Eficacia clínica de la terapia fotodinámica por 5-ALA tópico en el manejo onco-preventivo de lesiones de leucoplasia oral. Una revisión sistemática / Clinical efficacy of topical 5-ALA photodynamic therapy in the onco-preventive management of oral leukoplakia lesions. A systematic review

Objetivo: La leucoplasia oral es el desorden maligno de la mucosa bucal más prevalente a nivel global y su manejo clínico sigue siendo un desafío. Se llevó a cabo una revisión sistemática para determinar la eficacia clínica de la terapia fotodinámica mediada por ácido 5-aminolevulínico tópico como una alternativa de quimio-prevención para las diferen- tes formas clínicas de la leucoplasia oral. Materiales y métodos: Empleando términos MeSH, se realizó una búsqueda exhaustiva en diferentes bases digi- tales de ensayos clínicos publicados en inglés en los últimos 30 años acerca del uso de la terapia fotodinámica mediada por ácido 5-aminolevulínico tópico como fotosensibilizador, y radiación láser de baja intensidad o luz LED como posibles fuentes de iluminación. Resultados: La revisión sistematizada que aplicó la guía PRISMA mostró una eficacia del 88,6% para este modo de fototerapia en el manejo de leucoplasias orales, con un 60,7% de respuesta completa y 27,9% de respuesta parcial. Además, el tamaño de efecto fue mayor para las formas clíni- cas homogéneas con cambios displásicos, independientemen- te del tipo de fuente de luz. La ausencia de respuesta fue del 11,4%, pero la evidencia empleada en este análisis fue mo- derada. Conclusión: La terapia fotodinámica mediada por áci- do 5-aminolevulínico tópico parece ser una alternativa útil en el manejo onco-preventivo de lesiones de leucoplasia oral. Sin embargo, es recomendable ejecutar ensayos clínicos controla- dos y aleatorizados con metodologías homogéneas que per- mitan generar un meta-análisis con un alto nivel de evidencia

Aim: Oral leukoplakia is globally the most prevalent ma- lignant disorder of the oral mucosa and its clinical manage- ment remains a challenge. A systematic review was carried out to determine the clinical efficacy of photodynamic therapy mediated by topical 5-aminolevulinic acid as an alternative for chemoprevention in the different clinical forms of oral leu- koplakia. Materials and methods: Using MeSH terms, an ex- haustive search was carried out in different digital databases of clinical trials published in English in the last 30 years on the use of photodynamic therapy mediated by topical 5-ami- nolevulinic acid as a photosensitizer, and low-intensity laser radiation or LED light as possible lighting sources. Results: The systematized review using PRISMA guide- lines showed an efficacy of 88.6% for this mode of photother- apy in the management of oral leukoplakias, based on 60.7% of complete response and 27.9% of partial response. In addi- tion, the effect size was larger in homogeneous clinical forms with dysplastic changes, regardless of the type of light source. There was an 11.4% of absence of response, but the evidence used in this analysis was moderate. Conclusion: Photodynamic therapy mediated by topical 5-aminolevulinic acid seems to be a useful alternative in the onco-preventive management of oral leukoplakia lesions. However, it is recommendable to perform controlled and ran- domized clinical trials with homogeneous methodologies that allow the generation of a meta-analysis with a high level of evidence (AU)

Corneal crosslinking efficacy in patients with keratoconus under 18 years of age / Eficácia do crosslinking corneano em portadores de ceratocone com idade inferior a 18 anos

ABSTRACT Purpose: Keratoconus presents certain specificities in pediatric patients compared with adults. The greatest challenge is because the disease is typically more severe and progresses faster in children. This retrospective study aimed to report crosslinking procedure in patients under 18 years of age and their follow-up for at least 24 months after the procedure. Methods: Overall, 12 eyes from 10 patients were studied and data, such as visual acuity with and without correction, maximum keratometry, corneal thickness, foveal thickness, and endothelial microscopy, were assessed at both preoperative and postoperative visits. Corneal crosslinking was performed in all patients. Results: A tendency toward reduced Kmax and improved Corrected Distance Visual Acuity at all postoperative moments. Only one of the 12 eyes exhibited increased Kmax of more than 1 D during a time frame longer than 12 months. Regarding pachymetry, a tendency for corneal thinning was observed in the first four months after surgery. Conclusion: Encouraging results were obtained regarding the stabilization of the disease, progression, and procedural safety, corroborating to other authors' findings. The significance of early diagnosis and short-term follow-up were highlighted.

RESUMO Objetivo: O ceratocone na população pediátrica apresenta algumas particularidades em relação à população adulta. O maior desafio é devido à doença ser geralmente mais severa e rapidamente progressiva em crianças. Métodos: Este artigo utiliza uma análise retrospectiva para relatar o uso do crosslinking em jovens menores de 18 anos e sua evolução pelo menos 24 meses após o procedimento. Foram estudados 12 olhos de 10 pacientes, e dados como acuidade visual com e sem correção, ceratometria máxima, espessura corneana, espessura foveal e microscopia endotelial avaliados no pré e pós-operatórios. O crosslinking corneano foi realizado em todos os pacientes pelo mesmo cirurgião. Resultados: Observou-se uma tendência de redução do valor do Kmax e melhora da acuidade visual corrigida em todos os momentos de pós operatório. Com relação à paquimetria, observou-se afinamento corneano do ponto mais fino, nos primeiros quatro meses de pós-operatório. Conclusão: Resultados encorajadores foram obtidos com relação à estabilização da doença, progressão e segurança do procedimento, corroborando com as conclusões de outros autores. A importância do diagnóstico precoce e do acompanhamento a curto prazo do paciente deve ser destacada.

Use of gabapentin in management of postoperative pain after crosslinking / Uso da gabapentina no manejo da dor pós-operatória do crosslinking

ABSTRACT Objective: The objective was to evaluate the efficacy of gabapentin in the management of neuropathic pain in patients with keratoconus, who were treated with fast (10 minutes) epi-off corneal crosslinking (CXL). Methods: This was a prospective, double-blind, randomized study. The sample comprised patients with bilateral progressive keratoconus, aged 12 years or older, who underwent a bilateral epi-off corneal CXL (fast - 10 minutes) procedure. One group was given placebo orally, and the other group received gabapentin 600 mg orally, both preoperatively. The visual analogue scale (VAS) was applied to record postoperative pain up to 48 hours after procedure. The study was conducted at the Belotto Stock Centro Oftalmológico, in the city of Joaçaba, Santa Catarina, Brazil, from June 2018 to September 2019. Results: At no point in the study significant differences were observed between groups, in terms of pain intensity measured by means of the VAS questionnaire, or of opioid use (Paco®), though opioid consumption was 21% lower in the group receiving gabapentin. Conclusion: We concluded gabapentin has no efficacy in postoperative pain control after epi-off corneal CXL (fast - 10 minutes). Although there was no statistically significant difference, the group that received gabapentin suffered less pain, resulting in lower opioid consumption. UTN number: U1111-1256-0330.

RESUMO Objetivo: Avaliar a eficácia do uso da gabapentina no manejo da dor neuropática em pacientes portadores de ceratocone submetidos ao tratamento de crosslinking corneano epi-off fast de 10 minutos. Métodos: Tratou-se de pesquisa prospectiva, duplo-cega, randomizada. A amostra foi composta de pacientes com ceratocone progressivo bilateral, a partir dos 12 anos de idade, submetidos ao procedimento de crosslinking corneano acelerado epi-off fast de 10 minutos bilateral. Um grupo recebeu placebo via oral e o outro, gabapentina 600mg, via oral, ambos no pré-operatório. A Escala Visual Analógica foi aplicada para registrar a dor pós-operatória até 48 horas após o procedimento. A pesquisa foi realizada no período de junho de 2018 a setembro de 2019 em um centro oftalmológico. Resultados: Não foram observadas diferenças estatísticas significativas para ambos os grupos, tanto na intensidade da dor medida pela Escala Visual Analógica, como na redução do uso do opioide (Paco®), em qualquer horário analisado durante um período de 48 horas. No entanto, houve redução de 21% no consumo de opioides pelo grupo que fez uso da gabapentina. Conclusão: A gabapentina não demonstrou eficácia no controle da dor no pós-operatório do crosslinking corneano epi-off fast de 10 minutos. No entanto, observou-se que, mesmo não havendo diferença estatisticamente significativa, houve diminuição da dor no grupo em que foi usada a gabapentina, resultando na redução do consumo de opioides. Número UTN: U1111-1256-0330.

Progress on photodynamic therapy in oral diseases / 华西口腔医学杂志

Photodynamic therapy (PDT) has developed rapidly in basic and clinical research, and its therapeutic prospects have received increasing attention. PDT has the advantages of minimally invasive, low toxicity, high selectivity, good reproducibility, protection of appearance and vital organ function, and has become a treatment. With the development of medicine, the field of application of PDT becomes more wildly, and brings a new direction for the treatment of oral diseases. This article reviews the basic principles, treatment elements and research results of PDT in the treatment of oral diseases.

Accelerated corneal cross-linking with hypo-osmolar riboflavin in thin keratoconic corneas: 2-year follow-up / Cross-linking corneano acelerado com riboflavina hiposmolar em córneas ceratocônicas finas: 2 anos de acompanhamento

ABSTRACT Purpose: This study was performed to evaluate the outcomes of accelerated corneal cross-linking in keratoconic corneas with thinnest pachymetry values of <400 µm. Methods: The study included 28 eyes of 24 patients. The uncorrected and best-corrected visual acuities (logMAR), flattest and steepest keratometric readings, central corneal thickness at the thinnest point, corneal higher-order aberrations, and contrast sensitivity were assessed before and at 1, 3, 6, 12, and 24 months after corneal cross-linking. Result: The mean best-corrected visual acuity and contrast sensitivity increased (p=0.02, p=0.03, respectively), whereas the mean uncorrected visual acuity did not significantly differ (p>0.05) at 24 months after corneal cross-linking, compared with measurements before corneal cross-linking. Although the mean flattest keratometric reading showed no significant change (p=0.58), the mean steepest keratometric reading was reduced when compared with its value before corneal cross-linking (p=0.001). No change was observed in the mean central corneal thickness at the thinnest point at 24 months after corneal cross-linking, compared with its value before corneal cross-linking (p=0.12). Conclusion: Accelerated corneal cross-linking in keratoconic eyes with thin corneas could halt the progression of keratoconus in corneas thinner than 400 µm at 24 months after treatment.

RESUMO Objetivo: Este estudo foi realizado para avaliar os resultados do cross-linking corneano acelerado em córneas ceratocônicas com os valores mais baixos de paquimetria <400 µm. Métodos: O estudo incluiu 28 olhos de 24 pacientes. As acuidades visuais não corrigidas e melhor corrigidas (logMAR), leituras ceratométricas mais planas e íngremes, espessura corneana central no ponto mais fino, aberrações corneanas de mais alta ordem e a sensibilidade ao contraste foram avaliadas antes e em 1, 3, 6, 12 e 24 meses após a realização do do cross-linking. Resultados: A média da acuidade visual melhor corrigida e a sensibilidade ao contraste aumentaram (p=0,02, p=0,03, respectivamente), enquanto a média da acuidade visual não corrigida não diferiu significativamente (p>0,05) aos 24 meses após o cross-linking, comparada com medidas antes do procedimento. Embora a leitura da média da ceratometria mais plana não tenha apresentado alteração significativa (p=0,58), a leitura ceratométrica mais íngreme diminuiu quando comparada ao seu valor antes do cross-linking (p=0,001). Não foi observada alteração na média da espessura corneana central no ponto mais fino aos 24 meses após o cross-linking em comparação com seu valor antes do procedimento (p=0,12). Conclusão: O cross-linking corneano acelerado nos olhos ceratocônicos com córneas finas pode interromper a progressão do ceratocone nas córneas mais finas que 400 µm 24 meses após o tratamento.

Análise da eficácia do crosslinking transepitelial em pacientes portadores de ceratocone / Analysis of the effectiveness of transepithelial crosslinking in patients with keratoconus

Resumo Objetivo: Avaliar os resultados clínicos do Crosslinking Transepitelial (CXL) analisando sua eficácia em pacientes portadores de ceratocone progressivo. Métodos: Estudo transversal retrospectivo com 49 olhos e 37 pacientes com idades entre 10 e 50 anos, submetidos à técnica de CXL em 2017 no Instituto Panamericano da Visão, em Goiânia, Goiás, Brasil. Foi utilizado o sistema KXL Avedro programado no modo pulsado com intervalo (1/1 segundo), usando 45 mW/cm² com 7,2 J e solução de riboflavina a 0,25% da Avedro com córneas irradiadas por 8 minutos. Foram coletados os dados: sexo, idade, acuidade visual sem correção (AVSC), acuidade visual com correção (AVCC), astigmatismo, paquimetria no ponto mais fino e astigmatismo ceratométrico no pré-operatório e pós-operatório com 1, 6 e 12 meses. Foram utilizados os testes Kolmogorov-Smirnov, Qui-quadrado de Pearson, Friedman, Dunnett à posteriori e a correlação de Spearman. Resultados: Vinte e três pacientes (62,2%) eram do sexo feminino e 14 (37,8%) do sexo masculino. A média de idade foi de 27,89 (±10,89) anos. A AVSC e AVCC melhoraram significativamente no pré-operatório em relação a 1 mês (p=0,01) e (p<0,001), 6 meses (p<0,001 ambas) e 12 meses (p<0.001 ambas). O astigmatismo reduziu significativamente no pré-operatório em relação a 6 meses (p=0,02) e 12 meses (p=0,02). A paquimetria no ponto mais fino manteve-se constante no período (p=0,95). A diferença entre k2 e k1 (astigmatismo ceratométrico) mostrou redução significativa no pré-operatório em relação a 1 mês (p=0,01). Conclusão: A técnica de CXL foi segura e eficaz no tratamento e estagnação da doença em pacientes com ceratocone progressivo.

Abstract Objective: To evaluate the clinical results of Transepithelial Crosslinking (CXL) by analyzing its efficacy in patients with progressive keratoconus. Methods: Retrospective cross-sectional study with 49 eyes and 37 patients aged 10 to 50 years submitted to the CXL technique in 2017 at the Instituto Panamericano da Visão, in Goiânia, Goiás, Brazil. The Avedro KXL system was programmed in pulsed mode with interval (1/1 second), using 45 mW/cm² with 7.2 J and 0.25% riboflavin solution of Avedro with irradiated corneas for 8 minutes. Data were collected: sex, age, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), astigmatism, pachymetry at the thinnest point and keratometric astigmatism in the preoperative and postoperative periods at 1, 6 and 12 months. The Kolmogorov-Smirnov, Pearson's Chi-square, Friedman, Dunnett, and the Spearman correlation were used. Results: Twenty-three patients (62.2%) were female and 14 (37.8%) male. The mean age was 27.89 ± 10.89 years. The UDVA and CDVA significantly improved in the preoperative period in relation to 1 month (p = 0.01) and (p <0.001), 6 months (p <0.001 both) and 12 months (p <0.001 both). Astigmatism significantly reduced preoperatively in relation to 6 months (p = 0.02) and 12 months (p = 0.02). The pachymetry at the thinnest point remained constant in the period (p = 0.95). The difference between k2 and k1 (keratometric astigmatism) showed a significant reduction in the preoperative period in relation to 1 month (p = 0.01). Conclusion: The CXL technique was safe and effective in the treatment and stagnation of the disease in patients with progressive keratoconus.

Accelerated collagen cross-linking in the management of advanced Acanthamoeba keratitis / Cross-linking acelerado de colágeno no controle da ceratite por Acanthamoeba avançada

ABSTRACT Purpose: To report our initial experience in the treatment of Acanthamoeba keratitis with accelerated corneal collagen cross-linking. Methods: Retrospective chart review of patients diagnosed with Acanthamoeba keratitis with progressive corneal melting who were treated with accelerated collagen cross-linking. Results: A total of 6 eyes (5 patients) were reviewed. All the patients received adjuvant therapy with moxifloxacin and chlorhexidine. In 4 cases, the ulcer healed with a mean interval to epithelialization of 108.8 days (range 59-217). In 2 eyes, there was a persistent neurotrophic ulcer. The melting was not progressive in any case, nor did any eye required emergency penetrating keratoplasy. Conclusion: This study suggests a beneficial effect of accelerated collagen cross-linking in cases of Acanthamoeba keratitis with corneal melting. Thus, collagen cross-linking may be considered as adjuvant treatment for Acanthamoeba keratitis.

RESUMO Objetivo: Relatar nossa experiência inicial no tra tamento da ceratite por Acanthamoeba com reticulação acelerada de colágeno corneano. Métodos: Revisão retrospectiva de prontuários de pacientes diagnosticados com ceratite por Acanthamoeba, com deformação progressiva da córnea, tratados com reticulação acelerada de colágeno. Resultados: Seis olhos (5 pacientes) foram incluídos. Todos os pacientes receberam terapia adjuvante com moxifloxacina e clorexidina. Em 4 casos, a úlcera cicatrizou com uma média de epitelização de 108,8 dias (amplitude de 59-217 dias). Em dois pacientes, a úlcera apresentou um comportamento neurotrófico. A deformação não foi progressiva em nenhum dos pacientes e nenhum dos olhos exigiu ceratoplastia penetrante de emergência. Conclusão: Este estudo sugeriu um efeito benéfico da reticulação acelerada de colágeno em casos de ceratite por Acanthamoeba infecciosa com deformação corneal. A reticulação de colágeno parece ser uma alternativa coadjuvante possível para casos de ceratite por Acanthamoeba.

Use of photodynamic inactivation for in vitro reduction of prevalent bacteria in Fournier's Gangrene

ABSTRACT Fournier's Gangrene (FG) is an infectious disease caused by several synergic microbes, with high morbidity and mortality rates; therefore, the search for new less invasive and mutilating treatments, with faster recovery, has been proposed. Surgical intervention, the use of several systemic and topic antibiotics, and hyperbaric oxygen therapy are currently the best approach for the treatment of these patients. The use of Photodynamic Inactivation (PDI) aims to lower morbidity and mortality, by reducing bacterial microbiota and speeding wound healing. In the present study, viable bacteria were separated in four groups: Group L-/F- (no irradiation with red laser and absence of methylene blue photosensitizer), Group L-/F+ (no irradiation with red laser and presence of methylene blue), Group L+/F- (irradiation with red laser and absence of methylene blue) and L+/F+ (irradiation with red laser associated to methylene blue). In all groups, exposure time to treatment was 5, 10 and 15 minutes. The concentration of methylene blue photosensitizer was 0.1mg/L, and the dose of red laser (660nm wave length) was 176.9mW/cm2. Following irradiation, the reduction of number of bacteria was evaluated, and the results were expressed in colony forming units (CFU) and as exponential reduction. As the main results, in the L+/F+ group, there were no Clostridium perfringens and Staphylococcus aureus CFUs and there was a reduction of Escherichia coli that was not observed in the other groups.

Segmental lichen aureus: an uncommon presentation

Abstract: Pigmented purpuric dermatoses are chronic vascular inflammatory conditions characterized by the presence of pigmented macules. Among its different presentations, lichen aureus is distinguished by the lichenoid conformation of its plaques and the predilection for lower limb involvement. Its segmented form is rare and difficult to control, especially in cases of symptomatic lesions. We report a rare case of segmental lichen aureus with six years of evolution associated with light itching. We also discuss the main therapeutic approaches to control the disease.

Hemoporfin-mediated photodynamic therapy for the treatment of port-wine stain birthmarks in pediatric patients

Abstract: Port-wine stain is a type of common congenital superficial telangiectasia in the dermal layer mostly occurring on the forehead, face, and neck. The affected skin shows abnormal red or purple lesions, which darken and thicken. Nodular changes may develop with advancing age. If untreated, port-wine stains scarcely regress, which can have serious lifelong psychological impact on patients and affect their quality of life. In this report, we focused on two cases of port-wine stain in pediatric patients; the youngest patient was only 1.5 years old. During and after treatment, Hemoporfin-mediated photodynamic therapy features fewer adverse reactions, short light protection period, easy nursing, and good efficacy.

Daylight photodynamic therapy - Experience and safety in treatment of actinic keratoses of the face and scalp in low latitude and high brightness region

ABSTRACT Daylight photodynamic therapy has been used in countries with high latitudes during the summer for actinic keratoses treatment with reports of similar efficacy to conventional photodynamic therapy. We evaluate its safety in 20 patients in the city of Fortaleza, a local with low latitude and high brightness. Sixteen patients did not report any discomfort due to the procedure. Daylight photodynamic therapy is an easy application method with great tolerability by the patient and has the possibility of being performed throughout the year in these regions. It can mean a promising tool in the control of skin cancer.

In vitro activity of linezolid in combination with photodynamic inactivation against Staphylococcus aureus biofilms

Background: Biofilm infections are a major challenge in medical practice. Bacteria that live in a biofilm phenotype are more resistant to both antimicrobial therapy and host immune responses compared to their planktonic counterparts. So, there is need for new therapeutic strategies to combat these infections. A promising approach [known as Photodynamic Inactivation [PDI]] to kill bacteria growing as biofilms uses light in combination with a photosensitizer to induce a phototoxic reaction which produces reactive oxygen species that can destroy lipids and proteins causing cell death. PDI does not always guarantee full success, so, combination of PDI with antibiotics may give increased efficiency. This study aimed to determine if PDI was effective in the eradication of Staphylococcus aureus [S. aureus] biofilms in combination with linezolid

Methods: The susceptibility of biofilm cultures of three S. aureus strains to Methylene Blue [MB] and Toluidine Blue O [TBO]-mediated PDI was determined alone and in combination with linezolid

Results: Bactericidal activity [>/=3 log[10] reduction in viable cell count] was not achieved with MB/TBO-PDI or antibiotic treatment alone. When antibiotic treatment was combined with TBO-PDI, a greater reduction in viable count than antibiotic alone was observed for two strains

Conclusion: This study showed that although TBO-PDI did not have good bactericidal activity against S. aureus biofilms; it increased the antimicrobial activity of linezolid against these bacteria

Six-month outcomes of corneal crosslinking with dextran-free isotonic riboflavin solution / Resultados após seis meses de crosslinking de córnea com solução isotônica de riboflavina sem dextrano

ABSTRACT Purpose: To analyze the short-term clinical and topographic outcomes in patients with keratoconus after corneal collagen cross-linking treatment (CXL) with dextran-free isotonic riboflavin solution. Methods: In this retrospective case series, 26 eyes from 26 patients with keratoconus were studied. The best corrected visual acuity (BCVA) and refractive and topographic findings were analyzed at a 6-month follow-up. Results: The mean BCVA (Snellen lines) values before and 1, 3, and 6 months after CXL were 0.51 ± 0.2, 0.48 ± 0.2, 0.57 ± 0.2, and 0.64 ± 0.2, respectively, and the difference between the preoperative and 6-month values was statistically significant (p=0.006). The mean spherical equivalent refraction decreased from -5.6 ± 2.4 diopters (D) preoperatively to -5.0 ± 2.1 D, and mean simulated keratometry decreased from 48.5 ± 2.5 D to 47.8 ± 2.6 D at 6 months. (p=0.145 and p=0.001, respectively). In addition, the maximum keratometry decreased progressively and significantly from the preoperative value during follow-up (p=0.003). The central and minimal corneal thicknesses, including those of the epithelium, also decreased from 442.8 ± 25.6 µm and 430.5 ± 23.9 µm preoperatively to 420.7 ± 31.8 µm and 409.3 ± 28.7 µm at the most recent follow-up (p<0.001), respectively. No intraoperative or postoperative complications were observed. Conclusions: CXL with dextran-free isotonic riboflavin solution appears to be a safe treatment alternative for keratoconus and yields sustained short-term improvements in visual acuity, keratometric readings, and corneal thickness. However, long-term results are needed to confirm these outcomes.

RESUMO Objetivo: Analisar os resultados clínicos e topográficos curto prazo após crosslinking (CXL) de córnea com solução isotônica de riboflavina sem dextrano, em pacientes com ceratocone. Método: Estudamos 26 olhos de 26 pacientes com ceratocone, nesta série retrospectiva de casos. Melhor acuidade visual corrigida (BCVA), refração e achados topográficos foram analisados aos 6 meses de acompanhamento. Resultados: BCVA pré-operatória (linhas de Snellen) foi de 0,51 ± 0,2. BCVA após CXL foram de 0,48 ± 0,2, 0,57 ± 0,2 e 0,64 ± 0,2 no 1º, 3º e 6º meses, respectivamente. A diferença entre a BCVA pré-operatória e mais recente foi estatisticamente significativa (p=0,006). O equivalente esférico médio diminuiu de -5,6 ± 2,4 dioptrias (D) no pré-operatório para -5.0 ± 2.1 D e a média da ceratometria simulada diminuiu de 48,5 ± 2,5 D para 47, 8± 2,6 D aos 6 meses. (p=0,145 e p=0,001, respectivamente). A ceratometria máxima diminuiu progressivamente durante o acompanhamento com as mudanças sendo significativamente diferentes do valor pré-operatório (p=0,003). As espessuras corneanas central e mínima, diminuiram de 442,8 ± 25,6 µm e 430,5 ± 23,9 µm para 420,7 ± 31,8 µm e 409,3 ± 28,7 µm, respectivamente, na visita mais recente (p<0,001). Não foram observadas complicações intraoperatórias e pós-operatórias. Conclusões: CXL com solução de riboflavina isotônica sem dextrano parece ser uma opção segura de tratamento para o ceratocone com melhora mantida na acuidade visual, ceratometria e espessura corneana, no curto prazo. Resultados a longo prazo são necessários para confirmar estes resultados.

Factors affecting visual acuity after accelerated crosslinking in patients with progressive keratoconus / Fatores que afetam a acuidade visual após crosslinking acelerado entre pacientes com ceratocone progressivo

ABSTRACT Purpose: The present study aimed to report the outcomes of patients with progressive keratoconus who were treated via accelerated crosslinking (CXL) 6 months earlier and to determine the factors that promoted improved visual acuity after treatment. Methods: This retrospective study included 35 eyes of 34 patients with progressive keratoconus who underwent CXL. Topographical measurements were obtained preoperatively and in the first, third, and sixth months postoperatively using a rotating Scheimpflug camera. The uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), flat keratometry (K) value (K1), steep K value (K2), average K value (avgK), topographic cylindrical value (Cyl), apical keratoscopy front (AKf), apical keratoscopy back (AKb), symmetry index front (SIf), symmetry index back (SIb), and thinnest point of the cornea (ThkMin) were recorded. Results: At the 6-month follow-up, the mean UCVA and BCVA values were improved, and the K values remained stable. Statistically significant decreases in AKf (p=0.04) and the thinnest point of the cornea (p=0.001) and a statistically significant increase in AKb (p=0.01) were observed. A correlation analysis revealed that the preoperative BCVA, UCVA, K1, K2, avgK, AKf, and AKb values significantly affected visual acuity at the 6-month follow-up. Conclusions: Accelerated CXL is an effective treatment for the prevention or even reversal of keratoconus progression. The preoperative K values and apexes of the anterior and posterior cornea were found to affect visual acuity at 6 months after accelerated CXL. Both AKb steepening and AKf flattening appear to be important factors in the stabilization of keratometric values and improvement of visual outcomes.

RESUMO Objetivo: O objetivo do estudo é relatar os resultados do sexto mês após o tratamento de crosslinking acelerado (CXL) em pacientes com ceratocone progressivo e determinar os fatores que afetam a melhora da acuidade após o tratamento. Métodos: Neste estudo retrospectivo, foram incluídos 35 olhos de 34 pacientes com ceratocone progressivo que se submeteram CXL. Acuidade visual não corrigida (UCVA) e melhor acuidade visual corrigida (BCVA) foram registradas. Medidas topográficas foram obtidas utilizando uma câmara Scheimpflug rotativa no pré-operatório e no 1º, 3º e 6º meses após a cirurgia. Os valores de ceratometria (K) mais plana (K1), K mais curva (K2), médio de K (avgK), astigmatismo topográfico (Cyl), ápice anterior da ceratoscopia (AKf), ápice posterior da ceratoscopia (AKb), índice anterior de simetria (SIf), índice posterior de simetria (SIb) e ponto mais fino da córnea (ThkMin) foram avaliados. Resultados: A média UCVA e BCVA melhoraram, enquanto valores de K ficaram estáveis 6º mês. Houve uma diminuição estatisticamente significativa na AKf e um aumento estatisticamente significativo na AKb (p=0,04, p=0,01, respectivamente). O ponto mais fino da córnea diminuiu significativamente (p=0,001). Na análise de correlações, além da UCVA e BCVA pré-operatórias; valores K1, K2, avgK, AKf e AKb pré-operatórios influenciaram significativamente a acuidade visual no 6º mês de acompanhamento. Conclusões: CXL acelerado é uma forma eficaz de tratamento na prevenção ou no mesmo inversão da progressão do ceratocone. A acuidade visual no 6º mês após CXL acelerado foi afetada a partir dos valores de K e dos ápice anterior e posterior da córnea. Encurvamento do AKb e aplanamento do AKf parecem ser fatores importantes na estabilização dos valores ceratométricos e na melhora da acuidade visual.

Corneal collagen cross-linking for progressive keratoconus in patients aged 9 to 14 / Cross-linking corneano para ceratocone progressivo em pacientes de 9 a 14 anos de idade

RESUMO Objetivo: Determinar a segurança e eficácia do cross-linking corneano (CXL) em pacientes de 9 a 14 anos de idade com ceratocone progressivo. Métodos: Dezesseis olhos de onze pacientes (8 homens e 3 mulheres) com ceratocone progressivo foram submetidos ao CXL, de acordo com o protocolo padrão de Dresden. A média do tempo de seguimento foi de 26 meses (variando de 12 a 60 meses). Os exames pré e pós-operatórios incluíram: acuidade visual sem correção (AVSC), melhor acuidade visual com correção (AVCC), topografia corneana, tonometria, refração, paquimetria corneana, e contagem de células endoteliais. Resultados: Na última visita de acompanhamento ambulatorial, a AVCC melhorou pelo menos uma linha na tabela de Snellen em 6 olhos (37,5%) e permaneceu estável em 9 olhos (56,25%). Dois olhos (12,5%) de pacientes que coçam os olhos com frequência, exigiram retratamento devido à progressão do ceratocone, 15 e 28 meses após o primeiro CXL. A refração e contagem de células endoteliais mantiveram-se estáveis. Os resultados topográficos mostraram melhora estatisticamente significativa nos valores do K máximo até dois anos após o CXL. No entanto, houve perda de significância ao longo do tempo. Nenhuma complicação peroperatória foi observada. Dois olhos (12,5%) apresentaram haze grau I, que regrediu após um mês de terapia com esteróide tópico. Conclusão: Neste estudo com pacientes selecionados, de 9 a 14 anos de idade, o CXL mostrou ser uma opção segura e eficaz para o tratamento do ceratocone progressivo. No entanto, o efeito pode não ser duradouro, podendo ser necessário um novo tratamento. Maior amostragem e maior seguimento são necessários para verificar esta tendência.

ABSTRACT Purpose: To determine the safety and efficacy of corneal collagen cross-linking (CXL) for progressive keratoconus in patients aged between 9 and 14 years old. Methods: Sixteen eyes of 11 patients (8 male and 3 female) with progressive keratoconus underwent epithelium-off CXL according to the standard Dresden protocol. Mean follow-up was 26 months (range, 12 to 60 months). Pre- and postoperative examinations included: uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), corneal topography, tonometry, refraction, corneal pachymetry, and endothelium cell count. Results: At the last follow-up visit, BSCVA improved by at least one Snellen line in six eyes (37.5%) and remained stable in nine eyes (56.25%). Two eyes (12.5%) in habitual eye rubbers required a re-treatment due to keratoconus progression, at 15 and 28 months after first CXL. Manifest refraction and endothelium cell count remained stable. Topographic results showed statistically significant improvement in maximum K readings up to two years after CXL. However, this lost significance over time. No intraoperative complications were observed. Two eyes (12.5%) presented grade one haze, which regressed after a month of topical steroid therapy. Conclusion: In this study of selected patients aged 9 to 14, CXL was a safe and effective option for the treatment of progressive keratoconus. However, the effect in stemming the disease may not be long lasting and may require retreatment. A larger sample size and longer follow-up time are needed to verify this trend.

Hemangioma coroideo / Choroidal hemangioma

El hemangioma coroideo circunscrito es un tumor vascular hamartomatoso benigno de baja incidencia. Se presenta este caso debido a su evolución lenta y la pobre respuesta a tratamiento con terapia fotodinámica. El paciente, de sexo masculino, 49 años de edad, con disminución de la visión del ojo derecho de ocho meses de evolución y sin otra sintomatología asociada. Las exploraciones complementarias realizadas (retinografia, OCT, Ecografía y Angiografía flurosceínica) evidencian un tumor yuxtapapilar nasal que es diagnosticado como hemangioma circunscrito de coroides. Se decide tratarlo con terapia fotodinámica. En este caso, aunque el resultado en la ganancia visual no es el esperado, en los exámenes complementarios realizados se observa una discreta mejoría. La lenta evolución de este paciente responde, a criterio de los autores, a varios factores como la edad, el deterioro de la visión en el momento del diagnóstico, el número de aplicaciones de tratamiento con la TFD realizadas, el tiempo de evolución del tumor y el tamaño de la lesión(AU)

Circumscribed choroidal hemangioma is a benign hamartomatous vascular tumor of low incidence. This case is presented for its slow natural history and the poor response to treatment with photodynamic therapy. The 49-year-old male patient with right-eye visual reduction of eight month of evolution and without any other associated symptomatology. Complementary explorations carried out (retinography, OCT, sonogram, fluorescein angiography) evinces a juxtapapillary nasal tumor diagnosed as circumscribed choroidal hemangioma. The decision is to treat it with photodynamic therapy. In this case, despite the fact the visual gain outcome is not the desired, the complementary tests performed revealed a fair improvement. According to the authors, the slow evolution of this patient is due to several factors such as age, visual decay at the time of the diagnosis, the TFD number of applications, the tumor´s time of evolution and the lesion seize(AU)

Long-term recurrence of nonmelanoma skin cancer after topical methylaminolevulinate photodynamic therapy in a dermato-oncology department

Abstract: BACKGROUND: Most available studies on the efficacy of topical photodynamic therapy focus on short-to medium-term results. Long-term data are scarce. OBJECTIVE: To evaluate the long-term efficacy of photodynamic therapy with topical methylaminolevulinate to treat Bowen's disease and basal cell carcinoma in the clinical practice setting of a dermato-oncology department. METHODS: The study included patients diagnosed with Bowen's disease or basal cell carcinoma, and who received photodynamic therapy from 2004 to 2008. Treatment protocol and clinical follow-up were standardized. The primary endpoint was clinically observed recurrence in a previous photodynamic therapy-treated area. Descriptive and survival analyses were performed. RESULTS: A total of 31 Bowen's disease lesions and 44 superficial basal cell carcinoma were treated, with a median follow-up of 43.5 months. Recurrence was observed in 14 Bowen's disease lesions (53.8%) and in 11 superficial basal cell carcinoma (33.3%). Significantly higher estimates for recurrence rates were found in patients with Bowen's disease (p=0.0036) or those aged under 58 years (p=0.039). The risk of recurrence was higher in patients with Bowen's disease than in those with superficial basal cell carcinoma and younger patients. CONCLUSIONS: Recurrence should be considered when choosing to treat non-melanoma skin cancer with photodynamic therapy. Younger age and Bowen's disease were independent predictors for long-term recurrence, suggesting the need to establish an extended period of follow-up for this subset of patients.

Endoscopic Ultrasound-guided Local Therapy of Pancreatic Tumors / 대한소화기학회지

The development of curvilinear EUS has enabled EUS-guided fine-needle aspiration of intra-abdominal mass lesions. With the introduction of interventional EUS, this technology has undergone several modifications in order to be applied to clinical medicine. One of the potential uses of interventional EUS is the EUS-guided local therapy of pancreatic tumors. Various treatment modalities such as fine-needle injection, radiofrequency ablation, photodynamic therapy, laser ablation, and brachytherapy have been tried under EUS guidance. Some of these modalities are being applied clinically. These methods for EUS-guided local therapy of pancreatic tumors will be reviewed in this article.

Prognóstico visual de 'crosslinking' para ceratocone com base em tomografia de córnea pré-operatória / Visual prognosis of crosslinking for kearatoconus based on preoperative corneal tomography

Objetivo: Verificar índices tomográficos do pré-operatório de pacientes com ceratocone submetidos à crosslinking corneano (CXL) como fatores preditivos para a melhora na acuidade visual corrigidas (AVc) após um ano. Métodos: Estudo retrospectivo que incluiu 63 olhos de 53 pacientes com ceratocone progressivo submetidos à CXL segundo o protocolo de Dresden: deseptelização corneana, riboflavina 0,1% por 30 minutos e luz ultra-violeta A (UVA) a uma irradiância de 3mW/cm2 por 30 minutos. Foram avaliados exames de tomografia corneana com sistema de Scheimpflug rotacional (Pentacam, Oculus) antes do CXL e a acuidade visual corrigida antes e após a cirurgia. A análise estatística foi feita com o teste de Kolmorov-Smirnov, teste t de student e curvas de característica operador-receptor (ROC). Resultados: Houve diferença estatisticamente significante (p<0,05) entre os pacientes que obtiveram melhora de AVc em um ano e os que não experimentaram melhora na AVc nesse período nos índices tomográficos pré-operatórios relacionados com espessura e volume corneano. Entre os pacientes que obtiveram melhora na AVc todos possuíam volume corneano em 6,0mm maior que 14,55mm3 e 97,2% deles possuíam volume corneano em 6,5mm maior que 17,76mm3. Assim como, 94,29% desses pacientes apresentavam paquimetria média em 4,0mm maior que 487 μm e 82,86% paquimetria no ponto mais fino maior de 421 μm. Conclusão: Pacientes com ceratocone menos avançado (volume e espessura da córnea maiores) no período pré-operatório obtiveram mais chances de ter melhora da AVc um ano após CXL. Estudos prospectivos envolvendo outras variáveis relacionadas com a aberrometria total e o estudo biomecânico da córnea são relevantes para se aumentar a capacidade prognóstica do resultado após CXL. .

Purpose: To verify pre-operative tomographic indices as predictive parameters for the improvement in best corrected visual acuity (BCVA) in one year after corneal collagen crosslinking (CXL) procedure for keratoconus. Methods: Retrospective study that included 63 eyes of 53 patients with progressive keratoconus submitted to CXL following the Dresden’s protocol: topical anesthesia, 9.0 mm of epithelial abrasion, riboflavin 0.1% drops for 30 minutes and ultraviolet-light A (UVA) with an irradiance of 3mW/cm2 for 30 minutes. Corneal tomography taken by Scheimplug rotational system (Pentacam, Oculus) before CXL was evaluated along with pre and 1 year post-operative BCVA. Statistical analysis was accomplished with the Kolmogorov-Smirnov test, student’s t-test and Receiver Operating Characteristic (ROC) curve. Results: There were statistically significant differences (p<0.05) between patients who improved BCVA in one year after CXL and those who did not experienced improvement in BCVA in the same period of time in the pre-operative tomographic indices related to corneal volume and thickness. Among those who had its BCVA improved all of them had a corneal volume in 6.0mm grater then 14.55mm3 and 97.2% of them had corneal volume in 6.5mm grater then 17.76mm3. So with 94.29% of them hadthickness in 4.0mm grater then 487μm and 82.86% had thickness on the thinnest point grater then 421μm. Conclusion: Patients with less advanced keratoconus (grater corneal volume and thickness) in the pre-operative had more chances to improve its BCVA in one year after CXL. Prospective studies involving others variables related to total aberrometry and corneal biomechanics are relevant to increase the prognostic capability of CXL result. .