w The effect of intracameral epinephrine on pupil size during phacoemulsification

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REVISTA BRASILEIRA DE OFTALMOLOGIANOV-DEZ 2016VOLUME 75 NÚMERO 6 P. 419-504

The effect of intracameral epinephrine on pupil size during phacoemulsification w

Keratitis by Aspergillus after cataract surgery w

Lipid corneal degeneration after trabeculectomy w

Vol. 75 - nº 6 - Novembro/Dezembro 2016 Publicação bimestral ISSN 0034-7280

Versão impressa

Publicação oficial da Sociedade Brasileira de Oftalmologia, Associação Brasileira de Catarata e Cirurgia Refrativa

Scielo, Scopus Scielo, Scopus e Lilacs e Lilacs Scielo, Scopus

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5 25 75 95 100

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Associada a ABEC - Associação Brasileira

de Editores Científicos

Publicação bimestral Rev Bras Oftalmol, v. 75, n. 6, p. 419-504, Nov./Dez. 2016

Revista

Brasileira de

Oftalmologia

PUBLICAÇÃO OFICIAL:

SOCIEDADE BRASILEIRA DE OFTALMOLOGIA

ASSOCIAÇÃO BRASILEIRA DE CATARATA E CIRURGIA REFRATIVA

Indexada nas bases de dados:

Disponível eletronicamente:

Coordenação de Aperfeiçoamento de Pessoal

de Nível Superior

www.sboportal.org.br http://www.capes.gov.br

ISSN 0034-7280

(Versão impressa)

ISSN 1982-8551

(Versão eletrônica)

Sociedade Brasileira de Oftalmologia

LILACS

Literatura Latino-americana em Ciências da Saúde

SciELO

Scientific Electronic

Library OnLine www.freemedicaljournals.com

Editor Chefe André Luis Freire Portes (RJ) Editor Executivo Arlindo José Freire Portes (RJ) Co-editores

André Luiz Land Curi (RJ) Bruno Machado Fontes (RJ) Carlos Eduardo Leite Arieta (SP) Hamilton Moreira (PR)

Liana Maria Vieira de Oliveira Ventura (PE) Marcony R. Santhiago (RJ) Mario Martins dos Santos Motta (RJ) Maurício Maia (SP)

Miguel Ângelo Padilha Newton Kara-Junior (SP) Niro Kasahara (SP) Renato Ambrósio Jr. (RJ) Ricardo Augusto Paletta Guedes (MG) Rodrigo Pessoa Cavalcanti Lira (PE) Silvana Artioli Schellini (SP) Walton Nosé (SP) Corpo Editorial Internacional Baruch D. Kuppermann - Califórnia - EUA Christopher Rapuano - Phyladelphia - EUA Curt Hartleben Martkin - Colina Roma - México Daniel Grigera - Olivos - Argentina Deepinder Kauer Dhaliwal - Pittsburg - EUA Esmeralda Costa - Coimbra - Portugal Felipe A. A. Medeiros - Califórnia - EUA Felix Gil Carrasco - México – México Fernando Arevalo - Riyadh - Arábia Saudita Florent Aptel - Grenoble - França Francisco Rodríguez Alvira – Bogotá - Colombia Howard Fine - Eugene - EUA

Jean Jacques De Laey - Ghent - Bélgica Jean-Philippe Nordmann - Paris - França Jesús Merayo-LLoves - Oviedo - Espanha Kevin M. Miller - Califórnia - EUA Keweh Mansouri - Paris - Fraça Lawrence P. Chong - Califórnia - EUA Lihteh Wu – San José - Costa Rica Liliana Werner - Utah - EUA Miguel Burnier Jr. - Montreal - Canadá Pablo Cibils - Assunção - Paraguai Patricia Mitiko Santello Akaishi – Arábia Saudita Paulo Torres - Lisboa - Portugal Peter Laibson - Phyladelphia - EUA Steve Arshinoff - Toronto - Canadá Corpo Editorial Nacional

Abelardo de Souza Couto - Rio de Janeiro- RJ Abrahão da Rocha Lucena - Fortaleza - CE Alexandre Antonio Marques Rosa - Paraíba - PA Alexandre Augusto Cabral de Mello Ventura - Recife - PE Alexandre H. Principe de Oliveira – Salvador – BA Alexandre Seminoti Marcon – Porto Alegre - RS Ana Carolina Cabreira Vieira – Rio de Janeiro – RJ Ana Luisa Hofling de Lima - São Paulo - SP André Correa de Oliveira Romano – Americana - SP André Curi - Rio de Janeiro - RJ

André Luis Freire Portes - Rio de Janeiro - RJ André Marcio Vieira Messias – Ribeirão Preto – SP

Antonio Marcelo Barbante Casella - Londrina - PR Armando Stefano Crema- Rio de Janeiro- RJ Beatriz de Abreu Fiuza Gomes – Rio de Janeiro - RJ Bruna Vieira Ventura - Recife - PE Bruno Diniz – Goiânia - GO Carlos Augusto Moreira Jr.- Curitiba- PR Carlos Gabriel Figueiredo - São José do Rio Preto - SP Carlos Ramos de Souza Dias- São Paulo- SP Celso Marcelo da Cunha - Cuiabá - MT Claudio do Carmo Chaves - Manaus - AM Cristiano Caixeta Umbelino - São Paulo - SP Daniel Lavinsky – Porto Alegre - RS David Leonardo Cruvinel Isaac – Goiania - GO Diego Tebaldi Q. Barbosa - São Paulo - SP Edmundo Frota De Almeida Sobrinho- Belém- PA Eduardo Buchele Rodrigues – Florianópolis - SC Eduardo Cunha de Souza – São Paulo - SP Eduardo Damasceno - Rio de Janeiro - RJ Eduardo Dib – Rio de Janeiro - RJ Eduardo Ferrari Marback- Salvador- BA Eliezer Benchimol - Rio de Janeiro - RJ Enzo Augusto Medeiros Fulco – Jundiaí - SP Eugenio Santana de Figueiredo – Juazeiro do Norte - CE Fábio Marquez Vaz – Ondina – BA Felipe Almeida - Ribeirão Preto - SP Fernando Cançado Trindade - Belo Horizonte- MG Fernando Marcondes Penha - Florianópolis - SC Fernando Oréfice- Belo Horizonte- MG Fernando Roberte Zanetti – Vitória - ES Flavio Rezende- Rio de Janeiro- RJ Francisco de Assis Cordeiro Barbosa - Recife - PE Frederico Valadares de Souza Pena – Rio de Janeiro - RJ Frederico Guerra - Niterói - RJ

Giovanni N.U.I.Colombini- Rio de Janeiro- RJ Guilherme Herzog Neto- Rio de Janeiro- RJ Harley Biccas - Ribeirão Preto - SP Haroldo Vieira de Moraes Jr.- Rio de Janeiro- RJ Hélcio Bessa - Rio de Janeiro - RJ Helena Parente Solari - Niterói - RJ Heloisa Helena Abil Russ – Curitiba – PR Henderson Celestino de Almeida- Belo Horizonte- MG Hilton Arcoverde G. de Medeiros- Brasilia- DF Homero Gusmao de Almeida- Belo Horizonte- MG Italo Mundialino Marcon- Porto Alegre- RS Iuuki Takasaka – Santa Isabel - SP Ivan Maynart Tavares - São Paulo - SP Jaco Lavinsky - Porto Alegre - RS Jair Giampani Junior – Cuiabá - MT Jeffersons Augusto Santana Ribeiro - Ribeirão Preto - SP João Borges Fortes Filho- Porto Alegre- RS João Luiz Lobo Ferreira – Florianópolis – SC João Marcelo de Almeida G. Lyra - Maceió - AL João Orlando Ribeiro Goncalves- Teresina- PI Jorge Carlos Pessoa Rocha – Salvador – BA JorgeAlberto de Oliveira - Rio de Janeiro - RJ José Augusto Cardillo – Araraquara – SP José Beniz Neto - Goiania - GO

José Ricardo Carvalho L. Rehder- São Paulo- SP Laurentino Biccas Neto- Vitória- ES Leonardo Akaishi - Brasília - DF Leonardo Provetti Cunha - SP Leticia Paccola - Ribeirão Preto - SP Liana Maria V. de O. Ventura- Recife- PE Luiz Alberto Molina - Rio de Janeiro - RJ Manuel Augusto Pereira Vilela- Porto Alegre- RS Marcelo Hatanaka – São Paulo – SP

Redação:

Rua São Salvador, 107 Laranjeiras - CEP 22231-170 Rio de Janeiro - RJ Tel: (0xx21) 3235-9220 Fax: (0xx21) 2205-2240 Edição:Bimestral Secretaria: Marcelo Diniz Editoração Eletrônica:

Sociedade Brasileira de Oftalmologia Responsável: Marco Antonio Pinto DG 25341RJ

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Maria de Lourdes Veronese Rodrigues- Ribeirão Preto- SP Maria Rosa Bet de Moraes Silva- Botucatu- SP Maria Vitória Moura Brasil - Rio de Janeiro - RJ Mário Genilhu Bomfim Pereira - Rio de Janeiro - RJ Mario Luiz Ribeiro Monteiro - São Paulo- SP Mário Martins dos Santos Motta- Rio de Janeiro- RJ Marlon Moraes Ibrahim – Franca - SP Mauricio Abujamra Nascimento – Campinas - SP Maurício Bastos Pereira - Rio de Janeiro - RJ Maurício Dela Paolera - São Paulo - SP Miguel Ângelo Padilha Velasco- Rio de Janeiro- RJ Miguel Hage Amaro - Belém - PA

Milton Ruiz Alves- São Paulo- SP

Moyses Eduardo Zadjdenweber - Rio de Janeiro - RJ Nassim da Silveira Calixto- Belo Horizonte- MG Nelson Alexandre Sabrosa - Rio de Janeiro – RJ Newton Kara-José - São Paulo - SP Newton Leitão de Andrade – Fortaleza – CE Núbia Vanessa dos Anjos Lima Henrique de Faria - Brasília-DF Octaviano Magalhães Júnior - Atibaia - SP

Oswaldo Moura Brasil- Rio de Janeiro- RJ Otacílio de Oliveira Maia Júnior – Salvador - BA Patrick Frensel de Moraes Tzelikis – Brasília – DF Paulo Augusto de Arruda Mello Filho – São Paulo – SP Paulo Augusto de Arruda Mello- São Paulo- SP Paulo Schor - São Paulo - SP

Pedro Carlos Carricondo – São Paulo – SP Pedro Duraes Serracarbassa – São Paulo – SP Priscilla de Almeida Jorge – Recife – PE Rafael Ernane Almeida Andrade - Itabuna – BA Raul N. G. Vianna - Niterói - RJ Remo Susanna Jr.- São Paulo- SP Renata Rezende - Rio de Janeiro - RJ Renato Ambrosio Jr.- Rio de Janeiro- RJ Renato Luiz Nahoum Curi- Niterói- RJ Richard Yudi Hida – São Paulo – SP Riuitiro Yamane - Niterói - RJ Roberto Lorens Marback - Salvador - BA Roberto Pinto Coelho – Ribeirão Preto – SP Rodrigo França de Espíndola – São Paulo – SP Rogerio Alves Costa- Araraquara- SP Rogerio de Almeida Torres - Curitiba - PR Rubens Belfort Neto – São Paulo – SP Rubens Camargo Siqueira- São José do Rio Preto- SP Sebastião Cronemberger So.- Belo Horizonte- MG Sérgio Henrique S. Meirelles- Rio de Janeiro- RJ Sérgio Kwitko - Porto Alegre - RS Sérgio Luis Gianotti Pimentel – São Paulo – SP Silvana Artioli Schellini - Botucatu- SP Suel Abujamra- São Paulo - SP Suzana Matayoshi - São Paulo - SP Tânia Mara Cunha Schaefer – Curitiba – PR Vinícios Coral Ghanem - Santa Catarina - SC Vitor Cerqueira - Rio de Janeiro - RJ Walter Yukihiko Takahashi – São Paulo – SP Walton Nose- São Paulo- SP Wener Passarinho Cella - Plano Piloto - DF Wesley Ribeiro Campos- Passos- MG

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Revista Brasileira de Oftalmologia

Rua São Salvador, 107 - Laranjeiras - CEP 22231-170 - Rio de Janeiro - RJ

Tels: (0xx21) 3235-9220 - Fax: (0xx21) 2205-2240 - e-mail: [email protected] - www.sboportal.org.br Revista Brasileira de Oftalmologia, ISSN 0034-7280, é uma publicação bimestral da Sociedade Brasileira de Oftalmologia

Presidente:

João Alberto Holanda de Freitas (SP) Vice-presidentes:

Armando Stefano Crema (RJ) Durval Moraes de Carvalho Jr. (SP) Francisco de Assis Cordeiro Barbosa (PE)

Miguel Hage Amaro (PA) Sérgio Kwitko (RS)

Secretário Geral:

Arlindo José Freire Portes (RJ) 1º Secretário:

Oswaldo Ferreira Moura Brasil (RJ)

Associação Brasileira de Banco de Olhos e Transplante de Córnea Presidente: Ari de Souza Pena

Associação Brasileira de Catarata e Cirurgia Refrativa Presidente: Pedro Paulo Fabri

Associação Maranhense de Oftalmologia Presidente: Romero Henrique Carvalho Bertand Associação Matogrossense de Oftalmologia

Presidente: Jair Giampani Junior Associação Pan-Americana de Banco de Olhos

Presidente: Alvio Isao Shiguematsu Associação Paranaense de Oftalmologia

Presidente: Otavio Siqueira Bisneto Associação Rondoniense de Oftalmologia

Presidente: Renata Campos Sales Associação Sul Matogrossense de Oftalmologia

Presidente: Elson Yamasato Sociedade Alagoana de Oftalmologia

Presidente: Mário Jorge Santos

Sociedade Brasileira de Administração em Oftalmologia Presidente: Ronald Fonseca Cavalcanti

Sociedade Brasileira de Cirurgia Plástica Ocular Presidente: Murilo Alves Rodrigues

Sociedade Brasileira de Ecografia em Oftalmologia Presidente: Leila Sueli Gouveia José Sociedade Brasileira de Glaucoma Presidente: Marcelo Palis Ventura Sociedade Capixaba de Oftalmologia

Presidente: Adriana Vieira Cardozo Sociedade Catarinense de Oftalmologia

Presidente: Ayrton Roberto Bravo Ramos

SOCIEDADES FILIADAS À SOCIEDADE BRASILEIRA DE OFTALMOLOGIA

Presidente Pedro Paulo Fabri

Vice-Presidente Walton Nosé Secretário Geral Gustavo Victor de Paula Baptista

Tesoureiro Geral Carlos Heler Ribeiro Diniz

1º Tesoureiro Francisco Grupenmacher

Diretor de Cursos (Editor)

Mauro Silveira de Queiroz Campos

2º Secretário:

Jorge Carlos Pessoa Rocha (BA) Tesoureiro:

Mário Martins dos Santos Motta (RJ) Diretor de Cursos:

Gustavo Amorim Novais (RJ) Diretor de Publicações:

André Luis Freire Portes (RJ) Diretor de Biblioteca:

Evandro Gonçalves de Lucena Jr (RJ) Conselho Consultivo:

Carlos Alexandre de Amorim Garcia (RN)

Eduardo Henrique Morizot Leite (RJ) Marco Antonio Rey de Faria (RN)

Conselho Fiscal Efetivos:

Jacqueline Coblentz (RJ) Marcelo Lima de Arruda (RJ) Ricardo Lima de Almeida Neves (RJ)

Suplentes:

Arnaldo Pacheco Cialdini (GO) Helcio José Fortuna Bessa (RJ) Silvana Maria Pereira Vianello (MG)

Diretor de Cursos e Publicação (Seção Catarata)

Bruna Ventura, Ramon Coral Ghanem, Renata Attanasio de Rezende Bisol e Rachel

Lopes Rodrigues Gomes Diretor de Cursos e Publicação

(Seção Refrativa)

Marcony Rodrigues de Santhiago, Ricardo Menon Nosé e Sérgio Kwitko Diretor de Cursos e Publicação

(Seção Córnea)

Evandro Ribeiro Diniz, Nicolas Cesário Pereira, Victor Andrigheti Coronado Antunes

e Vinícius Coral Ghanem

Sociedade Cearense de Oftalmologia Presidente: Newton Andrade Júnior Sociedade Goiana de Oftalmologia

Presidente: Fausto da Paz Cazorla Sociedade Norte-Nordeste de Oftalmologia Presidente: Carlos Alexandre de Amorim Garcia

Sociedade de Oftalmologia do Amazonas Presidente: Leonardo Bivar Sociedade de Oftalmologia da Bahia Presidente: André Hasler Príncipe de Oliveira Sociedade de Oftalmologia do Nordeste Mineiro

Presidente: Mauro César Gobira Guimarães Sociedade de Oftalmologia de Pernambuco

Presidente: Paulo Jorge Rocha Saunders Sociedade de Oftalmologia do Rio Grande do Norte

Presidente: Nelson Roberto Salustino Galvão Sociedade de Oftalmologia do Rio Grande do Sul

Presidente: Afonso Reichel Pereira Sociedade de Oftalmologia do Sul de Minas

Presidente: Mansur Elias Ticly Junior Sociedade Paraense de Oftalmologia Presidente: Frederico José Correia Lobato

Sociedade Paraibana de Oftalmologia Presidente: Rodrigo Almeida Viera Santos

Sociedade Piauiense de Oftalmologia

Maria de Lourdes Cristina Alcântara Paz Carvalho do Nascimento Sociedade Sergipana de Oftalmologia

Presidente: Jussara Tavares da Cunha

Diretoria da SBO 2015-2016

Diretoria da ABCCR/BRASCRS 2016-2018

Diretor de Cursos e Publicação (Seção Superfície Ocular)

Richard Yudi Hida Diretor de Cursos e Publicação

(Seção Glaucoma) Victor Cvintal

Clube de Pesquisa e Publicação Newton Kara José Junior

Diretoras de Vídeo

Amaryllis Avakian e Andreia Peltier Urbano Diretor de Comunicação

Daniel Alves Montenegro, Durval Moraes de Carvalho Junior e João Marcelo de Almeida

Gusmão Lyra

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421

Publicação bimestral Rev Bras Oftalmol, v. 75, n. 6, p. 419-504, Nov./Dez

Editorial

423 A sabedoria começa na reflexão Wisdom begins in wonder

André Luis Freire Portes

Artigos Originais

425 The effect of intracameral epinephrine on pupil size during phacoemulsification and its postoperative effect on specular findings and macular thickness

O efeito da adrenalina intracameral no tamanho da pupila durante a facoemulsificação e seu efeito pós-operatória em achados especulares e espessura macular

Hassan Gamal El- Din Farahat, Asmaa Muhammed Ibrahim, Ahmed Abdelwahab Ali

432 Avaliação da adesão aos colírios em pacientes com glaucoma através da Escala de Morisky de 8 itens: um estudo transversal

Adherence assessment of eye drops in patients with glaucoma using 8 item Morisky Score: a cross sectional study

Marina Viegas Moura Rezende Ribeiro, Luiz Eduardo Feliciano Ribeiro, Êurica Adélia Nogueira Ribeiro, Caio Vítor Ferreira, Fabiano Timbó Barbosa

438 Estudo comparativo entre o teste fenol vermelho e o teste de schirmer no diagnóstico da síndrome do olho seco

Comparative study between phenol red thread test and the Schirmer’s test in the diagnosis of dry eyes syndrome

Guilherme Mafra Ghislandi, Gina Carriero Lima

443 Fatores de risco e incidência da retinopatia diabética Risk factors and incidence of diabetic retinopathy

Denise Borges de Andrade Mendanha, Mayara Martins Abrahão, Mateus Martins Cortez Vilar, João Jorge Nassaralla Junior^.

Sumário - Contents

Revista

Brasileira de

Oftalmologia

Disponível eletronicamente:

Coordenação de Aperfeiçoamento de Pessoal

de Nível Superior

www.sboportal.org.br

http://www.capes.gov.br

ISSN 0034-7280

(Versão impressa)

ISSN 1982-8551

(Versão eletrônica)

LILACS

Literatura Latino-americana em Ciências da Saúde

SciELO

Scientific Electronic

Library OnLine www.freemedicaljournals.com

Fundada em 01 de junho de 1942 CODEN: RBOFA9

PUBLICAÇÃO OFICIAL:

SOCIEDADE BRASILEIRA DE OFTALMOLOGIA

ASSOCIAÇÃO BRASILEIRA DE CATARATA E CIRURGIA REFRATIVA

Indexada nas bases de dados:

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422

447 Percepção de autoinstilação de gotas oculares em idosos com ou sem dispositivo de apoio facial Self instillation perception of eye drops in elderly patients with and without facial support device

Arlindo Jose Freire Portes, Ruan Machado Guilhon Lopes, Marcella Guimarães Cardoso, Rafael Abbud Fernandes, Thamara Abreu Souza

452 Exenteração orbitária: série de casos Orbital Exenteration: a series of cases

Gabriel de Almeida Ferreira, Natalia Mussi, Roberta Lilian Fernandes de Sousa Meneghim, José Vicente Tagliarini, Mariângela Esther Alencar Marques, Silvana Artioli Schellini

456 Perfil do paciente albino com visão subnormal e melhoria da acuidade visual com a adaptação de recursos ópticos e/ou eletrônicos

Profile of albinism with low vision and improvement of visual acuity with the adaptation of optical and / or electronic resources

Diego Fleury de Lemos Pereira, Evandro Lopes Araujo,Fernanda Viana Duarte Patuzzo

461 Análise de custos para clínicas oftalmológicas Cost analysis for ophthalmic clinics services

Eduardo Regonha, Ricardo Rinaldi Baungartner, Marinho Jorge Scarpi

Relato de Casos

470 Lipid corneal degeneration after trabeculectomy with mitomicin 0.02%

Degeneração lipídica da córnea após trabeculectomia com mitomicina C 0,02%

Larissa Rossana Souza Stival, Luis Fernando Oliveira Borges Chaves, Karine Sauter, Luiz Arthur Franco Beniz, Jordana Sandes Barbosa Soares, Francisco Wellington Rodrigues, Marcia Cristina Toledo, José Beniz

473 Keratitis by Aspergillus flavus infection after cataract surgery Ceratite por infecção com Aspergillus flavus após facoemulsificação

João Luiz Pacini Costa, Daniel Barra Edson Ando, Robert Pogue

476 Terapia nutricional proposta para conjuntivite lenhosa: Estudo de caso e revisão de literatura

Nutritional treatment for leagnous conjuntivitis: case report and literature review

Mariana Granito, João Maria Ferreira

481 Apresentação incomum e agressiva de melanoma intraorbitário Unusual and aggressive presentation of intraorbital melanoma

Ignatz Rohrbacher, Oswaldo Valentim Zandavalli Neto, Assad Rayes

484 Fibroma de Tarso Tarsal Fibroma

Assad Rayes, Gherusa Helena Milbratz, Tatiana Rocha Rayes de Aguiar, Guilherme Rocha Rayes, Vanessa Rocha Rayes, Ignatz Rohrbacher,

Artigo de Atualização

487 Pachychoroid, an update from the new finding to the usual investigation in selected diseases Atualização de espessamento de coroide

Miguel Hage Amaro, Jorge Mitre, Mario Martins dos Santos Motta, João Jorge Nassaralla Junior, Teruo Aihara

Índice Remissivo

492 Índice Remissivo do volume 75

Instruções aos autores

502

Normas para publicação de artigos na RBO

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E

DITORIAL 423

Wisdom begins in wonder

(Socrates, 470-399 BC.)

A sabedoria começa na reflexão

A

percepção crítica do escopo oftalmológico, referente aos periódicos científicos nacionais, suscita por buscas constantes no seu aperfeiçoamento e adequações às necessidades editoriais. O processo de publicação atualmen te proposto pela Sociedade Brasileira de Oftalmologia (SBO) tem aspectos voltados para facilitar a submissão dos artigos pelos autores, auxiliar os revisores e principalmente satisfazer aos anseios dos leitores, cada vez mais exigentes.

Por meio deste editorial, compartilhamos a análise de uma série de modificações e os seus resultados referentes aos últimos dois anos da diretoria atual.

Foram publicados 12 números consecutivos da Revista Brasileira de Oftalmologia (RBO) em dois volumes durante o período de janeiro de 2015 a dezembro de 2016. A regularidade no processo editorial com o envio dos arquivos para as bases de dados de indexação (SciELO e SCOPUS/SCimago) nos prazos estabelecidos e até antes (Ahead of Print), foi considerado um dos resultados mais importantes. Isso foi possível com a redução no trâmite editorial para a publicação dos artigos originais em aproximadamente três meses. As mudanças na plataforma digital da RBO e do seu sistema em nuvem, com a simplificação de todo o processo das revisões em pares, influenciou diretamente nesse tempo. A reestruturação digital também passou a utilizar todo o texto em versão XML (Extensible Markup Language) o que facilita o compartilhamento de informações em rede, necessário para obtenção do Digital Object Identifier (DOI), registrado na base CrossRef. O DOI, que foi desenvolvido pela American Publishers Association, identifica, localiza e autentica cada artigo disponível na internet.

Além de procurarmos adequar a quantidade de artigos aos critérios científicos recomendados da coleção SciELO para área de saúde, reestruturamos também o formato dos resumos, segundo orientações do Pubmed/Medline, com o propósito de requerer a sua futura indexação, que passa a ser elegível no próximo ano.

A RBO tem tido um aumento progressivo de acessos nos últimos anos sendo esses mais expressivos a partir de março de 2015 ^(1,2). A maior procura dos leitores foi por artigos originais, representando um total de aproximadamente 70% de todos os artigos pesquisados⁽¹⁾. Esses dados corroboram tanto para maior interesse pela pauta dos assuntos publicados na RBO quanto para o reconhecimento pelo rigor científico que a revista tem adotado, uma vez que mais de 1/3 dos artigos enviados para submissão têm sido rejeitados⁽³⁾.

Dentre os vários critérios de avaliação das revistas científicas, a citação dos seus artigos é considerada um dos que têm maior importância. Quanto maior a quantidade de artigos citados sobre um periódico, maior é a sua influência no meio acadêmico. A citação do periódico assume ainda mais relevância quando é feita por artigos publicados em outro periódico. Além do aumento total das citações nos últimos anos, observamos mais recentemente um aumento da propor- ção de citações externas em relação às autocitações na ordem de 50%⁽²⁾, o maior de toda série histórica da RBO desde de sua inclusão no ScieLO. Esses números refletem uma RBO mais atuante e em evidência, que se confirma ao analisar- mos ScieLO Citation Index para os últimos 2 anos (base 2016) que pontuou com 0.0559 e 0.135 segundo Scimago Journal& Country Rank^(1,2). Esses números ainda precisam ser melhorados para atingir os padrões dos principais perió- dicos internacionais.

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A transmissão do conhecimento envolve diferentes formas de ensino, que no processo editorial podem ser observadas principalmente por meio das análises críticas feitas pelos revisores dos artigos submetidos, procurando sempre orientar, discutir e aprimorar a sua qualidade científica. O envolvimento e comprometimento do corpo editorial foram fundamen- tais para as melhoras observadas e o crescimento da RBO. Registramos aqui os nossos sinceros agradecimentos.

Existem aqueles que veem as coisas do jeito que são e se perguntam: por que?

Sonho com as coisas que nunca aconteceram e me pergunto: por que não?

(Robert Kennedy, 1925-1968) André Luis Freire Portes Professor Adjunto da Disciplina de Oftalmologia do Curso de Medicina da Universidade Estácio de Sá (UNESA-RJ);

Doutor em Ciências do Programa de Oftalmologia da Faculdade de Medicina da Universidade de São Paulo (USP-SP);

Editor-chefe da Revista Brasileira de Oftalmologia (2015-2016).

R

^EFERÊNCIAS

1. Scieloanalytics. [Internet]. [cited 2016 Oct 10]. Availablefrom: http://analytics.scielo.org/w/accesses?journal=0034-7280&collection=scl 2. SJR ScimagoJournal& Country Rank. [Internet]. [cited 2016 Oct 10]. Availablefrom: http://www.scimagojr.com/

journalsearch.php?q=15100&tip=sid&clean=0

3. Portes AL. Só fazemos melhor aquilo que repetidamente insistimos em melhorar... RevBras Oftalmol. 2016;75(3):173.

Portes ALF

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A

^RTIGO

O

^RIGINAL425

1 Department of Ophthalmology, Menoufia University, Egypt.

2 Department of Ophthalmology, Menoufia University, Egypt.

3 Research Institute of ophthalmology, Giza.

The study was performed at Menoufia University Hospital and research institute of Ophthalmology.

This work was self-funded by the authors.

Os autores declaram não haver conflitos de interesse.

Recebido para publicação em 03/08/2016 - Aceito para publicação em 03/10/2016.

The effect of intracameral epinephrine on pupil size during phacoemulsification

and its postoperative effect on specular findings and macular thickness

O efeito da adrenalina intracameral no tamanho da pupila durante a facoemulsificação e seu efeito pós-operatório

em achados especulares e espessura macular

Hassan Gamal El-Din Farahat¹, Asmaa Muhammed Ibrahim², Ahmed Abdelwahab Ali³

Objective: To evaluate pupillary size and vital signs following intraoperative intracameral adrenaline during phacoemulsification and postoperative effect of on co specular microscopy findings and macular thickness by OCT. Methods: A prospective interventional study carried out from December 2014 to December 2015 on 90 eyes. They were divided randomly into further 6 groups (15 each). The inclusion criteria consisted of no history of ocular pathologic conditions, trauma, previous ocular surgery, or recent ocular medication use. All patients were dilated preoperatively by phenylephrine 10% and operated under local peribulbar anesthesia. Then systemic monitoring regarding (pulse rate, blood pressure) and measurement of the horizontal pupil diameter by a caliper to the nearest 0.25mm pre and post intracameral adrenaline injection. Results : In our study there were great effect for intracameral epinephrine, with concentrations used, in dilatation and maintainance of papillary dilatation, The mean pre intracameral epinephrine was 4.53± 1.27 mm.The mean post epinephrine papillary diameter was 6.46± 1.00 mm. Three cases from group 1/10000 weren’t dilated properly. Also three cases from group 1/9000 weren’t dilated properly after intracameral epinephrine. Conclusion: Intracameral epinephrine even in higher concentrations is effective in papillary dilatation especially in cases with long duration and poorly dilated cases by usual topical mydriatics.

Keywords: Epinephrine/administration & dosage; Phacoemulsification; Pupil/drug effects

A

BSTRACT

R

ESUMO

Objetivo: Avaliar o tamanho pupilar e os sinais vitais após adrenalina intracameral intra-operatória durante a facoemulsificação, e efeito pós-operatório de achados microscópicos especulares e espessura macular por OCT. Métodos: Um estudo prospectivo intervencionista realizado de dezembro de 2014 a dezembro de 2015 em 90 olhos. Eles foram divididos aleatoriamente em mais 6 grupos (15 cada). Os critérios de inclusão consistiram em ausência de histórico de patologias oculares, trauma, cirurgia ocular prévia ou uso recente de medicação ocular. Todos os pacientes foram dilatados antes da cirurgia com fenilefrina 10% e operados sob anestesia peribulbar local. Em seguida, o monitoramento sistêmico em relação à pulsação e pressão arterial e a medição do diâmetro horizontal da pupila por um compasso de calibração para a injeção de adrenalina pré e pós-intracameral mais próxima de 0,25mm.

Resultados: Em nosso estudo houve um grande efeito da epinefrina intracameral com as concentrações utilizadas na dilatação e na manutenção da dilatação papilar. A epinefrina pré-intracameral média foi de 4,53 ± 1,27 mm. O diâmetro papilar médio pós- epinefrina foi de 6,46 ± 1,00 mm. Três casos do grupo 1/10000 não foram dilatados adequadamente. Além disso, três casos do grupo 1/9000 não foram dilatados adequadamente após a epinefrina intracameral. Conclusão: A epinefrina intracameral, mesmo em concentrações mais altas, é eficaz na dilatação papilar, especialmente nos casos com longa duração e nos casos mal dilatados por midriáticos tópicos comuns.

Descritores: Epinefrina/administração & dosagem; Facoemulsificão; Pupila/efeito de drogas

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426 El-Din FarahatHG, IbrahimAM, AliAA

T

he routines for cataract surgery have undergone a remarkable development over the past two to three decades.⁽¹⁾Surgical techniques have improved constantly, and now require less extensive anesthesia,⁽²⁾decreased need for hospitalization⁽³⁾ and fewer postoperative controls.⁽⁴⁾

Phacoemulsification technique has the advantage of early visual rehabilitation after cataract surgery and this is mainly attributed to the small incision size used. Still, it is remarkable that some perioperative routines have undergone very little change, despite the general improvement.⁽⁵⁾ One of those more or less unchanged routines have been the routine for preoperative pupil dilatation. Regardless of surgical technique, adequate mydriasisis essential for all stages of cataract surgery.

Pupil constriction during phacoemulsification or the irrigation/

aspiration phase increases the chances of iris damage, incomplete cortical material removal, posterior capsule rupture, vitreous loss and difficulty with intraocular lens (IOL) implantation into the capsular bag.

Extended phaco time, excessive fluid turbulence, iris touch, improper surgical maneuvers) can cause pupillary miosis.

Although the preoperative use of mydriatic agents including anticholinergics and sympathomimetics can often achieve adequate mydriasis early during surgery, other mydriatic agents are often required to maintain pupillary dilation during the procedure.^(6,7)

Pupil dilation is maintained by preoperative topical mydriatic eyedrops and to some extent by retrobulbar, peribulbar, or sub-Tenon anesthesia. When these methods do not maintain adequate pupil dilation, intraoperative intracameral epinephrine is used. Intracameral mydriatics (ICM) is a method to dilate the pupil prior to cataract surgery.⁽⁸⁾

Corneal endothelial cell damage is the most common cause of corneal edema⁽⁹⁾, the current study was conducted to evaluate corneal endothelial cell changes using bisulfite preserved adrenaline at different concentrations.

Epinephrine maculopathy is a reversible change to the macula that occurs in aphakic eyes treated with topical epinephrine. The first symptom is transient blurred vision, which may be followed by decreased visual acuity, flame-shaped hemorrhages, and cystoid macular edema (CME). Onset of symptoms ranges from a few days after commencement of epinephrine therapy to several months thereafter.⁽¹⁰⁾

Cystoid macular edema is a significant cause of decreased vision after cataract surgery.⁽¹¹⁾ The accompanying intraretinal fluid accumulation is associated with retinal thickening and cyst formation, which can be identified on biomicroscopy, optical coherence tomography.

I

NTRODUCTION

M

^ETHODS

This is a prospective interventional study carried out from December 2014 to December 2015 on 90 eyes attending at department of Ophthalmology, Menoufia University and Research Institute of Ophthalmology, Giza undergoing phacoemulsification for IMSC. They were divided randomly into further 6 groups (15 each): Control Group: No intracameral epinephrine injection. 2nd Group: intracameral epinephrine 1:10000 for intraoperative miosis. 3rd Group: intracameral

epinephrine 1:9000 for intraoperative miosis. 4th Group:

intracameral epinephrine 1:8000 for intraoperative miosis. 5th Group:

intracameral epinephrine 1:7000 for intraoperative miosis. 6th Group:

intracameral epinephrine 1:6000 for intraoperative miosis.

Inclusion criteria consisted of no history of ocular pathologic conditions, trauma, previous ocular surgery, or recent ocular medication use. Systemically free patients. Presence of visually significant cataract, According to locus III classification grade less and II nuclear cataract will be taken and exclude grade III and more. Normal specular microscopy, OCT and FFA.

Exclusion criteria were diabetic, hypertensive and cardiac patients. Grade N III or more. Any abnormal intraocular pathology. Abnormal specular microscopy, OCT or FFA study.

All included patients underwent detailed medical and ophthalmic history, refraction using auto-refractometer, best corrected visual acuity (BSCVA) assessment using Log Mar units, anterior segment examination using slit lamp, intraocular pressure using Goldman applanation tonometer and posterior segment examination using slit lamp biomicroscopy with +90 D lens and indirect ophthalmoscope with + 20 D lens. Every patient will be subjected to specular microscopy using NIDEK CEM- 530 , FFA using Zeiss Visucam Pro NM Fundus Camera, OCT macula with a Stratus 3 optical coherence tomographer (Carl Zeiss Meditec) before cataract surgery.

All patients were dilated preoperatively by phenylephrine 10% and operated under local peribulbar anesthesia. Then systemic monitoring regarding (pulse rate, blood pressure) and measurement of the horizontal pupil diameter by a caliper to the nearest 0.25mm pre & post intracameral adrenaline injection.

Then every follow-up after the procedure specular microscopy, FFA, OCT macula will be done (one week & 3 months). Specular microscopic pictures will give us data concerning corneal thickness, endothelial cell morphology, cell count, cell volume, standard deviation and minimum & maximum cell size. OCT will give us data about macular thickness.

All cases were operated upon using (INFINITI^® Vision System).

•All collected data revised for completeness and accuracy.

• Pre coded data was entered on the computer using the statistical package of Medcalc biomedical statistical software version 15.8 (Medcalc software bvba, Belgium) and IBM SPSS v 21 (IBM Corp., NY, USA) to be statistically analyzed.

• Data was summarized using:

- Mean and SD for quantitative variables - Number and percent for qualitative variable.

• Comparison between quantitative variable done using paired-samples t test for variables which where normally distributed and nonparametric Wilcoxon for quantitative variables, which were not normally distributed.

• P Value (Probability):

- p > 0.05 means, it is not significant.

- p < 0.05 means, it is significant.

- p < 0.01 means, it is highly significant.

R

^ESULTS

The eyes were assessed for eligibility (n= 138). Eyes were excluded from the study (n=48) due to [not meeting inclusion criteria (n=13) & no need for intracameral epinephrine (n=35)].

Only 90 eyes of 82 patients who completed the preoperative visit and all postoperative visits were included in the data analysis.

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Percentage of males to females was 48.9 to 51.1% (Table 1). The mean age 60.38±5.84 years (range from 49-72 years).

Frequency Percent Valid percent Female 44 48.9 48.9 Male 46 51.1 51.1 Total 90 100.0 100.0

Table 1 Gender frequency

Table 2

Mean ± SD of horizontal pupil diameter in mm pre incision, pre intracameral epinephrine, post intracameral epinephrine in each group

The mean pre incision pupil dimeter was 7.40±0.89 mm.

The mean pre intracameral epinephrine pupil diameter was 4.53 ± 1.27 mm. The mean post epinephrine pupil diameter was 6.46 ± 1.00 mm. Table 2 show The mean ± SD of pupillary diameter pre incision, pre epinephrine, post epinephrine in each group. P value was calculated using (repeated measures analysis of variants, ANOVA) test: p<0.001 showing statistically significant effect of intracameral epinephrine injection on pupillary diameter. p=0.895 showing statistically non-significant difference between different groups.

The mean of pre intracameral epinephrine systolic blood pressure was 126.83±7.21mmHg. The mean of systolic blood pressure post intracameral epinephrine was 127.80±7.67. The mean of pre intracameral epinephrine diastolic blood pressure was 75.83±5.52mmHg. The mean of diastolic blood pressure post intracameral epinephrine was 76.13 ± 5.49 mmHg. The mean of pre intracameral epinephrine pulse rate was 71.17 ± 4. 34 bpm.

The mean of pulse rate post intracameral epinephrine was 71.08±4.59 bpm. P value was calculated using (repeated measures analysis of variants, ANOVA) test: p=0.863 showing non- significant change in heart rate. p=0.917 showing non-significant difference in heart rate between groups. p=0.033 showing significant change in systolic blood pressure. p=0.353 showing non-significant difference in systolic blood pressure between groups. p=0.321 showing non-significant change in diastolic blood pressure. p=0.414 showing non-significant difference in diastolic blood pressure between groups. Table 3 shows the mean of pulse rate, systolic blood pressure and diastolic blood pressure pre and post intracameral epinephrine in each group.

The mean of pre operative CCT was 531.48 ± 32.63 µm.

The mean 1week post operative was 534.00 ± 31.77 µm. The

mean 3 months post operative was 531.42 ± 31.89 µm. The mean of pre operative endothelial cell count 2744.45 ± 422.85 cell/

mm³.The mean 1 week post operative 2568.22 ± 417.95 cell/mm³. The mean 3 months later was 2566.43 ± 416.35 cell/mm³. The mean pre- and 1week postoperative endothelial cell pleomorphism were 62.23 ± 4.35% and 62.67 ± 4.13%

respectively. The mean endothelial cell pleomorphism 3 months postoperative was 62.18 ± 2.38%. The mean pre- and 1 week postoperative endothelial polymegethism values were 31.33%±

5.78% and 33.04% ± 4.81%, respectively. The mean 3 months postoperative endothelial polymegethism was 32.41%± 4.62%.

P value was calculated using (repeated measures analysis of variants, ANOVA) test: p<0.001 showing statistically significant decrease in Endothelial cell count. p=0.844 showing non- significant change of endothelial cell count in different groups.

p=0.021 showing significant change in CCT. p=0.091 showing non significant change in CCT between different groups. p<0.53 showing non significant change in endothelial cell pleomorphism.

p<0.12 showing non significant change in endothelial cell polymegathism. Table 4 shows the mean of CCT & Endothelial cell count pre, 1week, 3 months post operative in each group.

Group

Mean Standard Deviation Mean Standard Deviation Mean Standard Deviation Mean Standard Deviation Mean Standard Deviation Mean Standard Deviation

Control 10000 U 9000 U 8000 U 7000 U 6000 U Group Group Group Group Group Group

Pupil diameter Mm pre incision

Pre_epinephrine_pupillarydiameter_Mm

Post_epinephrine_pupil_diameter_Mm 7.8

7 7.0 3

.4 4 .6 4

7.5 7 4.2 0 6.7 3

.8 6 .7 7 .8 2

7.3 7 4.0 3 6.1 3

.72

.44

1.2 3

7.2 7 4.1 0 6.6 3

1.1 0

.60

.92 7.0

7 3.9 7 6.4 0

.82

.61

1.0 2

7.2 7 3.8 7 6.4 0

1.1 0

.60

1.0 4 The effect of intracameral epinephrine on pupil size during phacoemulsification and its postoperative effect on specular findings and...

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Table 3

Mean and SD of pulse rate, systolic blood pressure and diastolic blood pressure pre and post intracameral epinephrine in each group

Group

Table 4

Mean an SD of CCT & Endothelial cell count preoperative , 1week, 3 months post operative in each group

Systolic_BP_pre

Diastolic_BP pre

Pulse rate/ minute

Systolic_bloodpressure_post

Diastolic_blood_pressure_post

Pulse rate post

126 .00 75 00 71.

80 7.

37 5.

67 4.

06 127

.33 76.

00 70.

80 129

.33 76.

67 70.

60 7.

99 6.

04 4.

96 7.

99 5.

88 4.

70 127 .67 76.

67 70.

60 129 .00 76 67 70 87

7.

29 5.

88 4.

70 8.

49 5.

88 5.

78 127

.33 77.

00 70.

93 128

.00 77.

.00 70.

.93 7.

04 5.

28 4.

06 7.

75 5.

28 4.

06 126

.67 75.

33 71.

13 126

.67 75.

33 71.

20 7.

24 5.

16 4.

70 7.

24 5.

16 4.

69 126

00 75.

00 71.

80 126

.00 75.

.00 71.

80 7.

37 5.

67 4.

06 7.

37 5.

67 4.

06

CCT UM Cell count/Mm3 CCT 1 week Cell count / Mm3 1 week CCT 3 months Cell count 3 months

Group

538.53 2904.67 539.67 2695.33

537.13 2695.33

15.82 477.13 16.31 474.93

15.56 474.93

536.00 2904.67 537.13 2710.67

539.67 2695.33

15.74 477.13 15.56 473.61

16.31 474.93

521.67 2505.00 524.07 2331.13

524.07 2331.13

55.49 289.85 52.08 253.88

52.08 253.88

537.13 2904.67 538.87 2737.40

532.07 2737.40

15.56 477.13 23.24 461.73

18.56 461.73

538.53 2505.00 539.80 2370.07

538.53 2370.07

15.82 298.85 17.47 309.62

15.82 309.62

517.07 2742.73 524.47 2564.73

517.07 2569.33

47.02 264.11 45.18 339.25

47.02 331.38

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The mean of CMT pre operative was 259.95 ± 8.71ìm. The mean 1 week post operative was 534.00 ± 31.77ìm. The mean 3 months post operative was 259.60 ± 8.25ìm. P value was calculated using (repeated measures analysis of variants, ANOVA) test:

p=0.256 non-significant change in CMT. p=0.923 non-significant difference between different groups. Table 5 shows the mean of CMT preoperative, 1 week, 3 months post operative. No patients had severe complications during or after surgery.

Table 5

Mean and SD of CMT preoperative, 1 week, 3 months post operative

The use of intracameral mydriatic agents of various formulations in phacoemulsification has gained acceptance.^(12-14) These agents are important, especially in cases of inadequate pupil size during phacoemulsification in complicated cases (i.e, pseudoexfoliation, long surgery time, floppy iris). Epinephrine must be tried before mechanical pupil dilation methods because the latter have disadvantages, including iris trauma and sphincter rupture; in addition, mechanical dilation has financial ramifications, time consuming, and requires creation of additional incisions.⁽¹⁵⁾

In our study there was great effect for intracameral epinephrine, with concentrations used, in dilatation and maintainance of papillary dilatation, The mean pre intracameral epinephrine was 4.53± 1.27mm, The mean post epinephrine papillary diameter was 6.46± 1.00 mm. Three cases from group 1/

10000 weren’t dilated properly. Also three cases from group 1/

9000 weren’t dilated properly after intracameral epinephrine. Two cases from each of the other three groups weren’t dilated properly.

Our results are comparable with the results of the study⁽⁶⁾, (The sixty study cases were assigned randomly into 5 groups with different concentrations of epinephrine injection (1:25,000, 1:50,000, 1:100,000, 1:200,000, or 1:400,0000, respectively),The mean pupil diameter post intracameral epinephrine was 8.00 ± 0.6mm, p<0.05 showing statistically significant effect of intracameral epinephrine injection on pupillary diameter. Another paper for the same researchers⁽⁸⁾ was published after that (42 eyes received phacoemulsification, the study group 30 eyes received I/A solution containing adrenaline, the control group 12 eyes didn’t receive adrenaline on I/A solution) . The mean pupillary diameter before I/A in the study group was 8.00 ± 0.63mm, while for control group it was 5.96±1.34mm. P<0.001 showing statistically significant effect

D

^ISCUSSION of adding epinephrine to I/A solution. In 2007 carried out a prospective, randomized, double-blinded study⁽¹⁶⁾ of 140 patients with age-related cataracts, scheduled for unilateral phacoemulsiûcation. The first part of the study involved 90 patients divided into two groups. Patients in both groups were given 150 ll ICMs at the beginning of the procedure. In Group 1, 0.6 lg D ml epinephrine was added to the irrigating balanced salt solution. No epinephrine was added to the irrigation solution used in Group 2.

The second part of the study involved 50 patients, all of whom were given topical mydriatics (TMs) and then similarly divided into two Groups and treated as in the ûrst study setting. Results:

With ICMs, pupil sizes generally increased during the procedures.

Remarkably, this increase was signiûcantly greater without epinephrine (13 ± 19% versus 4 ± 14%; p ¼ 0.02). In the TMs setting, pupil sizes decreased intraoperatively in both groups;

signiûcantly more without epinephrine (5 ± 4%) versus (12 ± 7%); p < 0.001). In 2003⁽⁷⁾ a paper was published as a prospective, randomized, double-masked study in which the patients were randomly assigned either of two treatments. Traditional topical mydriatics with 3 drops each of cyclopentolate 1% and phenylephrine 10% with 15 minutes interval plus 150µl of preservative-free xylocaine 1% intracamerally at the beginning of the procedure, or intracameral mydriatics with placebo eye drops and 150µl of a preservative-free mixture of cyclopentolate 0.1%, phenylephrine 1.5% and lidocaine 1% intracamerally. Pupil sizes were recorded. After injection of intracameral mydriatics, the pupils reached 95±3% of their maximum size after 20 seconds. In the intracameral mydriatics group, the pupil size after viscoelastic injection was 6.7±1.0mm, which was about 1 mm smaller than with topical mydriatics, but when using intracameral mydriatics the pupils continued to enlarge throughout the procedure as opposed to when topical mydriatics were used. In 2009 a paper⁽¹⁷⁾ compared the efficacy of a solution of epinephrine 0.025% and lidocaine

OCT central macular thickness OCT 1 week OCT 3 months

Group

259.47

258.73 258.73

10.03

8.32 8.32

259.47

258.73 258.73

10.03

8.32 8.32

260.40

260.40 260.40

7.97

7.97 7.97

261.13

261.13 261.13

259.47

259.47 259.47 8.28

8.28 8.28

10.03

10.03 10.03

259.80

259.60 259.13

7.73

6.67 7.48 The effect of intracameral epinephrine on pupil size during phacoemulsification and its postoperative effect on specular findings and...

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0.75% in fortified balanced salt solution (“epi-Shugarcaine”) and the other group was injected by (cyclopentolate 0.1%, phenylephrine 1.5%, and lidocaine 1%). The study was designed as a pair-eye single-masked prospective study involving 84 eyes of 42 patients. Topical tropicamide was given to both treatment groups.

The pupils were statistically significantly larger with epi- Shugarcaine; 0.528mm larger 1 minute after instillation and 0.34 mm larger at the end of the procedure.

In our study, we used specular microscopy to evaluate the effect of intracameral epinephrine on corneal endothelial cell count, central corneal thickness (CCT) and endothelial cell morphology . We found that the mean of pre-operative CCT was 531.48±32.63ìm . The mean 1week post operative was 534.00± 31.77ìm. The mean 3 months post operative was 531.42± 31.89ìm . The mean of pre operative endothelial cell count 2744.45±422.85 cell/mm³.The mean 1 week post operative 2568.22± 417.95 cell/mm³. The mean 3 months later was 2566.43±416.35 cell/mm³. P <0.001 showing statistically significant decrease in endothelial cell count, p=0.844 showing non- significant change of endothelial cell count in different groups.

p=0.021 showing significant change in CCT p=0.091 showing non significant change in CCT between different groups. The mean pre- and 1week postoperative endothelial cell pleomorphism were 62.23±4.35% and 62.67±4.13% respectively. The mean endothelial cell pleomorphism 3 months postoperative was 62.18±2.38%. The Mean pre- and 1 week postoperative endothelial polymegethism values were 31.33%±5.78% and 33.04%±4.81%, respectively. The mean 3 months postoperative endothelial polymegethism was 32.41%±4.62% p<0.53 showing non-significant change in endothelial cell pleomorphism. p <0.12 showing non-significant change in endothelial cell polymegathism. So using of intracameral epinephrine with these concentrations used in the study didn’t affect cornea more than corneal affection that could occur in other cases in which no intracameral epinephrine was used. In another study⁽¹⁸⁾, 71 eyes of 71 patients scheduled for phacoemulsification were randomly assigned to two groups: one group (31 eyes) received bolus intracameral adrenaline (1:10,000) and the other group (30 eyes) received adrenaline infusion (1:1,000,000). Pre- and one month postoperatively, a complete ophthalmologic examination as well as endothelial evaluation using ConfoScan III was performed; effective phaco time (EPT) and mydriasis during surgery were also compared between the study groups.

The two study groups were not significantly different in terms of demographic characteristics, lens opacity and EPT. Endothelial cell density was 2737±321 cell/mm in the bolus group vs 2742±426 cell/mm in the infusion group preoperatively (p=0.1). One month postoperatively, the rate of cell loss was 7.21% in the infusion group versus 8.87% in the bolus group (p= 0.13). Pupil diameter was >6 mm in 48% of eyes in the infusion group vs 33% of eyes in the bolus group (p=0.5). In 2009another paper⁽¹⁹⁾ was published as a retrospective study comprised 70 patients with age-related cataracts who had undergone phacoemulsification cataract surgery with intraocular lens (IOL) implantation without any surgical complications. In the adrenaline group, patients with intraoperative intracameral adrenaline use were included. The intracameral adrenaline was composed of 1 mL of 1:100,000 Dilution adrenalin with Sodium bisulfate preservative. The control group included patients who underwent surgery without any intracameral adrenaline use. There were 36 patients in the adrenaline group and 34 patients in the control group. Corneal endothelial density, endothelial cell morphology, and endothelial cell area were measured via specular microscopy both preoperatively and 3 months after surgery. The 2 groups were compared with regard to changes in specular microscopy measurements. The mean (±

standard deviation) age was 66.51 ± 8.32 years in the adrenalin

group and 67.58 ± 7.83 years in the control group. The difference in age between the 2 groups was not significant (p = 0.611). The preoperative mean corneal endothelial cell density was 2,270 ± 286 cells/mm in the adrenalin group and 2,226 ± 260 cells/mm2 in the control group, and the difference between the 2 groups was not statistically significant (p=0.550). In the adrenalin group, the postoperative mean corneal endothelial cell density was 2,191 ± 268 cells/mm. Although the postoperative mean cell density was lower than the preoperative mean cell density, the difference between the 2 measurements was not statistically significant (p=0.117). In the control group, the postoperative mean corneal endothelial cell density was 2,169 ± 272 cells/mm², and the difference between the preoperative and postoperative measurements was not statistically significant (p=0.161). Comparisons of postoperative specular microscopy measurements between the adrenaline and control groups with regard to cell density, cell sizes, and cell shapes showed that there were no statistically significant differences in comparison of all parameters between the 2 groups, So our results are comparable to their results. In 2013another published paper⁽²⁰⁾ about intracameral mydriatics in phacoemulsiûcation cataract surgery – a 6-year follow-up. A total of 45 patients were examined 6 years after phacoemulsiûcation cataract surgery. The patients had previously participated in a prospective randomized double-blind study including 60 patients, operated with either ICM or TM. The follow-up included best-corrected visual acuity (BCVA), intraocular pressure (IOP), grade of posterior capsule opaciûcation (PCO), YAG laser capsulotomy rate, pupil size, corneal thickness and endothelial morphology. At 6 years, there were no statistical differences in BCVA, IOP and pupil size. The corneal thickness and endothelial cell loss did not differ signiûcantly between the groups.

At the 6-year follow-up, the total endothelial cell loss was 16.5 ± 14.6% in the TM group versus 15.0 ± 15.4% in the ICM group, p=0.7. Furthermore, the endothelial cell morphology (HSF, DE and CV) showed no statistical differences between the two groups. The median PCO fraction was 9% (0.8; 22) in the TM group versus 7.5%

(0; 17) in the ICM group, p=0.8. The median PCO severity grade was 0.12 (0.02; 0.31) versus 0.10 (0; 0.39), p=0.7. Two patients in each group had YAG laser capsulotomy, p = 1.0. No differences in postoperative BCVA, IOP, pupil size, PCO or YAG rate were observed between the groups. Endothelial cell loss, endothelial morphology and corneal thickness were also equivalent.

In our study, the mean of CMT pre operative was 259.95±

8.71 ìm. The mean 1 week post operative was 534.00± 31.77 ìm. The mean 3 months post operative was 259.60± 8.25 ìm. p= 0.256 non- significant change in CMT. p=0.923 non-significant difference between different groups. In 2010 a study⁽²¹⁾ was made to evaluate changes in central macular thickness using optical coherence tomography after uneventful cataract surgery combined with intracameral epinephrine use. This prospective case series comprised eyes of consecutive patients who had uneventful phacoemulsification and in-the-bag intraocular lens (IOL) implantation between August 2005 and January 2006. The eyes were randomly assigned to 1 of 2 groups. In 1 Group, 0.2mL epinephrine (1:5000 solution) was injected just after the clear corneal incision was created. The other group (control) did not receive epinephrine. Optical coherence tomography was performed in all eyes preoperatively as well as postoperatively at 1 day, 1 week, and 1, 3, and 6 months. The epinephrine group comprised 73 eyes (73 patients) and the control group, 76 eyes (86 patients). In both groups, the increase in retinal thickness from preoperatively to 1, 3, and 6 months postoperatively was statistically significant (p<0.05); the difference was not statistically significant at 1 day or 1 week in either group (p>.005). There were no statistically significant

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differences between the 2 groups in mean retinal thickness throughout the follow-up (p>0.05). Clinically significant macular edema occurred in 3 eyes in the epinephrine group and 3 eyes in the control group. Similar results have later been reported also for intracameral epinephrine from randiomized case series⁽²²⁾ of a total of 158 uneventful cataract procedures half of the eyes were given 0.2ml of 0.02% epinephrine as an intracameral injection. No difference was seen in central macular thickness with optical coherence tomography at any time point up to 6 months after surgery. In both treatment groups, the increase in macular thickness from preoperatively to 1, 3, and 6 months postoperatively was significant. In this rather large series, clinically significant macular edema was noted in 3 eyes in the epinephrine group and 3 eyes in the control group. The authors concluded that intracameral injection of 0.2ml of 0.02% epinephrine did not increase the risk for macular edema after uneventful phacoemulsification.

In our study, the mean of pre intracameral epinephrine systolic blood pressure was 126.83±7.21mmHg. The mean of systolic blood pressure post intracameral epinephrine was 127.80±7.67. The mean of pre intracameral epinephrine diastolic blood pressure was 75.83±5.52 mmHg. The mean of diastolic blood pressure post intracameral epinephrine was 76.13±5.49 mmHg. The mean of pre intracameral epinephrine pulse rate was 71.17±4.34 bpm. The mean of pulse rate post intracameral epinephrine was 71.08±4.59 bpm. p = 0.863 showing non-significant change in heart rate. p = 0.917 showing non-significant difference in heart rate between groups. p = 0.033 showing significant change in systolic blood pressure. p = 0.353 showing non-significant difference in systolic blood pressure between groups.

p=0.321 showing non-significant change in diastolic blood pressure.

p=0.414 showing non-significant difference in diastolic blood pressure between groups. Our results are comparable to results of paper⁽²³⁾ conducted byinvolving 90 patients intracameral mydriatics are safe on cardiovascular system. Also the study⁽⁶⁾, we mentioned before in this chapter, found that intracameral epinephrine is safe on pulse rate and blood pressure.

C

^ONCLUSION

To conclude from our study, we reached an understanding that intracameral epinephrine even in higher concentrations is effective in papillary dilatation especially in cases with long duration and poorly dilated cases by usual topical mydriatics. It is also safe on cardiovascular system, cornea and macula and doesn’t affect visual outcome when it is used. However, a longer duration of follow up is recommended for any further studies which will help to further validate the results.

R

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Corresponding author:

Ahmed Abdelwahab Ali

Research institute of ophthalmology Mob: 002/01116869575

Email: [email protected]

The effect of intracameral epinephrine on pupil size during phacoemulsification and its postoperative effect on specular findings and...