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J·-·. Universidad Universidad ,.,. I ::::.�j:.� �·-·. :::t.,.•• de Alcala COMISIÓN DE ESTUDIOS OFICIALES DE POSGRADO Y DOCTORADO ACTA DE EVALUACIÓN DE LA TESIS DOCTORAL Año académico 2016/17 DOCTORANDO: RODRÍGUEZ PÉREZ, MARÍA ISABEL D.N.1./PASAPORTE: ****779T PROGRAMA DE DOCTORADO: D325 DOCTORADO EN CIENCIAS DE LA SALUD DEPARTAMENTO DE: CIRUGÍA, CIENCIAS MÉDICAS Y SOCIALES TITULACIÓN DE DOCTOR EN: DOCTOR/A POR LA UNIVERSIDAD DE ALCALÁ En el día de hoy 13/09/17, reunido el tribunal de evaluación nombrado por la Comisión de Estudios Oficiales de Posgrado y Doctorado de la Universidad y constituido por los miembros que suscriben la presente Acta, el aspirante defendió su Tesis Doctoral, elaborada bajo la dirección de MIGUEL ÁNGEL TESUS GUEZALA // JUAN GROS OTERO. o < -o Sobre el siguiente tema: SEGURIDAD, EFICACIA Y PREDICTIBILIDAD EN CIGURÍA CON LÁSER EXCIMER: LASIK z MECÁNICO, LASIK FEMTOSEGUNDOY LASEK < ::,; ::, :,: Finalizada la defensa y discusión de la tesis, el tribunal acordó otorgar la CALIFICACIÓN GLOBAL6 de (no apto, < ..J aprobado, notable y sobresaliente): ____5 _t0_S_�_'.f,_o_(/2_�_1C___________ ____ o"' o z o ::,; Alcalá de Henares, .. Á.J..... de .. ?.fp.h...�-�- de _'!:-:!__1)- -< ..J< u ..J< "' EL PRESIDENTE EL SECRETARIO EL VOCAL o o < o "'- """' > z ::, Con fccha_� __ dc_�e.___de � lTia Comisión Delegada de la Comisión de Estudios Oficialesde Posgrado, a la vista de los votos emitidos de manera anónima por el tribunal que ha juzgado la tesis, resuelve: � Conceder la Mención de "Cum Laude" O No conceder la Mención de "Cum Laude" La Secretariade la Comisión Delegada 6 La calificación podrá ser "no apto" "aprobado" "notable" y "sobresaliente". El tribunal podrá otorgar la mención de "cum laude" si la calificación global es de sobresaliente y se emite en tal sentido el voto secreto positivo por unanimidad. ESCUELA DE DOCTORADO Servicio de Estudios Oficiales de Posgrado DILIGENCIA DE DEPÓSITO DE TESIS. Comprobado que el expediente académico de D./Dª ____________________________________________ reúne los requisitos exigidos para la presentación de la Tesis, de acuerdo a la normativa vigente, y habiendo presentado la misma en formato: soporte electrónico impreso en papel, para el depósito de la misma, en el Servicio de Estudios Oficiales de Posgrado, con el nº de páginas: __________ se procede, con fecha de hoy a registrar el depósito de la tesis. Alcalá de Henares a _____ de ___________________ de 20_____ Fdo. El Funcionario Programa de Doctorado en Ciencias de la Salud SEGURIDAD, EFICACIA Y PREDICTIBILIDAD EN CIRUGÍA CON LÁSER EXCIMER: LASIK MECÁNICO, LASIK DE FEMTOSEGUNDO Y LASEK Tesis doctoral presentada por MARÍA ISABEL RODRÍGUEZ PÉREZ 2017 Programa de Doctorado en Ciencias de la Salud SEGURIDAD, EFICACIA Y PREDICTIBILIDAD EN CIRUGÍA CON LÁSER EXCIMER: LASIK MECÁNICO, LASIK DE FEMTOSEGUNDO Y LASEK Tesis doctoral presentada por MARÍA ISABEL RODRÍGUEZ PÉREZ Director: PROF. MIGUEL ÁNGEL TEUS GUEZALA Co-director: DR. JUAN GROS OTERO Alcalá de Henares, 2017 la memoria de mi abuelo Luis Pérez Herrero, farmacéutico, estudioso de nuestro pasado y sabio consejero, que con su ejemplo logró toda mi admiración y respeto, y que ha A iluminado mis noches oscuras durante este proyecto. A mis queridos Marta, Marina, Teresa, Enrique y Beatriz, para que nunca dejen de luchar para alcanzar sus sueños. A todos los niños con TDAH que se superan cada día con enorme esfuerzo. “Mientras las cosas son realmente esperanzadoras, la esperanza es un nuevo halago vulgar: solo cuando todo es desesperado la esperanza empieza a ser completamente una fuerza.” Gilbert Keith Chesterton AGRADECIMIENTOS Mi agradecimiento profundo al Prof. Miguel Teus, a quien la fortuna cruzó en mi camino; gracias a todo tu apoyo y tu motivación conseguiste despertar en mí nuevas inquietudes y el amor por la excelencia en toda labor. El buen profesor permanece en la memoria de miles de personas para el resto de sus días y así permanecerás en la mía. Gracias al Dr. Juan Gros, mi co-director, porque sin tu ayuda hubiera sido imposible escribir esta tesis. Gracias por el rigor en todos tus consejos, pero sobre todo, gracias por tu disponibilidad, porque quienes nos dedican su tiempo, nos están regalando algo que nunca recuperarán. Gracias a mi familia, tan grande y tan divertida. En primer lugar a mis padres, por permitirme crecer en un hogar tan lleno de amor. Gracias por vuestra generosidad sin límites; es imposible devolveros tanto que me habéis dado. A mis hermanas, por preocuparse por mí, especialmente a Almudena, por cuidarme tanto y a Men, por tu ayuda con los últimos retoques de este trabajo. A mis sobrinos, a los que adoro; conseguís que los días cobren más brillo cuando estoy con vosotros. Gracias a todos los compañeros de la clínica Novovisión, Alberto Rodero, Susana Chumilla, Olga Prieto, etc., con los que comparto tantos momentos y con los que es un placer estar trabajando desde hace tanto tiempo, especialmente a la Dra. Montse García, por toda tu ayuda y por lo que me has enseñado, por tu generosidad y el optimismo que transmites siempre. Gracias a todos los compañeros de Sanitas que me han acompañado en estos años de tanto trabajo, especialmente a José Andrés Redondo, porque sabe todo lo que ha sufrido mi espalda y con tanta profesionalidad la ha cuidado. Gracias a los antiguos compañeros de Vissum, algunos también amigos, con los que viví una etapa profesional que nunca olvidaré, porque fue donde todo este proyecto se fraguó. ÍNDICE INTRODUCCIÓN ------------------------------------------------------------------------------------- 3 1. LA CIRUGÍA REFRACTIVA ---------------------------------------------------------------------------------- 3 1.1 Técnicas esclerales --------------------------------------------------------------------------------------- 3 1.2 Técnicas intraoculares ----------------------------------------------------------------------------------- 4 1.2.1 Procedimientos cristalinianos -------------------------------------------------------------- 4 1.2.2 Lentes fáquicas ------------------------------------------------------------------------------- 5 1.2.3 Bioptics y cirugía refractiva ajustada ----------------------------------------------------- 6 1.3 Técnicas corneales --------------------------------------------------------------------------------------- 7 1.3.1 Técnicas no sustractivas-no aditivas ------------------------------------------------------ 7 1.3.1.1 Técnica incisional ----------------------------------------------------------------- 7 1.3.1.2 Termoqueratoplastia -------------------------------------------------------------- 8 1.3.2 Técnicas aditivas ----------------------------------------------------------------------------- 9 1.3.2.1 Queratomileusis ------------------------------------------------------------------- 9 1.3.2.2 Epiqueratofaquia ----------------------------------------------------------------- 10 1.3.2.3 Implantes intraestromales ------------------------------------------------------- 10 1.3.3 Técnicas sustractivas ----------------------------------------------------------------------- 11 1.3.3.1 Queratectomía automatizada lamelar (ALK) --------------------------------- 11 1.3.3.2 Procedimientos basados en el láser excimer --------------------------------- 12 2. PROPIEDADES Y COMPORTAMIENTOS DE LA CÓRNEA --------------------------------------- 12 2.1. Anatomía corneal ---------------------------------------------------------------------------------------- 12 2.2. Propiedades biomecánicas: histéresis y resistencia corneal --------------------------------------- 16 2.3. Estudio preoperatorio de la córnea sospechosa ----------------------------------------------------- 17 2.3.1. Grosor corneal central --------------------------------------------------------------------- 19 2.3.2. Topografía y Tomografía corneal -------------------------------------------------------- 20 2.3.3. Modelos predictivos ------------------------------------------------------------------------ 22 3. CIRUGÍA REFRACTIVA LÁSER --------------------------------------------------------------------------- 25 3.1. Láser excimer -------------------------------------------------------------------------------------------- 25 3.2. Patrones de tallado corneal ----------------------------------------------------------------------------- 29 3.3. Respuesta celular y molecular tras la ablación ------------------------------------------------------ 33 3.4. Láser de femtosegundo --------------------------------------------------------------------------------- 36 3.5. Influencia de la edad en los resultados --------------------------------------------------------------- 41 3.6. Formas de medir los resultados refractivos ---------------------------------------------------------- 42 3.6.1. Estandarización de medidas de la agudeza visual -------------------------------------- 42 3.6.2. Medición de los resultados de la cirugía refractiva ------------------------------------ 44 4. TÉCNICAS DE ABLACIÓN CORNEAL CON LÁSER EXCIMER --------------------------------- 45 4.1. Técnicas de cirugía de superficie corneal ------------------------------------------------------------ 45 4.1.1. Queratectomía subepitelial asistida por láser excimer (LASEK) -------------------- 45 4.1.1.1. Técnica quirúrgica --------------------------------------------------------------- 46 4.1.1.2. Complicaciones: haze corneal -------------------------------------------------- 47 4.1.1.3. Mitomicina C en ablación de superficie -------------------------------------- 49 4.1.2. Otras técnicas de superficie
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