Role of reinsertion of the lower eyelid retractor on involutional entropion.

AIMS: To verify and evaluate the effect of reinsertion of the lower eyelid retractor aponeurosis to correct involutional entropion. METHODS: The involutional entropion is one affection that occurs mainly in the lower eyelid of patients over 60 years old. The surgical techniques proposed to correct this condition are based on correction of horizontal laxity-the preseptal orbicularis muscle overrides the pretarsal muscle, and the reinsertion of the lower eyelid retractor aponeurosis. 30 patients clinically diagnosed with involutional entropion and randomly selected underwent reinsertion of the lower eyelid retractor aponeurosis to the tarsal plate, without horizontal shortening or resection of the skin or orbicularis muscle. RESULTS: Good anatomical and functional correction was achieved in 96.6% of the patients and no recurrence was observed on 29 month follow up examination. The surgical result was very satisfactory. CONCLUSIONS: It was concluded that this procedure is effective and has low recurrence rate, showing the important role of the reinsertion of the lower eyelid retractor aponeurosis in this surgical correction.

The feasibility of introducing a visual screening test for children during vaccination campaigns.

PURPOSE: A visual screening test for children was prepared for the use of paramedics during vaccination campaigns. This test was used in a vaccination campaign in Taquaritinga, São Paulo, Brazil. METHODS: The campaign was carried out by two paramedics trained by ophthalmologists. The first 130 children vaccinated whose families showed interest in participating in the visual screening program were chosen. The program consisted of demographic information and eight questions, a visual screening test for children >4 years, and an external eye examination. After studying the data collected, the paramedic decided if the child needed a more thorough ophthalmologic examination. RESULTS: Of the 4505 children vaccinated, 130 children participated in the screening test. One (76.9%) hundred of the 130 children were reexamined by ophthalmologists. Of these, 38 (29.2%) were initially considered to have visual disorders. Ophthalmologic disorders were confirmed in 22 (57.9%) children; of these, 3 were already under ophthalmologic care. The paramedics correctly screened a total of 77 (77%) children. CONCLUSION: Visual screening during vaccination campaigns is simple and rapid, and provides the opportunity to identify children with visual disorders during the critical stage of visual development without the need of ophthalmologists.

Quantification (grading) of inferior oblique muscle recession for V-pattern strabismus.

PURPOSE: To determine the effectiveness of grading such surgery according to the magnitude of the V pattern and inferior oblique muscle overaction (IOOA). METHODS: We retrospectively reviewed all 53 cases we operated since 1984 for V pattern with IOOA, who had undergone graded inferior oblique recession, recessed according to the anatomical recession table of Apt and Call, ranging from 8mm for V pattern of 12 PD with +1 IOOA to 12mm for 30+ PD with +3 IOOA. RESULTS: A "satisfactory outcome" (defined as = V pattern of 8 PD or less) was observed in 75% of the cases with a preoperative V pattern less than 20 PD, in 70% of those with a preop' V pattern between 20 PD and 29 PD, and in 57% of those with a preop' V pattern greater than 29 PD. There were no overcorrections. All unsatisfactory outcomes were undercorrections. CONCLUSIONS: The principle of grading this surgery is supported and affirmed by these results. However, the results also suggest a need to increase the amount of surgery for all categories and add anterior transposition for larger V patterns.

[Evaluation of an educational program for patients with glaucoma]. / Avaliação de programa educativo para portadores de glaucoma.

PURPOSE: To analyze the results of an educational program applied to glaucoma patients; to serve as a guideline for a definitive educational program to be developed at the Glaucoma Service of the University of Campinas. METHODS: Fifty glaucoma patients were given information about the disease and its treatment by an experienced nurse and answered the same questionnaire before and 2.7 months after the initial explanation. The technique of eyedrop instillation was compared before and after the educational program. RESULTS: There was no significant improvement concerning the knowledge of the identification of the ocular disease, the side effects, the meaning of glaucoma, the importance of treatment, the purpose of medications and the normal value of intraocular pressure. There was a significant improvement in all steps of eyedrop instillation (p < 0.01) and in knowledge regarding the importance of heredity (p < 0.001) and the purpose of perimetry (p=0.033). CONCLUSION: Although a significant improvement was observed in the technique of eyedrop instillation, the authors conclude that this plan was not complete enough for its contents fully to be understood. These findings may be secondary to the vertical teaching-learning process, which is inappropriate for the patient, and to the difficulty in comprehending the information, which is associated with low cultural and instruction levels, and to psychosocial factors related to their disease.

An improved surgical technique for pterygium excision with intraoperative application of mitomycin-C.

A surgical technique was designed to improve safety after pterygium excision with intraoperative application of mitomycin-C (MMC). A limbic incision was performed in 40 eyes. The body of the pterygium was dissected from the episclera to allow its excision. Care was taken to avoid excessive delamination and cauterization of tissues. A 0.02% MMC solution was then applied. Only at the end of the surgery was the head of the pterygium dissected from the cornea. The 8-0 absorbable sutures were used to place both edges of the conjunctiva together to completely cover the area of bare sclera. After a mean follow-up time of 12 months, a recurrence rate of 5% was observed. No complications of therapy were observed. This is a logical alternative to other surgical techniques. However, randomized studies with more patients and longer follow-up are necessary to determine the potential of this procedure in improving the safety of pterygium excision with intraoperative MMC.

[Senile cataract: patient's characteristics and perceptions on a sight restoration communitary project]. / Características e percepções de pacientes portadores de catarata senil atendidos em projeto comunitário de reabilitação visual.

A survey was conducted to identify some patient's characteristics and perceptions related to senile cataract and delivery of cataract care. The patients were diagnosed by means of ophthalmic examination carried out on a Rehabilitation of the Aged Campaign at the Hospital das Clínicas of the University of São Paulo Medical School. A questionnaire was administered by interviewing 70 subjects, who presented the following characteristics: 32.86% were males and 67.14% were females; 42.86% with ages varying between 50 and 70 years; 67.14% took notice of campaign through TV; 60.00% underwent SUS previous ophthalmic evaluation; 72.86% presented low vision acuity on both eyes for a year or longer, (27.14% for 5 years or longer); 40.00% had previous surgery indication for a year or longer and 80.00% of the patients claimed declared financial reasons to explain their non-previous cataract surgery. We recommend eye health educational programs for prevention of blindness and sigh restoration.

Low-dose mitomycin C trabeculectomy in patients with advanced glaucoma.

PURPOSE: The purpose of this study was to analyze the efficacy and safety of low-dose (0.2 mg/ml) intraoperative mitomycin C in primary trabeculectomy. METHODS: Twenty-eight eyes of 28 patients with advanced primary open-angle glaucoma undergoing primary trabeculectomy were randomized to either mitomycin C (0.2 mg/ml) or saline solution intraoperatively for 3 min. Intraocular pressure was measured at 1 day; 1 week; 1, 3, and 6 months postoperatively; and at the final visit. RESULTS: Mean follow-up was 17.0 +/- 5.6 months for the mitomycin C group and 15.7 +/- 5.1 months for the control group. Mean intraocular pressures were significantly lower in the treated group on the first postoperative day (p = 0.021), at the 6-month interval (p = 0.001), and at the final visit (p = 0.001). At the last follow-up examination, intraocular pressure was < or = 15 mm Hg in 12 (85.7%) of the mitomycin C-treated eyes and in four (28.6%) of the control eyes (p = 0.002). Life table analysis showed a significantly higher probability of intraocular pressure control in the mitomycin C group than in the control group (p = 0.0065). Choroidal effusion was observed in five (35.7%) treated eyes and two (14.3%) control eyes, whereas shallow anterior chamber were present in five (35.7%) treated eyes and one control eye (7.1%). CONCLUSION: Despite inducing a higher short-term complication rate, low-dose mitomycin C may be an alternative in the treatment of eyes with advanced glaucomatous damage requiring low final intraocular pressures.

Single intraoperative application versus postoperative mitomycin C eye drops in pterygium surgery.

PURPOSE: To determine the minimum effective dosage, most effective route of administration and long-term effects of mitomycin C for prevention of recurrence after pterygium surgery. METHODS: In a prospective, masked study, 227 patients undergoing surgery for primary pterygia were assigned randomly to five groups: group 1 received a single intraoperative application of 0.2 mg/ml mitomycin C for 3 minutes; group 2 received a single intraoperative application of 0.4 mg/ml mitomycin C for 3 minutes; group 3 received mitomycin C eye drops 0.2 mg/ml three times daily for 7 days; group 4 received mitomycin C eye drops 0.4 mg/ml three times daily for 14 days; group 5 acted as a control (surgery alone). RESULTS: After a mean follow-up time of 28 months, recurrence rates of 6.66%, 4.08%, 4.26%, 4.44%, and 29.27%, respectively, were observed. Statistical analysis showed significant differences between groups receiving mitomycin C and the control (P < or = 0.001). There was no statistical difference among treated groups (P > or = 0.0681). No complications of therapy were observed. CONCLUSION: These results support the efficacy and relative safety of a single, low-concentration, intraoperative application of mitomycin C in pterygium surgery together with the use of a conjunctival flap, avoiding excessive cauterization of the sclera and leaving bare sclera.

[Use and causes of discontinuation of eye surgical interventions at a university ambulatory surgery center]. / Utilização e causas de suspensão de intervenções cirúrgicas oculares em centro cirúrgico ambulatorial universitário.

OBJECTIVE: To study the efficiency of an ambulatory surgery center located at a university public hospital we studied the number of surgical interventions performed and suspensions and their causes. METHODS: We collected data on the number of surgical interventions performed, suspension and causes of suspension from January to December of 1992 of the ambulatory surgery center of the Clinical Hospital of University of Campinas, UNICAMP, in São Paulo. A comparison of performance of the Ophthalmology Department and the other medical specialties were made. RESULTS: Of the 6,574 surgical interventions booked 4,938 (75.11%) were performed and 1,636 (24.88%) suspended. Of the 4,938 surgical interventions 2,514 (51%) were performed by the Ophthalmology Department and 2,423 (49%) by other 11 medical specialties. The main causes of suspension of eye operations were unfavorable clinical condition (46.38%), absence of the patient (32.71%) and administrative problems (8.44%). CONCLUSION AND SUGGESTIONS: The Ophthalmology Department has 40% of the space available at the facility and did 51% of the interventions. A better control and planning of the surgical operations may increase the number of interventions and performance of the ambulatory surgery center. It is important for the optimization of the available resources to introduce a periodic control of surgical interventions done, suspension and their causes.

[Practicability of cataract surgery at university hospitals: searching for an economic model]. / Exeqüibilidade da cirurgia de catarata em hospital-escola: em busca de um modelo econômico.

UNLABELLED: Resources available for health care all over the world are not enough to cover all the demand in this sector. Cataract Free Zones conducted in many regions of the country show that only 10% to 20% of blind patients caused by senile cataract can get operated on. PURPOSE: To demonstrate feasibility of a model for cataract surgery with intraocular lens implantation at the Clinical Hospital from the University of Campinas, Unicamp, São Paulo, when considering the remuneration payed by the government for universitary services. METHODS: Costs with disposable material were collected for extracapsular cataract surgery, with posterior intraocular lens implant, at the Clinical Hospital, Unicamp. The model includes outpatient surgery under local anesthesia, and costs rationalization in acquisition and wear of material. University Hospitals have a different situation in the health system, where fixed costs and part of the variable costs of cataract surgery are subsidized by the State government. RESULTS: Cataract surgery performed under the proposed methodology is economically feasible, considering disposable components only, and the price achieved was US$ 77 with government payment of US$ 474. More surgical interventions increases the efficiency of the institution, provides more surgical training to residents and better community health care. CONCLUSION: The authors consider that it is an obligation of University Hospitals, regard their commitment with training, research and quality of eye care deliverance, to increase the number of cataract surgeries for the lowest possible price.

Screening and surgical intervention results from cataract-free-zone projects in Campinas, Brazil and Chimbote, Peru.

Two cataract-free-zone projects, one in Brazil and the other in Peru, were designed to provide surgery to all those who need and want it within a defined geographic area. In-home visual acuity screening was accepted by three-fourths of the enumerated population aged 50 years or more. Those with reduced bilateral visual acuity were referred to a community health post for ophthalmic examination. Among those diagnosed as bilaterally blind (less than or equal to 20/200), comprising 5% of the screened population, two-thirds were thought to be blind from cataract. Because of other ocular pathology and general health conditions, surgery was not indicated for 30-50%. Two-thirds of those recommended for out-patient surgery accepted. Motivational efforts to convince the refusers were uniformly unsuccessful. The average age of those accepting and those refusing surgery was in the mid-seventies. Those already aphakic were 7-8 years younger. Post-operative acuity was greater than or equal to 20/50 for only one-half of those operated. A significant number of cases had previously undetected macular degeneration and other causes of decreased vision. These projects have given increased attention to cataract blindness and the need for further operational research to develop effective methods for its control using outpatient surgery.