Excepcional artigo produzido pela Dra. Jordana Sandes do CEROF, GO mostra os efeitos dos arcos de 140º em Ceratocones com valores de astigmatismo elevados.
Avaliação das alterações na curvatura anterior e posterior da Córnea, sua paquimetria, resultados visuais e refrativos após o Implante de Anel de Ferrara com o auxilio do Galilei.
Purpose: To evaluate the corneal volume (CV) before and after Ferrara intrastromal corneal ring segments (ICRS) implantation and its influence in clinical outcomes in keratoconus patients.
PURPOSE: To evaluate the long-term safety and effica- cy of Ferrara intrastromal corneal ring segments (ICRS) (Ferrara Ring; AJL, Boecillo, Spain) in patients with kera- toconus.
A multicentric nonrandomized study was conducted in which a new 320-ICRS was placed in 138 eyes of 130 patients with keratoconus. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), keratometry, corneal volume, asphericity, lines of vision gain/loss, and vectorial analysis were assessed preoperatively and at the final follow-up visit after the procedure.
Dr. Guilherme Rocha, Dr. Paulo Ferrara, Dr. Leonardo Torquetti, Dra. Luciene Barbosa analisam os resultados dos implantes de Anel de Ferrara de Arco longo no pós operatório de 6 meses
Resultados preliminares do implante de um novo anel associado ao PRK para pre...Ferrara Ophthalmics
Dr. Sandro Coscarelli, Dr. Pablo Rodrigues, Dr. Guilherme Rocha e Dr. Leonardo Torquetti compilaram e compartilham seus resultados com o uso de Segmentos de Anel de Ferrara HM associado ao PRK para a correção da miopia de pacientes com corneas finas e contra indicados para as técnicas de Excimer Laser apenas.
Avaliação das alterações na curvatura anterior e posterior da Córnea, sua paquimetria, resultados visuais e refrativos após o Implante de Anel de Ferrara com o auxilio do Galilei.
Purpose: To evaluate the corneal volume (CV) before and after Ferrara intrastromal corneal ring segments (ICRS) implantation and its influence in clinical outcomes in keratoconus patients.
PURPOSE: To evaluate the long-term safety and effica- cy of Ferrara intrastromal corneal ring segments (ICRS) (Ferrara Ring; AJL, Boecillo, Spain) in patients with kera- toconus.
A multicentric nonrandomized study was conducted in which a new 320-ICRS was placed in 138 eyes of 130 patients with keratoconus. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), keratometry, corneal volume, asphericity, lines of vision gain/loss, and vectorial analysis were assessed preoperatively and at the final follow-up visit after the procedure.
Dr. Guilherme Rocha, Dr. Paulo Ferrara, Dr. Leonardo Torquetti, Dra. Luciene Barbosa analisam os resultados dos implantes de Anel de Ferrara de Arco longo no pós operatório de 6 meses
Resultados preliminares do implante de um novo anel associado ao PRK para pre...Ferrara Ophthalmics
Dr. Sandro Coscarelli, Dr. Pablo Rodrigues, Dr. Guilherme Rocha e Dr. Leonardo Torquetti compilaram e compartilham seus resultados com o uso de Segmentos de Anel de Ferrara HM associado ao PRK para a correção da miopia de pacientes com corneas finas e contra indicados para as técnicas de Excimer Laser apenas.
PURPOSE: To report the clinical outcomes of implantation of a new Ferrara intrastromal corneal ring segment (ICRS) with a 210-degree arc length in eyes with keratoconus.
Comparative Study of Visual Outcome between Femtosecond Lasik with Excimer La...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Purpose: To evaluate the influence of age and severity of keratoconus in the clinical outcomes of implantation of Ferrara intrastromal corneal ring segments (ICRS).
The Journal of Implant & Advanced Clinical Dentistry - Oct. 2015Jay True
Amr Hosny Elkhadem, DDS, MSc
Lecturer, Prosthodontics, Faculty of Oral & Dental medicine, Cairo University
The keyless partial guidance using the simple guide kit and c-shaped sleeves is a promising economic alternative to conventional guided approach. Further investigations are required to evaluate
its accuracy and long term success rates.
www.SimpleGuideSystem.com
Tiwari R, Chakravarthi PS, Kattimani VS, Lingamaneni KP. A Perioral Soft Tissue evaluation after Orthognathic Surgery Using Three-Dimensional Computed Tomography Scan. The Open Dentistry Journal. 2018; 12:366-376. doi:10.2174/1874210601812010366.
Background: Nowadays, ICRS are a step in the treatment of keratoconus. The purpose of this study was to evaluate the refractive effect and the tomographic and biomechanical parameters in keratoconus patients implanted with Ferrara ICRS, and their stability after 18 months.
PURPOSE: To report the clinical outcomes of implantation of a new Ferrara intrastromal corneal ring segment (ICRS) with a 210-degree arc length in eyes with keratoconus.
Comparative Study of Visual Outcome between Femtosecond Lasik with Excimer La...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Purpose: To evaluate the influence of age and severity of keratoconus in the clinical outcomes of implantation of Ferrara intrastromal corneal ring segments (ICRS).
The Journal of Implant & Advanced Clinical Dentistry - Oct. 2015Jay True
Amr Hosny Elkhadem, DDS, MSc
Lecturer, Prosthodontics, Faculty of Oral & Dental medicine, Cairo University
The keyless partial guidance using the simple guide kit and c-shaped sleeves is a promising economic alternative to conventional guided approach. Further investigations are required to evaluate
its accuracy and long term success rates.
www.SimpleGuideSystem.com
Tiwari R, Chakravarthi PS, Kattimani VS, Lingamaneni KP. A Perioral Soft Tissue evaluation after Orthognathic Surgery Using Three-Dimensional Computed Tomography Scan. The Open Dentistry Journal. 2018; 12:366-376. doi:10.2174/1874210601812010366.
Background: Nowadays, ICRS are a step in the treatment of keratoconus. The purpose of this study was to evaluate the refractive effect and the tomographic and biomechanical parameters in keratoconus patients implanted with Ferrara ICRS, and their stability after 18 months.
Doktor Vedat Kaya, Canan Aslı Utine, Sezen Harmancı Karakuş, Işılay Kavadarlı ve Ömer Faruk Yılmaz tarafından hazırlanmış olan bu makaleyi ilginize sunarız.
SOLIX Essential is a technology built upon a proven foundation of high-speed Spectral Domain OCT. The SOLIX Essential offers state-of-the-art imaging from the cornea to the choroid with exclusive technology that will change your approach to disease diagnosis and management.
Diagnosis of Vertical Root Fracture Using Digital Radiography, Helical Comput...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Reconstruction of a facial defect is a complex modality either surgically or prosthetically, depending on the site, size, etiology, severity, age, and the patient’s expectation. The loss of an auricle, in the presence of an auditory canal, affects hearing, because the auricle gathers sound and directs it into the canal.
Surgical reconstruction is preferable but prosthetic approach may be necessary in some circumstances such as the presence of complex or large defects, requirement of the recurrence control, local or general contraindications of surgery, damaged neighboring tissues due to the radiotherapy, general poor health, failed reconstructive attempts previously made, refusal of the surgery by the patient, high esthetic demands, the desire for a quick recovery and palliatively operated patients.
Nowadays, craniofacial implants are used to support and retain such prostheses. Studies have shown successful retention and stability of auricular prostheses anchored to the temporal bone with titanium implants.
- An article describes what is the impact of refractive error on a layer of retina ( nerve fiber layer) in myopic subjects, Download its full text from Isra Medical Journal.
Objective: To evaluate myopic impact on thickness of nerve fiber layer of the retina in healthy myopic subjects.
Study Design: Prospective Observational study.
Place and Duration: Investigative Department of Ophthalmology of Al-Ibrahim Eye Hospital, Karachi from 1st May 2018 to 30th October 2018.
Methodology: In this study 80 eyes of myopic subjects (SE -0.5 to -11.0 DS) were enrolled. Each eye underwent through comprehensive ocular examination beginning with visual acuity, refraction, fundoscopy by slit lamp and ending up to optical coherence tomography of Nidek. Mean average peripapillary thickness of nerve fiber layer and thickness in superior, inferior, nasal and temporal quadrants was taken into consideration, calculated by Spectral Domain Optical Coherence Tomography (version 1.5.5.0).
Results: Forty subjects volunteered for study protocol among which 21 were male and 19 were female with a degree of refractive breakdown of 30% mild myopic, 50% moderately myopic and 20% highly myopic. The calculated average age was 25.0 ± 5.0 years (range 16-40 years). The average total nerve fiber layer thickness in myopic respondents was 90.85μm; superiorly 112.37μm; inferiorly 117.52μm; temporally 71.85μm and in nasal quadrant was 61.55μm. Retinal nerve fiber layer thickness was statistically significant in superior and temporal quadrant. In high myopes thickness was clinically significant in inferior quadrant in terms of quantity as compared to mild and moderate myopia
Conclusion: Average retinal nerve fiber layer thickness was significantly decreased in high myopia as compared to mild myopia while moderate group had slightly thicker thickness than high myopic group. Hence impact of dioptric power on nerve fiber layer thickness in myopic patients is significant.
Double Rings - New approachs to fine tune clinical outcomes.pdfFerrara Ophthalmics
Inimaginável há poucos anos, a associação de segmentos concêntricos adjuvantes no tratamento da miopia e ceratocone tem trazido resultados praticamente refrativo no tratamento de pacientes com alta miopia e astigmatismo. A associação de segmentos de 5mm e 6mm se faz possível pela alta qualidade e precisão dos Tomógrafos e Laser de Femtosegundo que tornam a cirurgia extremamente precisa e os resultados reprodutíveis e passíveis de reintervenção e adequação do planejamento inicial.
Confira a apresentação competa com as indicações, citação do artigo científico, os resultados do estudo clinico inicial com 42 olhos, os resultados, a técnica cirúrgica e o nomograma do Ferrara HM para pacientes com miopia moderada a alta e contraindicação a cirurgia de PRK por limitação de espessura corneana.
Na edição 1991 do terceiro trimestre de 2021 a Revisa Oftalmologia em Foco destacou em sua capa o Surgimento de um Novo Anel intra corneano com foco nos pacientes com miopia moderada a alta com contra indicação ao PRK por limitação da espessura da córnea
Estudo de Casos Clínicos do Implante de Anel de Ferrara para o tratamento do Ceratocone disponibilizado pela Dra. Jordana Sandes para Drylab da Ferrara Ophthalmics no Curso refrativa RIO 2022
Estudos do comportamento da luz e de sua refração no prisma demonstram como o filtro amarelo atua minimizando a formação de halos e glare no corpo dos segmentos de Anel de Ferrara™.
O intuito do filtro é minimizar qualquer desconforto que a presença do ICRS - Intra Corneal Ring Segments - possam causar ao paciente.
Esta tecnologia é exclusiva da Ferrara Ophthalmics e utilizada em 87 países.
Desde sua patente em 1987, o Anel de Ferrara e a técnica de implante vêm se aprimorando. Hoje, com indicações seguras e reprodutíveis a técnica é realizada em 87 países e mais de 600.000 olhos já forma implantados.
Acompanhe este resumo do Implante de Anel de Ferrara para correção do Ceratocone. Característica, Mecanismo de Ação, técnica Cirúrgica, os diferentes arcos e efeitos são alguns dos tópicos abordados
A Aula apresenta os conceitos básicos sobre implantes intra corneanos, a evolução do nomograma da Ferrara Ophthalmics, a classificação morfologia do aspecto coreano e alguns casos clínicos.
Autor: Dr. Guilherme Rocha
Indicações de nomograma de utilização de segmentos de 320º de arco a partir de analise estatística de 26 casos operados e correlação com diferentes arcos existentes.
Using a diamond knife, set at 90% of corneal thickness at (90 degrees meridian), at 8 mm optic zone, a radial incision was done and corneal pockets were created. A 6.0 nylon preloaded spatula was then inserted into the corneal pocket and in a counterclockwise direction rotated in 3600 to create a deep stromal tunnel
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. 802
·Clinical Research·
Clinical outcomes after implantation of a new intrastromal
corneal ring with 140-degree of arc in patients with
corneal ectasia
Jordana Sandes1
, Larissa R. S. Stival1
, Marcos Pereira de Ávila1
, Paulo Ferrara2
, Guilherme Ferrara2
,
Leopoldo Magacho1
, Luana P. N. Araújo3
, Leonardo Torquetti4
1
Center of Reference in Ophthalmology (CEROF), Goiânia
64605-020, Brazil
2
Paulo Ferrara Eye Clinic, Belo Horizonte-MG 30110-921, Brazil
3
Fundação Altino Ventura, Recife-PE 50070-040, Brazil
4
Center of Excellence in Ophthalmology, Pará de Minas
35660-017, Brazil
Correspondence to: Jordana Sandes. Street T-15, Sector Bueno,
Number 715, Apartment 2601, Goiânia-GO 74230-010, Brazil.
jordana.oftalmo@gmail.com
Received: 2017-09-08 Accepted: 2017-11-14
Abstract
● AIM: To evaluate the clinical and tomographic outcomes
after implantation of a new intrastromal corneal ring segment
(ICRS) with 140-degrees of arc in eyes with corneal ectasia.
● METHODS: We evaluated patients with corneal ectasia
implanted with Ferrara 140° ICRS from April 2010 to February
2015. Outcome measures included preoperative and
postoperative corrected distance visual acuity (CDVA),
keratometry simulated (K) reading, tomographic astigmatism
and asphericity. All patients were evaluated using the
Pentacam Scheimpflug system.
● RESULTS: The study evaluated 58 eyes. The mean follow-
up was 16.81±10.8mo. The CDVA (logMAR) improved from
0.5±0.20 (20/60) to 0.3±0.21 (20/40) (P<0.01). The average
K reduced from 49.87±7.01 to 47.34±4.90 D (P<0.01). The
asphericity changed from -0.60±0.86 to -0.23±0.67 D (P<0.01).
The mean preoperative tomographic astigmatism decreased
from -8.0±3.45 to -4.53±2.52 D (P<0.01).
● CONCLUSION: The new ICRS model with 140-degrees of
arc effectively improve the visual acuity and reduce the high
astigmatism usually found in patients with corneal ectasia.
● KEYWORDS: keratoconus; intrastromal corneal ring
segment; corneal ectasia
DOI:10.18240/ijo.2018.05.14
Citation: Sandes J, Stival LRS, Ávila MP, Ferrara P, Ferrara G, Magacho
L, Araújo LPN, Torquetti L. Clinical outcomes after implantation of
a new intrastromal corneal ring with 140-degree of arc in patients with
corneal ectasia. Int J Ophthalmol 2018;11(5):802-806
INTRODUCTION
Intrastromal corneal ring segments (ICRS) are an efficacious
alternative in patients with clear corneas who have
unsatisfactory corrected visual acuity with glasses or contact
lens and contact lens intolerance[1-5]
. It acts according to
Barraquer’s postulate which states that tissue addition
in corneal periphery leads to corneal flattening. The ring
diameter (optical zone) determines how much the cornea
will be flattened. The thicker and smaller the optical zone
of the implanted segment, the more flattening effect and
myopic reduction is achieved[6-8]
. The main advantages of this
procedure are its safety, reversibility, and stability, as well as
the fact that the segments do not affect the visual axis[9-10]
.
There are different models of ICRS with varying sizes and arc
thicknesses. Theoretically, a shorter segment induces a greater
astigmatic correction and induces lesser asphericity change,
comparing with long arch segments. The new model presents
a short arc length of 140 degrees (140-ICRS) with the main
advantage of astigmatism reduction. The primary indication is
in keratoconus patients with high astigmatism[11-12]
.
The intrastromal tunnel for ring implantation was initially
manually constructed; however, complications such as
epithelial defects, depth asymmetry and perforation, were
reported[13]
. Femtosecond laser has recently been used to create
the tunnel for ring implantation. This technique reportedly
creates a tunnel with precise depth, width and location
leading to faster visual recovery and less incidence of surgical
complications[14-15]
.
The main purpose of this study is to evaluate the clinical
results of the implantation of 140-ICRS regarding its efficacy
and capacity of corneal astigmatism reduction. Moreover we
compared the clinical outcomes of patients implanted with the
Ferrara 140-ICRS using the manual and femtosecond laser
assisted technique.
SUBJECTS AND METHODS
This retrospective study included keratoconus eyes with
high astigmatism that were intolerant to contact lens or
disease progression and presented visual acuity worse than
0.2 logMAR (20/30). An informed consent was given to all
eligible patients prior to data collection, requesting permission
A new intrastromal corneal ring with 140-degree arc in corneal ectasia
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803
for the research and use of data from their medical records
relating to the pre and postoperative periods. All bioethical
principles were considered in accordance with the Declaration
of Helsinki and Brazilian regulations.
The same surgeon (Paulo Ferrara) performed all surgical
procedures using the manual or femtosecond laser-assisted
technique for ICRS implantation. Both techniques have
been widely described in the literature[2,5,13-15]
. Patients were
randomized to receive a manual or laser-assisted surgical
technique.
The corneal depth of ICRS were 80% for all cases (manual
and laser). In the manual technique, the surgery was performed
under topical anesthesia, and the visual axis is marked; a 5-mm
optical zone and incision side were aligned with the desired
axis in which the incision would be made, in the steepest
axis. The diamond blade was set at 80% of corneal depth at
the incision site. After the incison, a stromal spreader creates
a pocket on each side of the incision. Two semi-circular
dissecting spatulas were consecutively inserted through the
incision and gently pushed with some quick rotary back
and forth movements. Following channel creation, the ring
segments were implanted.
Using the femtosecond laser, LDV Z4 (Ziemer, Switzerland),
tunnel depth is set at 80% of the thinnest corneal thickness
within the probable ring track. The channel’s inner diameter
is set to 4.4 mm, the outer diameter 5.6 mm and the entry cut
thickness was 1 μm (at the steepest topographic axis). The ring
energy used for channel creation is 1.3 mJ. The femtosecond
laser takes approximately 15s to create the channel. The
segments are implanted immediately after channel creation
before the disappearing of the bubbles, which reveals the exact
tunnel location. The segments were placed in the final position
with a Sinskey hook through a dialing hole at both ends of the
segment[14-16]
.
According to the Ferrara Ring nomogram, for 140-ICRS,
the selection of the thickness of the segment to be implanted
varies with the preoperative tomographic astigmatism. For
asymmetric keratoconus a single segment was implanted and
for symmetrical keratoconus 2 segments were implanted.
Asymmetry means that, by dividing the cornea into two halves
from the more curved meridian considering the anterior sagittal
map of the pentacam, asymmetric corneas are those that the
halves are unequal, and symmetrical corneas are those that the
halves are very similar.
Descriptive analysis such as age, sex, technique and follow-
up was collected for all patients. Statistical analysis included
preoperative and postoperative, corrected distance visual acuity
(CDVA), refractive astigmatism, tomographic astigmatism,
keratometry simulated (K) readings, mean flattest axis (K1), mean
steepest axis (K2) and asphericity. Corneal tomography and
pachymetry were obtained using the software included within
the Pentacam rotation Scheimpflug camera (Oculus Pentacam,
Wetzlar, Germany). Statistical analysis was carried out using
the Minitab software (Minitab Inc., Chicago, USA).
Analysis of Astigmatism The astigmatism results were
analyzed arithmetically (nonvector analysis) and using vector
analysis when concerning the cylindrical axis. Although
observed changes in cylinders were commonly reported, they
do not accurately reflect the actual nature of the change in the
cylinder. The magnitude and axis of the cylinder are related to
the spherical power. The vector analysis used for calculating
surgically induced astigmatism change was a Doubled-Angle
polar plot.
Due to astigmatism traverses an entire cycle in 180 degrees,
the doubled-angle polar plot was described as the most
appropriate plot for aggregating astigmatism data. In this
method, the centroid is the mean of a set of x and y values.
The standard deviation can be represented in a graphic by an
area surrounding the centroid. The shape of this area will vary
depending on the length of the major and minor axis. The
shape factor (ρ) has been used to describe this relationship[17]
.
Statistical Analysis Normality of data was evaluated with the
Kolmogorov-Smirnov test. The analysis of primary outcome
measures was based on a normal distribution of the data.
Student’s t-test for paired variables was used to compare pre
and postoperative data considering a significance level of
P<0.05. Graphic analysis was made using the Microsoft Excel
2007 (USA) and SPSS Sigma Plot 12.0 (USA).
RESULTS
Fifty eight eyes/patients were evaluated. The average follow-
up was 16.81±10.8mo. The mean age was 33.3±13.2y. Forty
six patients (79.3%) were male, and twelve patients (20.7%)
were female. Considering the analysis by groups, in group 1
(17 eyes) 2 segments of 200 μm (140/200) were implanted;
in group 2 (30 eyes) a single 150 μm segment (140/150) was
implanted and in group 3 (11 eyes) a single 200 μm segment
(140/200) was implanted (Table 1).
Last follow up, 12.2% of patients maintained the same CDVA,
13.7% of patients had the CDVA worsened, and 74.1% of
patients had improvement in CDVA. The improved average
Table 1 Segment thickness according to preoperative tomographic
astigmatism
Tomographic astigmatism (D) Segment thickness
Asymmetric keratoconus
<4.00 1 segment 150 μm
>4.00 and <8.00 1 segment 200 μm
>8.00 1 segment 250 μm
Symmetric keratoconus
<6.00 2 segments 150 μm
>6.00 and <10.00 2 segments 200 μm
>10.00 2 segments 250 μm
3. 804
was four lines of vision (gain of 1 to 9 lines of vision), three
patients lost two lines of vision, and five patients lost one line
of vision (Table 2).
In group 1 (2 segments 140/200), the CDVA improved
from 0.4±0.3 logMAR (20/50) to 0.2±0.1 logMAR (20/30)
(P=0.02), K1 decreased from 48.8±6.4 to 46.4±4.3 D (P<0.01),
K2 decreased from 59.1±7.1 to 52.2±4.4 D (P=0.05), average
keratometry (Km) decreased from 54.4±6.6 to 49.3±4.3 D
(P<0.01), asphericity changed from -1.1±0.6 to -0.5±0.6
(P<0.01). The tomographic astigmatism had a significant
decrease from -10.3±2.9 to -5.7±1.8 D (P<0.01).
In group 2 (1 segment 140/150) the CDVA improved from
0.4±0.2 logMAR (20/50) to 0.2±0.1 logMAR (20/30)
(P<0.01), K2 decreased from 50.0±7.4 to 46.6±3.6 D (P=0.01),
the asphericity changed from 0.0±0.3 to 0.1±0.4 (P=0.01)
and the tomographic astigmatism improved from -6.3±2.9 to
-3.8±2.2 D (P<0.01).
In group 3 (1 segment 140/200) there was a statistically
significant change only in K2 and tomographic astigmatism.
The K2 decreased from 54.9±7.6 to 52.2±6.5 D (P<0.01)
and the tomographic astigmatism decreased from -7.5±3.9 to
-3.7±2.2 D (P<0.01; Figure 1).
The tomographic astigmatism using the manual technique
decreased the average 3.7 D and femtosecond technique
decreased 3.1 D (P>0.01). The refractive astigmatism
improved in 1.7 D in manual technique and 2.9 D in fento
technique (P>0.01). The Km using manual technique flattened
-2.5 D and in femto technique flattened -2.4 D (P>0.01). The
anterior asphericity improved in 0.4 in manual technique and
0.3 in femto technique (P>0.01).
Figure 2 shows the double-angle plots of the individual
cylinders, providing an overview of the cylinder magnitude
(diopter) and axis (degree) of each data point. The radius from
the center of the plot to each point represents the magnitude
of the cylinder. The centroid of preoperative keratometric
astigmatism was 1.22 D at 23.17°±6.39°, ρ=0.77 and the
postoperative centroid was 0.68 D at 22.37°±3.91°, ρ=0.74.
The keratometric astigmatism centroid is 0.54 D closer to zero,
Table 2 Preoperative and postoperative data of all patients
mean±SD
Parameters Preoperative Postoperative P
CDVA (logMAR) 0.5±0.20 (20/60) 0.3±0.21 (20/40) <0.01
K1 (D) 45.49±6.38 45.14±5.10 0.35
K2 (D) 54.19±8.40 49.54±5.11 <0.01
Km (D) 49.87±7.01 47.34±4.90 <0.01
Asphericity (D) -0.60±0.86 -0.23±0.67 <0.01
Tomographic
astigmatism (D)
-8.00±3.45 -4.53±2.52 <0.01
CDVA: Corrected distance visual acuity; K1: Mean flattest axis; K2:
Mean steepest axis; Km: Average keratometry.
Figure 1 Pre- and post-operative K1, K2 and Km (A), tomographic astigmatism (B), CDVA (logMAR) (C) in the 3 groups.
Figure 2 Doubled-angle plot of the pre- and post-operative keratometric cylinder at the corneal plane A: The preoperative centroid of
the keratometric astigmatism was 1.22 D at 23.17°±6.39°, ρ=0.77; B: The postoperative centroid of the keratometric astigmatism was 0.68 D
at 22.37°±3.91°, ρ=0.74; C: The relationship between the preoperative and postoperative keratometric astigmatism. There was a significant
reduction in the keratometric astigmatism.
A new intrastromal corneal ring with 140-degree arc in corneal ectasia
4. Int J Ophthalmol, Vol. 11, No. 5, May 18, 2018 www.ijo.cn
Tel:8629-82245172 8629-82210956 Email:ijopress@163.com
805
and the standard deviation of the astigmatism was reduced by
a factor of 1.63 (6.39 D/3.91 D). The relocation of the centroid
closer to the origin and the contraction of the ellipse on the
doubled-angle plots demonstrate the amount of improvement.
DISCUSSION
The analysis of our results revealed that the implantation of
140-ICRS was efficacious and improved the visual acuity in
most patients. Postoperatively, there was a significant decrease
in Km, tomographic astigmatism and improvement of CDVA.
In group 1 (2 segments 140/200) we observed a significant
flattening effect, a marked improvement in asphericity
and a substantial reduction of tomographic astigmatism; it
seems to be a good option for cases of symmetrical cones
with hyperprolate cornea, high keratometry and very high
astigmatism. In group 2 (1 segment 140/150) and group 3
(1 segment 140/200), a significant reduction in astigmatism
was observed. There was little change in asphericity and
keratometry. This was in agreement with the effect needed
in some cases of asymmetric cones with high astigmatism,
corneal asphericity close to normal values and curvatures not
significantly steep.
A study realized by Ruckhofer et al[18]
about correction of
astigmatism with short arch segments showed a significant
correction of low to moderate compound myopic astigmatism
safely and predictably. However, the study evaluated healthy
astigmatic corneas, not eyes with keratoconus. In our study,
we analyzed corneas with ectasia and demonstrated proper
correction of tomographic astigmatism with short arc length
(140°) ICRS. These segments may provide a useful alternative
for the surgical correction of astigmatism in corneal ectasia.
Many studies have confirmed the efficacy and safety of
the ICRS in reducing sphero cylindrical error and corneal
steepening in keratoconus over the short and long term[3-4]
, but
most do not analyze astigmatism as a vector. They evaluate
changes in the magnitude of astigmatism only. However, it is
important to investigate variations in the axis of the cylinder
and to determine whether the astigmatic correction was
induced in the targeted meridian. Errors in the correction of
the astigmatic axis could induce aberrations and lead to poor
predictability of the sphero cylindrical correction.
Our study demonstrated changes in astigmatism after ICRS
implantation in patients with keratoconus using vectorial
analysis[19]
and showed that despite the reduction of the
magnitude of corneal astigmatism, not always the corrected
meridian was the planned, with a tendency for undercorrection,
especially in corneas with higher astigmatism. The importance
of the vector analysis of astigmatism is to avoid incorrect or
incomplete conclusions.
The use of femtosecond laser as a safe and accurate method
for the creation of the intrastromal tunnel was recently
proposed[14-15]
. Studies comparing the manual technique with
femtosecond technique found that there was no differences
between the improve in visual acuity and decrese in keratectomy
comparing both techniques, but the incidence of peroperative
complications is less in femtosecond technique[15]
. Thus, the
use of femtosecond laser may not provide better outcomes,
but rather an easier and more reproducible technique for the
surgeon. In this study, we did not find significant improvements
in the results when comparing the manual technique with
the femtosecond laser technique, considering an experienced
surgeon.
In conclusion, there was a significant improvement of all
parameters analyzed. The short arc intrastromal corneal ring
segments seem to be a valuable treatment, which can provide
satisfactory visual outcomes[20]
. A few potential limitations
were apparent in this study as the small sample of treated eyes
and the lack of a comparative group. Future larger, comparative
studies are needed to confirm the results found in this study.
ACKNOWLEDGEMENTS
Conflicts of Interest: Sandes J, None; Stival LRS, None;
Ávila MP, None; Ferrara P, Comercial interest in Ferrara
ICRS; Ferrara G, Comercial interest in Ferrara ICRS; Magacho
L, None; Araújo LPN, None; Torquetti L, None.
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A new intrastromal corneal ring with 140-degree arc in corneal ectasia