{"id":31248,"date":"2020-09-02T08:05:01","date_gmt":"2020-09-02T08:05:01","guid":{"rendered":"https:\/\/www.elza-institute.com\/?p=31248"},"modified":"2020-11-20T14:21:28","modified_gmt":"2020-11-20T14:21:28","slug":"treating-infectious-keratitis-with-cxl","status":"publish","type":"post","link":"https:\/\/www.elza-institute.com\/pt\/treating-infectious-keratitis-with-cxl\/","title":{"rendered":"Tratar a queratite infecciosa com CXL n\u00e3o \u00e9 como tratar o queratocone com CXL"},"content":{"rendered":"

Tratar a queratite infecciosa com CXL n\u00e3o \u00e9 como tratar o queratocone com CXL. Recentemente, tivemos de escrever uma carta para a revista Ophthalmology, para chamar a aten\u00e7\u00e3o para as falhas numa publica\u00e7\u00e3o recente da revista.<\/span><\/p>\n

O artigo em quest\u00e3o utilizou um dos aspectos mais interessantes do reticulado da c\u00f3rnea (CXL), um procedimento denominado crom\u00f3foro fotoactivado para queratite-CXL, ou PACK-CXL, como m\u00e9todo de tratamento da queratite f\u00fangica. No seu estudo, 111 doentes receberam agentes antif\u00fangicos t\u00f3picos (natamicina 5% ou anfotericina 0,15%) com ou sem PACK-CXL. No entanto, no final, conclu\u00edram que \"parece n\u00e3o haver benef\u00edcio do CXL adjuvante no tratamento prim\u00e1rio de \u00falceras f\u00fangicas filamentosas moderadas, e pode resultar numa diminui\u00e7\u00e3o da acuidade visual\".<\/span><\/p>\n

Pensamos que cometeram um erro b\u00e1sico que implicou a aplica\u00e7\u00e3o de uma quantidade inadequada de irradia\u00e7\u00e3o UV (flu\u00eancia) durante o PACK-CXL para tratar infec\u00e7\u00f5es f\u00fangicas.<\/span><\/p>\n

Este artigo tinha falhas. Faltavam-lhe pormenores b\u00e1sicos como o tamanho da \u00falcera de base e a flu\u00eancia UV aplicada. No entanto, olhando para a sec\u00e7\u00e3o de m\u00e9todos, citaram o cl\u00e1ssico \"protocolo de Dresden\" de reticula\u00e7\u00e3o do ceratocone (30 minutos de instila\u00e7\u00e3o de riboflavina 0,1%, seguidos de 30 minutos de ilumina\u00e7\u00e3o UV de 3 mW para uma flu\u00eancia total de 5,4 J\/cm2), pelo que consider\u00e1mos seguro assumir que foi utilizado aqui. <\/span><\/p>\n

Mas o protocolo de Dresden \u00e9 totalmente inadequado para tratar a queratite infecciosa, quer seja bacteriana ou f\u00fangica. Para explicar porqu\u00ea, temos de explorar o que acontece quando uma c\u00f3rnea \u00e9 reticulada. <\/span><\/p>\n

Quando o estroma saturado com riboflavina \u00e9 atingido por um fot\u00e3o UV, a riboflavina \u00e9 activada, reage, gera uma esp\u00e9cie reactiva de oxig\u00e9nio \"ROS\" que pode ligar as mol\u00e9culas do estroma entre si, ou fixar as membranas celulares e os \u00e1cidos nucleicos de quaisquer agentes patog\u00e9nicos presentes. Mas \u00e9 consumida. \u00c9 dif\u00edcil para a luz UV penetrar muito mais profundamente, uma vez que a riboflavina actua como um escudo (que \u00e9 consumido) contra a sua penetra\u00e7\u00e3o. Isto \u00e9 bom em muitos aspectos, pois protege as c\u00e9lulas endoteliais da c\u00f3rnea na base da c\u00f3rnea de serem danificadas pela irradia\u00e7\u00e3o UV. Mas tamb\u00e9m significa que a absor\u00e7\u00e3o da energia UV decai de forma logar\u00edtmica. Por conseguinte, a quantidade de energia UV fornecida pelo protocolo de Dresden apenas reticula os primeiros 100 \u00b5m.<\/span><\/p>\n

\"\"<\/a><\/p>\n

Qual era a profundidade das \u00falceras destes doentes? A sec\u00e7\u00e3o M\u00e9todos refere que os olhos com \"envolvimento do ter\u00e7o posterior do estroma\" e \"paquimetria central inferior a 350 mm\" foram exclu\u00eddos e que 46% e 68% de CXL tratados com\u00a0<\/span>(com natamicina e anfotericina, respetivamente) tinham profundidades de \u00falcera de 33-67% da profundidade do estroma. <\/span><\/p>\n

Vamos fazer alguma aritm\u00e9tica para descobrir qual seria a profundidade de \u00falcera mais rasa poss\u00edvel (e, por conseguinte, teria a maior hip\u00f3tese de tratamento bem sucedido com um protocolo PACK-CXL que trata apenas os 100 \u00b5m superiores da c\u00f3rnea).<\/span><\/p>\n

Se a c\u00f3rnea mais fina era de 350 \u00b5m no estudo e o intervalo de profundidade da \u00falcera mais superficial era de 33-67%, isto significa que as profundidades das \u00falceras variavam entre 111,5-234,5 \u00b5m - e, por conseguinte, c\u00f3rneas mais espessas teriam \u00falceras ainda mais profundas.<\/span><\/p>\n

Por fim, tudo isto pressup\u00f5e que a c\u00f3rnea \u00e9 uma c\u00f3rnea queratoc\u00f3nica e n\u00e3o uma c\u00f3rnea com \u00falcera - que \u00e9 opaca, o que significa que \u00e9 ainda mais dif\u00edcil para a luz UV penetrar na c\u00f3rnea. Em suma, isto significa que, mesmo na melhor das hip\u00f3teses, n\u00e3o foi fornecida energia UV suficiente \u00e0 c\u00f3rnea para tratar toda a infe\u00e7\u00e3o.<\/span><\/p>\n

J\u00e1 demonstr\u00e1mos que o PACK-CXL \u00e9 mais eficaz na elimina\u00e7\u00e3o de bact\u00e9rias quando s\u00e3o utilizadas flu\u00eancias UV mais elevadas, e estamos a verificar no nosso ensaio cl\u00ednico em curso que a efic\u00e1cia do PACK-CXL com uma flu\u00eancia total de 7,2 J\/cm<\/span>\u00b2<\/span> \u00e9 semelhante ao da terapia antimicrobiana. Por estas raz\u00f5es, acreditamos que os autores deste artigo utilizaram uma flu\u00eancia inadequada para tratar as \u00falceras f\u00fangicas destes doentes.<\/span><\/p>\n

\"\"<\/a><\/p>\n

Refer\u00eancias<\/b><\/span><\/p>\n

    \n
  1. Hafezi F, Torres-Netto EA, Hillen MJP. Re: Prajna et al: Cross-Linking-Assisted Infection Reduction: um ensaio cl\u00ednico aleat\u00f3rio que avalia o efeito do cross-linking adjuvante nos resultados da queratite f\u00fangica. Ophthalmology. 2020. 13 de agosto. Online antes da impress\u00e3o<\/a>. <\/span><\/li>\n
  2. Prajna NV, Radhakrishnan N, Lalitha P, et al. Um ensaio cl\u00ednico aleat\u00f3rio que avalia o efeito do cross-linking adjuvante nos resultados da queratite f\u00fangica. Oftalmologia. 2020;127: 159<\/span>e<\/span>166.<\/span><\/li>\n
  3. Kling S, Hufschmid FS, Torres-Netto EA, et al. Alta <\/span>fl<\/span>aumenta a efic\u00e1cia antibacteriana<\/span>fi<\/span>efic\u00e1cia da liga\u00e7\u00e3o cruzada PACK. Cornea. 2020;39:1020<\/span>e<\/span>1026.<\/span><\/li>\n<\/ol>","protected":false},"excerpt":{"rendered":"

    Tratar a queratite infecciosa com CXL n\u00e3o \u00e9 como tratar o queratocone com CXL. Recentemente, tivemos de escrever uma carta para a revista Ophthalmology, para chamar a aten\u00e7\u00e3o para as falhas numa publica\u00e7\u00e3o recente da revista.<\/p>","protected":false},"author":4,"featured_media":31267,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[214,95],"tags":[452,125,105,116,453,454,104],"class_list":["post-31248","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-farhad-hafezi","category-scientific-article","tag-clinical-trial","tag-cornea","tag-corneal-infection","tag-corneal-ulcer","tag-criticism","tag-letter","tag-pack-cxl"],"acf":[],"yoast_head":"\nTreating infectious keratitis with CXL: more UV energy is needed 5.4 J\/cm\u00b2!<\/title>\n<meta name=\"description\" content=\"Treating infectious keratitis with CXL is not like treating keratoconus with CXL. 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