Algorithm approach for revision surgery following late-onset bleb complications after trabeculectomy: long-term follow-up / Algoritmo de abordagem para cirurgia de revisão nas complicações da bolha de início tardio após trabeculectomia: acompanhamento de longo prazo

ABSTRACT Purpose: The aim of this study was to introduce a reproducible algorithm for the surgical management of late-onset (>2 months) bleb complications after trabeculectomy with mitomycin C. Methods: We performed a retrospective review of eyes treated using a reproducible algorithm approach by a single surgeon for the surgical management of late-onset bleb complications from July 2006 to April 2014. Exclusion criteria were bleb revision with less than 3 months of follow-up or bleb revision combined with other glaucoma procedures at the time of surgery. Success was evaluated using the Kaplan-Meier survival method and defined as achieving all of the following criteria: primary surgery indication resolved, no additional surgery required for decreasing the intraocular pressure (IOP), and IOP of ≥6 mmHg and ≤18 mmHg. Results: Twenty-three eyes from 20 patients were evaluated. Indications for bleb revision were hypotonic maculopathy (47.8%), bleb leak (30.4%), and dysesthetic bleb (21.7%). The overall primary outcome success rate calculated using the Kaplan-Meier survival method was 65.2% at 48 months. When the IOP target was changed to ≤15 mmHg, the bleb survival rate was 47.8% at 48 months. At the most recent postoperative visit, 95.7% of eyes had an IOP of ≤15 mmHg and 56.5% were being treated with an average of one medication per eye. One eye (4.3%) required a second bleb revision for persistent hypotony and two eyes required glaucoma surgery to reduce IOP during follow-up. Conclusions: An algorithm approach for the surgical management of late-onset bleb complications with a success rate similar to those reported in specialized literature is proposed. Randomized trials are needed to confirm the best surgical approach.

RESUMO Objetivo: Descrever um algoritmo reprodutível para o tratamento cirúrgico das complicações da bolha de início tardio (>2 meses) após trabeculectomia com mitomicina-C. Métodos: Revisão retrospectiva de olhos que foram submetidos a um algoritmo reprodutível para o tratamento cirúrgico das complicações da bolha de início tardio por um único cirurgião, de julho de 2006 a abril de 2014. Os critérios de exclusão foram revisão de bolha com menos de 3 meses de seguimento ou revisão de bolha combinado com outro procedimento antiglaucomatoso no momento da cirurgia. O sucesso foi avaliado pelo método de sobrevida de Kaplan-Meier e definidos como ter atingido todos os seguintes critérios: indicação de cirurgia primária resolvido, nenhuma cirurgia adicional necessária para diminuir a pressão intraocular (IOP), IOP ≥6 mmHg e ≤18 mmHg. Resultados: Vinte e três olhos de 20 pacientes foram incluídos. Indicações para revisão bolha foram maculopatia hipotônica (47,8%), extravasamento da bolha (30,4%) e bolha elevada (21,7%). A taxa de sucesso do resultado primário global calculada pelo método de sobrevivência de Kaplan-Meier foi de 65,2% aos 48 meses. Quando a IOP foi diminuída para ≤15mmHg, a taxa de sobrevivência bolha foi de 47,8% em 48 meses. Na visita pós-operatória mais recente, 95,7% dos olhos apresentavam PIO ≤15mmHg e 56,5% estavam sob tratamento com uma média de um medicamento por olho. Um olho (4,3%) necessitou de uma segunda revisão da bolha para hipotonia persistente e dois olhos necessitaram cirurgia de antiglaucomatosa para reduzir a IOP durante o seguimento. Conclusões: Um algoritmo de abordagem para o tratamento cirúrgico das complicações tardias da bolha com uma taxa de sucesso semelhante aos relatados na literatura especializada é proposto. Ensaios clínicos randomizados são necessários para confirmar a melhor abordagem cirúrgica.

Trombolisis mecánica de tronco basilar con Solitaire FR®: caso clínico / Mechanical thrombolysis of the basilar artery: Report of one case

We report a 40year-old male presenting in the emergeney room with headache, vértigo and left hemiparesis. A magnetic resonante imaging reporten a left cerebellar infarction with occlusion of the basilar artery ana dissection ofthe right vertebral artery. Thepatient experienced a clinical deterioration with the appearance ofa right hemiparesis. Therefore a brain angiography wasperformed alongwith a mechanical thrombolysis using a Solitaire FR® revascularization device. A thrombus located in the distal third ofthe artery was eliminated obtaining a complete perfusión ofthe artery. Thepatient had a satisfactory evolution.

Queratitis fúngica: revisión actual sobre diagnóstico y tratamiento / Fungal keratitis: review of diagnosis and treament

La queratitis fúngica es una infección característica de zonas tropicales, asociada a trauma vegetal. Existen dudas respecto al método diagnóstico óptimo y la efectividad de los tratamientos disponibles. ¿Cuál es el manejo más apropiado en queratitis fúngica? y ¿Cuál es la mejor forma de establecer el diagnóstico? El cultivo para hongos es el gold standard diagnóstico de elementos fúngicos. Respecto al tratamiento, natamicina y anfotericina B fueron los más utilizados y no demostraron efectividad en estudios prospectivos. Voriconazol demostró efectividad en múltiples infecciones fúngicas. Pudiera ser la droga de elección en condiciones óptimas, dado su mejor penetración intraocular. Se ha reconocido su elevado costo dificultando su aplicación generalizada. Esta revisión entrega recomendaciones para el manejo y establece la necesidad de realizar estudios que evalúen la costo-efectividad de voriconazol para la queratitis fúngica.

Fungal keratitis is a characteristic infection upon tropical zones, associated with vegetal trauma. Doubt exists about the best diagnostic test and the effectiveness of available treatment. Which is the best diagnostic method for fungal keratitis? And, which is the best management? Fungal culture remains as diagnostic gold standard of fungal elements. As of treatment, natamycin and amphotericin B are the most popular drugs for fungal keratitis and they have not shown effectiveness in randomized controlled trials or systematic reviews. Voriconazole showed effectiveness and security in multiple fungal infections. It may be the drug of choice in optimal conditions, because of its better ocular penetration and wider coverage. However, its high price difficult general application. This review establishes management recommendations and the need to perform studies that address cost-effectiveness analysis of voriconazole for fungal keratitis.

Función pulmonar en niños sanos de 7 y 8 años de las comunas de Cerro Navia y Los Andes expuestos a diferentes niveles de contaminación por MP10 / Lung functionin healthy children aged 7 and 8 of the comunes of Cerro Navia and Los Andes exposes to different levels of pollution by MP10

Objetivo: Determinar si difieren los valores espirométricos evaluados en niños sanos de 7- 8 años provenientes de comunas con niveles históricos de alta versus baja contaminación atmosférica en Chile. Materiales y métodos: Estudio descriptivo, no experimental, exploratorio y transversal y ex post facto causa y efecto. Se realizaron en total 261 encuestas de salud respiratoria y calificaron, según criterios de inclusión, 110 niños sanos de 7 y 8 años (55 niños en cada comuna). Se realizaron exámenes espirométricos: Con espirómetro de turbina SPIROBANK G, considerando variables vefi, FEF25-75, pef y cvf. La obesidad, actividad física, contaminación intramuros por calefacción y exposición a humo de tabaco también fueron descritas. Resultados: Las variables espirométricas analizadas vefi y FEF25-75 mostraron diferencias significativas (p<0.05) y pef mostró diferencias altamente significativas (p <0.005) según localidad, es decir, que la media de estas variables en Los Andes, comuna agroindustrial con baja contaminación atmosférica, es mayor que la de Cerro Navia, comuna con altos niveles de contaminación del aire. En la variable pef se encontró, además, significancia entre género. La cvf no presentó diferencia entre comunas. Conclusiones: Los niños sanos de 7 y 8 años que habitan en comunas donde la exposición a contaminación atmosférica es alta presentan una menor función pulmonar comparada con los niños sanos, de similares características, que habitan en comunas con bajos niveles de contaminación atmosférica. Existen otros factores que podrían influir en el detrimento de la función pulmonar y que en este estudio fueron descritos como factores confundentes.

Objective: To determine if spirometric values evaluated in healthy children aged 7-8 years differ from one locality with high historical levels of air pollution versus a locality with lower levels of air pollution in Chile. Materials and methods: Descriptive, non-experimental, exploratory and ex post facto cross and cause and effect. In total 261 surveys were performed of respiratory health and rated according to inclusion criteria, 110 healthy children between 7 and 8 years (55 children in each commune). Spirometric tests were performed, considering variables FEV1, FEF25-75, PEF and FVC. Obesity, physical activity, indoor pollution from heating and snuff smoke exposure were also described. Results: The analyzed spirometry FEV1 and FEF25-75 showed significant differences (p <0.05) and PEF showed high significant differences (p<0.005) by location, that it to say, the average of these variables in the locality of Los Andes, commune with low air pollution is greater than Cerro Navia, a commune with high levels of air pollution. Variable in PEF was found also between gender significance. FVC showed no difference between communities. Conclusions: Healthy children of 7 and 8 who live in the locality where exposure of air pollution is high, have lower lung functions compared with healthy children with similar characteristics who live in communities with lower levels of air pollution. There are other factors that could influence the detriment of pulmonary function, in this study were described as confounding factors.