{"id":13754,"date":"2019-02-06T09:06:52","date_gmt":"2019-02-06T09:06:52","guid":{"rendered":"https:\/\/www.staging.elza-institute.com\/?p=13754"},"modified":"2020-10-02T15:38:52","modified_gmt":"2020-10-02T15:38:52","slug":"cxl-in-the-usa-part-2-best-practice","status":"publish","type":"post","link":"https:\/\/www.staging.elza-institute.com\/pt\/cxl-in-the-usa-part-2-best-practice\/","title":{"rendered":"Cross-Linking nos EUA - Parte 2: Melhores pr\u00e1ticas"},"content":{"rendered":"<p><strong>Seguir as melhores pr\u00e1ticas<\/strong><\/p>\n<p><strong><em>Anestesia<\/em><\/strong><\/p>\n<p>T\u00f3pica, normalmente com tetraca\u00edna ou proparaca\u00edna, embora as crian\u00e7as e os doentes n\u00e3o cooperantes possam necessitar de formas alternativas de anestesia. O CXL utilizando protocolos padr\u00e3o (aprovados pela Dresden\/FDA), uma vez que a imers\u00e3o em riboflavina antes da ilumina\u00e7\u00e3o UV, seguida de 30 minutos de ilumina\u00e7\u00e3o UV-A, pode demorar mais de uma hora a concluir, pelo que a anestesia t\u00f3pica ter\u00e1 de ser administrada repetidamente durante o procedimento. Uma vantagem adicional da anestesia t\u00f3pica \u00e9 o facto de enfraquecer as liga\u00e7\u00f5es epiteliais, facilitando a remo\u00e7\u00e3o do epit\u00e9lio.<\/p>\n<p><strong><em>Abras\u00e3o da c\u00f3rnea<\/em><\/strong><\/p>\n<figure id=\"attachment_13798\" aria-describedby=\"caption-attachment-13798\" style=\"width: 300px\" class=\"wp-caption alignleft\"><img fetchpriority=\"high\" decoding=\"async\" class=\"wp-image-13798 size-medium\" src=\"https:\/\/www.staging.elza-institute.com\/wp-content\/uploads\/2020\/10\/cxl-in-the-usa-debrided-epithelium-wikipedia-300x212-1.jpg\" alt=\"cxl-na-usa-debridada-epitelial-wikipedia\" width=\"300\" height=\"212\" \/><figcaption id=\"caption-attachment-13798\" class=\"wp-caption-text\">Epit\u00e9lio desbridado<\/figcaption><\/figure>\n<p>A remo\u00e7\u00e3o dos 9,0 mm centrais do epit\u00e9lio da c\u00f3rnea \u00e9 um passo crucial: permite que a riboflavina penetre no estroma rico em colag\u00e9nio, onde ocorre a rea\u00e7\u00e3o de reticula\u00e7\u00e3o. Existem v\u00e1rias op\u00e7\u00f5es para o conseguir:<\/p>\n<ul>\n<li>Com um instrumento rombo (por exemplo, uma faca de h\u00f3quei), utilizado num \u00e2ngulo pouco profundo para evitar danificar a membrana de Bowman<\/li>\n<li>Uma escova mec\u00e2nica<\/li>\n<li>\u00c1lcool t\u00f3pico (semelhante \u00e0 forma como a remo\u00e7\u00e3o epitelial \u00e9 efectuada no PRK)<\/li>\n<\/ul>\n<p><strong>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/strong><\/p>\n<p><strong><em>Riboflavina e ilumina\u00e7\u00e3o<\/em><\/strong><strong><em>\u00a0<\/em><\/strong><\/p>\n<p>Tal como referido anteriormente, existem atualmente duas formula\u00e7\u00f5es de riboflavina aprovadas pela FDA - a formula\u00e7\u00e3o isot\u00f3nica, Photrexa Viscous, e a formula\u00e7\u00e3o hiposs\u00f3mica, Photrexa, no entanto, ambas s\u00e3o utilizadas da mesma forma. No entanto, ambas as solu\u00e7\u00f5es devem ser utilizadas antes da realiza\u00e7\u00e3o do procedimento, uma vez que a espessura da c\u00f3rnea pode diminuir durante o procedimento devido \u00e0 evapora\u00e7\u00e3o do fluido, e a utiliza\u00e7\u00e3o de Photrexa pode ajudar a dilatar a c\u00f3rnea.<\/p>\n<p>O processo de reticula\u00e7\u00e3o \u00e9 efectuado da seguinte forma:<\/p>\n<figure id=\"attachment_13784\" aria-describedby=\"caption-attachment-13784\" style=\"width: 659px\" class=\"wp-caption aligncenter\"><img decoding=\"async\" class=\"wp-image-13784 size-full\" src=\"https:\/\/www.staging.elza-institute.com\/wp-content\/uploads\/2020\/10\/cxl-instillation-illumination.png\" alt=\"\" width=\"659\" height=\"849\" \/><figcaption id=\"caption-attachment-13784\" class=\"wp-caption-text\">AC, c\u00e2mara anterior; q, quaque (todos).<\/figcaption><\/figure>\n<p><strong>Compreender as potenciais complica\u00e7\u00f5es <\/strong><\/p>\n<p>A import\u00e2ncia de discutir com os doentes, no pr\u00e9-operat\u00f3rio, as potenciais complica\u00e7\u00f5es que podem surgir do procedimento de reticula\u00e7\u00e3o (incluindo o insucesso do tratamento) n\u00e3o pode ser subestimada. Complica\u00e7\u00f5es como neblina corneana, cicatrizes, queratite infecciosa e infiltra\u00e7\u00f5es est\u00e9reis, perfura\u00e7\u00e3o da c\u00f3rnea, fotofobia e achatamento excessivo com um desvio hiper\u00f3ptico s\u00e3o problemas raros, mas poss\u00edveis. Pode ocorrer insucesso do tratamento, por vezes em 8 em cada 100 doentes, sendo o fator de risco mais significativo a queratometria m\u00e1xima pr\u00e9-operat\u00f3ria elevada.<\/p>\n<p><strong>N\u00e9voa<\/strong><\/p>\n<p>Muitos doentes apresentam uma turva\u00e7\u00e3o precoce do estroma no p\u00f3s-operat\u00f3rio, mas esta resulta dos processos de cicatriza\u00e7\u00e3o que ocorrem em resposta ao procedimento de reticula\u00e7\u00e3o. Normalmente, atinge o pico num m\u00eas e depois estabiliza ao longo do ano seguinte. No entanto, cerca de 8% dos doentes submetidos a CXL apresentam uma turva\u00e7\u00e3o significativa do estroma que persiste durante mais de um ano, resulta numa diminui\u00e7\u00e3o significativa da acuidade visual e \u00e9 resistente ao tratamento com ester\u00f3ides. Os autores da Corneal Society referem que \"o ceratocone avan\u00e7ado deve ser considerado como tendo um risco mais elevado de desenvolvimento de turva\u00e7\u00e3o ap\u00f3s o reticulado epit\u00e9lio-fora padr\u00e3o\".<\/p>\n<p>A causa do embaciamento induzido pelo CXL ainda n\u00e3o \u00e9 clara, mas os estudos de microscopia confocal in vivo e in vitro sugeriram que \"o CXL resulta numa perda aguda de querat\u00f3citos no estroma anterior da c\u00f3rnea, seguida de uma repopula\u00e7\u00e3o de querat\u00f3citos activados que se inicia aos 2 meses e termina por volta dos 6 meses\", pelo que \u00e9 poss\u00edvel que estes querat\u00f3citos activados estejam a produzir colag\u00e9nio anormal, o que pode contribuir para o desenvolvimento do embaciamento da c\u00f3rnea p\u00f3s-CXL.<\/p>\n<p><strong>Achatamento<\/strong><\/p>\n<p>O refor\u00e7o da c\u00f3rnea aplana o cone - o CXL aumenta a for\u00e7a biomec\u00e2nica da c\u00f3rnea e torna-a mais capaz de contrariar a press\u00e3o intraocular que pressiona a c\u00f3rnea e a faz inchar nas partes mais fracas. A maioria dos olhos apresenta um achatamento da c\u00f3rnea de 1-2,6 D nos dois anos ap\u00f3s o procedimento. Raramente, pode ocorrer um achatamento da ordem dos 5 D, embora isto pare\u00e7a ser mais comum nas c\u00f3rneas de crian\u00e7as que foram submetidas a CXL do que noutras popula\u00e7\u00f5es de doentes.<\/p>\n<p><strong>Infe\u00e7\u00e3o<\/strong><\/p>\n<p>A infe\u00e7\u00e3o da c\u00f3rnea - queratite infecciosa - \u00e9 uma complica\u00e7\u00e3o incrivelmente rara do CXL. Um estudo sobre o CXL realizado num centro de cuidados terci\u00e1rios na \u00cdndia (4) efectuou uma an\u00e1lise retrospetiva de 2350 procedimentos e registou uma incid\u00eancia de infe\u00e7\u00e3o de 0,0017%. Apesar de rara, trata-se de uma complica\u00e7\u00e3o grave, que acarreta o risco de derretimento e cicatriza\u00e7\u00e3o da c\u00f3rnea, resultando em perdas de acuidade visual que requerem um transplante de c\u00f3rnea para serem rectificadas.<\/p>\n<p>\u00c9 de salientar que apenas dois casos de queratite f\u00fangica (fusarium e microsporidia) e um caso de <em>Acanthamoeba<\/em> foram registadas. A irradia\u00e7\u00e3o UV mata tanto as bact\u00e9rias como os fungos, pelo que \u00e9 prov\u00e1vel que qualquer infe\u00e7\u00e3o da c\u00f3rnea neste contexto ocorra no per\u00edodo p\u00f3s-operat\u00f3rio precoce, e n\u00e3o durante a cirurgia. O m\u00e9todo de reticula\u00e7\u00e3o e a forma como a energia UV \u00e9 aplicada n\u00e3o parecem afetar as taxas de infe\u00e7\u00e3o; embora haja alguma indica\u00e7\u00e3o de que a infe\u00e7\u00e3o possa estar relacionada com o tipo de defeito epitelial presente no olho reticulado. Na maioria das vezes, os agentes patog\u00e9nicos agressores s\u00e3o bact\u00e9rias gram-positivas (<em>Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus salivarius e Streptococcus oralis<\/em>), embora por vezes as bact\u00e9rias gram-negativas (<em>Escherichia coli<\/em> e <em>Pseudomonas aeruginosa<\/em>). A ceratite por Acanthamoeba deve ser considerada em todos os casos resistentes ao tratamento, particularmente em doentes com falta de higiene e nos casos em que os sintomas (como a dor) s\u00e3o desproporcionados em rela\u00e7\u00e3o aos sinais.<\/p>\n<p>O tratamento deve seguir os procedimentos habituais para o tratamento de infec\u00e7\u00f5es da c\u00f3rnea: a cultura e a colora\u00e7\u00e3o de Gram devem ser consideradas em todos os casos; os infiltrados pequenos e superficiais podem ser tratados topicamente com monoterapia antibi\u00f3tica, mas os infiltrados maiores ou que n\u00e3o respondem devem ser tratados de forma mais agressiva com m\u00faltiplos agentes. Deve suspeitar-se de queratite f\u00fangica em todos os casos que n\u00e3o respondam ao tratamento com antibi\u00f3ticos.<\/p>\n<p>Por fim, se os doentes tiverem uma hist\u00f3ria de doen\u00e7a herp\u00e9tica, deve ser considerada a profilaxia antiviral sist\u00e9mica antes da realiza\u00e7\u00e3o do CXL.<\/p>\n<p><a href=\"\/pt\/blog\/cxl-in-the-usa-part-3-off-label-applications\/\">Parte 3: Aplica\u00e7\u00f5es \"off-label<\/a><\/p>","protected":false},"excerpt":{"rendered":"<p>A Cornea Society publicou uma revis\u00e3o das melhores pr\u00e1ticas de CXL nos EUA. O cross-linking \u00e9 relativamente novo nos EUA (mas n\u00e3o na Europa) - vamos atualizar-nos.<\/p>","protected":false},"author":4,"featured_media":16087,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_angie_page":false,"page_builder":"","footnotes":""},"categories":[214,95],"tags":[148,287,288,100,289,104,290,291,292,293],"class_list":["post-13754","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-farhad-hafezi","category-scientific-article","tag-accelerated-cxl","tag-avedro","tag-customized-cxl","tag-cxl","tag-infection","tag-pack-cxl","tag-photrexa","tag-photrexa-viscous","tag-riboflavin","tag-usa"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Cross-linking in the USA - what is today&#039;s CXL Gold Standard?<\/title>\n<meta name=\"description\" content=\"Cross-linking (CXL) is still relatively new in the USA. The Cornea Society reviewed best-practice for treating keratconus, and it&#039;s epi-off CXL.\" \/>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"pt_PT\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Cross-linking in the USA - what is today&#039;s CXL Gold Standard?\" \/>\n<meta property=\"og:description\" content=\"Cross-linking (CXL) is still relatively new in the USA. The Cornea Society reviewed best-practice for treating keratconus, and it&#039;s epi-off CXL.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.elza-institute.com\/de-ch\/cxl-in-den-usa-teil-2-empfohlene-praxis\/\" \/>\n<meta property=\"og:site_name\" content=\"The ELZA Institute\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/ELZA.Institute\/\" \/>\n<meta property=\"article:published_time\" content=\"2019-02-06T09:06:52+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2020-10-02T15:38:52+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.elza-institute.com\/wp-content\/uploads\/2019\/02\/ribo-cxl-in-the-usa.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"600\" \/>\n\t<meta property=\"og:image:height\" content=\"300\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Mark Hillen\" \/>\n<meta name=\"twitter:label1\" content=\"Escrito por\" \/>\n\t<meta name=\"twitter:data1\" content=\"Mark Hillen\" \/>\n\t<meta name=\"twitter:label2\" content=\"Tempo estimado de leitura\" \/>\n\t<meta name=\"twitter:data2\" content=\"4 minutos\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/\"},\"author\":{\"name\":\"Mark Hillen\",\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/#\\\/schema\\\/person\\\/e3929262886a5a60dd6965a6bc721d15\"},\"headline\":\"Cross-Linking in the USA \u2013 Part 2: Best Practice\",\"datePublished\":\"2019-02-06T09:06:52+00:00\",\"dateModified\":\"2020-10-02T15:38:52+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/\"},\"wordCount\":844,\"publisher\":{\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/www.staging.elza-institute.com\\\/wp-content\\\/uploads\\\/2019\\\/02\\\/ribo-cxl-in-the-usa.jpg\",\"keywords\":[\"Accelerated CXL\",\"avedro\",\"customized CXL\",\"CXL\",\"infection\",\"PACK-CXL\",\"photrexa\",\"photrexa viscous\",\"riboflavin\",\"USA\"],\"articleSection\":[\"Farhad Hafezi\",\"Scientific article\"],\"inLanguage\":\"pt-PT\"},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/\",\"url\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/\",\"name\":\"Cross-linking in the USA - what is today's CXL Gold Standard?\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/www.elza-institute.com\\\/de-ch\\\/cxl-in-den-usa-teil-2-empfohlene-praxis\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/www.staging.elza-institute.com\\\/wp-content\\\/uploads\\\/2019\\\/02\\\/ribo-cxl-in-the-usa.jpg\",\"datePublished\":\"2019-02-06T09:06:52+00:00\",\"dateModified\":\"2020-10-02T15:38:52+00:00\",\"description\":\"Cross-linking (CXL) is still relatively new in the USA. 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