A influência do segmento de anel intraestromal corneano de arco longo na cirurgia de córnea
Data
2024-11-19
Autores
Rocha, Guilherme Andrade do Nascimento 
Orientadores
Sousa, Luciene Barbosa de
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Objetivo: Avaliar as mudanças nas médias de acuidade visual à distância com correção (AVCC), de equivalente esférico (EE), das medidas ceratométricas (K) e da asfericidade média (Q) após o implante dos segmentos de anel intraestromal corneano de arco longo para o tratamento do ceratocone e para a correção da ametropia residual e da irregularidade corneana pós-transplante de córnea.
Métodos: Foram objetos desta tese a publicação de três estudos envolvendo o uso dos anéis de arco longo em pacientes com ceratocone e pós-transplante de córnea. Os três estudos foram prospectivos, não randomizados e não comparativos. Nos dois estudos sobre cirurgia no ceratocone, foram incluídos 172 olhos de 161 pacientes: 34 olhos de 31 pacientes no estudo unicêntrico e 138 olhos de 130 pacientes no estudo multicêntrico. Neste último estudo, os pacientes foram recrutados e operados em 10 diferentes hospitais oftalmológicos no Brasil. No estudo referente ao implante dos segmentos em olhos pós-transplante de córnea, foram incluídos 18 olhos de 18 pacientes. Nos dois estudos sobre cirurgia no ceratocone foram implantados segmentos com 320 graus de arco e no estudo pós-transplante de córnea, segmentos com 340 graus de arco. No estudo multicêntrico, 45 olhos foram operados com a técnica manual, enquanto 93 olhos foram operados com assistência do laser de femtosegundo. Já no estudo unicêntrico e no estudo pós-transplante, todos os olhos foram operados com assistência do laser de femtosegundo. A medida de desfecho primário nos três estudos foi a mudança nas médias de AVCC após a inserção dos segmentos. As medidas de desfecho secundário foram as alterações nas médias do EE, das medidas ceratométricas e da asfericidade corneana média. Em ambos os estudos de ceratocone avaliamos a porcentagem de pacientes que apresentaram perda ou ganho de linhas de AVCC aos 3 e 6 meses após a cirurgia e, no estudo pós-transplante de córnea, aos 12 meses de pós-operatório. No estudo multicêntrico e no estudo pós-transplante realizamos análise vetorial para os achados refracionais e para o astigmatismo topográfico. E, finalmente, no estudo unicêntrico fizemos uma comparação entre duas estratégias para escolha da espessura dos segmentos a serem implantados.
Resultados: O implante de anéis de arco longo melhorou significativamente a AVCC, com redução do EE, ganhando consideravelmente linhas de AVCC e a maioria dos pacientes alcançou AVCC melhor ou igual a 0,3 logMar. No estudo multicêntrico, a AVCC melhorou de 0,7 logMar para 0,3 logMar (p < 0,001), com redução do EE de -7,02 ± 4,80 D para -3,29 ± 3,80 D (p < 0,001). Ao final do seguimento pós-operatório, 92,4% dos pacientes ganharam pelo menos 1 linha de AVCC, apenas 1,9% perderam pelo menos 1 linha de AVCC e, 75,9% alcançaram pelo menos 0,3 logMar de AVCC. No estudo unicêntrico, a AVCC melhorou de 0,51 ± 0,22 logMar para 0,18 ± 0,12 logMar (p < 0,01), com redução do EE de -7,52 ± 4,18 D para -3,61 ± 3,79 D (p < 0,01). Ao final do seguimento pós-operatório, 88,24% dos pacientes ganharam pelo menos 1 linha de AVCC, apenas 2,94% perderam pelo menos 1 linha de AVCC e, 88,23% alcançaram pelo menos 0,3 logMar de AVCC. No estudo pós-transplante de córnea, a AVCC melhorou de 0,26 ± 0,12 logMar para 0,10 ± 0,10 logMar (p < 0,001), com redução do EE de -5,22 ± 2,96 D para -2,52 ± 2,83 D (p < 0,001). Ao final do seguimento pós-operatório, 94,45%% dos pacientes ganharam pelo menos 1 linha de AVCC, apenas 5,55% perderam pelo menos 1 linha de AVCC e, 95% alcançaram pelo menos 0,3 logMar de AVCC. Em relação aos resultados topográficos da córnea extraídos de Scheimpflug em todos os três estudos obtivemos melhora significativa (p < 0,05) em todos as medidas ceratométricas e na medida de asfericidade média. A análise vetorial do astigmatismo no estudo multicêntrico mostrou baixa previsibilidade dos resultados após os implantes e, no estudo pós-transplante, o componente vetorial do astigmatismo não alcançou significância estatística (J0 – p = 0,52 e J45 – p = 0,15). A análise da escolha da espessura dos segmentos a serem implantados realizada no estudo unicêntrico demonstrou que a escolha baseada no EE apresentou performance superior à escolha baseada no Q na maioria das comparações dos resultados de topografia extraída de Scheimpflug, apesar dos resultados semelhantes na acuidade visual e nos dados refracionais. Não ocorreram complicações intraoperatórias ou pós-operatórias no estudo unicêntrico e no estudo pós-transplante de córnea. No entanto, no estudo multicêntrico, houve 4 casos de migração pós-operatória do segmento e 2 casos de perfuração intraoperatória. Todas estas complicações aconteceram em pacientes operados com a técnica manual, e os resultados foram excluídos da análise.
Conclusões: Nossos resultados sugerem que os segmentos de anel intraestromal corneano de arco longo podem melhorar a acuidade visual à distância com correção, com redução da média do equivalente esférico, das médias das medidas ceratométricas e da média asfericidade corneana média no tratamento do ceratocone e para a correção da ametropia residual e da irregularidade corneana pós-transplante de córnea.
Purpose: To evaluate the changes in mean corrected distance visual acuity (CDVA), spherical equivalent (SE), keratometries (K), and mean asphericity (Q) after implantation of the long-arch corneal intrastromal ring segments for the treatment of keratoconus and for the correction of residual ametropia and corneal irregularity after corneal transplantation. Methods: The objects of this thesis were the publication of three studies involving the use of long-arch rings in patients with keratoconus and post-corneal transplantation. All three studies were prospective, non-randomized, and non-comparative. In the two studies on keratoconus surgery, 172 eyes from 161 patients were included: 34 eyes from 31 patients in the single-center study and 138 eyes from 130 patients in the multicenter study. In this last study, patients were recruited and operated on in 10 different ophthalmological hospitals in Brazil. In the study regarding the implantation of segments in eyes after corneal transplantation, 18 eyes from 18 patients were included. In the two studies on keratoconus surgery, segments with 320 degrees of arch were implanted, and in the post-corneal transplant study, segments with 340 degrees of arch. In the multicenter study, 45 eyes were operated with the manual technique, while 93 eyes were operated with the assistance of the femtosecond laser. In the single-center study and in the post-transplant study, all eyes were operated with the assistance of femtosecond laser. The primary outcome measure in all three studies was the change in mean CDVA after segment insertion. The secondary outcome measures were changes in the mean SE, mean keratometries, and mean corneal asphericity. In both keratoconus studies, we evaluated the percentage of patients who had loss or gain of CDVA lines at 3 and 6 months postoperatively, and in the post-corneal transplant study, at 12 months postoperatively. In the multicenter study and in the post-transplant study, we performed vector analysis for refractive findings. And, finally, in the single-center study, we made a comparison between two strategies for choosing the thickness of the segments to be implanted. Results: The implantation of long-arch rings significantly improved CDVA, with a reduction in SE, considerably gaining CDVA lines and most patients achieved CDVA better than or equal to 0.3 logMar. In the multicenter keratoconus study, CDVA improved from 0.7 logMar to 0.3 logMar (p < 0.001), with a reduction in SE from -7.02 ± 4.80 D to -3.29 ± 3.80 D (p < 0.001). At the end of the postoperative follow-up, 92.4% of the patients had gained at least 1 CDVA line, only 1.9% had lost at least 1 CDVA line, and 75.9% had achieved at least 0.3 CDVA logMar. In the single-center keratoconus study, CDVA improved from 0.51 ± 0.22 logMar to 0.18 ± 0.12 logMar (p < 0.01), with a reduction in SE from -7.52 ± 4.18 D to -3.61 ± 3.79 D (p < 0.01). At the end of the postoperative follow-up, 88.24% of the patients had gained at least 1 CDVA line, only 2.94% had lost at least 1 CDVA line, and 88.23% had achieved at least 0.3 CDVA logMar. In the post-corneal transplant study, CDVA improved from 0.26 ± 0.12 logMar to 0.10 ± 0.10 logMar (p < 0.001), with a reduction in SE from -5.22 ± 2.96 D to -2.52 ± 2.83 D (p < 0.001). At the end of the postoperative follow-up, 94.45% of the patients had gained at least 1 CDVA line, only 5.55% had lost at least 1 CDVA line, and 95% had achieved at least 0.3 CDVA logMar. Regarding the corneal topographic results extracted from Scheimpflug, in all three studies we obtained a significant improvement (p < 0.05) in all keratometric parameters and in the measurement of mean asphericity. The vector analysis of astigmatism in the multicenter study showed low predictability of the results after implantation and in the post-transplant study, the vector component of astigmatism did not reach statistical significance (J0 – p = 0.52 and J45 – p = 0.15). The analysis of the choice of the thickness of the segments to be implanted performed in the single-center study showed that the choice based on SE presented a superior performance to the choice based on Q in most comparisons of the results of topography extracted from Scheimpflug, despite similar results in visual acuity and refraction data. There were no intraoperative or postoperative complications in the single-center study and in the post-corneal transplant study. However, in the multicenter study, there were 4 cases of postoperative segment migration and 2 cases of intraoperative perforation. All these complications occurred in patients operated with the manual technique, and the results were excluded from the analysis. Conclusions: Our results suggest that the long-arch corneal intrastromal ring segments can improve distance visual acuity with correction, with reduction of mean spherical equivalent, mean keratometric measurements, and mean corneal asphericity in the treatment of keratoconus and for the correction of residual ametropia and corneal irregularity after corneal transplantation.
Purpose: To evaluate the changes in mean corrected distance visual acuity (CDVA), spherical equivalent (SE), keratometries (K), and mean asphericity (Q) after implantation of the long-arch corneal intrastromal ring segments for the treatment of keratoconus and for the correction of residual ametropia and corneal irregularity after corneal transplantation. Methods: The objects of this thesis were the publication of three studies involving the use of long-arch rings in patients with keratoconus and post-corneal transplantation. All three studies were prospective, non-randomized, and non-comparative. In the two studies on keratoconus surgery, 172 eyes from 161 patients were included: 34 eyes from 31 patients in the single-center study and 138 eyes from 130 patients in the multicenter study. In this last study, patients were recruited and operated on in 10 different ophthalmological hospitals in Brazil. In the study regarding the implantation of segments in eyes after corneal transplantation, 18 eyes from 18 patients were included. In the two studies on keratoconus surgery, segments with 320 degrees of arch were implanted, and in the post-corneal transplant study, segments with 340 degrees of arch. In the multicenter study, 45 eyes were operated with the manual technique, while 93 eyes were operated with the assistance of the femtosecond laser. In the single-center study and in the post-transplant study, all eyes were operated with the assistance of femtosecond laser. The primary outcome measure in all three studies was the change in mean CDVA after segment insertion. The secondary outcome measures were changes in the mean SE, mean keratometries, and mean corneal asphericity. In both keratoconus studies, we evaluated the percentage of patients who had loss or gain of CDVA lines at 3 and 6 months postoperatively, and in the post-corneal transplant study, at 12 months postoperatively. In the multicenter study and in the post-transplant study, we performed vector analysis for refractive findings. And, finally, in the single-center study, we made a comparison between two strategies for choosing the thickness of the segments to be implanted. Results: The implantation of long-arch rings significantly improved CDVA, with a reduction in SE, considerably gaining CDVA lines and most patients achieved CDVA better than or equal to 0.3 logMar. In the multicenter keratoconus study, CDVA improved from 0.7 logMar to 0.3 logMar (p < 0.001), with a reduction in SE from -7.02 ± 4.80 D to -3.29 ± 3.80 D (p < 0.001). At the end of the postoperative follow-up, 92.4% of the patients had gained at least 1 CDVA line, only 1.9% had lost at least 1 CDVA line, and 75.9% had achieved at least 0.3 CDVA logMar. In the single-center keratoconus study, CDVA improved from 0.51 ± 0.22 logMar to 0.18 ± 0.12 logMar (p < 0.01), with a reduction in SE from -7.52 ± 4.18 D to -3.61 ± 3.79 D (p < 0.01). At the end of the postoperative follow-up, 88.24% of the patients had gained at least 1 CDVA line, only 2.94% had lost at least 1 CDVA line, and 88.23% had achieved at least 0.3 CDVA logMar. In the post-corneal transplant study, CDVA improved from 0.26 ± 0.12 logMar to 0.10 ± 0.10 logMar (p < 0.001), with a reduction in SE from -5.22 ± 2.96 D to -2.52 ± 2.83 D (p < 0.001). At the end of the postoperative follow-up, 94.45% of the patients had gained at least 1 CDVA line, only 5.55% had lost at least 1 CDVA line, and 95% had achieved at least 0.3 CDVA logMar. Regarding the corneal topographic results extracted from Scheimpflug, in all three studies we obtained a significant improvement (p < 0.05) in all keratometric parameters and in the measurement of mean asphericity. The vector analysis of astigmatism in the multicenter study showed low predictability of the results after implantation and in the post-transplant study, the vector component of astigmatism did not reach statistical significance (J0 – p = 0.52 and J45 – p = 0.15). The analysis of the choice of the thickness of the segments to be implanted performed in the single-center study showed that the choice based on SE presented a superior performance to the choice based on Q in most comparisons of the results of topography extracted from Scheimpflug, despite similar results in visual acuity and refraction data. There were no intraoperative or postoperative complications in the single-center study and in the post-corneal transplant study. However, in the multicenter study, there were 4 cases of postoperative segment migration and 2 cases of intraoperative perforation. All these complications occurred in patients operated with the manual technique, and the results were excluded from the analysis. Conclusions: Our results suggest that the long-arch corneal intrastromal ring segments can improve distance visual acuity with correction, with reduction of mean spherical equivalent, mean keratometric measurements, and mean corneal asphericity in the treatment of keratoconus and for the correction of residual ametropia and corneal irregularity after corneal transplantation.
Descrição
Citação
ROCHA, Guilherme Andrade do Nascimento. A influência do segmento de anel intraestromal corneano de arco longo na cirurgia de córnea. 2024. 150 f. Tese (Doutorado em Oftalmologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP). São Paulo, 2024.