as well as the treatment of this pathology.

Análise da variação da pressão intraocular após injeção intravítrea de ranibizumabe / Analysis of intraocular pressure variation after intravitreal injection of ranibizumab

Resumo Objetivo: O tratamento com anti-angiogêncios é uma das modalidades mais utilizadas em patologias relacionadas ao edema macular. A injeção intravítrea de um inibidor do VEGF-A tem alta efetividade, porém está relacionada com efeitos adversos, como o aumento da pressão intraocular. O objetivo deste estudo foi avaliar a variação da pressão intraocular (PIO) em pacientes que se submeteram a injeções intravítreas de ranibizumabe, a variação de acordo com facia e com história de injeções prévias. Métodos: Este foi um estudo um estu-do observacional transversal. Foram incluídos todos os pacientes submetidos a injeções intravítreas com diagnóstico de degeneração macular relacionada à idade exsudativa, oclusão de veia central da retina com edema macular, ou edema macular diabético. A pressão intraocular foi aferida antes da injeção, imediatamente após e 30 minutos após a injeção com tonômetro portátil. Resultados Foram realizadas 143 injeções intravítreas, restando para a análise 96 injeções realizadas em 55 participantes. A comparação entre a PIO antes e 30 minutos após a injeção intravítrea mostrou-se estatisticamente significativa com PIO final maior que a inicial (p<0,0001) em pacientes com edema macular diabético. Pacientes fácicos e afácicos não mostraram diferenças significativas com relação a variação da PIO. Quando analisados apenas os participantes que haviam recebido injeções prévias, não foi encontrado uma variação significativa. Conclusão: Concluímos neste estudo que existe uma diferença significativa entre a pressão intraocular antes e 30 minutos após a injeção intravítrea de ranibizumabe em pacientes com edema macular diabético, mos-trando que esse período de tempo não foi suficiente para a regressão da PIO ao valor pré-injeção. Não encontramos diferenças significativas entre outros grupos, comparação entre fácicos e afácicos, nem em pacientes que haviam recebido injeções prévias.

Abstract Objective: Treatment with anti-angiogenic drugs is one of the most widely used modalities of treatment of macular edema related conditions. Intravitreal injection of a VEGF-A inhibitor is highly effective, but is related to adverse effects such as increased intraocular pressure. The objective of this study was to evaluate intraocular pressure (IOP) variation in patients who underwent intravitreal injections of ranibizumab, variation according to phakic/aphakic and history of previous injections. Methods: This was a cross-sectional observational study. All patients submitted to intravitreal injections with diagnosis of exudative age-related macular degeneration, retinal central vein occlusion with macular ede-ma, or diabetic macular edema were included. The IOP was measured before the injection, immediately after and 30 minutes after the injection with a portable tonometer. Results: 143 intravitreal injections were performed, with 96 injec-tions performed in 55 participants. The comparison between IOP before and 30 minutes after intravitreal injection showed to be statistically significant with higher than initial IOP (p <0.0001) in patients with diabetic macular edema. Phakic and aphakic patients did not show significant differences regarding IOP variation. When only those participants who had received previous injections were analyzed, no significant variation was found. Conclusion: We conclude in this study that there is a significant difference between intraocular pressure before and 30 minutes after intravitreal injection of ranibizumab in patients with diabetic macular edema, showing that this period of time was not sufficient for regression of IOP at the pre-injection value . We did not find significant differences between other groups, comparing phakic and aphakic patients, nor in patients who had received previous injections.

Exercise training prevents increased intraocular pressure and sympathetic vascular modulation in an experimental model of metabolic syndrome

The present study aimed to study the effects of exercise training (ET) performed by rats on a 10-week high-fructose diet on metabolic, hemodynamic, and autonomic changes, as well as intraocular pressure (IOP). Male Wistar rats receiving fructose overload in drinking water (100 g/L) were concomitantly trained on a treadmill for 10 weeks (FT group) or kept sedentary (F group), and a control group (C) was kept in normal laboratory conditions. The metabolic evaluation comprised the Lee index, glycemia, and insulin tolerance test (KITT). Arterial pressure (AP) was measured directly, and systolic AP variability was performed to determine peripheral autonomic modulation. ET attenuated impaired metabolic parameters, AP, IOP, and ocular perfusion pressure (OPP) induced by fructose overload (FT vs F). The increase in peripheral sympathetic modulation in F rats, demonstrated by systolic AP variance and low frequency (LF) band (F: 37±2, 6.6±0.3 vs C: 26±3, 3.6±0.5 mmHg2), was prevented by ET (FT: 29±3, 3.4±0.7 mmHg2). Positive correlations were found between the LF band and right IOP (r=0.57, P=0.01) and left IOP (r=0.64, P=0.003). Negative correlations were noted between KITT values and right IOP (r=-0.55, P=0.01) and left IOP (r=-0.62, P=0.005). ET in rats effectively prevented metabolic abnormalities and AP and IOP increases promoted by a high-fructose diet. In addition, ocular benefits triggered by exercise training were associated with peripheral autonomic improvement.

Miopia aguda e hipertensão intraocular após uso de topiramato / Acute miopia and intraocular hypertension after topiramate use

A migrânea acomete cerca de 6% a 7% dos homens e 18% a 20% das mulheres, principalmente entre 25 e 55 anos de idade, e é responsável por enorme impacto na atividade produtiva. O topirama-to é um das drogas antiepilépticas aprovadas pela Food and Drug Administration (FDA), sendo usado para a prevenção da migrânea. É uma droga segura, mas não isenta de efeitos adversos. Embora alterações oftalmológicas causadas pelo uso dessa medicação não sejam comuns, aqui é relatado um caso de uma paciente que, ao procurar profilaxia para as crises de migrânea, apresentou efeito adverso ocular, o qual, se não fosse reconhecido em tempo hábil, causaria efeitos maiores e mais danosos à paciente.

Migraine affects approximately 6% and 7% of men and 18% and 20% of women mainly between 25 and 55 years old, responsible for its enormous impact on productive activity. Topiramate is one of the Food and Drug Administration (FDA) approved antiepileptic drugs used for migraine prevention. It is a safe drug but not without side effects. Although ophthalmologic changes caused by this medication are not common, here is reported a case of a patient looking for pro-phylaxis of migraine attacks exhibited an ocular adverse effect, and if not recognized in due time, larger and more harmful effects could be inflicted to the patient.

Effect of dacryocystorhinostomy on systemic adverse effects of topical timolol maleate.

Purpose: To evaluate whether transformation of the naso-lacrimal passage as happens after dacryocystorhinostomy (DCR) operation has any effect on the systemic adverse effects of topically administered timolol maleate. Materials and Methods: Fifty otherwise healthy adult patients without any prior history of cardiac or pulmonary problems scheduled for elective DCR surgery received a drop of timolol maleate 0.5% on the healthy eye. This eye served as a control. Six weeks after successful DCR surgery, the operated eye received the same medication. Parameters compared included intraocular pressure (IOP), pulse rate, blood pressure and forced expiratory volume in the first second (FEV1) findings. Observations: Post DCR patients showed an increased incidence of reduced pulse rate and FEV1. Conclusion: Timolol maleate ophthalmic preparation should be used with caution in post-DCR patients.

Effectiveness of diode laser trans-scleral cyclophotocoagulation in patients following silicone oil-induced ocular hypertension in Chinese eyes.

We evaluated the effectiveness of diode laser trans-scleral cyclophotocoagulation (TSCPC) on intraocular pressure (IOP) in nine patients having raised IOP following use of silicone oil (SO) for retinal detachment (RD) surgery in a retrospective observational case series. Diode laser TSCPC was applied at a power setting of 1.75 to 2.5 watts, for two sec with a maximum of 30 applications. The patients were followed up for 40 to 312 weeks. The mean pre-laser IOP was 32.06 mm Hg (SD 7.32). The mean post-laser IOP at one month, three months and six months was 17.89 mm Hg (SD 8.23), 21.89 mm Hg (SD 8.16) and 21.67 mm Hg (SD 7.55) respectively. The final IOP (at the last follow-up) was 19.56 mm Hg (SD 7.85) (P=0.021). Seven of them had undergone SO removal. In our observation, effectiveness of TSCPC in long-term control of SO-induced ocular hypertension was limited as compared to short-term control of IOP.

Meloxicam e prednisona: efeitos do tratamento oral de curto prazo sobre os níveis de pressão intraocular em cães / Meloxican and prednisone: the effects of orally short term treatment on the intra-ocular pressure levels in dogs

Para possível observação da hipertensão ocular com o uso de antiinflamatórios, foram selecionados 28 cães da raça Beagle. Para avaliação da pressão intra-ocular antes do tratamento, no dia 0 (zero) todos os animais tiveram a pressão intra-ocular avaliada às 08 horas e às 16 horas. No dia seguinte dez cães receberam meloxicam na dose de0,2 mg/kg, e 0,1mg/kg nos restantes quatro dias. Nove cães receberam prednisona na dose de 1,0 mg/kg durante cinco dias. Nove cães receberam somente porção de ração úmida. No quinto dia do tratamento todos os animais tiveram novamente a pressão intra-ocular avaliada às 08 horas e às 16 horas. Em todos os grupos, incluindo o grupo-controle, as maiores médias de pressão intra-ocular foram observadas no dia 5 (cinco). A diferença dos valores de pressão intra-ocular observada entre as medições das 08 horas e das 16 horas foi significativa, independente do tratamento e do dia considerado. O uso dos anti-inflamatórios esteroidal e não-esteroidal não foi capaz de causar hipertensão ocular e alguns fatores podem ser incriminados, como via de administração, dose e duração do tratamento utilizado, além da ausência de doença glaucomatosa nos cães selecionados

In order to observe a possible ocular hypertension associated with the use of anti-inflammatory drugs, 28 beagle dogs were selected. For evaluation of intraocular pressure before treatment, the totality of animals had their intraocular pressure measured at 8 a.m. and 4 p.m.on day 0 (zero). On the following day 10 animals received meloxican on dose of 0.2 mg/Kg and 0.1 mg/Kg on the four remaining days. Nine dogs received prednisone on dose of 1,0 mg/Kg during five days. Nine dogs received only wet feeding. On the fifth day of treatment the totality of dogs had their intraocular pressure measured at 8 a.m.and 4 p.m. For all groups, including control-group, the highest average values of intraocular pressure were observed on day 5 (five). The difference between the two evaluations of intra-ocular pressure (8a.m. and 4 p.m) was significant, independent of treatment and of the considered day. The use of both steroidal or non-steroidal antiinflammatory were not capable of causing ocular hypertension and some factors can be pointed out, such as route of administration, dosage and duration of therapy chosen, besides absence of glaucomatous disorder between the selected dogs

Oculohypotensive effects of foeniculum vulgare in experimental models of glaucoma.

PURPOSE: Evaluation of oculohypotensive activity of single drop application of aqueous extract of Foeniculum vulgare in experimental models of glaucoma. METHODS: The evaluation of oculohypotensive activity of Foeniculum vulgare was done in rabbits with normal intraocular pressure (IOP) and with experimentally elevated IOP. The experimental increase in IOP was achieved using water loading and steroid induced glaucoma models. RESULTS: The aqueous seed extract of Foeniculum vulgare exhibited 17.49, 21.16 and 22.03% reduction of intraocular pressure (IOP) in normotensive rabbits at 0.3%, 0.6% and 1.2% (w/v) concentrations respectively. The 0.6% concentration was further evaluated in acute and chronic models of glaucoma. A maximum mean difference of 31.20% was observed between vehicle treated and extract treated eyes in water loading model while a maximum mean IOP lowering of 31.29% was observed in steroid induced model of glaucoma. CONCLUSIONS: The aqueous extract of Foeniculum vulgare possesses significant oculohypotensive activity, which was found to be comparable to that of timolol. Further investigations into the mechanism of action, possible toxicity and human clinical trials are warranted before the Foeniculum vulgare finds place in the arsenal of antiglaucoma drugs prescribed by physicians.

Topical diclofenac versus dexamethasone after strabismus surgery: a double-blind randomized clinical trial of anti-inflammatory effect and ocular hypertensive response.

BACKGROUND: Compared to steroids non-steroidal anti-inflammatory drugs offer comparable anti-inflammatory action without ocular side-effects. AIM: To compare the anti-inflammatory effect and effect on IOP (Goldmann) of topical diclofenac 0.1% with dexamethasone 0.1% after strabismus surgery. DESIGN: Prospective, randomized, double-blind, single-center, clinical trial. MATERIALS AND METHODS: Forty-three cases of constant horizontal strabismus, qualifying for standard uniocular recession-resection surgery on two horizontal rectus muscles were randomized to either the dexamethasone or diclofenac group. They were excluded if they had previous ocular surgery, recently used anti-inflammatory drugs and had a neurological, systemic or an ocular inflammatory condition. In addition all received ciprofloxacin 0.3% four times daily. Assessment was done on the first postoperative day and at two and four weeks. The inflammatory characteristics graded from nil (0) to severe (3) were: discomfort, chemosis, injection, discharge and drop-intolerance. Their sum provided the total inflammatory score (TIS). RESULTS: Dexamethasone group (n=21) was comparable in age, gender, preoperative IOP, strabismus, anesthesia administered and baseline IOP, to diclofenac (n=22). There were no significant differences in the inflammatory characteristics and TIS. The dexamethasone group had IOP significantly higher at two weeks (95% CI 0.17 to 3.25) and four weeks (95% CI 1.09 to 4.24) compared to diclofenac group and the net change of IOP at four weeks (95% CI 0.60 to 3.14). Compared to the baseline IOP. CONCLUSION: Topical diclofenac is comparable to dexamethasone in providing anti-inflammatory and analgesic effect with the advantage of significantly lesser IOP rise and should be preferred after strabismus surgery.

Ocular Hypertensive Response to Topical Dexamethasone Ointment in Children

PURPOSE: To investigate the rate and the degree of the ocular hypertensive response to dexamethasone ointment in children undergoing eyelid surgery. METHODS: Dexamethasone ointment (Dexcosil(R)) was applied three times a day for the first week and twice a day for the second to third week postoperatively to children undergoing epiblepharon surgery. Intraocular pressure (IOP) was measured on the day before surgery, postoperative day 1, 7, 14, 21, 28 and 2 weeks thereafter until the IOP reached preoperative levels. Peak IOP, IOP net increase and time to reach a peak IOP were analyzed. Dexamethasone ointment was discontinued if the IOP was 25 mmHg or more. RESULTS: A total of 96 children (mean age, 6.5+/-2.7 years) were included. Preoperative mean IOP was 13.6+/-2.9 mmHg (range 7-19). After dexamethasone ointment treatment, the children showed a significant rise in IOP as compared with the preoperative values. The peak IOP was 20.6+/-4.9 mmHg (range 11-39) and the time to reach peak IOP was 8.5+/-5.9 days. The low responders (delta IOP or =16) comprised 8.3% (8/96) of patients. A net increase in IOP was significantly higher in children 5 years old or less as compared with those older than 5 years (age5, 6.3+/-4.4 mmHg; p=0.015, unpaired t-test). CONCLUSIONS: Ocular hypertensive response after dexamethasone ointment to the eyelids occurred frequently in children, especially those 5 years old or younger.

Triamcinolone-Induced Intraocular Pressure Elevation: Intravitreal Injection for Macular Edema and Posterior Subtenon Injection for Uveitis

PURPOSE: To assess the effect of intravitreal and posterior subtenon injections of triamcinolone acetonide (TA) on intraocular pressure (IOP). METHODS: we reviewed 42 consecutive eyes after intravitreal TA injection (IVTA) and 43 eyes following posterior subtenon TA injection (PSTA). All cases had a minimum follow-up time of three months. After injection, the value and time of the maximal IOP, the amount of IOP elevation and the needs of the medication were assessed. RESULTS: The IOP increased significantly (p<0.001) from 16.3+/-2.5 mmHg preoperatively to a mean maximum of 21.7+/-5.3 mmHg in the IVTA group, and from 15.3+/-4.5 mmHg to 20.6+/-3.0 mmHg in the PSTA group. An elevation in the IOP of more than 5 mmHg from the baseline IOP was seen in 52.4% of the IVTA group at a mean time of 3.1 weeks postoperatively, and 44.2% of the PSTA group displayed an IOP elevation at 5.9 weeks. CONCLUSIONS: Both developed significant elevations of IOP, but this appeared at a later date in the PSTA group. Careful follow-up after local injection of steroids is necessary.

O campo visual azul-amarelo é mais sensível que o campo visual branco-branco? / Is blue-yellow visual field more sensitive than white-white visual field?

Objetivo: Comparar a sensibilidade entre o campo visual com estímulo azul-amarelo com o campo visual com estímulo branco em indivíduos normais e suspeitos de glaucoma. Métodos: Foram comparados dois grupos de pacientes: um deles com 25 pacientes suspeitos de glaucoma (50 olhos) conforme critérios clínicos previamente definidos e outro com 12 pacientes (24 olhos) dados como normais do ponto de vista clínico e campimétrico. Estes pacientes foram submetidos à campimetria computadorizada com estímulo branco-branco- Sita Standart 30-2 (Humphrey Instruments, San Leandro, Ca, USA) e com estímulo azul-amarelo Full-Threshold 30-2 (Humphrey Instruments, San Leandro, Ca, USA). Foram realizadas três medidas da pressão intra-ocular (PO) em dias diferentes e a média destas foi computada. Estes dados foram submetidos a tratamento estatístico com o SPSS para Windows ("Statistical Package for the Social Sciences", Chicago, II, USA). Resultados: A média das POs OD do grupo com suspeita de glaucoma foi de 15,3mmHg e no grupo de pessoas normais foi de 12mmHg (p=0,004). A média das POs OE no grupo com suspeita de glaucoma foi de 14,5mmHg e no grupo de pessoas normais foi de 11,8mmHg (p=0,014). Nenhum dos pacientes normais apresentou campo visual (CV) com estímulo branco alterado (Sensibilidade = 6 porcento e Especificidade = 100 porcento). Quarenta e oito olhos do grupo com suspeita de glaucoma apresentaram campo visual com estímulo azul-amarelo alterado (Sensibilidade = 96 porcento e Especificidade = 71 porcento). Conclusão: A realização do campo visual com estímulo azul-amarelo parece auxiliar na detecção precoce do dano glaucomatoso, devido a sua maior sensibilidade. Os autores acreditam que este seja um bom exame complementar para avaliação de casos com suspeita de glaucoma.