RBO-Jan-Fev-2018 Inglês Revisão 01 · 1 Associada a José Ricardo Carvalho L. Rehder- São Paulo-...

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Vol. 77 - nº 1 - Janeiro/Fevereiro 2018

Publicação bimestral

ISSN 0034-7280Versão impressa

Publicação oficial da Sociedade Brasileira de Oftalmologia

Scielo, Scopus Scielo, Scopus e Lilacse Lilacs

Scielo, Scopus e Lilacs

w Variação da pressão intraocular após injeção

w Pseudoxantoma elástico

w Plasmocitoma intraconal e infiltração uvealOptical coherence tomography and congenital retinoschisis

Study of asphericity coefficient and longitudinal spherical aberration surface corneal

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Associada a ABEC - Associação Brasileira

de Editores Científicos

Publicação bimestral Rev Bras Oftalmol, v. 77, n. 1, p. 1-60, Jan./Fev. 2018

RevistaBrasileira de

OftalmologiaPUBLICAÇÃO OFICIAL:

SOCIEDADE BRASILEIRA DE OFTALMOLOGIA

Indexada nas bases de dados:

Disponível eletronicamente: Coordenação deAperfeiçoamento de Pessoal de Nível Superiorwww.sboportal.org.br http://www.capes.gov.br

ISSN 0034-7280(Versão impressa)

ISSN 1982-8551(Versão eletrônica)

Sociedade Brasileira de Oftalmologia

LILACSLiteratura Latino-americana em Ciências da Saúde

SciELOScientific ElectronicLibrary OnLine www.freemedicaljournals.com

Editor ChefeMarcony Rodrigues de Santhiago (RJ)

Editor ExecutivoArlindo José Freire Portes (RJ)

Co-editoresAndré Luis Freire Portes (RJ)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 PadilhaNewton 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 InternacionalBaruch D. Kuppermann - Califórnia - EUAChristopher Rapuano - Phyladelphia - EUACurt Hartleben Martkin - Colina Roma - MéxicoDaniel Grigera - Olivos - ArgentinaDeepinder Kauer Dhaliwal - Pittsburg - EUAEsmeralda Costa - Coimbra - PortugalFelipe A. A. Medeiros - Califórnia - EUA Felix Gil Carrasco - México – MéxicoFernando Arevalo - Riyadh - Arábia SauditaFlorent Aptel - Grenoble - FrançaFrancisco Rodríguez Alvira – Bogotá - ColombiaHoward Fine - Eugene - EUAJean Jacques De Laey - Ghent - BélgicaJean-Philippe Nordmann - Paris - FrançaJesús Merayo-LLoves - Oviedo - EspanhaKevin M. Miller - Califórnia - EUAKeweh Mansouri - Paris - FraçaLawrence P. Chong - Califórnia - EUALihteh Wu – San José - Costa RicaLiliana Werner - Utah - EUAMiguel Burnier Jr. - Montreal - CanadáPablo Cibils - Assunção - ParaguaiPatricia Mitiko Santello Akaishi – Arábia SauditaPaulo Torres - Lisboa - PortugalPeter Laibson - Phyladelphia - EUASteve Arshinoff - Toronto - Canadá

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Revista Brasileira de OftalmologiaRua 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.brRevista Brasileira de Oftalmologia, ISSN 0034-7280, é uma publicação bimestral da Sociedade Brasileira de Oftalmologia

Presidente:Armando Stefano Crema (RJ)

Vice-presidentes:Edna Emilia G. da M. Almodin (PR)

José Beniz Neto (GO)Leila Suely Gouvea José (AM)

Marco Antônio Rey de Faria (RN)Newton Kara José Júnior (SP)

Secretário Geral:André Luís Freire Portes (RJ)

1º Secretário:Bruno Machado Fontes (RJ)

2º Secretário:Evandro Gonçalves de Lucena Junior (RJ)

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Associação Brasileira de Banco de Olhos e Transplante de CórneaPresidente: Ari de Souza Pena

Associação Brasileira de Catarata e Cirurgia RefrativaPresidente: Pedro Paulo Fabri

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

Presidente: Renato J. Bett CorreiaAssociação Pan-Americana de Banco de Olhos

Presidente: Alvio Isao ShiguematsuAssociação Paranaense de Oftalmologia

Presidente: Marcello FonsecaAssociação Rondoniense de Oftalmologia

Presidente: Renata Campos SalesAssociação Sul Matogrossense de Oftalmologia

Presidente: Elson YamasatoSociedade Alagoana de Oftalmologia

Presidente: Mário Jorge Santos Sociedade Brasileira de Administração em Oftalmologia

Presidente: Paulo Gilberto Jorge FadelSociedade Brasileira de Cirurgia Plástica Ocular

Presidente: Murilo Alves RodriguesSociedade Brasileira de Ecografia em Oftalmologia

Presidente: Norma AllemannSociedade Brasileira de Glaucoma

Presidente: Wilma Lelis Barboza Sociedade Capixaba de Oftalmologia

Presidente: Adriana Vieira CardozoSociedade Catarinense de OftalmologiaPresidente: Ayrton Roberto Bravo Ramos

SOCIEDADES FILIADAS À SOCIEDADE BRASILEIRA DE OFTALMOLOGIA

Diretor de Publicações:Marcony Rodrigues de Santhiago (RJ)

Diretor de Biblioteca:Oswaldo Ferreira Moura Brasil (RJ)

Conselho Consultivo:Durval Moraes de Carvalho Jr. (DF)Fernando Cançado Trindade (MG)

Renato Ambrósio Jr. (RJ)Conselho Fiscal:

Efetivos:Mário Ursulino Machado Carvalho (SE)

Nelson Alexandre Sabrosa (RJ)Tiago Bisol (RJ)

Suplentes:Eduardo Henrique Morizot Leite (RJ)

Gustavo Amorim Novais (RJ)Marco Antônio de Souza Alves (RJ)

Sociedade Cearense de OftalmologiaPresidente: Newton Andrade Júnior

Sociedade Goiana de OftalmologiaPresidente: Fausto da Paz Cazorla

Sociedade Norte-Nordeste de OftalmologiaPresidente: Carlos Alexandre de Amorim Garcia

Sociedade de Oftalmologia do AmazonasPresidente: Leonardo Bivar

Sociedade de Oftalmologia da BahiaPresidente: Amilton de Almeida Sampaio Júnior

Sociedade de Oftalmologia do Nordeste MineiroPresidente: Mauro César Gobira Guimarães

Sociedade de Oftalmologia de PernambucoPresidente: Marcelo Maia Valença

Sociedade de Oftalmologia do Rio Grande do NortePresidente: Nelson Roberto Salustino Galvão

Sociedade de Oftalmologia do Rio Grande do SulPresidente: Isabel Habeyche Cardoso

Sociedade de Oftalmologia do Sul de MinasPresidente: Mansur Elias Ticly Junior

Sociedade Paraense de OftalmologiaPresidente: Frederico José Correia Lobato Sociedade Paraibana de Oftalmologia

Presidente: Rodrigo Almeida Viera SantosSociedade Piauiense de Oftalmologia

Maria de Lourdes Cristina Alcântara Paz Carvalho do NascimentoSociedade Sergipana de OftalmologiaPresidente: Jussara Tavares da Cunha

Diretoria da SBO 2017-2018

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Publicação bimestral Rev Bras Oftalmol, v. 77, n. 1, p. 1-60, Jan./Fev. 2018

Originals Artticles 5 Causes of low vision in patients referred to the Low Vision Service in a Reference Center

of Ophthalmology Causas de baixa visão em pacientes encaminhados ao Serviço de Visão Subnormal em um

Centro de Referência em Oftalmologia José Maurício Garcia, Luciana Castro Lavigne, Éricka Campos Freitas, Lívia Maria Oliveira Salviano, João

Jorge Nassaralla Neto, David Leonardo Cruvinel Isaac, Marcos Pereira de Ávila 9 Clinical and epidemiological study in patients with primary open-angle glaucoma

Estudo clínico-epidemiológico em indivíduos com glaucoma primário de ângulo aberto Luciana dos Mares Guia Ribeiro, Ronilson Ferreira Freitas, Lucas Mares Guia Ribeiro, Marise Fagundes Silveira,

Maísa Tavares de Souza Leite 14 Intraocular pressure behavior in the Goldmann and pneumatic tonometer during water

drinking testComportamento da pressão intraocular no tonômetro de aplanação de Goldman e pneumático durante o teste de sobrecarga hídrica

Rodrigo Egidio da Silva, Isabella Cristina de Sousa Paiva, Juliana Ferreira de Souza, Francisco Wellington Rodrigues

20 Validation of a new ergonomic design of application of eye drops for individuals with physical changesValidação de um novo conceito ergonômico de aplicação do colírio para indivíduos com alterações motorasAlan Patricio da Silva, Francis Meire Fávero, Acary Souza Bulle Oliveira, Célia Regina Nakanami, Thais Massetti, Luiz Carlos de Abreu, Vagner Rogério dos Santos

Contents - Sumário


Oftalmologia

ISSN 0034-7280(Versão impressa)

ISSN 1982-8551(Versão eletrônica)

Fundada em 01 de junho de 1942CODEN: RBOFA9

PUBLICAÇÃO OFICIAL:SOCIEDADE BRASILEIRA DE OFTALMOLOGIA

Indexada nas bases de dados:

Disponível eletronicamente: Coordenação deAperfeiçoamento de Pessoal de Nível Superiorwww.sboportal.org.br http://www.capes.gov.br

LILACSLiteratura Latino-americana em Ciências da Saúde

SciELOScientific ElectronicLibrary OnLine www.freemedicaljournals.com

4

25 Comparison of biometric predictability and final refraction expected in phacoemulsification surgery with and without trabeculectom Comparação da previsibilidade biométrica e refração final esperada em cirurgia de facoemulsi-ficação com e sem trabeculectomia

Fernanda Guedes Oliveira, Cláudia Gomide Vilela de Sousa Franco, Marcelo Limongi dos Passos Miranda Damasceno, Marcos Pereira de Ávila, Leopoldo Magacho

30 Clinical analysis therapy and tomographic parameters of patients diagnosed with keratoconus attended at Fundação Hilton Rocha Análise clínica, terapêutica e dos parâmetros tomográficos de pacientes portadores de ceratocone atendidos na Fundação Hilton Rocha

Izabela dos Santos de Moura e Silva, Cristiane Samara Botteon 34 Analysis of intraocular pressure variation after intravitreal injection of ranibizumab

Análise da variação da pressão intraocular após injeção intravítrea de ranibizumabe Ignatz Rohrbacher, Eduardo Soares Maia Vieira de Souza

Case Report

38 Simultaneous bilateral and unilateral recurrent posterior scleritis Esclerite posterior bilateral simultânea e unilateral recorrente

Ana Paula da Silva Maganhoto, Sara Correia, Letícia Oliveira Squillace, Roberto Ivo Pasquarelli Neto

43 Intraconal plasmocytoma and uveal infiltration in a patient with multiple myelomaPlasmocitoma intraconal e infiltração uvealem paciente portadora de mieloma múltiplo Ana Paula da Silva Maganhoto, Sara Correia, Roberto Ivo Pasquarelli Neto

47 Optic neuropathy toxic after methanol inhalation Neuropatia óptica tóxica por inalação de metanol

Frederico Gustavo Telles e Souza, Vanessa Veloso Eleutério Nogueira, Luana Inostrosa Maynart, Rafael Leite de Oliveira, Thatiane Célia dos Santos Mendonça, Pablo Dias Oliveira

50 Vaso-occlusive retinopathy by systemic lupus erythematosus associated with the antiphospholipid antibody syndromeRetinopatia vaso-oclusiva por lúpus eritematoso sistêmico associada à síndrome do anticorpo antifosfolipídeoBruna Costa Monteiro Hadler, Humberto Borges

54 Pseudoxanthoma elastic Pseudoxantoma elásticoLuiza Pinto Lindenberg Braga

Authors Instructions 58 Instruções aos autores

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Rev Bras Oftalmol. 2018; 77 (1): 5-8

Original article

Resumo

Objetivo: identificar a prevalência dos distúrbios mais comuns em pacientes do Serviço de Visão Subnormal do Centro de Referência de Oftalmologia (CEROF - UFG). Método: Foram avaliados 713 registros de pacientes, todos apresentavam erros refrativos corrigidos. Coletaram-se dois elementos: melhor acuidade visual corrigida (MAVC) no melhor olho e o diagnóstico da doença oftalmológica responsável pela deficiência visual. Todos os grupos etários foram incluídos, sem distinção entre sexo ou raça. Resultados: As doenças mais prevalentes foram distrofias retinianas hereditárias (124 pacientes; 20,63%), cicatrizes coriorretinianas por toxoplasmose (118-19,63%), maculopatia miópica (38-6,32%), Degeneração macular relacionada à idade (DMRI) (36-6%). 220 pacientes (36,6%) preencheram critério de baixa visão (grupo 1), e 381 (63,39%) apresentaram definição de cegueira legal (grupos 2, 3, 4 e 5) recomendada pelo Grupo de Estudos para a Prevenção da Cegueira WHO (Genebra, l972). Conclusão: Estudos nacionais mostram resultados semelhantes sobre cicatrizes coriorretinianas. Estudos epidemiológicos mostram maior prevalência de DMRI, provavelmente porque as clínicas oftalmológicas primárias falham no encaminhamento destes pacientes. A proporção de cegueira relacionada à ROP nos países desenvolvidos é maior, possivelmente porque não há plano de ação público oferecendo acompanhamento oftalmológico adequado para essas crianças. Não havia número significativo de pacientes com glaucoma congênito no departamento, o que pode se relacionar com as condições socioeconômicas e saúde no Brasil. Ações preventivas em oftalmologia necessitam de conhecimento científico de problemas oftalmológicos regionais aplicados à realidade, que será foco de tal ação. Um suporte social, incluindo parceria entre escola, família e sistema público de saúde, seria importante para gerar benefícios para a população.

Descritores: Baixa visão; Saúde Pública; Cegueira; Visão/epidemiologia; Cegueira/prevenção & controle

AbstrAct

Purpose: To identify the prevalence of the most common diseases diagnosed in the Low Vision Service (LVS) Methods: Seven hundred and thirteen patient’s clinical records were evaluated. The best corrected visual acuity (BCVA) in the better eye was collected. All of the diagnosed diseases related to visual impairment were identified and classified. A total of 220 patients (36.6%) fulfilled the concept of low vision (group 1), and 381 patients (63.39%) presented legal blindness (groups 2, 3, 4 and 5), according to the WHO Study Group on the Prevention of Blindness (Geneva, l972). Results: The most prevalent disorder was the group of Retinal Inherited Distrophies (n=124; 20.63%). Following the first group were Ocular toxoplasmosis with chorioretinal scars (118 cases, representing a prevalence of 19.63%), Myopic Maculopathy (38-6.32%), Age related Macular Degeneration (AMD) (36 cases, representing a prevalence of 6%). Conclusion: Planning and implementing preventive actions in ophthalmology requires appropriate comprehension about regional clinical problems. Social support, and a proper partnership between educational and health systems, are important to improve visual outcomes in patients diagnosed with low vision and legal blindness.

Keywords: Low vision; Public health; Blindness; Vision, low/epidemiology; Blindness/prevention & control

José Maurício Garcia1, Luciana Castro Lavigne2, Éricka Campos Freitas3, Lívia Maria Oliveira Salviano4, João Jorge Nassaralla Neto4, David Leonardo Cruvinel Isaac5, Marcos Pereira de Ávila5

1 Fellowship in Retina and Vítreo, Universidade Federal de Goiás, Goiânia, GO, Brazil. 2 Fellowship in Vision, Universidade Federal de Goiás, Goiânia, GO, Brazil. 3 Departament of Subnormal Vision, Universidade Federal de Goiás, Goiânia, GO, Brazil. 4 Physician Graduation Course, Universidade Federal de Goiás, Goiânia, GO, Brazil. 5 Departament of Ophthalmology, Universidade Federal de Goiás, Goiânia, GO, Brazil.

Causes of low vision in patients referred to the Low Vision Service in a

Reference Center of Ophthalmology

The authors declare no conflict of interests.Received for publication 18/01/2017 - Accepted for publication 13/11/2017.

Causas de baixa visão em pacientes encaminhados ao Serviço de Visão Subnormal em um Centro de Referência em Oftalmologia

Local of study: Centro de Referência em Oftalmologia da Universidade Federal de Goiás (CEROF-UFG)

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IntRoductIon

The current concept of “low vision” (LV), according to the 10th Revision of the International Classification of Diseases and Related Health Problems (ICD 10) by

World Health Organization (WHO), includes patients with visual impairment, with a habitual correction, and a visual acuity (VA) worst than 20/70, but equal or better than 20/400, or less than 20° in radius around central fixation in the better eye with the best corrected visual acuity.(1, 2) The WHO refers 45 million patients diagnosed with legal blindness worldwide, and an additional of 135 million individuals visually impaired.(1-4) Taking into account the population growth and increased life expectancy, 76 million people might become blind by 2020, in case of no changes in our current health system.(5) Globally, uncorrected refractive errors and cataract remain as the most common diseases related to visual impairment, and cataract remains as the leading cause of treatable blindness in developing world.(6) Although highly prevalent, both are amenable to treatment. The WHO launched the “VISION 2020: right to sight” in 1999. The goal of this project is the elimination of avoidable blindness related to cataract, trachoma, onchocerciasis, vitamin A deficiency, and refractive errors.

Its most frequent cause in United States is Age related Macular Degeneration (AMD), accounting for almost half of visually impaired patients. International Among other important causes of blindness and visual impairment are glaucoma, corneal scarring, diabetic retinopathy, childhood blindness, trachoma and onchocercosis.(4,7-9) Approximately 2.9 million patients over the age of 40 are diagnosed with low vision (LV).(4) Kirchner and Petterson estimated that 71% of patients with LV are over 65 years old. (10,11) Symptoms attributed to clinical are also related closely with the ability to perform daily tasks, and a psychological support might provide low vision assistance (LVA). (3, 7, 12-15)

In Brazil, although the scarcity of previous studies, the WHO estimates that blindness prevalence affecting individuals over 50 years old is 1.3%, similar to Barbados and Paraguay.(4) In a study performed with patients attended in a tertiary service, retinal disorders accounted as the most common cause of LV, with uveitis coming as the second most common cause, and toxoplasmosis being the most frequent in uveitic group.(5) The frequency of toxoplasmosis and its ocular features is highly relevant in our population, possibly related to our public health conditions.(5, 6, 16, 17) All these data brings new elements and perspectives, different than was found in developed countries.

The purpose of this study is identifying the frequency and most common disorders diagnosed in patients attended in the low vision service (LVS) of Centro de Referência em Oftalmologia – Federal University of Goias, aiming to compare with previous data in Brazil.

methods

A cross sectional study was conducted after analysis of 713 clinical charts, referred to the LVS at the Centro de Referência em Oftalmologia – Federal University of Goias Patients were referred from other outpatient subspecialties after complete ophthalmologic examination, including correction of refractive errors Patients were classified in legal blindness and visual impairment, according to the WHO score of distance visual acuity. The best corrected visual acuity (BCVA) in the better eye was collected, and the disease directly responsible for visual impairment was identified. All age groups were included in the

study, and there was no distinction among sex or race. In the present study, all the patients on their first visit were evaluated by a specific questionnaire (in attachment), including a detailed anamnesis, BCVA, and, then, VA with optical aids tested according to each case. Patients’ clinical data were assessed in a proper illuminated room, with interactive playground area for children, blackboard for training telescope and texts with various types for speed reading training. The BCVA was evaluated using the ETDRS (Early Treatment Diabetic Retinopathy Study) charts for literate patients (Lighthouse Illuminated Box; Lighthouse International, New York, NY) at different distances (50 cm; 1.0 m; 2.0 m and 4.0 m), and Lea Symbols (GoodLite, New York, NY) for illiterate children and adults, at different distances (75 cm; 1.5 m; 3.0m) individually. Patients with cognitive disorders and children with no ability to inform vision through any of these described methods were subjected to VA examination with the Teller cards. The patients were then classified into categories according to the WHO score of distance VA, separating VA into four strata (6) (Table 1).

Patients referred without registered VA, or not included in the definition of LV, incomplete clinical data or lack of confirmed diagnoses were excluded from the study. The Microsoft Excel for Mac 2011 (14.4.3; 140616) was the software package used for statistical analyses.

Garcia JM, Lavigne LC, Freitas EC, Salviano LMO, Nassaralla Neto JJ, Isaac DLC, Ávila MP


Table 1 The classification of severity of visual impairment

recommended by a WHO Study Group on the Prevention of Blindness (Geneva, l972).(6)

Visual Acuity with Best Possible Correction

Category of Visual Minimum equal to Impaiment Maximum less than or better than

1 6/18 6/60 3/10 (0.30) 1/10 (0.10) 20/70 20/200

2 6/60 3/60 1/10 (0.10) 1/20 (0.50) 20/200 20/400

3 3/60 1/60 (CF at 1 meter) 1/20 (0.05) 1/50 (0.02) 20/400 5/300 (20/1200)

4 1/60 (CF at 1 meter) 1/50 (0.02) Light perception 50/300

5 No light perception

9 Undetermined/unspecified

CF= central fixationThe term low vision in category H54 comprises categories 1 and 2 of the table, the term blindness categories 3, 4 and 5, and the term unqualified visual loss category 9.In the extent of visual field is taken into account, patients with a field no greater than 10 degrees but greater than 5 around central fixation should be placed in category 3, patients with a field greater than 5 around central fixation should be placed in category 4, even if the central accuiy is not impaired.

7Causes of low vision in patients referred to the Low Vision Service in a Reference Center of Ophthalmology


Results

The mean age of the subjects was 18.7 years, ranging from 2 months to 89 years old. Females responded for 62.5% of our population. The most prevalent diseases related to LV and visual impairment were Retinal inherited distrophies (n=124; 20.63%), followed by chorioretinal scars presumably caused by toxoplasmosis (19.63%; n = 118), myopic maculopathy (6.32%; n = 38) and AMD (6%; n = 36). When analyzed by the severity of the subnormal vision, 220 patients (36.6%) fulfilled the concept of low vision (Group 1), and 381 patients (63.39%) had the definition of legal blindness (Groups 2, 3, 4 and 5) (Table 1). Other causes of low vision were: Cerebral Palsy, corresponding to 35 patients (5.82%); Optic Neuropathy (n=34; 5.65%); Congenital Cataract (n=27; 4.5%); Diabetic Retinopathy (n=19; 3.16%); Glaucoma (n=17; 2.82%); Optic Nerve Hypoplasia (n=14; 2.33%), Congenital Glaucoma (n=14; 2.33%), Amblyopia (n=14; 2.33%), Retinal Detachment (n=14; 2.33%), Retinopathy of Prematurity (n=13; 2.16%), others (n=67; 11.14%) (Table 2).

dIscussIon

To our knowledge, this is the first population-based survey in our region that considered the prevalence of LV and its related disorders. Only the patients with corrected refractions errors were included, despite the fact of other studies still incorporate uncorrected refraction errors as causes of low vision and visual impairment.(15) It is known that patients with legal blindness usually are not referred to rehabilitation clinics.(18) According to Sampaio et al there is a direct relationship between VA and the application of LV aids to the patients. The use of optical and nonoptical aids aims to provide magnification of retinal image in patients with BCVA worse than 20/80, but better than 20/400. In patients with BCVA worse than 20/500, but better than 20/1000,

the most indicated nonoptical aids are audio alternatives and tactile or “braile” labeling. (19)

In our study, adults with operable cataract and uncorrected refractive errors were excluded. Cataract remains one of the most prevalent disorder related to blindness.(4) In a study performed in an adult population in Bangladesh, the majority of legally blind people was diagnosed with operable cataract.(11) Carlos et al estimate the frequency of cataract in 4.94% of general population, and blindness related to cataract was found in 0.52% of this group of patients. These findings are similar to rates found in the developed world.(20) Uncorrected refractive errors were detected in 13.8% of patients in a study in Sao Paulo.(21) Both cataract and uncorrected refractive errors occur worldwide, but have sight-restoring interventions.(22-26)

However, patients referred to a LVS are already diagnosed with untreatable disorders. In the present study, chorioretinal scars presumably related to ocular toxoplasmosis was the major cause of LV, including its congenital and acquired forms. National studies has shown similar results, with different frequency observed according to geographic distribution, such as found in Bahia (10.4%) and in São Paulo (16.7%).(16,17) The macular retinochoroiditis, related to ocular toxoplasmosis, is the most frequent posterior uveitis in Brazil, affecting 60 - 85% of patients in a uveitic studied group.(6) It is an important disease associated to visual impairment in the world, with a relative higher incidence in our country, considering daily practices, and general public health conditions.(6, 16, 17) In Norway, it was found a 0.17% frequency of primary infection during pregnancy, among previously noninfected women.(26)

In United States, both dry and wet forms of AMD correspond to the most common primary diagnosis (55%) in patients under visual rehabilitation(7, 8) affecting approximately 2 million adults.(7) In Bangladesh, macular degeneration responds for 1.86% of subjects with LV.(1) In our study, 6% of the patients have been diagnosed with AMD, but Silva et al found it in 20.8% in a tertiary service.(5) It is important to highlight how primary ophthalmic clinics are referring patients diagnosed with AMD, since it is known that initial diagnosis and early treatment may avoid visual loss, when referred appropriately.

Retinopathy of prematurity (ROP) corresponded to 2.16% of our group studied. The prevalence of blindness related to ROP in the developed world ranges from 6 to 18%.(25-29) In Latin America, ROP accounts for a third to a half of infants with severe visual impairment, and its appearance may be an indicator of perinatal quality, associated with higher survival in low birth weight infants.(23,

24) Although the social advances, there is no action plan to provide an appropriate ophthalmologic follow up for these infants.

The congenital cataract, or patients operated after prior diagnosis, was found in 4.5% of our patients. Cataract accounts for 5% to 20% of childhood blindness, and patients with untreated cataract, or treated in a late moment, represent 10% of children attending schools for the blind in developing countries.(16, 24-26,29) Rodrigues et al presented 13 infants diagnosed with congenital cataract in a group of 29 children.(28)

In the present study, among 601 patients, 14 had congenital glaucoma. International data indicate that congenital glaucoma accounts for 6% of blind children worldwide (16, 30) It is important to point out that, in developing world, corneal scarring is still a frequent cause of LV, mainly resulting of vitamin A deficiency. Haddad et al. demonstrated that corneal scarring accounts for 20% to 50% of the blind children.(16) In the present study, it was not found a significant number of patients affected, which might

Table 2 Frequency and causes of low vision

in the Low Vision Service

Causes o low vision Number %

Retinal inherited distrophies 124 20.63

Ocular toxoplasmosis 118 19.63

Myopic maculopathy 38 6.32

Age related macular degeneration 36 6.00

Cerebal palsy 35 5.82

Optic neuropathy 34 5.65

Congenital cataract 27 4.50

Diabetic retinopathy 19 3.16

Glaucoma 17 2.82

Optic nerve hypoplasia 14 2.33

Congenital glaucoma 14 2.33

Amblyopia 14 2.33

Retinal detachment 14 2.33

Retinopathy of prematurity 13 2.16

Others 67 11.14

Total 601 100

8

be related to improvement in social, economical and health care conditions in Brazil.

conclusIon

It has been stated that planning, and implementing preventive actions in ophthalmology, require scientific knowledge of regional ophthalmologic problems, applied to the reality that will be the object of such actions.Furthermore, early diagnosis and aggressive treatment also may have prevented a significant amount of LV caused by AMD and diabetic retinopathy in our population. This indicates that a social support, including a partnership between school, family and general health public system, would be important to generate good visual outcomes.

RefeRences

1. Dineen BP, Bourne RR, Ali SM. Prevalence and causes of blindness and visual impairment in Bangladeshi adults. Br J Ophthalmol 2003; 87(7):820-8.

2. Monteiro MM, Montilha RC, Carvalho KM. Optical and nonoptical aids for reading and writing in individuals with acquired low vision. Arq Bras Oftalmol. 2014; 77(2): 91- 4.

3. Binns AM, Bunce C, Dickinson C, Harper R, Tudor-Edwards R, Woodhouse M, Et al. How Effective is Low Vision Service Provision? A systematic review. Surv Ophthalmol. 2012;. 57(1):34-65.

4. Araújo Filho A, Salomão SR, Berezowski A. Prevalence of visual impairment, blindness, ocular disorders and cataract surgery outcomes in low-income elderly 247 from a metropolitan region of São Paulo – Brazil. Arq Bras Oftalmol. 2008; 71(2):246-53

5. Silva LM, Muccioli C, Oliveira F, Arantes TE, Gonzaga LR, Nakanami CR. Visual impairment from uveitis in a reference hospital of Southeast Brazil: a retrospective review over a twenty years period. Arq Bras Oftalmol. 2013;76(6):366-9

6. WHO Fact Sheet No 282. VISION 2020: The Right to Sight, the Global Initiative for the Elimination of Avoidable Blindness. Magnitude and causes of visual impairment—No cause for complacency WHO: Geneva; 2004.

7. American Academy of Ophthalmology Vision Rehabilitation Committee. Preferred practice pattern guidelines: vision rehabilitation for adults. San Francisco: American Academy of Ophthalmology; 2013.

8. Goldstein JE, Massof MW, Deremeik JT, Braudway S, Jackson ML, Kehler KB, et al. Baseline Traits of Low Vision Patients Served by Private Outpatient Clinical Centers in the United States. Arch Ophthalmol. 2012;130(8):1028-37.

9. Klein BEK, Klein R. Projected prevalences of age-related eye diseases. Invest Ophthalmol Vis Sci. 2013; 5414): ORSF14-ORSF17.

10. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol. 2012;96(5):614-8.

11. Kirchner C, Petterson R. The latest data on visual disability from NCHS. J Vis Impair Blind. 1979;73(6):151-3.

12. West SK, Rubin GS, Broman AT, Muñoz B, Bandeen-Roche K, Turano K, et al. How does visual impairment affect performance on tasks of everyday life? The SEE Project. Salisbury Eye Evaluation. Arch Ophthalmol. 2002;120(6):774-80.

13. Rovner BW, Casten RJ, Hegel MT, et al. Low vision depression prevention trial in age-related macular degeneration: a randomized clinical trial. Ophthalmology. 2014;121(11):2204–11.

14. Nyman SR, Gosney MA, Victor CR. Psychosocial impact of visual impairment in working-age adults. Br J Ophthalmol 2010; 94(11):1427-31.


15. Brown JC, Goldstein JE, Chan TL, Massof R, Ramulu P, et al. Characterizing functional complaints in patients seeking outpatient low-vision services in the United States. Ophthalmology. 2014;121(8):1655-62.

16. Haddad MA, Lobato FJ, Sampaio MW, Kara José N. Pediatric and adolescent population with visual impairment: study of 385 cases. Clinics. 2006;61(3):239-46.

17. Silva AMTCP, Matos MHBR, Lima HC. Serviço de visão subnormal do Instituto Brasileiro de Oftalmologia e Prevenção da Cegueira (IBOPC): análise dos pacientes atendidos no 1o ano do departamento (2004). Arq Bras Oftalmol. 2010;73(3):266-70.

18. Ramezani A, Pardis M, Rafati N, Kazemi-Moghaddam M, Katibeh m, Rostami P, et al. Causes of visual impairment among patients referred to a visual rehabilitation clinic in Iran. Korean J Ophthalmol. 2012;26(2):80-3.

19. Bonatti FA. Development of a low vision aid device. Arq Bras Oftalmol. 2006;69(2):221-6.

20. Carlos GA, Schellini SA, Espíndola RF, Lana FP, Rodrigues AC, Padovani CR. Cataract prevalence in Central-West region of São Paulo State, Brazil. Arq Bras Oftalmol. 2009;72(3):375-9.

21. da Cost Filho HA, Berezovsky A. Critical analysis of the progressive performance flow vision in Benjamin Constant Institute. Arq Bras Oftalmol. 2005;68(6):815-20.

22. Ferraz FH, Corrente JE, Opromolla P, Schellini SA. Influence of uncorrected refractive error and unmet refractive error on visual impairment in a Brazilian population. BMC Ophthalmol. 2014;14:84.

22. Frick KD, Forster A. The magnitude and cost of global blindness: an increasing problem that can be alleviated. Am J Ophthalmol. 2003;135(4):471-6.

24. Muñoz B, West SK. Blindness and visual impairment in the Americas and the Caribbean. Br J Ophthalmol. 2002;86(5):498-504.

25. Limburg H, Von-Bischhonffshausen FB, Gomez P, Silva JC, Foster A. Review of recent surveys on blindness and visual impairment in Latin America. Br J Ophthalmol. 2008;92(3):315-9.

26. Heijthuijsen AA, Beunders VA, Jiawan D, de Mesquita-Voigt AM, Pawiroredio J, Mourits M, et al. Causes of severe visual impairment and blindness in children in the Republic of Suriname. Br J Ophthalmol. 2013;97(7):812-5.

27. Jenum PA, Stray-Pedersen A, Melby KK, Kapperud G, Whitelaw A, Eskild A, Eng J. Incidence of Toxoplasma gondii infection in 35,940 pregnant women in Norway and pregnancy outcome for infected women. J Clin Microbiol. 1998;36(10):2900-6.

28. Carvalho KM, Freitas CC, Kimolto EM, Gasparetto ME. Avaliação e conduta em escolares portadores de visão subnormal atendidos em sala de recursos. Arq Bras Oftalmol 2002;65(4):445-9.

29. Rodrigues AL, Prado RB, Miguel L. Implantação do exame do reflexo vermelho em crianças da região do Hospital das Clínicas da Faculdade de Medicina de Botucatu - SP – Brasil. Arq Bras Oftalmol. 2012;75(5):337-40.

30. Brito PR, Veitzman S. Causes of blindness and low vision in children. Arq Bras Oftalmol. 2000; 63(1):49-54.

Garcia JM, Lavigne LC, Freitas EC, Salviano LMO, Nassaralla Neto JJ, Isaac DLC, Ávila MP

Corresponding author: José Maurício Garcia Av. Primeira Avenida, S/N - Setor Leste Universitário, Zip code: 74605-020, Goiânia GO, Brazil. Phone: + 55 (62) 3269-8200 E-mail: [email protected]

9

Clinical and epidemiological study in patients with primary open-angle glaucomaEstudo clínico-epidemiológico em indivíduos

com glaucoma primário de ângulo aberto

Luciana dos Mares Guia Ribeiro1, Ronilson Ferreira Freitas2, Lucas Mares Guia Ribeiro3, Marise Fagundes Silveira1, Maísa Tavares de Souza Leite1

AbstrAct

Objective: To evaluate the clinical and epidemiological profile of patients with primary open-angle glaucoma. Methods: This is a quantitative study with cross-sectional and analytical design, which sample consisted of 425 patients treated in an unit of Specialized Care in Ophthalmology, located in the northern state of Minas Gerais, from 2004 to 2015. We collected the data using formularies that addressed demographic and clinical aspects, risk factors and the presence of undercurrent diseases. We conducted an ophthalmological examination to evaluate anatomical and functional changes. We used statistical analysis, and the results are presented by mean, standard deviation and percentiles 25, 50 and 75. Results: Females predominate (56.8%), the age group of 60 years or older (44%) and mixed skin (81.7%). A minority of participants present risk factors such as high myopia (6.3%) and diabetes mellitus (17.9%). Regarding the clinical examination, there is a prevalence of increased optic nerve excavation (≥ 0.8) and low thickness of the corneas (≤ 535 microns). Conclusion: Most people develop advanced glaucoma, with increased optic nerve excavation and changed visual fields. Other common risk factors are: family history of glaucoma, decreased thickness of the cornea and hypertension. Early diagnosis and treatment can prevent vision loss. Primary care physicians should consider referring patients who have glaucoma risk factors, for an ophthalmologic examination.

Keywords: Glaucoma primary open-angle/diagnosis; Glaucoma primary open-angle /epidemiology; Blindness; Eye health

Resumo

Objetivo: Avaliar o perfil clínico-epidemiológico dos indivíduos com glaucoma primário de ângulo aberto. Métodos: Trata-se de estudo quantitativo com desenho transversal e analítico, mediante amostra constituída de 425 pacientes atendidos em uma Unidade de Atenção Especializada em Oftalmologia localizada no norte do estado de Minas Gerais, Brasil, cadastrados no período de 2004 a 2015. As variáveis analisadas foram: características demográficas e clínicas, fatores de risco e presença de doenças associadas. Foi realizado exame oftalmológico para avaliar alterações anatômicas e funcionais. Para as análises estatísticas foram utilizados os programas Statistical Package for the Social Sciences (SPSS), versão 19.0. Considerou-se nível de significância p<0,05 para as variáveis categóricas. As variáveis descritivas foram apresentadas pela média, desvio-padrão e percentis 25, 50 e 75. Resultados: Predominou o gênero feminino (56,8%), a faixa etária de 60 anos ou mais (44%), e a cor da pele parda (81,7%). Fatores de risco como alta miopia (6,3%) e diabetes mellitus (17,9%) foram relatados pela minoria dos participantes. Em relação ao exame clínico, houve prevalência de escavação do nervo óptico aumentada (≥ 0,8 mm2) e baixa espessura central das córneas (≤ 535 micras). Conclusão: A maioria dos indivíduos apresenta glaucoma avançado, com escavações do nervo óptico aumentadas e campos visuais alterados. Outros fatores de risco frequentes foram: história familiar positiva para glaucoma, espessura central da córnea diminuída e hipertensão arterial sistêmica. Diagnóstico e tratamento precoces podem prevenir contra a perda de visão no glaucoma. Médicos da atenção primária à saúde devem encaminhar os pacientes que tenham fatores de risco para glaucoma, para a consulta especializada e exames oftalmológicos.

Descritores: Glaucoma de ângulo aberto/diagnóstico; Glaucoma de ângulo aberto/epidemiologia; Cegueira; Saúde ocular

1 Universidade Estadual de Montes Claros, Montes Claros, MG, Brazil. 2 Faculdades Integradas do Norte de Minas, Montes Claros, MG, Brazil. 3 Santa Casa de Misericórdia de Belo Horizonte, Belo Horizonte, MG, Brazil.

Received for publication 21/02/2017 - Accepted for publication 09/11/2017.The authors declare no conflict of interests.

Original article


Institution where the work was done: Postgraduate Program in Primary Health Care, State University of Montes Claros - Unimontes.

10

IntRoductIon

Glaucoma is considered a public health problem, being the main cause of irreversible blindness in the world.(1) In 2013, the number of people with glaucoma in the world

was estimated at 64.3 million, and is expected to increase to 76 million by 2020 and 111,8 million by 2040.(2) In Brazil, the Brazilian Council of Ophthalmology estimates that there are 985.000 people with glaucoma over the age of 40.(3)

Primary open angle glaucoma (POAG) is an optic neuropathy with a slow evolution, usually bilateral and often asymmetrical. It only occurs in adults with open angles of the anterior chamber and absence of other eye diseases that lead to changes in the optic nerve.(4)

Literature describes several risk factors for POAG(3): increased intraocular pressure (IOP),(5) age (over 60 years old),(6) gender,(7) black ethnicity,(7) high myopia,(6,8) family history of glaucoma,(9) central thickness of the cornea decreased (ECC),(10) hypertension (SAH), (8) diabetes mellitus (DM),(11) migraine(5) and sleep apnea.(5) Increased IOP is a major risk factor for glaucoma, and the only one that can be measured with the possibility of intervention.(12)

Because of the lack of data related to the glaucomatous population in the north of Minas Gerais, studies in this area are relevant in order to generate individual and collective changes that contribute to social transformation and improved quality of life. Works that describe the clinical and epidemiological profile of individuals with glaucoma will contribute to a better understanding of the processes involved in this disease, favoring also the identification of risk factors, allowing multidisciplinary care and comprehensive approach to the health condition of this population.

This study is aimed to evaluate the clinical and epidemiological profile of patients with primary open-angle glaucoma.

methods

This is a quantitative study with analytical and cross-sectional design.

The target population consisted of 3198 patients with GPAA who were cared for at a Specialized Ophthalmology Unit located in the north of the state of Minas Gerais from 2004 to 2015. To define the number of participants we considered the following parameters: proportion estimated in 50% of patients with risk factors for APAG, 95% confidence level, sample error (5%) and population size of 3198. A 20% increase was made for the non-response rate. The calculations evidenced the need to interview and examine at least 413 patients.

We used simple random sampling. We identified individuals by numbers from 1 to 3198 and drew 475 using the program Minitab. Of these, 50 (10,5%) did not agree to participate in the study or did not attend the examination. The final sample consisted of 425 individuals, who signed the Informed Consent Form.

The subjects were selected considering the inclusion criteria of being a patient of the service, having a diagnosis of APAG and being 18 years of age or older. No individuals with other types of glaucoma, hypertensive ocular, suspected glaucoma, and optic neuropathies of other etiologies participated in the study.

We collected all the data from a form we created especially for this study, addressing demographics (gender, age and skin color) and clinical information concerning risk factors for developing glaucoma (family history of glaucoma, hypertension and DM).

After telephone contact, we made an appointment for the completion of the form and the carrying out of tests to evaluate the anatomical and functional changes that occur in the angle of the anterior chamber of the eye, the optical disc, visual field and IOP measurement, which normal value is up to 21 mmHg.(13) The ECC, which the average adopted value considered normal was 535 microns, and auto refraction were also measured.

When they reached the center for the exams, participants filled out the form with their data. Then, we performed the tests: measurement of ECC in the pachymeter Topcon SP-3000P, and auto-refraction in the device Topcon KR-8000PA to assess whether the patient had myopia >-6.00 diopters;(14) we conducted perimetry, in order to detect defects in the central 30 degrees of the visual field, with TOP strategy, in the automated perimeter Octopus 311, the HAAG-STREIT INTERNATIONAL.

After all the procedures, patients had an appointment with a specialist doctor in ophthalmology. They conducted a gonioscopy with three lens mirrors (ocular instruments, inc.), and also with a slit lamp Topcon SL-2ED, to classify the angle of the anterior chamber open or closed. We measured the IOP using a Goldmann tonometer (AT 900 model, HAAG-STREIT INTERNATIONAL), for being a practical and reliable method of measurement(15) after instillation of anesthetic eye drops and fluorescein.

Next, we evaluated the optical disc, by means of fundus biomicroscopy, using 78 diopter lens (Volk,) after instillation of tropicamide, to dilate the pupils.

To carry out the statistical analysis we used the Statistical Package for Social Sciences (SPSS) version 19.0. In all statistical analyzes, we considered a significance level of 5%.

We described categorical variables by their frequency distributions; and numeric variables, by means of its descriptive measures (mean, standard deviation and percentiles 25, 50 and 75).

We also evaluated the normality of the variable excavation of the optic nerve using the Kolmogorov-Smirnov test; the results showed that this variable is not normally distributed. Therefore, we adopted a non-parametric test for performing inferences on this variable. To compare the IOP measured according to ECC, we used the Mann-Whitney.

Because it is a study involving humans, we conducted the research after being approved by the Ethics Committee of the Universidade Estadual de Montes Claros, which took into account their ethical precepts, being adopted under the instruction no. 911.256.

Results

The sample consisted of 425 individuals with POAG, of which 56.8% were female. The mean age of the subjects was 57.7 (± 14.5) years.

There was a predominance of age ≥ 61 years (44%), and self-reported skin color as brown (81,7%) (Table 1).

When we assessed other risk factors, 46,6% had a family history of POAG, 49.2% had hypertension and 17.9% reported being diabetic (Table 2).

Table 3 presents the averages of the clinical characteristics of the glaucoma, in the study participants.

When we evaluated the visual fields, 74.6% subjects showed changes in the right eye (RE), and 67.5% in the left eye (LE). In the evaluation of the fundus, we discovered that the excavation of the optic disc was greatly increased (≥ 0.8) both in the right eye (58.5%) and in the left eye (60.2%) (Table 4).


Ribeiro LMG, Freitas RF, Ribeiro LMG, Silveira MF, Leite MTS

11


Clinical and epidemiological study in patients with primary open-angle glaucoma

It was possible to observe that 95.5% of participants had decreased ECC (≤ 535) in the right eye, and 93.6% in the left eye, respectively. Regarding auto refraction, 2.7% of subjects had high myopia in RE, and 2.9% in the LE (Table 4).

Regarding the excavation of the optic disc, we observed that both the right eye and the left showed 50 and 75 percentile equal to 0.80, which implies that 50% of the patients have the excavation of the optic disc superior than or equal to 0.8. The 25 percentile was equal to 0.7 in both eyes, indicating that 25% of patients have the excavation of the optic nerve less than or equal to 0.70. The average of the excavation was equal to 0.75 and 0.74 in right and left eyes, respectively (Figure 1).

Table 5 presents the descriptive measures of intraocular pressure (IOP) of the right and left eyes, according to the ECC. We observed that there was a statistically significant difference in IOP in the left eye (p = 0.026). Patients with low ECC showed IOP values less important. In the right eye there was no significant difference (p = 0.086).

Table 1 Distribution of patients with Primary Open-Angle

Glaucoma who visited the Specialized Care in Ophthalmology Unit according to demographic

characteristics

Variáveis n %

Gender* Female 241 56.8 Male 183 43.2Age group* ≤ 40 years 49 11.6 41 to 50 years 61 14.4 51 a 60 years 127 30.0 ≥ 61 years 187 4.0Skin color* Yellow 1 0.2 White 46 10.8 Black 31 7.3 Brown 346 81.7

Total 425 100.0

*lack of information on 1 patient

Table 2 Distribution of patients with Primary Open-Angle

Glaucoma treated at the Specialized Care in Ophthalmology Unit according risk factors

Variáveis n %

Family history of POAG Yes 198 46.6 No 227 53.4Hypertension Yes 209 49.2 No 216 50.8

Diabetes Yes 76 17.9 No 349 82.1

Total 425 100.0POAG: Primary Open-Angle Glaucoma

Table 3 Clinical characteristics of patients with Primary Open-Angle Glaucoma treated at the Specialized

Care in Ophthalmology Unit

Variables Minimum Maximum mean(±dp)

IOP - RE 8.0 43.0 15.4 (±4.2)

IOP - LE 5.0 40.0 15.1 (±4.2)

Excavation of the optic nerve - RE 0.0 1.0 0.8 (±0.2)

Excavation of the optic nerve - LE 0.2 1.0 0.7 (±0.2)Paquimetry - RE 387.0 596.0 489.6 (±36.8)

Paquimetry- LE 364.0 591.0 492.8 (±36.0)

Auto refraction- RE -12.8 5.3 -0.3 (±2.2)

Auto refraction- LE -15.5 6.8 -0.2 (±2.2)

OD: right eye; OE: left eye; IOP: intraocular pressure; dp: standard deviation

Table 4 Distribution of patients with Primary Open-Angle Glaucoma treated at the Specialized Care Unit in Ophthalmology according to clinical examination

Variables n %

Visual field – RE* Normal 136 32.5 Changed 283 67.5

Visual field – LE* Normal 106 25.4 changed 313 74.6

IOP – RE ≤ 15 247 58.1 >15 178 41.9

IOP – LE ≤ 15 260 61.2 >15 165 38.8

Normal (<0.6) 32 7.5Optic nerve Moderately increased excavation - RE in (0.6 to 0.79) 144 34.0 Very increased (≥ 0.8) 248 58.5

Normal (<0.6) 43 10.2Optic nerve Moderately increased excavation – LE in (0.6 to 0.79) 126 29.6 Very increased (≥ 0.8) 256 60.2

ECC – RE Ideal (> 535) 19 4.5 Low (≤ 535) 406 95.5

ECC – LE Ideal (> 535) 27 6.4 Low(≤ 535) 398 93.6

Not short-sighted 211 51.2Auto refraction Light myopia 163 39.6 -RE** Moderate myopia 27 6.6 High myopia 11 2.7

Not short-sighted 226 55.1Auto refraction Light myopia 152 37.1 -LE Moderate myopia 20 4.9 High myopia 12 2.0

Total 425 100

RE: right eye; LE: left eye; IOP: intraocular pressure; ** Absence information 05 patients; *** Auto refraction not myopic: 0, light Myopia: 0 to -2.99, moderate myopia: -3.00 to -5.99 and severe Myopia:> -6.00.

12 Ribeiro LMG, Freitas RF, Ribeiro LMG, Silveira MF, Leite MTS


dIscussIon

The results showed a predominance of females. Prevalence studies of POAG differ in relation to gender. Some authors reported that women are more affected than men,(16,17) and others,(2,18) that men are more likely to have glaucoma.

In this investigation, there was a predominance of glaucomatous individuals aged over 60 years. This result is similar to the national study findings(19) and international(20), which observed higher incidence of POAG in this age group.

Most participants in this study are self-reported as brown, synthesis of a variety of classifications that express the character of miscegenation of the Brazilian population.(21) Study in US territory revealed prevalence of POAG in black people, six times higher than in whites.(22) The results of this study connote discussion around the concepts of race and ethnicity and imperfection of self-referrals on skin color.(22)

Most of the subjects evaluated had ECC ≤ 535 micrometers. The mean IOPs might be underestimated, since the thinner the corneas, the lower the PIOs.(23) Study to demonstrate the utility of measuring ECC to evaluate the IOP found also a lower IOP average in corneas with decreased center thickness.(24)

In this study, we observed that almost half of patients with POAG had hypertension. Other studies have shown differing results, Díaz et al.,(24) in a study conducted in Cuba, found 62% of occurrence of hypertension; Zao et al.,(18) found 9.17% in patients in China. In a study conducted in the city of Santa Maria, in the south part of Brazil, Rossi et al.,(25) found 48.2%, a very close percentile to the findings of this investigation.

Table 5 Comparison between the IOP of patients with Primary

Open-Angle Glaucoma according to ECC

Intraocular pressure among individuals with POAG

Ideal ECC Low ECC p-value*

Average P25 P50 P75 Average P25 P50 P75 (d.p) (d.p)

RE 1.5(3.0) 14.0 16.0 19.0 15.3(4.2) 12.0 15.0 17.0 0.086

LE 17.9(7.3) 14.0 16.0 18.8 15.0(3.9) 12.0 14.0 17.0 0.026

POAG: primary open-angle glaucoma; RE: right eye; LE: left eye; P25: 25th percentile; P50: 50th percentile; P75: 75th percentile; * Mann-Whitney test.

Figura 1: Optic nerve excavation

Among the participants, 17.9% declared themselves diabetics. However, it is referenced in the literature that approximately 50% of people with diabetes are unaware of the fact that they are carriers of this disease.(26) A systematic review and meta-analysis of case-control and cohort studies conducted by Zhou et al.,(27) emphasized a significant association between diabetes and increased risk of developing primary open-angle glaucoma.

In the present study, we observed an increase of the excavation ≥0.8 in 60% of individuals, close to the results of the findings of Osaki et al.,(28) who analyzed patients referred to the glaucoma Service of Santa Casa de Misericórdia de São Paulo, finding 67.7% with total excavation of 0.8.

Family history is another important risk factor for glaucoma. First-degree relatives of patients with POAG have a risk 10 times greater of having the disease than people who have no family history.(10) Nearly half of the study participants had a family history of glaucoma, more than double that the findings of Kong et al.,(29)

in which 21.49% of POAG patients had a positive family history.We found that most of the patients showed changes in visual

fields in both eyes. Peripheral vision is the most susceptible to glaucomatous damage and approximately 50% of retinal ganglion cells must be damaged so visual field defects are detected.(4)

This study had limitations, like other studies in this field.(17) The number of patients with POAG, which declared themselves non-diabetic suggests the possibility that many of them are unaware of their diagnosis. For clarification of this fact, it is necessary to perform or submit complimentary tests.

With regard to skin color, there was a limitation due to the fact that the majority of individuals have self-reported themselves as brown. Participants had four choices (white, black, brown and yellow), and they had to chose the color that fitted them best. The IBGE´s color classification of the skin can be arbitrary and have limitations, but it is the only source of categories at a national level.(21, 30)

conclusIon

In the present study, most subjects had advanced glaucoma, with increased excavation of the optic disc and changed visual fields. The most frequent risk factors were advanced age, hypertension, central corneal thickness decreased and positive family history of glaucoma. Early diagnosis and treatment can prevent against the loss of vision due to this disease. Primary care doctors should refer patients who have risk factors to a specialist for consultation and eye exams. Therefore, it is essential that from the formulation to the implementation of policies and programs of primary health care, the factors associated with glaucoma are taken into consideration.

RefeRences

1. Díeza RC, Romána JJ, Barbosa MJI. Concepto de sospecha de glaucoma de ángulo abierto: definición, diagnostic y tratamient. Rev Mex Oftalmol. 2014; 88(4): 153-60.

2. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014; 121(11): 2081-90.

3. Gonçalves MR, Guedes MM, Chaves MA, Pereira CC, Otton R. Analysis of risk factors and epidemiology of blindness prevention campaign by glaucoma in João Pessoa, Paraíba. Rev Bras Oftalmol. 2013; 72(6): 396-9. .

13


Clinical and epidemiological study in patients with primary open-angle glaucoma

Corresponding author: Luciana dos Mares Guia Ribeiro Rua Juca Macedo 330, apto 901, Funcionários. Montes Claros, Minas Gerais, Brazil. Phone: 38 32122234 E-mail: [email protected]

4. Weinreb RN, Aung T, Medeiros FA. The pathophysiology and treatment of glaucoma: a review. JAMA. 2014; 311(18):1901-11.

5. Sociedade Brasileira de Glaucoma. Consenso Brasileiro Glaucoma Primário de Ângulo Aberto. 3ª ed. São Paulo: BestPoint; 2009.

6. Osaki TH, Kasahara N. Qual a gravidade com que pacientes portadores de glaucoma se apresentam em um serviço terciário? Glaucoma. 2010;(13):5-8.

7. Worley A, Grimmer-Somers K. Risk factors for glaucoma: What do they really mean? Aust J Prim Health. 2011; 17(3): 233-9.

8. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006; 90(3): 262-7.

9. Paletta Guedes RA, Paletta Guedes VM, Chaoubah A. Focusing on patients at high-risk for glaucoma in Brazil: a pilot study. J Fr Ophtalmol. 2009; 32(9):640-5.

10. Quigley HA. Glaucoma. Lancet. 2011; 377(9774):1367-77. 11. Khandgave TP, Puthran N, Ingole AB, Nicholson AD. The assessment

of sleep apnoea as a risk factor in glaucoma. J Clin Diagn Res. 2013; 7(7):1391-3.

12. Silva JA, Silva RS, Ambrosio Júnior R. Relevancy of corneal biomechanical in glaucoma. Rev Bras Oftalmol. 2014; 73(1):37-9.

13. Thomas R, Loibl K, Parikh R. Evaluation of a glaucoma patient. Ind J Ophthalmology. 2011; 59(1): S43-S52.

14. Qiu M, Wang SY, Singh K, Lin SC. Association between myopia and glaucoma in the United States PopulationMyopia and glaucoma in US population. Invest Ophthalmo Vis Sci. 2013;54(1):830-5.

15. Goldman H, Schmidt TH. Uber applanation-stonometrie. Ophthalmologica. 1957; 134:221-42.

16. Cook C, Foster P. Epidemiology of glaucoma: what’s new? Can J Ophthalmol. 2012; 47(3):223-6.

17. Thasarat SV, Shuang W, Mina T, Rohit V. The Changing Face of Primary Open-Angle Glaucoma in the United States: Demographic and Geographic Changes from 2011–2050. Am J Ophthalmol. 2012; 154(2):303-14.

18. Zhao Y, Fu JL, Li YL, Li P, Lou FL. Epidemiology and clinical characteristics of patients with glaucoma: An analysis of hospital data between 2003 and 2012. Ind J Ophthalmol. 2015; 63(11): 825-31.

19. Salai AF, Souza TT, Adam Netto A, Oliveira LSO, Shimono CT, Cunha RD. Perfil clínico epidemiológico de pacientes com glaucoma encaminhados ao serviço de oftalmologia do Hospital Universitário da Universidade Federal de Santa Catarina. ACM Arq Catarin Med. 2011; 40(3):37-42.

20. Akpek EK, Smith RA. Overview of age-related ocular conditions. Am J Manag Care. 2013;19(5):67-75.

21. Pena SD, Di Pietro G, Fuchshuber-Moraes M, Genro JP, Hutz MH, Kehdy Fde S, et al. The genomic ancestry of individuals from different geographical regions of Brazil is more uniform than expected. PLoS One. 2011; 6:e17063.

22. Dueker DK, Singh K, Lin SC, Fechtner RD, Minckler DS, Samples JR, et al. Corneal thickness measurement in the management of primary open-angle glaucoma: a report by the American Academy of Ophthalmology. Ophthalmology. 2007; 114(9):1779-87.

23. Sakata K, Scapucin L, Sakata LM, Carvalho AC, Selonke I, Sakata VM, et al. Projeto glaucoma: resultados parciais 2000 na região de Piraquara - PR. Arq Bras Oftalmol. 2002; 65(3):333-7.

24. Díaz AL, Suárez RB, Curbelo M, Soto SY, Milanés AA. Caracterización epidemiológica del glaucoma primario de ángulo abierto. MediSur. 2010; 8(5): 42-6.

25. Rossi AG, Correa RV, Botton B, Schmitt EU, Hwas AA. Campanha de detecção do glaucoma na cidade de Santa Maria: resultados de 2009 e 2010. Saúde. 2012; 38(1): 93¬-100.

26. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. Brasília: Ministério da Saúde; 2013.

27. Zhou M, Wang W, Huang W, Zhang X. Diabetes mellitus as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. PLoS One. 2014; 9(8): e102972.

28. Osaki TH, Kasahara N, Della Paolera M, Cohen R, Nishiwaki-Dantas MC. Presentation of glaucoma in an urban tertiary care hospital in South America: legal blindness and prevalence. Int Ophthalmol. 2010; 30(4): 361-6.

29. Kong X, Chen Y, Chen X, Sun X. Influence of family history as a risk factor on primary angle closure and primary open angle glaucoma in a Chinese population. Ophthalmic Epidemiol. 2011;18(5):226-32.

30. Oliveira F. Ser negro no Brasil: alcances e limites. Estudos Avançados. 2004;18(50):57-60.

14Original article

Received for publication 19/05/2017 - Accepted for publication 21/10/2017.

Rev Bras Oftalmol. 2018;77 (1): 14-9

The authors declare no conflict of interests.

Comportamento da pressão intraocular no tonômetro de aplanação de Goldman e pneumático

durante o teste de sobrecarga hídrica

Intraocular pressure behavior in the Goldmann and pneumatic tonometer during

water drinking test

Rodrigo Egidio da Silva1, Isabella Cristina de Sousa Paiva2, Juliana Ferreira de Souza2, Francisco Wellington Rodrigues1

1 Pontifícia Universidade Católica de Goiás, Goiânia, GO, Brazil. 2 Academic Course in Medicine at Pontifícia Universidade Católica de Goiás – Goiânia, GO, Brazil.Study carried out at Pontifícia Universidade Católica de Goiás – Goiânia, GO, Brazil.

Resumo

Objetivo: Avaliar a concordância entre os tonômetros de aplanação de Goldman e pneumático na realização do teste de sobrecarga hídrica (TSH). Métodos: Estudo descritivo transversal composto por uma amostra de 102 olhos proveniente de um hospital particular em Goiânia (GO) entre 2013 a 2016, com avaliação das diferentes pressões intraoculares (PIO) nos tonômetros de aplanação de Goldman e pneumático quando submetidos ao TSH. Resultados: A média de idade foi de 52,17 (± 15,21) anos , sendo que60,8% dos pacientes pertenciam ao sexo feminino e 39,2% ao masculino. A média da espessura da córnea foi de 531,9(± 72,75) micra. Por regressão linear as variaveis idade e espessura da cornea central não ocorreram significancia estatistica entre os dois dispositivos analisados. Conclusão: Observou-se boa concordância nas medições entre os aparelhos de aplanação e o pneumático durante o teste de sobrecarga hídrica, porém necessita-se de novos estudos de maior impacto epidemiológico para confirmação desta assertiva.

Descritores: Pressão intraocular; Glaucoma; Paquimetria; Reprodutibilidade; Tonometria/métodos

AbstrAct

Objective: To evaluate the consonance betweenthe Goldman and pneumática planation to nometers under the effect of the water drink test. Methods: Cross-sectional descriptive study consisting of a sample of 102 eyes from a private hospital in Goiânia (GO) from 2013 to 2015,with na evaluation of different intraocular pressures (IOP) in the Goldman and pneumatic flattening to nometers when submitted to TSH. Results: The average age was 52.17 (± 15.21) years old, 60.8% of the patients were female and 39.2% were male.The mean corneal thickness was 531.9(± 72.75) By linear regression the variables age and corneal thickness did not occur statistical significance between the two devices analyzed. Conclusion: Good agreement was observed in the measurements between the applanation devices and the tire during the water drink test, but new studies with a greater epidemiological impact were required to confirm this assertion.

Keywords: Intraocular pressure; Glaucoma; Pachymetry; Reproducibility; Tonometry/methods

15

IntRoductIon

Glaucoma is a multifactorial disease with progressive, insidious optic neuropathology with loss of the visual field in which the main risk factor is increased intraocular

pressure (IOP).(1,2) It represents the second cause of blindness in the world.(2) The estimate is that in 2020 there will be 79.6 glaucoma patients in the world.(2,3) In Brazil, its prevalence may reach 3.4%.(4) According to data from the study of Yih-Chung Than et al.(3), the number of individuals with glaucoma in the world will increase from 64.3 million in 2013 to 111.8 million in 2040, affecting mainly the African and Asian populations.

Increased IOP is the main risk factor for glaucoma progression as well as its fluctuation in primary open-angle glaucoma (POAG).(5,6) Tonometer is the apparatus used to detect the increased IOP. Despite the existence of various models, Goldman applanation is considered the golden standard for this measurement.(7-8) This method is quite accurate. However, errors can occur in the result due to fluorescein patterns, very thick corneas, excessive pressure on the eyeball, among others.(8)

The IOP measure can also be made with other kind of tonometer: the non-contact one (pneumatic or blow). It was used for the first time in 1973 by Forbes, and the advantages are: 1) no need to use eyedrops; 2) can be made by people other than doctors, 3) low risk of contamination; and 4) can be used for screening programs.(9,10)

In their study, Sanchez-Tocino et al.(11) compared the pneumatic tonometer to Goldman’s, and differences between the apparatuses could occur in about 2 mmHg.

The Water Load Test (WLT) was used a lot during the decades of 1960 and 1070 to diagnose glaucoma. However, more recent studies changed the focus of this test due to its low diagnostic precision. WLT indirectly assesses the drain capacity of the aqueous humor.(6,12) Its importance is due to the fact of detecting peaks of IOP undetected during regular working hours.

The values of IOP obtained during a period of 24 hours are important data, as they are necessary to control and conduct glaucoma treatment.(13,14) In the past, WLT was frequently used to diagnose patients with this pathology. A series of studies(15,16) showed that WLT can be used as a tool to assess peak changes of IOP.

The objective of the present study is to verify the similarities between Goldman’s and pneumatic applanation tonometers to measure IOP during WLT, and analyze possible variables that could directly influence these measures.

methods

It is a cross-sectional descriptive study with review of electronic medical records of a private ophthalmological hospital in Goiânia (GO) from 2013 to 2016. The present study was submitted and approved by the research ethics committee of Pontifícia Universidade Católica de Goiás (PUC-GO).

The study comprised 102 individuals, with a sample of 102 eyes with primary open-angle glaucoma and/or suspected glaucoma. The following variable were observed: gender, age, intraocular pressure, and pachymetry. All patients underwent complete ophthalmologic examination, including Goldmann’s and pneumatic tonometries.


Intraocular pressure behavior in the Goldmann and pneumatic tonometer during water drinking test

The inclusion criteria were patients over 18 years of age, complete medical records, and individuals with suspected and/or confirmed glaucoma. Patients with suspected glaucoma had a positive family history and/or IOP above 21 mm Hg, and/or increased excavations above 0.6, and/or asymmetry between the eyes greater than 0.2. Glaucoma patients were considered with IOP above 22 mmHg, excavations greater than 0.6 with focal or diffuse loss of neuronal rhyme, open angle confirmed by gonioscopy, loss of visual field according to Anderson criteria(6,17) with minimum reproducibility of at least two visual fields. The exclusion criteria were patients under 18 years of age with incomplete data on electronic medical records, contact lens users, and/or other ophthalmological diseases and/or previous ophthalmologic surgeries and/or systemic diseases.

Patients with glaucoma and/or suspected glaucoma underwent the Water Load Test (WLT), which consists in the intake of 800 to 1000ml of water in a short period of time (about 05 minutes).(12,18) In the present study, the patient was instructed to remain in an absolute fast for 8 hours. In the morning period, pneumatic IOP was measured, followed by aplanation tonometry, and the patient was then instructed to drink 800 ml of water in a period of 5 minutes. Then the IOP measurement was performed in a sitting position every 15 minutes, until the period of 1 hour and 15 minutes was completed, thus making a total of six measurements.

All patients had the IOP measured with the pneumatic tonometer of Topcon computerized CT-80 Japan tonometer, and with the applanation tonometer of Goldmann Optilasa S.I, Spain.

After the data were collected, they were transcribed in Microsoft Excel® software. StatisticalPackage for Social Science (SPSS) version 21.0 was used to analyze the data.

The categorical variables were presented as absolute value (n) and percentage value (%). Continuous variables were presented as average ± standard deviation, median (95% CI).

The Kappa test was used to verify the possible existence of an agreement with the results obtained from the IOP in the applanation and pneumatic apparatuses. For this analysis the intraocular pressure was classified into categories. A 95% confidence level was considered for all tests, that is, p <0.05 was considered significant.

Results

The average age of the patients was 52.17 ± 15, 21 years. Patients were analyzed according to the use of eyedrops, and 47 (46.1%) did not use it and 55 (53.9%) used it. The average corneal thickness (ACT) was 531.9 ± 72.75 microns (Table 1).

The analysis of the values showed the agreement between the apparatuses when comparing the categories analyzed (Table 2).

When the IOP measurement between the two apparatuses was compared, the peak pressure occurred at 8:15 (Figure 1).

Despite the significance of the measurement at 8:45, the averages and the confidence interval between them are very close in individuals with and without the use of eyedrops (Table 3).

Table 4 shows a comparative study between the peak and the fluctuation between the two devices analyzed, where the significance between the two devices is observed in corneas below 500 and between 501-550.

There were no significant differences between the devices analyzed and the categorical variables of the central corneal thickness (Table 5).

16

Table 6 compares the intraocular pressure between the applanation and pneumatic apparatuses in relation to the different classes of medication.

In table 7, linear regression was performed, and no statistical significance was observed between the variables analyzed.

Table 8 compares individuals suspected of glaucoma and individuals with glaucoma between pneumatic and aplanation devices.


Silva RE, Paiva ICS, Souza JF, Rodrigues FW

Table 1 Distribution of patients according to gender, age,

use of eyedrops and corneal thickness

Variables Number of patients

Gender N %Female 62 60.8Male 40 39.2Use of eyedrops No 47 46.1Yes 55 53.9Age (average) 52.17±15.21 Central corneal thickness (average) 531.9±72.75

Figure 1: Average intraocular pressure in 102 eyes analyzed according to the type of apparatus at the given moments.

Table 2 Agreement test and distribution of pressure categories in the 102 eyes analyzed, measured by applanation and

pneumatic in patients at certain hours

Applanation Pneumatic (n. of patients) K P value

≤ 10 11 - 21 ≥ 22

7:45 am n=9 n=86 n=7 ≤ 10 (n=9) 6 3 - 11– 21 (n=85) 3 81 1 0.69 < 0.001*≥ 22 (n=8) - 2 6 8:00 am n=8 n=80 n=14 ≤ 10 (n=7) 4 3 - 11 – 21 (n=79) 4 71 4 0.544 < 0.001*≥ 22 (n=16) - 6 10 8:15 am n=5 n=82 n=15 ≤ 10 (n=1) 1 - - 11 – 21 (n=77) 4 68 5 0.370 < 0.001*≥ 22 (n=24) - 14 10 8:30 am n=5 n=85 n=12 ≤ 10 (n=4) 4 - - 11 – 21 (n=84) 1 76 7 0.49 < 0.001*≥ 22 (n=14) - 9 5 8:45 am n=9 n=84 n=9 ≤ 10 (n=6) 6 - - 11 – 21 (n=87) 3 80 4 0.62 < 0.001*≥ 22 (n=9) - 4 5 9:00 am n=10 n=84 n=8 ≤ 10 (n=11) 7 4 - 11 – 21 (n=83) 3 78 2 0.66 < 0.001*≥ 22 (n=8) - 2 6

K = Kappa test, p = statistical significance, * Significant p <0.05; n = number of eyes

Table 3 Comparison of intraocular pressure in 102 eyes analyzed between patients who used eyedrops and those who did

not use eyedrops at different times

Variable Use of eyedrops P value

No (n=47) Yes (n=55)

Applanation 7:45:00 am 16.0 (15.2 – 17.6) 15.0 (13.9 – 15.9) 0.0848:00:00 am 18.0 (16.6 – 19.3) 16.0 (15.4 – 17.7) 0.0798:15:00 am 19.0 (17.6 – 20.2) 18.0 (16.3 – 18.6) 0.1068:30:00 am 17.0 (16.8 – 19.2) 16.0 (15.4 – 17.4) 0.0838:45:00 am 17.0 (16.1 – 18.5) 16.0 (14.8 – 16.6) 0.024*9:00:00 am 16.0 (15.5 – 17.8) 15.0 (14.6 – 16.7) 0.116Pneumatic 7:45:00 am 17.0 (15.4 – 18.2) 16.0 (14.6 – 16.8) 0.3428:00:00 am 18.0 (16.1 – 19.0) 16.0 (15.3 – 18.0) 0.1928:15:00 am 18.0 (16.9 – 19.8) 17.0 (16.0 – 18.6) 0.2168:30:00 am 17.0 (16.2 – 18.9) 17.0 (15.9 – 18.2) 0.7088:45:00 am 16.9 (15.6 – 18.2) 16.0 (14.8 – 17.1) 0.2419:00:00 am 17.0 (15.4 – 18.0) 16.0 (14.9 – 17.4) 0.347

Test: Mann-Whitney, p = statistical significance, * Significant p <0.05; n = number of eyes

Table 4 Comparison between the peak and fluctuation of

intraocular pressure in 102 eyes analyzed between the Applanation and Pneumatic devices regarding the central

corneal thickness and the use of eyedrops

Variables Aparattus P value

Applanation Pneumatic Peak Central corneal thickness≤ 500 (n=18) 17.6 ± 4.3 16.6 ± 3.8 0.039*501 – 550 (n=38) 19.5 ± 4.0 20.0 ± 4.6 0.137> 550 (n=45) 19.4 ± 4.4 20.2 ± 5.1 0.156Use of eyedrops No (n=47) 19.8 ± 4.4 19.7 ± 4.9 0.595yes (n=55) 18.6 ± 4.1 19.3 ± 4.9 0.062Fluctuation Central corneal thickness≤ 500 (n=18) 4.6 ± 2.4 4.3 ± 1.3 0.915501 – 550 (n=38) 4.7 ± 2.8 5.9 ± 3.1 0.002*> 550 (n=45) 4.4 ±1.8 4.5 ± 2.6 0.874Use of eyedrops No (n=47) 4.4 ± 2.1 4.8 ± 2.2 0.398yes (n=55) 4.7 ± 2.6 5.2 ± 3.1 0.204

Test: Mann-Whitney, p = statistical significance, * Significant p <0.05; n = number of individuals

17Intraocular pressure behavior in the Goldmann and pneumatic tonometer during water drinking test

dIscussIon

Glaucoma is a serious ocular health problem, since it has a high incidence and prevalence, being the main cause of irreversible blindness in the world.(1,2,5) Some studies report that females may be the most affected, accounting for 55% of primary open-angle glaucoma in the year 2020.(2,19) This data is in agreement with the sample of the present study, since 60.8% are female and 30.9% male, thus showing a higher prevalence among women. Some studies have shown that males have a great resistance to the demand for health services, highlighting the incompatibility of time and/or the fragility, morbidity and mortality of the disease.(20,21) In this specific study, we cannot corroborate this statement, since the sample analyzed was of convenience. Therefore, high-impact studies are recommended to corroborate the data found here.

According to some authors,(22,23) the prevalence of POAG increases with age. In the present study, the average age of suspected and/or glaucoma was 52.17, which corroborates the literature data.

Changes in the corneal structure cause changes in the IOP measurements, and this can be due to Goldman’s applanation tonometer.(2,10,23) These measurements can generally hypothesize measurements in corneas with reduced thickness, and as a consequence increase the risk of optic nerve damage as a result of an increased real IOP.(11,24)


Table 5 Comparison between the intraocular pressure in 102 eyes

analyzed between the Applanation and Pneumatic apparatuses regarding the central corneal thickness at different times

Corneal thickness Aparattus P value

Applanation Pneumatic

7:45:00 am ≤ 500 (n=18) 14.5 (12.4 – 16.4) 14.0 (11.7 – 15.7) 0.645501 – 550 (n=38) 16.0 (14.4 – 16.5) 16.0 (14.7 – 16.9) 0.591> 550 (n=45) 16.0 (14.9 – 17.7) 17.0 (15.9 – 18.9) 0.2478:00:00 am ≤ 500 (n=18) 16.5 (13.3 – 17.9) 14.5 (12.4 – 16.3) 0.417501 – 550 (n=38) 17.0 (16.0 – 18.4) 16.0 (15.3 – 18.0) 0.552> 550 (n=45) 18.0 (16.2 – 19.2) 18.0 (16.8 – 20.1) 0.7908:15:00 am ≤ 500 (n=18) 16,5 (14.6 – 18.8) 16.0 (12.9 – 16.6) 0.220501 – 550 (n=38) 19.5 (17.2 – 19.9) 18.0 (16.4 – 19.6) 0.395> 550 (n=45) 18.0 (16.9 – 19.5) 17.0 (17.2 – 20.1) 0.7848:30:00 am ≤ 500 (n=18) 15.5 (13.2 – 17.6) 16.0 (12.4 – 16.7) 0.582501 – 550 (n=38) 16.0 (16.0 – 18.6) 18.0 (15.9 – 18.7) 0.983> 550 (n=45) 17.0 (16.5 – 18.6) 17.0 (16.9 – 19.5) 0.6528:45:00 am ≤ 500 (n=18) 15.5 (13.1 – 16.8) 15.0 (12.0 – 16.2) 0.568501 – 550 (n=38) 16.0 (15.8 – 18.4) 16.5 (15.2 – 18.3) 0.715> 550 (n=45) 16.0 (15.4 – 17.5) 16.0 (15.7 – 18.0) 0.5309:00:00 am ≤ 500 (n=18) 15.0 (12.5 – 16.1) 14.5 (12.0 – 15.4) 0.513501 – 550 (n=38) 16.0 (12.5 – 16.1) 16.0 (15.5 – 18.8) 0.851> 550 (n=45) 16.0 (14.8 – 16.9) 16.0 (15.5 – 17.9) 0.352


Table 6 . Comparison between the intraocular pressure in 102 eyes

analyzed between the Applanation and Pneumatic apparatuses regarding the class of eyedrops at different times

Class Aparattus P value Applanation Pneumatic

7:45:00 am 1 14.0 (13.1 – 16.4) 16.0 (15.2 – 17.8) 0.102 2 16.0 (14.8 – 18.7) 18.0 (14.7 – 19.2) 0.988 3 14.0 (11.8 – 14.7) 14.0 (11.5 – 15.6) 0.9678:00:00 am 1 16.0 (14.4 – 17.9) 16.0 (15.0 – 18.8) 0.661 2 18.0 (16.5 – 21.3) 19.0 (15.3 – 21.4) 0.682 3 14.0 (12.8 – 16.1) 14.0 (12.5 – 16.3) 0.7708:15:00 am 1 18.0 (15.8 – 19.1) 17.5 (15.9 – 19.1) 0.870 2 20.0 (16.9 – 21.5) 18.0 (16.3 – 22.1) 0.682 3 16.0 (13.7 – 17.3) 14.0 (13.2 – 17.1) 0.6308:30:00 am 1 16.0 (14.9 – 17.9) 18.0 (15.8 – 18.7) 0.383 2 18.0 (15.4 – 19.6) 17.0 (15.8 – 20.1) 0.872 3 16.0 (13.8 – 17.2) 15.0 (13.4 – 18.7) 0.8028:45:00 am 1 16.0 (14.2 – 16.8) 16.5 (15.4 – 18.5) 0.164 2 16.0 (14.9 – 18.8) 16.0 (14.4 – 18.5) 0.837 3 14.0 (13.3 – 16.5) 14.0 (12.1 – 17.0) 0.5029:00:00 am 1 15.5 (13.6 – 16.4) 16.0 (14.9 – 17.8) 0.147 2 16.0 (14.6 – 18.9) 15.0 (14.1 – 19.2) 0.826 3 14.0 (12.4 – 16.5) 14.0 (11.7 – 17.4) 0.770

Test: Mann-Whitney, p = statistical significance; * Significant p <0.05. 1 = one class of antiglaucomatous medication (In use of only one of the following medications: Prostaglandin analog, selective β-blockers, non-selective β-blockers or α 2 -adrenergic agonist), 2 = two different classes of antiglaucomatous medication (In combination with two of the following medications: non-selective β-blockers, α2 adrenergic agonist, carbonic anhydrase inhibitor, prostaglandin analogue, and 3 = three different classes of antiglaucomatous medication (Using the combination of three of the following medications: α2 adrenergic agonist, non-selective β-blockers, carbonic anhydrase inhibitor or prostaglandin Analogue).

Other authors,(2,5,10) suggest that IOP in patients with thicker corneas may be overestimated with applanation tonometry and less influenced with the pneumatic one.(11) Due to that, these patients are exposed to a lower risk of progression of the IOP-related glaucomatous lesion. The present study showed that even with the possible corneal deformities the general corneal thickness did not influence the IOP reproducibility between the two apparatuses during WLT. The possible justification for this fact could be related to the fact that the average found for the pachymetric value is compatible with the global average, and thus would be less influenced by distortions when measured. When we analyzed the isolated peak and fluctuation variables, there was a slight discrepancy between the two devices. It is observed that the peak is slightly more underestimated in thinner corneas with the pneumatic tonometer, and a greater fluctuation in this device. It is worth mentioning that corneal thickness is an important factor influencing the IOP measurement alone. (2,5,10,24) Intrinsic factors such as biomechanics(25), besides the thickness itself, could influence this result, and thus we recommend specific studies for

18

Table 7 Linear regression of the difference of intraocular

pressure in 102 eyes analyzed between the Applanation and Pneumatic apparatuses at different times regarding

age and the central corneal thickness

Variable R2 B P valueAge/Time 7:45:00 am 0.027 -0.011 0.0998:00:00 am 0.036 -0.024 0.0558:15:00 am 0.025 -0.018 0.1118:30:00 am 0.019 -0.015 0.1628:45:00 am 0.008 0.008 0.3739:00:00 am 0.001 0.003 0.746Corneal thickness /Time 7:45:00 am 0.004 0.003 0.5228:00:00 am 0.004 0.003 0.5328:15:00 am 0.011 0.005 0.3058:30:00 am 0.015 0.005 0.2298:45:00 am 0.001 -0.001 0.7989:00:00 am 0.022 0.005 0.140

R2 = Coefficient of determination, B = Slope of the line, p = statistical significance, * Significant p <0.05.

Table 8 Comparison of intraocular pressure in 102 eyes analyzed

between the Applanation and Pneumatic devices regarding suspected Glaucoma (n = 73) and Glaucoma (n = 29)

Glaucoma Aparattus P value

Applanation Pneumatic

7:45 Suspected glaucoma 16.5 ± 3.9 17.4 ± 4.2 0.004*Glaucoma 13.4 ± 3.3 13.2 ± 3.6 0.6738:00 Suspected glaucoma 18.2 ± 4.5 18.2 ± 4.9 0.747Glaucoma 14.8 ± 3.5 14.2 ± 3.7 0.1918:15 Suspected glaucoma 19.1 ± 4.2 18.9 ± 4.8 0.693Glaucoma 15.7 ± 3.5 14.9 ± 3.7 0.0778:30 Suspected glaucoma 17.9 ± 3.9 18.1 ± 4.4 0.976Glaucoma 15.2 ± 3.5 15.2 ± 3.9 0.9658:45 Suspected glaucoma 17.1 ± 3.9 17.2 ± 4.1 0.841Glaucoma 14.7 ± 3.0 14.3 ± 4.2 0.3779:00 Suspected glaucoma 16.7 ± 4.1 17.1 ± 4.6 0.055Glaucoma 14.5 ± 3.2 14.5 ± 3.9 0.954


later analysis. Literature(6,12) discusses the influence that a particular class of hypotensive medication could influence both peak and fluctuation of IOP during TSH. When we compared the effect of the medication between the two devices in the isolated form (peak and fluctuation), the medication class, and the general average at different times, the agreement between the devices was maintained. It is always worth mentioning the importance of the hypotensive medications for the stability and reduction of the IOP measured during the WLT with the applanation tonometer, since it is the gold standard for measurement.

In figure 2, a greater increase in the IOP of the third measure between the two apparatuses is observed. One hypothesis to consider is that IOP values are subject to cyclical fluctuations throughout the day, and the average fluctuation in normal individuals may vary from 3 to 6 mmHg.(2) This variation is generally higher in glaucoma patients.

The pattern of the daily IOP fluctuation cycle describes the pressure peaks in the early hours of the morning, which can be observed in approximately 40% of the cases.(2) Another possible hypothesis for the increase of IOP in the third measurement in the two devices during WLT would be the maximum effect of the water intake action, which would reduce its action after the other measurements.

Some studies(5,25-27) show that the variation of IOP may be an important risk factor for the progression of glaucoma, since it is believed to be the main characteristic of the disease. Therefore, the physician should give more attention during this exam, so that there is no escape from the third measure, whose maximum value may directly influence the IOP variability. It is interesting to note that only the measurement at 7:45 showed a lower agreement between the applanation and pneumatic devices in suspect patients, which may be justified by the use or not of eyedrops, or biomechanical effects on the cornea during the sleep period.

Despite the agreement between the devices during WLT, it is recommended to use applanation tonometry for such measurements. We must emphasize the limitations of this study. A proposal for future studies would be to carry out longitudinal, double-blind and randomized studies to observe this possible reproducibility, especially when the IOP measurements or corneal thickness have extreme maximum and minimum values.

conclusIon

The present study demonstrated that although the Goldman applanation tonometer is considered gold standard for the IOP measurement, there is good agreement of the IOP measurement between the devices during the water overload test.

New studies with greater epidemiological impact should be performed in this area to identify the degree of agreement between the devices, especially if the IOP extreme values and corneal thickness would have the same degree of agreement.

Acknowledgements

We thank Pontifícia Universidade Católica de Goiás for the initiative to foster this research project. We thank Hospital Ver for having welcomed us and allowed the data used to be collected from their medical records. We thank the teachers for the knowledge, material available and patience. Thanks to Professor Antônio Wilson for the statistical guidance we had.

RefeRences

1. Salai FA, Souza TT, Netto AA, Oliveira SL, Shimono TC, Cunha DR. Perfil clínico epidemiológico de pacientes com glaucoma encaminhados ao serviço de oftalmologia do Hospital Universitário da Universidade Federal de Santa Catarina. ACM Arq Catarin Med. 2011;40(3):37-42.

2. Sociedade Brasileira de Glaucoma. 3o. Consenso Brasileiro: Glaucoma Primário de Ângulo Aberto. Sã Paulo: Sociedade Brasileira de Glaucoma; 2009.

Silva RE, Paiva ICS, Souza JF, Rodrigues FW


19

3. Tham Y-C, Li X, Wong YT, Quigley AH, Aung T, Cheng C-Y. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014; 121(11): 2081-90.

4. Sakata K, Sakata LM, Sakata VM, Santine C, Hopker LM, Bernardes R, et al. Prevalence of glaucoma in South Brazilian Population: Projeto Glaucoma. Invest Ophthalmol Vis Sci. 2007; 48 (11):4974-9.

5. Medeiros AF, Sample AP, Zangwill ML, Bowd C, Aihara M, Weinreb NR. Corneal thickness as a risk factor for visual field loss in patients with preperimetric glaucomatous optic neuropathy. Am J Ophthalmol. 2003; 136(5):805-13.

6. Caiado RR, Basaró E, Kasahara N. Intraocular pressure fluctuation in healthy and glaucomatous eyes: a comparative analysis between diurnal curves in supine and sitting positions and the water drinking test. Arq Bras Oftalmol. 2014; 77(5):288-92.

7. Costa TR, Barreto PB, Lopes PF, Lira CP. Analysis of calibration of Goldmann applanationtonometers in opthalmology services in Recife. Arq Bras Oftalmol 2004; 67(2):267-70.

8. Regev G, Harris A, Siesky B, Shoshani Y, Egan P, Moss A, et al. Goldmann applanation tonometry and dynamic contour tonometry are not correlated with central corneal thickness in primary open angle glaucoma. J Glaucoma. 2011; 20(5):282-6.

9. Forbes M, Pico Jr. G, Grolman B. A noncontact applanation tonometer. Sight Sav Rev. 1973;43(3):155-61.

10. Estrada EII. Estudo comparativo entre o tonómetro de aplanação de goldman e o tonómetro de não contacto em pacientes com glaucoma primário de ângulo aberto [tese]. Lisboa: Universidade de Algarve; 2014.

11. Sanches-Tocino H, Brigas-Calvo R, Iglesias-Cortinas D. Estudio comparativo entre el neumotonómetro de no contacto Canon TX-10 y el tonómetro de Goldmann. Arch Soc Esp Oftalmol. 2005;80 (11):643-9.

12. Susanna R, Hatanaka M. Teste de sobrecarga hídrica e sua importância no manejo da glaucoma. E- Oftalmol. 2015; 1(2). Disponível em: https://aeo.emnuvens.com.br/cbo/article/view/20

13. Quaranta L, Konstas PGA, Rossetti L, Garcia-Feijó J, O`Brien C, Nasr BM, Fogagnolo P, Demos MC, Stewart AJ, Stewart CW. Untreated 24-h intraocular pressures measured with Goldmann applanation tonometry vs nighttime supine pressures with Perkins applanation tonometry. Eye (Lond) 2010;24(7):1252-8.

14. Skata R, Aihara M, Murata H, Saito H, Iwase A, Yasuda N, Araie M. Intraocular pressure change over a habitual 24-hour period after changing posture or drinking water and related factors in normal tension glaucoma. IOVS. 2013;54(8):5314.

15. Medina CM, Rodrigues PK, Pierre Filho PT, Matsuo T, Vansconcelos CP, Costa PV. Reproducibility of water drinking test performed at diferente times of the day. Arq Bras Oftalmol. 2009;72(3):283-90.

16. Meirelles SH, Yamane R, Álvares MR, Botelho BP, Morais BF, Moreira BP, Dantas MA, Júnior MV. Comparative study between diurnal intraocular pressure curve and the association of ambulatory intraocular pressure curve with the water-drinking test in open angle glaucoma, normal tension glaucoma and normal eyes. Arq Bras Oftalmol. 2007; 70(3):471-9.

17. Anderson. D. Automated static perimetry. St Louis: Mosby-Year Book; 1992.

18. Magacho L, Reais R, Pigini AM, Ávila PM. Ibopamina 2% vs. Sobrecarga hídrica como teste procativo para glaucoma. Arq Bras Oftalmol. 2008;71 (4):499-503.

19. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006; 90(3):262-7.

20. Oliveira SR, Barbosa CG, Dias PJ, Oliveira SM, Oliveira SJ, Ottoni MA, Souto TG. Baixa procura dos homens ao serviço de saúde: uma revisão de literatura. Rev Dig Buenos Aires. 2014; 188. [citado 2017 Out 13]. Disponível em: www.efdeportes.com

21. Oliveira MM, Daher VD, Silva LLJ, Andrade AC. A saúde do homem em questão: busca por atendimento na atenção básica de saúde. Ciênc Saúde Coletiva. 2015; 20(1):273-8.

22. Burr J, Mowatt G, Hemández R, Siddiqui M, Cook J, Lourenco T. The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation. Health Technol Assessm. 2007 ;11(41):iii-iv, ix-x, 1-190.

23. Gordon M, Beiser J, Brandt J, Heuer D, Higginbotham, EJ, Keltner J. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophphthalmol. 2002; 120(6): 714-20.

24. Güller M, Bilak S, Bilgin B, Simsek A, Çapkm M, Reyhan AH. Comparison of intraocular pressure mesurement obtained by Icare PRO Rebound Tonometer, Tomey FT-1000 Noncontact Tonometer, and Goldmann Applanation tonometer in healthy subjects. J Glaucoma. 2015; 24(8):613-8.

25. Silva SA, Silva SR, Ambrósio Jr R. Relevância da biomecânica da córnea no glaucoma. Rev Bras Oftalmol. 2012;71(2):115-8.

26. Silva LM, Vasconcelos JP, Temporini ER, Costa VP, Kara-José N. Tratamento clínico do glaucoma em um hospital universitário: custo mensal e impacto na renda familiar. Arq Bras Oftalmol. 2002; 65(3):299-303.

27. Lima APF, Tecchio TL, Ferreira AL, Magarifuchi M, Machado GR. Avaliação do comportamento da pressão intraocular em pacientes com glaucoma primário de ângulo aberto assimétrico submetidos ao teste provocativo da ibopamina. Rev Bras Oftalmol. 2010; 69(3):165-9.

Corresponding author: Rodrigo Egidio da Silva Av. Americano do Brasil, n°260, Goiânia (GO), Brazil. ZIP Code: 74180-110 E-mail: [email protected]

Intraocular pressure behavior in the Goldmann and pneumatic tonometer during water drinking test


20Original article



Validação de um novo conceito ergonômico de aplicação do colírio para indivíduos com alterações motoras

Validation of a new ergonomic design of application of eye drops for individuals

with physical changes

Alan Patricio da Silva1, Francis Meire Fávero², Acary Souza Bulle Oliveira3, Célia Regina Nakanami4, Thais Massetti5, Luiz Carlos de Abreu6, Vagner Rogério dos Santos7

1 Master em in Health Science - Faculdade de Medicina do ABC- FMABC, Santo André, SP, Brazil. Product Design Specialist - Fundação Armando Álvares Penteado - FAAP, São Paulo, SP, Brazil. 2 Doctor in Sciences from the Department of Neurology and Neurosurgery of Universidade Federal de São Paulo - UNIFESP, São Paulo - SP, Brazil. 3 Discipline of Neurology at Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil. 4 Department of Visual Rehabilitation and Subnormal Vision, Department of Ophthalmology and Visual Sciences at Universidade Federal de São Paulo, São Paulo, SP, Brazil. 5 Master and Doctorate in Sciences, by the Rehabilitation Sciences program of the Medicine School at Universidade de São Paulo- FMUSP, São Paulo, SP, Brazil. 6 Laboratory of Study Design and Scientific Writing, Faculdade de Medicina do ABC, Santo André, SP, Brazil. 7 Department of Ophthalmology and Visual Sciences of the Department of Neurology at Universidade Federal de São Paulo, São Paulo, SP, Brazil.

Study carried out in the Department of Ophthalmology at Universidade Federal de São Paulo / Escola Paulista de Medicina, São Paulo, SP, Brazil.

Resumo

Introdução: As alterações motoras podem comprometer diversas atividades funcionais, o que impacta a qualidade de vida. Considerando as complicações relacionadas à secura da córnea e a dificuldade de realizar lubrificação regular devido à perda de amplitude de movimentos e consequentemente a perda funcional e autonomia torna-se relevante o estudo de novas soluções para suprir a necessidade dos indivíduos, sendo assim dispositivos são criados com o intuito de minimizar as dificuldades motoras. Objetivo: Avaliar um novo conceito ergonômico de um frasco facilitador para aplicar colírio utilizado por pessoas que apresentam alterações motoras. Métodos: Foi analisado a alteração dos movimentos do indivíduo e aplicado os conceitos do design associados a parâmetros ergonômicos para o desenvolvimento do produto. Resultados: O protótipo de frasco para aplicação de colírio foi elaborado e testado em um indivíduo que apresenta alteração nos membros superiores e importante limitação de amplitude de movimento. Este teste de uso do conceito ergonômico obteve sucesso para acessar o objeto e posicionar corretamente para a aplicação. Conclusão: O protótipo de frasco de aplicação de colírio obteve sucesso no teste submetido e o conceito ergonômico foi avaliado pelo participante com comprometimento motor como um objeto adequado para a função proposta.

Descritores: Lubrificantes oftálmicos/administração & dosagem; Equipamentos de autoajuda; Liberdade; Engenharia humana; Instrumentação

AbstrAct

Introduction: Motor alterations can compromise several functional activities, which impact the quality of life. Considering the complications related to dryness of the cornea and the difficulty to perform regular lubrication due to the loss of range of movements and consequently the functional loss and autonomy becomes relevant the study of new solutions to supply the need of the individuals, being thus devices are created with the aim of minimizing motor difficulties. Objective: To evaluate a new ergonomic concept of a facilitator bottle to apply eye drops used by people with motor alterations. Methods: It was analyzed the alteration of the movements of the individual and applied the concepts of the design associated to ergonomic parameters for the development of the product. Results: The prototype flask for the application of eye drops was elaborated and tested in an individual who presented alteration in the upper limbs and important limitation of range of motion. This test of use of the ergonomic concept was successful to access the object and position correctly for the application. Conclusion: The developed prototype of eyewash application bottle was successful in the submitted test and the ergonomic concept was evaluated by the participant with motor impairment as a suitable object for the proposed function. Keywords: Lubricant eye drops/ Administration & dosage; Self-help devices; Freedom; Human Engineering; Instrumentation

21


IntRoductIon

In Brazil, the population stating to have some kind of disability accounts for a total of 45. 6 million (23. 9%), and 7% of which have some motor alteration. (1) Among the various limitations

of the individual, what stands out the most are those that make it impossible to perform activities of daily living (ADL). (2) Thus, understanding the main complaints and creating ways to allow the independence can provide possibilities of technological innovations that can help the individuals affected by some type of motor alteration.

A study of Persson in 2014 highlights the accessibility of equipment to help them in certain activities.(3)As the capacity for apprehension and the strength to hold or operate objects and to understand the characteristics of this commitment are of paramount importance,(3) manual executions are more important due to the complex movement to perform many tasks of the ADL. (2,3)

When the individual is affected by some pathology or trauma that prevents or limits their motor actions, simple movements can become complex or even unfeasible, like dosing medications or dripping eyedrops. Considering this last observation, we can observe that this activity involves a high degree of motor performance, balance, in depth visual perception, since it is necessary to approach the object to the eyes, and this movement may be difficult for these individuals. (3,4)

Another important fact in many cases of individuals with motor limitations is the ophthalmologic condition, which may also be associated to damages of the oculomotor system, compromising the tear film and its functions; this natural barrier against foreign particles to the body and responsible for the lubrication of the ocular surface promotes proper healing and transport of oxygen to the eye. Accelerated evaporation or poor tear formation affects eye protection function of the eye, impairs ocular health, and can trigger serious infections. (5,6)

This study presents an instrument to help individuals with motor alterations instil eyedrops on their own. We have created a new ergonomic concept of eyedrops applicator bottle, so that these people can execute their ADLs autonomously and explore the potentialities of their functional residue.

methods

This project was developed at Fundação Armando Álvares Penteado and approved at the research ethics committee ZIP Code 1092211014 of Universidade Federal de São Paulo / Escola Paulista de Medicina - UNIFESP. Due to the possibility of inserting a new product into the market, the application for industrial property registration was filled to the National Institute of Industrial Property (INPI) under the protocol number 018140015068 of DIREG SP.

Development

The present work brings the idea of elaboration, construction and validation of an ergonomic device to instil eyedrops for individuals with motor alterations. A market study was carried out to understand and improve the technology of eyedrops packs and support devices, in order to understand the average variation of the opening of a nozzle, its formats and types of applicators, to measure the size of a drop defining the dose of a drug and the instillation mechanism. (6)

We also studied the anatomy of the face, such as the distance from the center of the nasal bone to the center of the zygomatic bone process, and the width and height of the mean distance close to the limit of the supra orbital fissure and the zygomatic process of the jaws. (7,8) Standardized measures of the hand evaluating and classifying the kinematic and ergonomic movements of individuals with motor alterations, functional losses of the upper limbs and their impact using a bottle of eyedrops. (9-10)

Based on this information, a prototype and new packaging concept of the eyedrops bottle were developed to be used by individuals with motor alterations.

Validation

The prototype of the ergonomic concept of the eyedrops applicator was tested in a 23-year-old woman, graduated, with diagnosis of rheumatoid arthritis, ICD 10-M 08.0 (juvenile rheumatoid arthritis) presenting motor paralysis in the upper and lower limbs, wheelchair user, semi-dependent for daily activities, muscle strength % MRC 40% in 12 muscles tested in upper limbs, with motor compensation with gradual variation from moderate to severe for the use of objects requiring fine motor coordination.

After the development of the prototype, the validation test of the ergonomic concept was performed in an individual with motor alterations, and the whole process was duly explained and the Free and Informed Consent Term was signed.

In order to evaluate the prototype of the ergonomic concept of the eyedrops applicator, a questionnaire was answered after the test had been performed twice, about the use of the product, the interface of the object, the comfort, the shape to hold the object, the efficiency, the ease of handling, the size and shape, and anchorage on the face. For its classification the Likert scale was used. (11) The eight questions were scored from 1 to 5, where 1 is very dissatisfied, 2 dissatisfied, 3 neither dissatisfied nor satisfied, 4 satisfied, 5 very satisfied.

Analysis

A descriptive analysis of the development of the product was carried out, and the test performed in an individual with motor alteration.

Results

Prototype

Development of the orbit support

The first sketches were based on the data found in the anatomical research of the face and hand measures to hold an object by different individuals, establishing a balance between the shapes and the characteristics of the curves and main lines of the composition, based on the support points of the face and adequate proportion of the shape of the object. (7-10) The measure found in the specimen from the distance from the center of the nasal bone to the center of the zygomatic bone process was 44 mm, and we considered the measure as the width of the prototype and its height, the distance close to the limit of the supra orbital fissure and the zygomatic process of the jaws of 36 mm. These measures emerge as the basis for the ergonomics model, the design to be created to cover individuals with variations in the width and height of the orbit. (9-10,12)

After the dimensional study, the cranial reference measures were added to the measures of swimming goggles, which have geometric parameters similar to the technologies defined in this prototype for ocular fitting (Figure 1).

Validation of a new ergonomic design of application of eye drops for individuals with physical changes

22


Development of the applicator support

In order to define the basic technological concept, the study of the orbit was implemented to define orbital measures. Literature has shown that men and women aged from 10 to 60 years indicate an average variation of 8.77 mm among the skulls studied, with proximal measures of the calibration points at orbit height using as anatomical reference the foramina and gauging of the orbit width. (6,8)

Regarding the drop formation process, literature shows that the geometry of the nozzle influences the formation of the drop and its volume in different products available on the market, as they presented an average variation of 33 microliters per dose of drug, with a drug loss rate of 15% to 90% due to the lack of standardization of the vial nozzles. (6)

The prototype was designed to avoid accumulation of residues and organic cultures contaminating the product while respecting the aesthetic and ergonomic characteristics to provide comfort during application (Figure 2).

Validation

The commitment of limbs prevents full movement, which impairs great physical efforts, so the movement and the effort made by the individual are compensated by the way and position of application.

Based on the perception of the user on the new model of eyedrop applicator, it is possible to validate it in individuals with motor alterations at moderate levels, showing greater efficiency and comfort, thus indicating greater autonomy during the activities of daily life. The space distribution for the fingers was effective to hold the object, and its shape was approved. Tests with volunteers demonstrate the efficiency of the new position for instillation and support on the face, and movement and coordination to bring it close to the face became comfortable due to the contact surface.

During use, the volunteer demonstrated that the new device to instil eyedrops has good performance, and mentions: “Regarding use, it is much better, easier, comfortable, and with more efficient application.” The shape is efficient regarding movements and coordination to bring it to the eye, comfortable due to its flexible, smooth cushioning surface, and soft to touch the face, as she mentions: “It is really comfortable, it doesn’t hurt the eyes during instillation.”

The fitting positions for the fingers seemed efficient to hold the object, and it was approved:“The shape to hold the object is safe due to the spaces to place the fingers, making it easier to hold the object at a table without the help of others.” The questionnaire with the score of Likert scale presented a total of 27 points, and average = 4, making the product satisfactory.

The package shape undertakes the movement patterns and measures of the hand to allow a greater number of users to use the object in an autonomous, comfort way, and giving easy mobility of use. It favors the independence of the individual impaired from using any type of eyedrops package. Figure 3 shows the ergonomic concept of the vial to instil the eyedrops. (6-8,10,12-13)

dIscussIon

The use of ophthalmic drugs is a challenge for people with motor alterations, as handling a vial to instil eyedrops encompasses the involvement of various motor and sensory pathways to perform this activity. The instrument developed offers a possibility of independent access, since besides the autonomy provided to the individual with motor alteration, it can give the family greater confidence about the safety of the bottle, the use and the continuity of the treatment. (13,14)

A package shape undertaking the movement patterns and measures of the hand allows a greater number of users to use the

Silva AP, Fávero FM, Oliveira ASB, Nakanami CR, Massetti T, Abreu LC, Santos VR

Figure 1: Construction of the prototype based on the model of swimming goggles. A) Side view of the swimming goggles. B) Upper view and paper modeling. C) Preliminary model.

Figure 2: Prototype of the ergonomic concept of the applicator of eyedrops. a) Drug storage refill. b) ergonomic model of the applicator. c) Side view of ergonomic concept set of eyedrops applicator.

Figure 3: Test with a volunteer to validate the ergonomic concept of the eyedrops applicator

23


object in an autonomous, comfort way, and with better mobility for individuals with motor alterations to accomplish the task, favoring their independence. (2-4,6-10, 12-13)

One of the areas of knowledge presenting great potential for generating solutions is design, which aims at the philosophical concept the design, idealization, conception and elaboration of an object, considering the ease of use, emotional and social aspects in the aesthetic structure of solutions. (3,9)

In general, technological solutions are created to minimize the difficulties of people with disabilities. However, there are few who relate the design and the specific analysis of individuals to the daily problems that they face. (3)

Industrial products usually follow development lines that do not consider the special needs of people with disabilities. (6) In view of this reality, the Human Rights Secretariat of the Presidency of the Republic (SDH-PR) proposed academic interdisciplinarity in research, aiming at the development of strategies that have as technological solutions products and resources for inclusion and independence of people with disabilities, reduced mobility or impairments. (2,15)

To that end, the concept of assistive technology stimulates the research and development of objects to facilitate functional performance providing stimuli to the perception and the capacity to learn promoting independence and autonomy in ADL. (2-3)

Linked to assistive technology is the concept of assistive design, which aims at interdisciplinary strategies to create and design technological solutions to present innovative proposals, focusing on the best performance of the individual in the accomplishment of a certain action. (3)

The importance of developing solutions to treat people with disabilities draws attention to factors that contribute to daily practices such as dressing, eating and carrying out their personal hygiene. 3. According to this point, the assistive design provides studies of concepts and solutions of products and services specifically designed to improve the quality of life in the ADL, with the adoption of disruptive strategies putting innovation into practice to focus on development and research. (3-10,12)

The evaluation of the social context for the performance of ADL, the functional range and the restrictions that the disability provides to the individual are the basis to direct research to the search for solutions that provide well-being, autonomy and comfort with better performance. (16)

The family context and consequently its importance for the disabled individual is of utmost importance for the technological development and guidance of researches in assistive design, and its impact provides greater autonomy in the activities of daily life, creates a comfortable situation in order to make possible the reduction of the emotional burden, strengthening relationships of trust in the family. (2-3,9-10,12-13,15)

Ergonomics and usability are the satisfactory and efficient operation for the interaction between the individual and technology, it is the experience of how technology is used. It deals directly with the characteristics of a product that makes it easy to understand and use it intuitively, allowing the improvement of the task to be performed by the user. (9)

According to the International Standards Organization (ISO), identifying factors to influence usability such as efficacy, efficiency, and satisfaction, that is, a good performance takes into account the attitude of the user regarding the object in the context of use that increases the satisfaction with the product. These factors and items prone to verification by a specific group of users can achieve goals defined in different social contexts. (2,9-10,12,17)

Validation of a new ergonomic design of application of eye drops for individuals with physical changes

We studied the relationship between the mobility of a person with motor impairment and their autonomy through functional residual capacity to perform an activity of daily life with the study of the limitations of a volunteer to validate a new ergonomic concept of the eye drops applicator.

Handling an applicator bottle of eyedrops requires high neuromuscular and visual activities and mechanical stability. The use of drugs for ophthalmology presents challenges for individuals with motor disorders. Thus, the instrument developed can solve this problem, since besides the autonomy provided, it can give the family greater confidence about the safety of the bottle, the use and the continuity of the treatment.

The volunteer’s acceptance of the model indicates the idealized ergonomic concept as viable, capable of further studies for its improvement. After evaluation and study of products available on the market, the decision was to develop a bottle of eyedrops that can be used by holding it in the face, because based on the literature, there is a natural symmetry between the orbits on both sides of the face, similar orbital dimensions with minimal variations between genders, and age groups are normally distributed. (6-8)

The technological solution used presents a support to help proper instillation of eyedrops, becoming a good alternative as it allows both the correct position of the eyedrops vial and the estability of the position, thus supporting the device on the face and assuring the correct position of the vial regarding the ocular bulb.

No technological solutions were found requiring the use of fine movements of the hand and upper limbs in order to have the necessary pressure to generate the drop during instillation. (1,3)

conclusIon

O protótipo de frasco de aplicação de colírio obteve sucesso no teste submetido e o conceito ergonômico foi avaliado pelo participante com comprometimento motor como um objeto adequado para a função proposta com eficiência e conforto.

Figura 1. Construção do protótipo com base no modelo óculos de natação. A) Vista lateral dos óculos de natação. B) Vista superior e modelagem em papel. C) modelo preliminar.

Figura 2. Protótipo do conceito ergonômico do aplicador de colírio. a) Refil de armazenamento do fármaco. b) modelo ergonômico do aplicador. c) Vista lateral de conjunto conceito ergonômico de aplicador de colírio.

Figura 3. Teste com voluntária para validação do conceito ergonômico de aplicador de colírio.

RefeRences

1. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico. Vamos conhecer o Brasil [Internet]. Brasília (DF): IBGE; 2014. [citado 2014 Mai 6]. Disponível em: http://7a12.ibge.gov.br/vamos-conhecer-o-brasil/nosso-povo/caracteristicas-da-populacao

2. Brasileiro IC, Moreira TM, Jorge MS, Queiroz MV, Mont’Alverne DG. Atividades e participação de crianças com paralisia cerebral conforme a Classificação Internacional de Funcionalidade, Incapacidade e Saúde. Rev Bras Enferm. 2009;62(4):503-11.

3. Persson H, Åhman H, Yngling AA, Gulliksen J. Universal design, inclusive design, accessible design, design for all: different concepts—one goal? On the concept of accessibility— historical, methodological and philosophical aspects. Univ Access Inf Soc. 2014;14(4):1-22.

24


Silva AP, Fávero FM, Oliveira ASB, Nakanami CR, Massetti T, Abreu LC, Santos VR

Corresponding author: Alan Patrício da Silva Avenida Dom João VI, 1285, Taboão da Serra,Diadema, São Paulo ZIP Code 09940-150 Mobile: (11) 984237455 Phone: (11) 40712376

4. GMFCS – E & R: Sistema de Classificação da Função Motora Grossa. Ampliado e Revisto. Traducão de Daniela Baleroni Rodrigues Silva, Luzia Iara Pfeifer e Carolina Araújo Rodrigues Funayama. [citado 2014 Mai 6 ]. 2007. 6p. Disponível em: https://canchild.ca/system/tenon/assets/attachments/000/000/075/original/GMFCS-ER_Translation-Portuguese2.pdf

5. Sasaki H, Yamamura K, Nishida K, Nakamura J, Ichikawa M. Delivery of drugs to the eye by topical application. Progr Retinal Eye Res. 1996;15(2):583-620.

6. Chung M, Santos VR. Avaliação do volume e da uniformidade das gotas de sete colírios a venda no mercado brasileiro. In: 51° Reunião Anual da SBPC para o Avanço do Projeto da Ciência; 2001 Jan 16. Porto Alegre, Brasil.

7. Rocha JR, Lambert PL, Carneiro Junior B, Sarmento VA, Almeida Junior E. Avaliação da simetria de dimensões lineares em órbitas de crânios humanos secos. Clin Pesq Odontol. (Curitiba). 2006; 2(3):195-201.

8. Rossi M, Ribeiro E, Smith R. Craniofacial asymmetry in development: an anatomical study. Angle Orthodont. 2003; 73(4):38-5.

9. International Ergonomics Association (IEA). Definition and domains of ergonomics [Internet]. [cited ]2014 May 6]. Available from: http://www.iea.cc/whats/index.html.

10. ISO/IEC GUIDE 71:2001(E). Guidelines for standards developers to address the needs of older persons and persons with disabilities [Internet]. [cited 2015 May 6 ]. Available from: http://www.iso.org/iso/iso_iec_guide_71_2001.pdf

11. Likert R. A technique for the measurement of attitudes. Arch Psychol. 1932;140:1-55.

12. Associação Brasileira de Ergonomia (ABERGO). O que é ergonomia [Internet]. [citado 2017 Nov 5]. Disponível em: http://www.abergo.org.br/internas.php?pg=o_que_e_ergonomia.

13. Santvliet LV, Ludwig A. Determinants of eye drop size. Surv Ophthalmol. 2004: 49(2):197- 213.

14. Freedman VA, Martin LG. Commentary: dissecting disability trends – concepts, measures, and explanations. Int J Epidemiol. 2006; 35:1261-3.

15. Roberto AM. Conceito Bobath tratamento neuroevolutivo [Internet]. São Paulo: Associação Brasileira de Assistência e Desenvolvimento Social - ABADS. [ citado 2014 Mai 6]. Disponível em: http://www.abads.org.br/view_materia.php?i=420&s=68

16. Petean EB, Murata MF. Paralisia cerebral: Conhecimento das mães sobre o diagnóstico e o impacto deste na dinâmica familiar. Paidéia. 2000;10: 40-6.

17. International Standards Organization (ISO) ISO 9241-11:1998. Ergonomic Requirements for Office Work with Visual Display Terminals (VDTs) – Part II Guidance on usability [ Internet]. 1998. 22p. [cited 2014 May 6]. Available from: http://www.iso.org/iso/catalogue_detail.htm?csnumber=16883

25


Original article


Comparison of biometric predictability and final refraction expected in phacoemulsification

surgery with and without trabeculectomyComparação da previsibilidade biométrica e refração

final esperada em cirurgia de facoemulsificação com e sem trabeculectomia

Fernanda Guedes Oliveira1, Cláudia Gomide Vilela de Sousa Franco1, Marcelo Limongi dos Passos Miranda Damasceno1, Marcos Pereira de Ávila1, Leopoldo Magacho1, 2

1 Ophthalmology Department, Universidade Federal de Goiás, Goiânia, GO, Brazil. 2 VER – Excellence in Ophthalmology, Goiânia, GO, Brazil

AbstrAct

Objective: The main purpose of this article is to compare the predictability of biometric results and final refractive outcomes expected in patients undergoing cataract surgery through phacoemulsification with and without associated trabeculectomy. Methods: Cataract patients who have undergone phacoemulsification surgery alone (control group) or associated with trabeculectomy (study group) screened. All surgeries were performed following standard protocol. For enrollment, biometrics calculated by IOL Master (Carl Zeiss Meditec, Inc.) biometry, refraction and intraocular pressure (IOP) before and after surgery were required. Data was compared between groups in addition to the correlation between variation of IOP and final refraction. Results: Thirty eyes per group were enrolled. Only prior IOP (p <0.001), IOP post-surgery (p = 0.01) and the difference in IOP (p <0.001) were statistically significant. Axial length, IOL diopter used, expected spherical refraction by biometrics and astigmatism pre- and post-surgery were similar in both groups (p=0.1; 0.4; 0.4; 0.5 and 0.3, respectively). Spherical predictability by biometrics within 0.25 diopters was noted in both the control group (range 0.06 ± 0.45) and study group (range 0.25 ± 0.97, p = 0.3). There was no statistical significance between groups for the difference between final cylinder and corneal astigmatism (p = 0.9), and the difference between axis of refractive and corneal astigmatism (p = 0.7). Conclusion: The biometric predictability in phacoemulsification surgery and the expected final refraction are significant, andare not modified by trabeculectomy in the combined surgeries.

Keywords: Ocular refraction; Cataract; Glaucoma; Phacoemulsification; Trabeculectomy

Resumo

Objetivo: Comparar a previsibilidade dos resultados refracionais e da biometria em pacientes submetidos à cirurgia de catarata por facoemulsificação com e sem trabeculectomia (Trec) associada. Métodos: Pacientes com catarata submetidos à cirurgia de facoemulsificação isolada (grupo controle) ou associada a Trec (catarata + glaucoma, grupo estudo) foram consecutivamente selecionados. Todas as cirurgias foram feitas seguindo protocolo padrão. Para inclusão, era necessário apresentar biometria calculada pelo biômetro IOL Master (Carl Zeiss, Meditec, Inc), refração e pressão intraocular (Pio) pré e pós-operatórios. Os dados foram comparados entre os grupos, além da correlação entre a variação da Pio e a refração final. Resultados: Foram incluídos 30 olhos por grupo. Na comparação, apenas a Pio prévia (p<0,001), Pio pós cirurgia (p=0,01) e a diferença de Pio pré-pós cirurgia (3,8 ± 4,4mmHg vs. 15,5 ± 9,3mmHg, grupos controle e estudo, respectivamente, p<0,001) foram estatisticamente significativos. Diâmetro axial, dioptria da Lio utilizada, dioptria esperada pela biometria e astigmatismo prévio e pós- cirurgia foram estatisticamente semelhantes entre os grupos (p=0,1; 0,4; 0,4; 0,5 e 0.3, respectivamente). Notou-se previsibilidade esférica pela biometria dentro de 0,25 dioptrias, tanto no grupo controle (variação de 0,06 ± 0,45), quanto no grupo estudo (variação de 0,25 ± 0,97, p=0,3). Não houve significância estatística entre os grupos para a diferença entre o cilindro final e o astigmatismo corneano em dioptrias (p=0,9), e diferença entre o eixo do astigmatismo refracional e corneano (p=0,7). Conclusão: A previsibilidade biométrica e a refração na cirurgia de facoemulsificação aferida pelo biômetro IOL Master é significativa, e não sãoalteradas na cirurgia combinada com trabeculectomia.

Descritores: Refração ocular; Catarata; Glaucoma; Facoemulsificação; Trabeculectomia

26

IntRoductIon

The association of cataract with glaucoma is frequent.(1)

Ocular hypotensive medication and reduced intraocular pressure (IOP) can also be identified as inducers of cataract

in patients with glaucoma.(2-3)

For a safer surgerywithcombined procedures involving phacoemulsification and trabeculectomy (TRAB), with a more diffuse bleb with thicker walls, one of the modifications suggested in the original technique, among others, was toincreasing the size of the scleral flap.(4) This change may cause astigmatism on the incision site to increase the corneal meridian in this position and allow the flow of aqueous humor towards the filtering bleb. On the other hand, tighter scleral flap or conjunctival sutures could also induce astigmatism, increasing the curvature of the corneal axis. In addition, it is possible that reduction of IOP to safe considered levels in TRAB could coincide with a decrease in the anterior-posterior ocular diameter, which can be theoretically more pronounced when higher levels of IOP are found preoperatively in relation to the final IOP.

These confounding factors could affect the predictability of biometry to artificially modify two important variables in the formulas used, keratometry and ocular axial length, making it possible to assume the need for prior correction. (5-6) This study aims to compare the predictability of biometric results and final refractive outcomes expected in patients undergoing cataract surgery through phacoemulsification with andwithout associated trabeculectomy.

methods The study was conducted after approval by the Research

Ethics Committee of the Federal University of Goiás (UFG) and VER Hospital. One or both eyes of all patients who underwent cataract surgery,by phacoemulsification associated with TRAB (study group) or phacoemulsification only(control group) performed by the same experienced surgeon (LM), were consecutively screened, from January 2013. The study aimed to enroll 30 eyes per group, in accordance with predetermined criteria and matched by type of IOL.

The inclusion criteria for both groups were: patients of both sexes, one or both eyes with cataract and spectacle-corrected visual acuity (SCVA) of 20/40 or less, and inadvertent phacoemulsification with IOL implantation within the capsular bag. In the control group, patients were required to have IOP <21 mmHg and an examination with no signs of glaucoma.(7) In the study group, the recommendation of filtration surgery, which also should have been performed without any problem, occurred when the target intraocular pressure was not achieved even with the use of ocular hypotensive agents, when the patient had been on three ocular hypotensive medications or, in case of severe glaucoma, on two medications. Furthermore, IOP reduction of at least 30% without using ocular hypotensive medication was required for inclusion in the study group.

Patients were excluded if they had irregular astigmatism in the computerized corneal keratometry, pterygium, prior anterior and/or posterior segment surgery, any corneal pathology that could affect the accuracy of biometry, absence of IOL Master biometry, and amblyopia. Any intraoperative complications, such as posterior capsule rupture or vitreous loss during any procedure, was considered an exclusion factor.

Pre and postoperative routine consisted of medical historicaland complete eye examination, including best corrected


Oliveira FG, Franco CGVS, Damasceno MLPM, Ávila MP, Magacho L

visual acuity, biomicroscopy, applanation tonometry with the same calibrated Goldmann tonometer, gonioscopy with Goldmann4-mirrorlens in the glaucoma group, ophthalmoscopy, corneal keratometry (Orbscan, Baush& Lomb, Inc. San Dimas CA, USA), specular microscopy (Topcon Medical Systems, Oakland, NJ), ultrasound (Alcon Ultra scan, Fort Worth, TX, USA) and optical biometry (IOLMaster, Carl-Zeiss Meditec, Germany). According to the axial length, the following formulas were used in the biometry: Hoffer-Q if ≤22 mm, Holladay I if >22 mm and ≤24.50 mm and SRK-T if >24.50 mm. Clinical examinations were performed by the same surgeon. Complementary examinations were performed by an experienced technician, except for ultrasound, which was performed by a certified ophthalmologist.

All phacoemulsification surgeries were performed with the “Phaco-Chop” technique and Infiniti phacoemulsification system (AlconLabs, Fort Worth, TX, USA) under topical anesthesia.(8)The phacoemulsification incision was performed on the 140o axis in all patients with a disposable 2.2-mm scalpel and paracentesis with a 15º disposable scalpel on the 20º axis. The postoperative regimen in these patients consisted of a combination of Moxifloxacin and Dexamethasone (Vigadexa®), Alcon Labs, Fort Worth, TX, USA) QID and nepafenac 0.1% (Nevanac®, Alcon Labs, Fort Worth, TX , USA) TID for 15 days.

For the study group, the axis of phacoemulsification incisions was always the same (140o), with the glaucoma surgery being performed in the upper nasal quadrant of the right eye and in the superior temporal quadrant of the left eye, about 90° away from the phacoemulsification incision. The combined surgeries were performed under peribulbar anesthesia.

TRAB was performed with fornix-based conjunctival opening, light cauterization of any bleeding spots, marking the scleral flap with a disposable 11-blade (Feather Safety Razor, Ohyodo-Minami, Japan) measuring about 4 mm horizontally by 3 mm vertically and application of mitomycin C 0.4 mg/ml for 2 minutes using 3 parts of a Merocel sponge soaked in adjuvant, two placed on the bottom area of the bag, and one extended to the delineated flap. Then, flushingoff the area with about 2-3 ml of BSS and dissection of the scleral flap with the same 11-blade towards the corneal limbus to about 1 mm was performed. Phaco-Chop phacoemulsification was then performed, followed by penetration into the anterior chamber with a 2.2-mm blade, centrally on the flap. Removal of trabecular tissue was performed using the Kelly-Descemet Punch with 0.75 mm measurement and iridectomy with the use of Vannas scissors. The scleral flap was sutured with two fixed stitches about 45° lateral to the scleral flap edge with 10-0 mononylon tightened to the desired filtration. A third central point, 90° of the scleral incision, was to be performed if the filtration was in excess. Then the conjunctiva/tenon was closed using 10-0 Nylon, two-side stitches tightening the incision and a central stitch in “U”.

The stitches from the scleral flap could be removed with Diode laser and Hoskins lens according to the postoperative need of IOP reduction, from the third day after surgeryon, and was not considered a complication. The three external stitches were removed as they were loosening, causing discomfort to the patient after at least seven days following surgery or thirty days after surgery. Postoperative regimen in the study group included the use of Prednisolone 1% eye drops (Predfort®, Allergan Labs, Irvine, CA, USA) every two hours, with weekly reduction, for six weeks, gatifloxacin 0.5% eye drops (Zymar XD®, Labs Allergan, Irvine, CA) every twelve hours for ten days and Ketorolac trometamol 0.45% eye drops (Acular CMC®, Labs Allergan, Irvine, CA, USA) every twelvehours for twenty days.

27Comparison of biometric predictability and final refraction expected in phacoemulsification surgery with and without trabeculectomy


The IOP used for calculation purposes was assessed on the same day the refraction was performed, after at least forty-fivedays for patients in the study group and at least thirty days for patients in the control group.

All statistical tests were performed with SPSS 15.0 (SPSS Inc, Chicago, IL, USA). The unpaired Student t-test was used when comparing pairs. Correlation between IOP variation and refraction found was performed with Pearson’s Correlation. In this study, p values <0.05 were considered statistically significant.

Results Eighteen patients (30 eyes) in the control group (10 women,

15 right eye, 15 left eye) and 20 patients (30 eyes) in the study group (12 men, 18 right eye, 12 left eye) were enrolled. The mean age was 70.9 ± 5.9 years-oldfor the control group and 66.6 ± 7.4 years-oldfor

the study group, p = 0.01. There was a similar distribution of IOL types implanted between groups (p = 1.0) (Table 1).

Patients in the study group decreased the number of ocular hypotensive medications preoperatively from 2.2 ± 0.8 to 0.05 ± 0.3 in the last postoperative assessment (p <0.001). Suture lysis of the scleral flap was required in thirteen eyes, 1 suture lysis in 10 eyes, two suture lysis (2 stitches) in 2 eyes and 3 suture lysis (3 stitches) in one eye. Preoperative spectacle-corrected visual acuity (SCVA) (LogMAR) was 0.4 ± 0.2 for the control group and 0.4 ± 0.3 for the study group (p = 0.9), and the postoperative one was 0.1 ± 0.3 and 0.2 ± 0.3, respectively (p = 0.2).

There was no statistically significant difference between characteristics of the groups studied, except for pre-surgery IOP (p <0.001), post-surgery IOP (p=0.01) and difference in pre- vs. post-surgery IOP (3.8 ± 4.4 mmHg vs. 15.5 ± 9.3 mmHg, control and study groups, respectively; p <0.001). Axial length, IOL diopter used, expected spherical refraction by biometry and astigmatism pre- and post-surgery were similar between groups (Table 2).

Table 1 IOL used for each group (p=1.0)

Acrysof IQ Akreos MI B-Lens Envista Tecnis ZCB00 Total

Control Group 2 6 4 1 17 30Study Group 2 6 4 2 16 30

Total 4 12 8 3 33 60

. IOL used for each group (p=1.0)

Table 2 Comparison between groups (Control Group; Study Group).

Control Group n=30 Study Group n=30 “p”(between groups) Preoperative IOP (mmHg) Average 15.5 25.2 <0.001 Standard Deviation 4.2 9.1

Postoperative IOP (mmHg) Average 11.7 9.7 0.01 Standard Deviation 2.4 3.5

Spherical Refraction Average -0.12 -0.14 0.85Expected by Biometry (D) Standard Deviation 0.41 0.43

Final Spherical Refraction (D) Average -0.05 0.1 -0.42 Standard Deviation 0.6 0.9

Final Cylinder Refraction (D) Average -0.9 -1.05 0.37 Standard Deviation 0.5 0.7

K2 - K1 (D) Average -0.99 -1.14 0.5 Standard Deviation 0.7 0.9

Final Cylinder Axis (°) Average 97.15 111.93 0.22 Standard Deviation 44.4 49.1

Corneal Astigmatism Axis (°) Average 94.5 104.23 0.49 Standard Deviation 51.5 57.8

K1 (D) Average 43.51 42.78 0.04 Standard Deviation 1.5 1.5

K2 (D) Average 44.51 43.92 0.11 Standard Deviation 1.6 1.6

Axial length – AL (mm) Average 23.16 23.58 0,1 Standard Deviation 1 1.1

IOL diopter used Average 22.31 21.81 0,4 Standard Deviation 2.4 2.8

Comparison between groups (Control Group; Study Group).

28

Pre-corneal mean astigmatism (as measured by IOL Master) in the control group was -0.99 ± 0.78 D and -1.14 ± 0.93D in the study group, p= 0.5. Time between surgery and refraction was 71.5 ± 70.0 days for the control group and 59.9 ± 35.6 days for the study group, p= 0.4.

Spherical predictability for biometry within 0.25 diopters was noted in both the control group (0.06 ± 0.45) and the study group (0.25 ± 0.97, p = 0.3). There was no statistical significance between groups for the difference between final measured cylinder and corneal astigmatism in diopters (0.09 ± 0.7 vs. 0.09 ± 1.2, p = 0.9), and the difference between the refrationalaxis and pre-corneal astigmatism (2.6 ± 49.2º vs. 7.7 ± 66.3º, p = 0.7). The change in IOP after surgery was neithercorrelated with the spherical nor cylindrical difference found (r = 0.242, p = 0.06, r = -0.075, p = 0.5, respectively), northe variation of the astigmatic axis (r = 0.089, p = 0.5) (Figure1).

dIscussIon

These results showed a statistically significant reduction of IOP for the patient group undergoing a combined surgery of phacoemulsification and TRAB. Control group had lower IOP reduction compared to the study group. These findings support what is found in literature, i.e. phacotrabeculectomy(PHACO-TRAB) results in lower average IOP compared to phacoemulsification alone in patients with glaucoma.(9-10)Additionally,patients undergoing PHACO-TRAB had a reduced need to use ocular hypotensive medication postoperatively within a short follow-up period. These data supports the study group in evaluating the influence of TRAB, and as a result, the influence of the higher IOP reduction in biometric calculation for patients undergoing PHACO-TRAB.

For combined surgeries, separate incision technique was used. This technique is easily reproduced, widely used and has good postoperative results, which is believed to induce less astigmatism. In single site surgeries, the movement of the phacoemulsification tip, and the heat emanating from it could alter the incision architectureand thus, induce astigmatism. Compared


Oliveira FG, Franco CGVS, Damasceno MLPM, Ávila MP, Magacho L

to single site surgery another bias would be that patients in the control group would have a corneal incision not performed in the study group, leading to a potential cause of variation in the corneal axis. For both groups, corneal incision during cataract surgery was performed in the same location and with the same dimensionsthus, neutralizing this factor. Therefore, only the influence of TRAB and the greater IOP reduction in the final results were checked for any differences found.

A decrease in axial length was shown by combined surgeries and TRAB only, however, it did not influence the expected spherical refraction provided by biometry.(11) The axial length variation was not subject to preoperative and postoperative comparison, since biometry was performed only before surgery. This can be considered as a limitation, or at least as a relative one. However, the objective of this study was the biometric predictability in relation to final refraction, so that this method, although subjective, was adopted as the standard for final comparison.

Although several corneal astigmatism evaluation methods are available, it is believed that the measurements obtained with IOL Master may be a significant representation of corneal astigmatism, therefore, it was used for this preoperative measurement. Since the goal of the study was to assess the expected refraction, a new keratometry measurement was not made; only the refractive astigmatism assessment was performed, and the data was used for both groups. Although the use of third generation formulas in the IOL calculation may be considered a weakness of the study, both groups used the same protocol to perform it thus, avoiding an inclusion bias. Additionally, the final spherical refraction was low and it was estimated preoperatively with high precision by IOL Master in the control group.

A previous paper showed a 0.44D induction of with-the-rule astigmatism(11), different from induced against-the-rule astigmatism in this study. This difference could be explained by the technique used, corneal suturing with phacoemulsification incision in the combined surgeries, associating the continuous sutures of the conjunctival flap, which may induce flattening of the vertical meridian of the cornea.

Studies on induction of corneal astigmatism after PHACO-TRAB and the comparison between them are limited due to the different surgical techniques used. Tzu et al reported a higher corneal induced astigmatism in combined surgery compared to PHACO only; in average 1.31 D of corneal astigmatism was induced by combined surgery.(12)There are reports suggesting that these corneal topography changes evolve in about 12 months. However, other authors have illustrated a stable keratometry postoperatively after about 2 months.(13) Thus, it is believed that the time taken to carry out the final calculations did not influence the results. However, it is possible that some modifications can be made after a few months.

In this study, the control group showed similar spherical results (0.06 ±0.4D) as estimated by biometry. In the study group, a small myopic tendency (-0.25D) was demonstrated, probably caused by the reduction in axial length when performing IOP control. Thus, a possible desired correction of the spherical refraction regarding biometry results can be suggested, as reported by Jonathan et al. who found a greater myopic value (-0.5D) for the group undergoing combined PHACO-TRAB surgery. However, in their analysis, surgeries were performed by different surgeons with no single surgery technique described for comparison, and therefore it was not homogeneous. Despite a slightly less precise predictability compared to this study, 74% of refractions were

Figure 1: Correlation between change in IOP after surgery and the spherical or cylindrical difference found, or variation of the astigmatic axis.

29Comparison of biometric predictability and final refraction expected in phacoemulsification surgery with and without trabeculectomy


obtained within the planned range regardless of possible changes induced by errors in keratometric readings, axial length and value of selected lenses.(14) Recently, other authors found a myopic tendency in the group undergoing combined PHACO-TRAB surgery, but with only 27.6% of patients achieving final subjective refraction within ±0.5D. (15) Differences in the surgery technique may be responsible for this difference.

The described surgery seeks to avoid excessive loosening of the sutures, which would cause an increase in corneal curvature in the meridian of TRAB and cylindrical axis, or excessive strain leading to the opposite, flattening and against-the-rule astigmatism. Apparently, tighter stitches could lead to increased IOP, and hence would be removed. On the other hand, sutures too loose would lead to hypotonia and consequent exclusion from the study, a fact that was not noted. Thus, it is possible to assume that this “ideal strain” apparently does not alter the astigmatism values which could be induced in surgery.

Another factor of potential cylindrical induction is conjunctival stitches, which can alter the symmetry of the eye, especially if pinching the cornea, or even with increased tension. However, a small variation of the final cylinder axis was found in relation to the preoperative corneal astigmatism axis, for both control group and study group, as well as a slight variation in the average location of the cylindrical end shaft, and the K2-K1 difference.

El-Saied et al.(13) found a prevalence of with-the-rule astigmatism in TRAB only. However, some differences in the surgical technique used by them compared to the current study may explain this difference, such as the change of TRAB location (at 110º in right eye and 70º in left eye), leading to force vectors at different locations within the eye, creating a bias for comparison when both eyes are evaluated. In this study, regardless of the eye included, TRAB was always performed on the same meridian, about 90° from the phacoemulsification incision, which was always performed at the 140° axis. Furthermore, as previously mentioned, induction of against-the-rule astigmatism is generally expected in these combined procedures.(13-16)

IOP variation after surgery was not correlated with the spherical or cylindrical differences found. Law et al. obtained a statistically significant relationship between change in the axial length of eyes that underwent combined surgeries (PHACO-TRAB) and IOP postoperatively.(11) On the other hand, reduction of the axial length was not correlated with reduction of IOP. Thus, despite a large IOP reduction in patients with glaucoma, a slight decrease of the axial diameter occurred, culminating in a spherical error of about -0.25D compared to what was expected. In addition, as noted by a small standard deviation, the final IOP was similar, which apparently homogenized the patients in terms of axial length variation, reducing or even avoiding a bias if patients had been evaluated with different levels of IOP reduction. However, a larger number of patients, evaluation of results with different surgeons to check the “surgeon factor”, and longer patient follow-up are still needed.

The biometric predictability in phacoemulsification surgery and the expected final refraction are significant, and not influenced by trabeculectomy in the combined surgeries. These findings suggest a compensation of -0.25D in the IOL used when calculated by IOL Master in patients undergoing combined surgeries of PHACO-TRAB to get to postoperative spherical emmetropia.

RefeRences

1. Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol. 1996;80(5):389-93. Comment in Br J Ophthalmol. 1996;80(5):385-6. Br J Ophthalmol. 1997;81(1):93.

2. Tsai JC, McClure CA, Ramos SE, Schlundt DG, Pichert JW.Compliance barriers in glaucoma: a systematic classification. J Glaucoma. 2003;12(5):393-8.

3. Nordstrom BL, Friedman DS, Mozaffari E, Quigley HA, Walker AM. Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140(4):598-606.

4. Khaw PT, Chiang M, Shah P, Sii F, Lockwood A, Khalili A.Enhanced trabeculectomy: the morfields safer surgery system. developments in ophtalmology. Dev Ophthalmol. 2012; 50:1-28.

5. Bloch S, Rosenthal AR, Friedman L, Caldarolla P. Patient compliance in glaucoma. Br J Ophthalmol. 1977;61(8):531-4.

6. Susanna Júnior R. Mudando conceitos na cirurgia de trabeculectomia. OptometryNews. 2009. 3p.

7. Bankes JL, PerkinsES, Tsolakis S, Wright JE. Bedford glaucoma survey. Br Med J.1968; 1(5595):791-6.

8. Ripart J, Nouvellon E, Chaumeron A. Regional anesthesia for eyesurgery. RegAnesth Pain Med. 2005;30(1):72-82.

9. Belyea DA, Dan JA, Leiberman MF, Stamper RL. Midterm follow-up results of combined phacoemulsification, lens implantation, and mitomycin-C trabeculectomy procedure. J Glaucoma. 1997;6(2):90-8.

10. Clement CY,Tham FR, Yolanda YY, Kwong MR, Dexter YL, Leung FR, et al. Phacoemulsification versus combined phacotrabeculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts. Ophtalmology. 2009; 116(4): 725-31, 731.e1-3.

11. Law SK, Mansury AM, Vasudev D, Caprioli J. Effectsofcombinedcataractsurgeryandtrabeculectomywithmitomycin C on ocular dimensions. Br J Ophthalmol. 2005;89(8):1021-5.

12. Tzu JH, Shah CT, Galor A, Junk AK, Sastry A, Wellik SR.Refractive outcomes of combined cataract and glaucoma surgery. J Glaucoma. 2015;24(2):161-4.

13. Heba MA, El-Saied MD, Pakinam H, Foad, MD, Mohamed A. EldalyMD, et al. Surgically induced astigmatism following glaucoma surgery in Egyptian pacientes.

14. Tzu JH, Shah CT, Galor A, Junk AK, Sastry A, Wellik SR. Refracti-veoutcomesofcombinedcataractand glaucoma surgery. J Glaucoma. 2015;24(2):161-4.

15. Ong C, Nongpiur M, Peter L, Perera SA. Combined Approach toPhacoemulsificationandtrabeculectomyresults in less ideal refractiveoutcomescomparedwiththesequential approach. J Glaucoma. 2016 Oct;25(10):e873-e878.

16. Dietze PJ, Oram O, Kohnen T, Feldman RM, Koch DD, Gross RL. Visual functionfollowingtrabeculectomy: effectoncornealtopographyandcontrastsensitivity. J Glaucoma. 1997;6(2):99-103.

Corresponding author: Cláudia Gomide Vilela de Sousa Franco First Avenue, Sector East University – Goiânia, GO, Brazil. Zip code:74605-020 Phone: (62) 981586202 E-mail: [email protected]

30


Original article

Análise clínica, terapêutica e dos parâmetros tomográficos de pacientes portadores de ceratocone atendidos

na Fundação Hilton Rocha

Clinical analysis therapy and tomographic parameters of patients diagnosed with

keratoconus attended at Fundação Hilton Rocha

Izabela dos Santos de Moura e Silva1, Cristiane Samara Botteon1

1 Department of Cornea, Fundação Hilton Rocha, Belo Horizonte, MG, Brazil. Study carried out at Fundação Hilton Rocha, Belo Horizonte, Minas Gerais, Brazil

Resumo

Objetivo: Analisar dados clínicos, terapêuticos e parâmetros tomográficos dos pacientes portadores de ceratocone atendidos na Fundação Hilton Rocha. Métodos: É um estudo retrospectivo com amostra aleatória de 150 pacientes submetidos a tomografia de córnea e segmento anterior (Pentacam - Oculus, Wetzlar, Alemanha) na Fundação Hilton Rocha no ano de 2015. Os pacientes foram classificados como portadores ou suspeitos de ceratocone através dos parâmetros: paquimetria, elevação central anterior e posterior, Ambrosio Relational Thinnest (ART), valor de D e ceratometria. Após a seleção foi realizada análise dos prontuários, coletados dados clínicos e terapêuticos dos pacientes. Os dados foram colocados em tabela e analisados. Resultados: Dos pacientes classificados como portadores de ceratocone, 23% tinham 6 parâmetros alterados, e 10% foram classificados com apenas 1 parâmetro alterado. O índice ART foi o que mais se alterou (83%) nos pacientes portadores de ceratocone. Na análise dos dados clínicos e terapêuticos, 76,8% dos pacientes apresentaram acuidade visual melhor ou igual a 20/60, e 19% mencionaram apresentar atopia e, 90% dos pacientes utilizavam como tratamento apenas lentes corretoras (óculos e lente de contato). Conclusão: A utilização de índices tomográficos para o diagnóstico do ceratocone têm aumentado a sensibilidade e a especificidade na triagem de pacientes portadores desta ectasia, possibilitando o diagnóstico de maneira mais precoce e consequentemente maior sucesso terapêutico.

Descritores: Ceratocone, Córnea, Diagnóstico, Ectasia Tomografia.


AbstrAct

Objective: Analyze clinical data, therapy and tomographic parameters of patients attended at Fundação Hilton Rocha. Methods: This essay is a retrospective study based on a random sample of 150 patients submitted to cornea tomography and previous segment (Pentacam – Oculus, Wetzlar, Germany) at Fundação Hilton Rocha in the year 2015. The patients were classified as carriers or suspects of keratoconus through the following parameters: pachymetry, anterior and posterior central elevation, Ambrosio Relational Thinnest (ART), value of D and keratometry. After the selection an analysis of the medical records was done, followed by harvest of clinical and therapeutical data of the patients. The data was put on table and then analyzed. Results: From the numbers of the patients diagnosed with carriers of keratoconus, 23% had 6 altered parameters, and 10% were classified with only 1 altered parameter. The ART index was the one that suffered the largest change (83%) on the keratoconus carriers. After analysis of clinical and therapeutical data, 76.8% of patients showed better or more of 20/60 degree of visual acuity, and 19% mentioned signs of atopy, 90% of the patients were using only corrective lenses as treatment (glasses and contact lenses). Conclusion: The use of tomographic indexes for the diagnosis of keratoconus has been increasing the sensibility and specificity of the triage of carriers of this ecstasy, allowing an earlier and better diagnosis of this medical condition.

Keywords: Keratoconus, Cornea, Diagnosis, Ecstasy, Tomography.

31

IntRoductIon

The cornea is a transparent structure which tends to be spherical, and together with the sclera make up the fibrous tunic of the eye. (1) Keratoconus is a non-inflammatory,

usually bilateral, asymmetric corneal ectasia characterized by progressive thinning causing an increase in corneal curvature, irregular astigmatism leading to gradual decrease of vision.(2-5) The approximate incidence of keratoconus in the general population is between 50 and 230 / 100,000 inhabitants.(4)

The etiology proposed for keratoconus includes physical, biochemical and molecular changes in the corneal tissue. However, no theory fully explains the findings related to keratoconus.(4,5) There is already a well-established correlation to hereditary diseases, atopic diseases, some systemic diseases, prolonged use of contact lenses, collagen diseases and frequent eye friction.(4,5)

The differentiation between moderate and severe keratoconus is made through the analysis of the classic signs present in retinoscopy and biomicroscopy (thinning of the localized cornea, Fleischer ring, Munson’s sign, Rizzuti’s sign, and Vogt’s striae.(1,5) On the other hand, the identification of initial and subclinical forms is a challenge, since the patient mostly presents good visual acuity with correction, and shows no signs to the examination.(1)

The identification of subclinical keratoconus is important for the follow-up of patients with irregular astigmatism, irregular keratoconus, and family history of keratoconus.(1,6) Corneal tomography is the most effective method for the diagnosis of early forms of keratoconus. It can be made by various methods: horizontal scanning slot (Orbscan II®, Bausch & Lomb), rotating Scheimpflug camera (Pentacam®, Oculus), high frequency ultrasound (Artemis®, Ultralink), and anterior segment optical coherence tomography (Visante®, Zeiss)¹.

The tomographs have maps and displays that aid in the diagnosis of early forms of keratoconus, increasing the sensitivity and specificity in screening patients for ectasia.(7) These parameters are able to detect smooth abnormalities related to ectasia previous to the alterations of the topographic parameters. (7)

objectIve

The objective of the present study is to analyze clinical, therapeutic and tomographic parameters of patients with keratoconus treated at Fundação Hilton Rocha, a reference center in ophthalmology located in Belo Horizonte / MG.

methods

Retrospective study with a random sample of 150 patients drawn from the universe of 1535 patients submitted to corneal and anterior segment tomography (Pentacam - Oculus, Wetzlar, Germany) at Fundação Hilton Rocha/ Belo Horizonte in the year 2015, with subsequent analysis of the of patients’ medical records considered suspected or suffering from keratoconus.

Patients were considered suspected or suffering from keratoconus when they presented at least one of the following characteristics: pachymetry lower than 500 μm for suspected and lower than 450 μm for patients with keratoconus; anterior central elevation between 12 and 15 for suspected of keratoconus and greater than 15 for keratoconus patients; posterior central

Clinical analysis therapy and tomographic parameters of patients diagnosed with keratoconus attended at Fundação Hilton Rocha

elevation between 17 and 20 for suspected keratoconus and greater than 20 for keratoconus patients; Ambrosio Relational Thinnest (ART) between 340 and 380 for suspected of keratoconus and lower than 340 for keratoconus patients; D value greater than or equal to 1.6 for suspected and greater or equal to 2.6 for keratoconus patients; and, keratometry greater than 47.2D for suspected and greater than 48.7D for patients of the disease.

After the sample selection, the medical records were analyzed, and the clinical and therapeutic data of the patients was collected. We collected data on visual acuity after refraction, changes in biomicroscopy, underlying diseases of the patient, and treatment instituted.

The inclusion criteria were patients diagnosed with suspect of or with keratoconus who fulfilled the criteria described above and presented CT scans performed correctly with reliability rate with no changes (“OK”) and complete, legible, and dated.

The exclusion criteria were patients with other corneal pathologies such as scars, dystrophies, degenerative processes, and active infectious or inflammatory changes.

Data was inserted in a Windows Excel spreadsheet and analyzed using the IBM SPSS Statistics Editor software. A chi-square test was performed for the frequency analysis, with a significance level of 0.05 for interpretation.

The project was posted at Plataforma Brasil (CAAE: 65029616.9.0000.5141) and forwarded for analysis by the Research Ethics Committee of Associação Educativa do Brasil – SOEBRAS/Faculdades Unidas do Norte de Minas, with opinion number: 2.092.932

Results

Of the 150 selected patients, 40 were excluded from the study because they had an altered reliability rate due to lack of data, patient blinking during examination, non-collaborative patient, patient with other corneal diseases, and improperly completed medical records.

A total of 110 patients were analyzed, with a total of 220 eyes. The majority of the patients (n = 169, 76.8%) had visual acuity greater than or equal to 20/60, and 18 patients presented vision worse than or equal to 20/200 (8.1 %) (Table 1).

As for the biomicroscopic findings, the papillae were found in 34 eyes, being present in about 15% of the eyes studied, and Vogt’s striae in 18 eyes (8.18%) (Table 2).

Regarding the systemic diseases associated, 75% of patients did not report any disease, and among those who reported it, 21 reported atopy, 10 reported systemic arterial hypertension (SAH), and 2 reported diabetes mellitus (DM). Regarding the treatment used, 70 patients wore glasses; 29 wore contact lenses; 7 underwent intraestromal ring placement, and 4 underwent corneal transplant.

Of the total of 220 eyes evaluated, the majority had keratoconus (n = 189, 85.9% of total). 21 eyes (9.5%) had suspected keratoconus, and 10 eyes (4.6%) neither were suspected nor had keratoconus. Of the patients with keratoconus, 52 eyes presented the 6 criteria altered (23.6% of total), and 42 eyes had 5 criteria altered (19.1%) (Figure 1).

The ART diagnostic criterion considered most eyes with keratoconus (n = 183, 83.2%), and pachymetry considered the smallest part (n = 87, 39.5%). In the eyes with suspected keratoconus, pachymetry considered most of them (n = 86; 39.1%), and the posterior central elevation considered the smallest part of the eyes (n = 8, 3.6%). (Figure 2).


32 Silva ISM, Botteon CS

dIscussIon

The study showed that, regarding the treatment, 99 patients wore glasses or contact lenses, and 76.8% presented visual acuity better than 20/60. The prescription for glasses and contact lens is made in the initial and soft cases of keratoconus, in which it is possible to have a good visual acuity without invasive treatments.(5,8) Seven patients (6.3%) underwent intraethromal ring placement. The ring is used as an option in patients with no corneal changes and intolerant to contact lens in an attempt to decrease or delay the corneal transplant. (5,8)

Twenty-one patients (19%) reported atopy, and 34 eyes of the 220 analyzed (28.3%) had papillae. This data is in agreement with other studies found in the literature, as in the study of Mianet al.(5) which found a prevalence of 19.2% of patients with keratoconus and atopic. According to Botelho et al.(9)

who analyzed 27 medical records of atopic patients, 48.3% had keratoconus. Along with that, Elias et al. (10) analyzed patients with keratoconus and found a prevalence of 53.3% with atopy.

Pentacam® has maps and displays that aid in the diagnosis of early forms of keratoconus, increasing the sensitivity and specificity in screening patients for ectasia.(4,7) In the present study, the patients were considered as suspected of keratoconus or with keratoconus after the analysis of 6 parameters of Pentacam®, and about 23% of patients were considered as having keratoconus with 6 parameters changed, and only 10% were considered with only 1 parameter changed. This was probably due to the fact that the patients selected were referred to the ambulatory of Fundação Hilton Rocha, many times already being suspected of keratoconus, or were referred for follow-up after an established diagnosis of keratoconus.

The Ambrosio Relational Thinnest (ART) criterion was the one that considered the patients as having keratoconus, and was altered in about 83% of patients with keratoconus. The value of ART is the best parameter to rank keratoconus patients and evaluates the lowest pachymetric value found and correlates to pachymetric progression.(1) On the other hand, the value of isolated pachymetry was the one that changed the most among the patients suspected of keratoconus, but it should not be evaluated in isolation, since, despite the patients with keratoconus present low pachymetry, it is not every patient who has low pachymetry

Table 1 Values of visual acuity per eye analyzed

Fractional notation of visual acuity (V=20/p) N %

20/20 46 20.9 20/25 33 15.0 20/30 40 18.2 20/40 25 11.4 20/50 17 7.7 20/60 8 3.6 20/70 13 5.9 20/80 6 2.7 20/100 13 5.9 20/150 1 0.5 20/200 5 2.3 20/400 5 2.3 CD 2 M 1 0.5 CD 1 M 5 2.3 MM 1 0.5 NPL 1 0.5 Total 220 100.0

Table 2 Biomicroscopic findings of each eye

Biomicroscopic findings N

Central thinning 10Paracentral thinning 10Hydrops scar 4Fleisher ring 2Cataracts 8Vogt’s striae 18Central opacity 6Central leukoma 2Intraocular lens 4Nubule 2Pterygium 6Paracentral opacity 10Papillae 34Corneal transplant 4

Total 120

Figure 1: Classification of the eyes of the sample according to topographic criteria such as suspected keratoconus and presence of keratoconus

Figure 2: Classification of eyes according to topographic criteria (no keratoconus, no suspected keratoconus, suspected of keratoconus, presence of keratoconus) - percentage.


33Clinical analysis therapy and tomographic parameters of patients diagnosed with keratoconus attended at Fundação Hilton Rocha

that has keratoconus, so this parameter should be analyzed along with the others.

Only 45.9% of patients analyzed presented changes in keratometry, and in case only aceratometry as it is used by many authors who analyze data from topographic examinations was used for keratoconus classification, more than 50% of the patients would not be considered as having keratoconus.

conclusIon

Based on the results of the present study, we concluded that there is a considerable amount of patients with atopy related to the habit of scratching the eyes, which can worsen the ectasia. The majority of patients presented a vision better than 20/60, with the most used treatment being wearing glasses and contact lenses.

The tomographic classification allows an analysis by maps and displays and rates that aid in the diagnosis of early forms of keratoconus, increasing the sensitivity and specificity in screening patients for ectasia. With this, the diagnosis is possible in an earlier way, with greater therapeutic success. In the present study, the Ambrosio Relational Thinnest (ART) criterion was the one that considered the patients as having keratoconus.

Many authors suggest rates to diagnose early keratoconus. The development of propaedeutic methods, as well as the use of more modern equipment, has improved the screening of the disease, facilitating the diagnosis of susceptibility to ectasia.

RefeRences

1. Ambrosio R, Alonso RS, Luz A, Velarde RG. Corneal thickness spatial profile and corneal volume distribution: Tomographic índices to detect. Journal Catract Refract Surg. 2006; 32:1851-9.

2. Ambrosio R. Simplifying ectasia screeneing with Pentacam corneal tomography. Highlights Ophthalmol. 2010; 38(3):12-20.

3. Junqueira LC, Carneiro J. Histologia básica. 9a ed. Rio de Janeiro: Guanabara Koogan; 2012.

4. Lopes AC, Pinto AGT, Sousa BA. Ceratocone: uma revisão. Rev Med Saude (Brasília). 2015; 4(2): 219-32

5. Mian CL, Carvalho DA, Souza MA, Moraes TC, Costa MI, Moreira GA, et. al. Perfil epidemiológico dos pacientes portadores de ceratocone atendidos em um hospital privado de Campo Grande- MS. Ensaios Ciênc. 2013; 17(3):113-21.

6. Valbon BF, Salomão M, Ramos I, Canedo AL, Nogueira L, Ambrosio Junior R. Importância da tomografia de córnea para o diagnóstico de ectasia. Rev Bras Oftalmol. 2012; 51(5)302-8.

7. Belim MW, Khachikian SS, Ambrosio Junior R. Keratoconus/ Ectasia detection with the Oculus Pentacam: Belim/ Ambrosio enhanced ectasia display. Highlights of ophthalmology. 2010; 35(6):5-12.

8. Siqueira AV, Polo J, Gomes MB, Moreira H. Anel corneano intraestromal assimétrico no tratamento do ceratocone. Arq Bras Oftalmol. 2010; 73(5):454-8.

9. Botelho PB, Marback P, Sousa LB, Campos M, Vieira LA. Ceratoconjuntivite alérgica e complicações no segmento ocular anterior de pacientes. Arq Bras Oftalmol. 2003; 66(1):25-8.

10. Elias RM, Lipener C, Uras R, Pavês R. Ceratocone: fatores prognósticos. Arq Bras Oftalmol. 2005; 68(4):491-4.

Corresponding author: Izabela dos Santos de Moura e Silva Avenida José do Patrocínio Pontes, 1355, Mangabeiras, Belo Horizonte, Minas Gerais, Brazil E-mail: [email protected]


34

1 Ophthalmology Service, Hospital Governador Celso Ramos, Florianópolis, SC, Brazil. 2 Retinal and Vitreous Department, Ophthalmology Service, Hospital Governador Celso Ramos, Florianópolis, SC, Brazil.

Original article



Análise da variação da pressão intraocular após injeção intravítrea de ranibizumabe

Analysis of intraocular pressure variation after intravitreal injection of ranibizumab

Ignatz Rohrbacher1, Eduardo Soares Maia Vieira de Souza2

Resumo

Objetivo: O tratamento com anti-angiogêncios é uma das modalidades mais utilizadas em patologias relacionadas ao edema macular. A injeção intravítrea de um inibidor do VEGF-A tem alta efetividade, porém está relacionada com efeitos adversos, como o aumento da pressão intraocular. O objetivo deste estudo foi avaliar a variação da pressão intraocular (PIO) em pacientes que se submeteram a injeções intravítreas de ranibizumabe, a variação de acordo com facia e com história de injeções prévias. Métodos: Este foi um estudo um estu-do observacional transversal. Foram incluídos todos os pacientes submetidos a injeções intravítreas com diagnóstico de degeneração macular relacionada à idade exsudativa, oclusão de veia central da retina com edema macular, ou edema macular diabético. A pressão intraocular foi aferida antes da injeção, imediatamente após e 30 minutos após a injeção com tonômetro portátil. Resultados: Foram realizadas 143 injeções intravítreas, restando para a análise 96 injeções realizadas em 55 participantes. A comparação entre a PIO antes e 30 minutos após a injeção intravítrea mostrou-se estatisticamente significativa com PIO final maior que a inicial (p<0,0001) em pacientes com edema macular diabético. Pacientes fácicos e afácicos não mostraram diferenças significativas com relação a variação da PIO. Quando analisados apenas os participantes que haviam recebido injeções prévias, não foi encontrado uma variação significativa. Conclusão: Concluímos neste estudo que existe uma diferença significativa entre a pressão intraocular antes e 30 minutos após a injeção intravítrea de ranibizumabe em pacientes com edema macular diabético, mos-trando que esse período de tempo não foi suficiente para a regressão da PIO ao valor pré-injeção. Não encontramos diferenças significativas entre outros grupos, comparação entre fácicos e afácicos, nem em pacientes que haviam recebido injeções prévias.

Descritores: Pressão intraocular; Injeções intravitreas; Segmento posterior do olho; Saúde ocular; Ranibizumabe

AbstrAct

Objective: Treatment with anti-angiogenic drugs is one of the most widely used modalities of treatment of macular edema related conditions. Intravitreal injection of a VEGF-A inhibitor is highly effective, but is related to adverse effects such as increased intraocular pressure. The objective of this study was to evaluate intraocular pressure (IOP) variation in patients who underwent intravitreal injections of ranibizumab, variation according to phakic/aphakic and history of previous injections. Methods: This was a cross-sectional observational study. All patients submitted to intravitreal injections with diagnosis of exudative age-related macular degeneration, retinal central vein occlusion with macular ede-ma, or diabetic macular edema were included. The IOP was measured before the injection, immediately after and 30 minutes after the injection with a portable tonometer. Results: 143 intravitreal injections were performed, with 96 injec-tions performed in 55 participants. The comparison between IOP before and 30 minutes after intravitreal injection showed to be statistically significant with higher than initial IOP (p <0.0001) in patients with diabetic macular edema. Phakic and aphakic patients did not show significant differences regarding IOP variation. When only those participants who had received previous injections were analyzed, no significant variation was found. Conclusion: We conclude in this study that there is a significant difference between intraocular pressure before and 30 minutes after intravitreal injection of ranibizumab in patients with diabetic macular edema, showing that this period of time was not sufficient for regression of IOP at the pre-injection value . We did not find significant differences between other groups, comparing phakic and aphakic patients, nor in patients who had received previous injections.

Keywords: Intraocular pressure; Intravitreal injections; Posterior eye segment; Ranibizumab

35

IntRoductIon

Treatment with anti-angiogenic is one of the most widely used modalities in pathologies related to macular edema, and one of the factors leading to the onset of edema is

the increased release of vascular endothelial growth factor A (VEGF-A).(1) Intravitreal injection of a VEGF-A inhibitor is highly effective but is related to adverse effects such as increased intraocular pressure.(2) This increase is considered transitory, although new evidence shows that it can con-tinue in a sustainable way.(3,4)

The objective of the present study was to evaluate the intraocular pres-sure (IOP) variation in patients who underwent intravitreal injections of ranibizumab, varying according to facia and history of previous injections.

methods

This was a cross-sectional study with measurements carried out on the same day. We included all patients submitted to intravitreal injections diagnosed with exudative age-related macular degeneration (AMD), central retinal vein occlusion (CRVO) with macular edema, or diabetic macular edema (DME) from January to May 2017 at the Ophthalmology Department of Hospital Governador Celso Ramos. Patients who had incomplete medical records or other ocular pathologies, such as neovascular glaucoma, neovascular membranes related to angioid streaks or high myopia, proliferative diabetic retinopathy were excluded from the analysis. All patients underwent ophthalmologic evaluation, including slit-lamp biomicroscopy and history of intravitreal injections, and received an informed consent form approved by the institution’s Research Ethics Committee (1.861.123/2016).

The medication used was ranibizumab (Lucentis® Genentech Inc.) used by a single ophthalmologist. The protocol for application starts with local anal-gesia with anesthetic eyedrops based on tetracaine hydrochloride 1%, asepsis and antisepsis of the palpebral skin, surgical field positioning, application of top-ical iodine-polyvidone in the conjunctiva 5%, placement of blepharostat Bar-raquer and marking a distance of 3.5mm in pseudophakic and 4mm in phakic between conjunctival limb and sclera in the upper temporal quadrant of the eyeball. Aspiration of 0.05 ml of the drug with 18G needle with filter, and prepa-ration of the application with 30G needle. A cotton swab was used to laterally draw the conjunctiva at the site of application, then the needle was positioned at 90° and inserted to infuse the medication. Repositioning of the conjunctiva with the swab after withdrawal of the needle. After the procedure, a drop of eyedrops dexamethasone 0.1% was applied with neomycin sulfate 0.5% and polymyxin sulfate B 600,000 IU% (Figure 1).

Intraocular pressure was measured prior to injection, immediately after and 30 minutes after the injection with portable tonometer Tono-Pen AVIA® (Reichert Technologies). Patients were advised of complications of the procedure and were instructed to return in case of worsening of visual acuity, pain, discomfort, or any other symptom in the eye that received the injection.

The data were entered into a spreadsheet of software Numbers 3 OS X® (Apple inc.) and presented as average + standard deviation (SD). The tests t and Spearmantest were used to analyze the associations between the variables of interest considering values of p <0.05% as significant.



Results

We carried out 143 intravitreal injections between January and May 2017. We excluded 17 patients because they had incomplete records, 10 patients had pathologies described in the exclusion criteria (2 neovascular glaucoma, 3 neovascular membrane related to angioid streaks, 1 neovascular membrane of the high myopic, 4 proliferative diabetic retinopathy), with 96 injections remaining for the analysis performed in 55 patients. The results of meas-urements of the intraocular pressure were described in table 1.

Figure 1: Descriptive photos of the steps of the intravitreal injection protocol

A. aspiration of medication B. medication vial C. surgical field placement D. ap-plication of iodine polisher 5% E. blepharostat positioning F. limbal-scleral dis-tance marking G. lateral traction of the conjunctiva H. intravitreal injection of medication perpendicular to the sclera

IOP = intraocular pressure; SD = standard deviation

Table 1 Result of IOP measurements before,

immediately after and 30 minutes after the intravitreal injection of ranibizumab

IOP average + SD

IOP before the injection 16.7 mmHg ± 3.14

IOP immediately after the injection 39.98 mmHg ± 8.47

IOP 30 minutes after the injection 18.11 mmHg ± 3.81

The average age ± SD was 70 ± 11 years, with 17 males and 44 females. Exudative AMD was the reason for the application in 30 participants, the DME in 18, and the CRVO with macular edema in 7. The ophthalmologic examination showed 17 pseudophakic and 35 phatic eyes. Regarding previous treatments, 13 patients applied the injection for the first time, whereas 42 received at least one previous injection in the same eye, with an average of 3.27 ± 2.70 injections.

The comparison between IOP before and 30 minutes after intravitreal injection was statistically significant, with higher IOP than the initial IOP. Phakic and aphakic patients did not show significant differences regarding IOP variation. When only participants who had received previous injections were analyzed, no significant variation in the IOP was found (Table 2).

36


Rohrbacher I, Souza ESMV

Table 2 Result of the analysis comparing the IOP before and

30 minutes after the intravitreal injection in all patients, comparing phasic and pseudo-phasic ones

and patents with history of previous injections.

T testComparison between average IOP before (16.71 mmHg ) p < 0.0001and 30 minutes after injection (18.11 mm Hg)

Comparison between IOP variation in phasic (1.54 mmHg) p = 0.430and aphasic patients (1,04 mm Hg) during the first 30 minutes Spearman Test Relation between the number of previous injections and increased IOP p = 0.884

IOP = intraocular pressure

The sub-analysis of the groups showed that IOP before and 30 minutes after injection was statistically higher in the DME group (p <0.0001), but was not significant in the group with AMD (p = 0.0514), nor in the group with CRVO (p = 0.0563).

fter the injection, 5 participants reported irritative symptoms, such as foreign body sensation due to areas of corneal desepithelialization. No other complications were observed.

dIscussIon

The increase in IOP is an existing concern with the application of intravitreal medications. Several methods have been reported to avoid or prevent this increase and thus prevent damage. We can mention ocular massage as a non-invasive procedure, and anterior chamber paraesthesia as an invasive proce-dure.(5) There is no evidence suggesting that such techniques reduce the risk of complications related to increased blood pressure, but patients at higher risk may receive some of those techniques to avoid damage.(5) The development of the technique with the use of thinner needles or pertuitotunellization reduces the reflux of medication and vitreous, which may be related to an immediate and transient increase in the IOP.(6)

Our study identified an initial peak immediately after intravitreal injection and a reduction at 30 minutes, but the comparison between the IOP before it and the IOP after 30 minutes showed a significant difference, suggesting that this time interval was not enough for the IOP normalization. Subanalysis of the data showed that only the DME group had a significant persistence of the IOP after 30 minutes. Our result contrasts with another study which detected normalization of IOP within 30 minutes after injection in general.(7) We suggest other studies with measurements in larger time intervals to assess the time required for normalization of IOP.

A meta-analysis evaluating the IOP in patients receiving anti-VEGF ap-plications demonstrated sustained long-term increase of the IOP, mainly in glaucoma patients.(8) The reason for the sustained increase in IOP is not com-pletely understood and seems to be multifactorial, and may be due to the pas-sage of high molecular weight molecules through the anterior hyaloid or zonule and consequent obturation or damage of the trabecular

mesh with repeated applications.(9-11) Evaluating the patients who had received previous injections, our study did not find a significant relation between the IOP variation and the number of previous injections, a result similar to another study showing that IOP change in patients receiving multiple injections was of little significance.(12,13) Our analysis considered only the measurements made on the day of the injections, as we did not have access to the patients’ data before starting treatment with intravitreal injections. The comparison between phakic and pseudophakic pa-tients did not show significant differences in relation to IOP variation.

Our limitations were the reduced number of patients and the lack of eval-uation of the camerular angle and other aspects of the patients, such as diag-nosis and treatment of glaucoma. We suggest such evaluation in future studies with the aim of analyzing intraocular pressure variation.

conclusIon

In the present study, we concluded that there is a significant difference between intraocular pressure before and 30 minutes after intravitreal injection of ranibizumab in patients with diabetic macular edema, showing that this period of time was not enough for IOP regression at the pre-injection value. We did not find significant differences between patients with age-related macular disease, central retinal vein occlusion, phakic and aphakic comparison, nor in patients who had received previous injections.

RefeRences

1. Lazzeri S, Ripandelli G, Sartini MS, Parravano M, Varano M, Nardi M, et al. Aflibercept ad-ministration in neovascular age-related macular degeneration refractory to previous anti-vascular endothelial growth factor drugs: a critical review and new possible approaches to move forward. Angiogenesis. 2015; 18(4):397-432.

2. Myers L, Almeida D, Abràmoff MD. Intravitreal injection technique: a primer for ophthal-mology residents and fellows [Internet]. EyeRounds.org. [cited 2015 Jan 6]. Available from: http://www.EyeRounds.org/tutorials/intravitreal-injection/.

3. Hoang QV, Jung JJ, Mrejen S, Freund KB. Influence of axial length and post injection reflux on sustained intraocular pressure elevation as a result of intravitreal anti-vascular endothelial growth factor therapy. Retina. 2014; 34(3):519-24.

4. SooHoo JR, Seibold LK, Kahook MY. The link between intravitreal antivascular endothelial growth factor injections and glaucoma. Curr Opin Ophthalmol. 2014; 25(2):127-33.

5. Avery RL, Bakri SJ, Blumenkranz MS, Brucker AJ, Cunningham ET Jr, D’Amico DJ, et al. Intravitreal injection technique and monitoring: updated guidelines of an expert panel. Retina. 2014; 34 Suppl 12:S1-S18.

6. Merani R, Hunyor AP. Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review. Int J Retina Vitreous. 2015; 21;1:9.

7. Lim HB, Kim MS, Jo YJ, Kim JY. Short-Term Visual Acuity and Intraocular Pressure Changes and Their correlation after anti-vascular endothelial growth factor injection. Ophthalmologica. 2016; 236(1):36-42.

8. Zhou Y, Zhou M, Xia S, Jing Q, Gao L. Sustained elevation of intraocular pressure associated with intravitreal administration of anti-vascular endothelial growth factor: a systematic review and meta-analysis. Sci Rep. 2016; 6: 39301.

37

Corresponding author: Ignatz Rohrbacher Rua Irmã Benwarda, 297 – Centro – Florianópolis, SC, Brazil. ZIP Code - 88015-270. E-mail [email protected]



9. Menke MN, Salam A, Framme C, Wolf S. Long-term intraocular pressure changes in patients with neovascular age-related macular degeneration treated with ranibizumab. Ophthalmologica. 2013; 229(3):168-72.

10. Reis GM, Grigg J, Chua B, Lee A, Lim R,Higgins R, et al. Incidence of intraocular pressure elevation following intravitreal ranibizumab (lucentis) for age-related macular degeneration. J Curr Glaucoma Pract. 2017; 11(1): 3–7.

11. Dedania VS, Bakri SJ. Sustained elevation of intraocular pressure after intravitreal anti-vegf agents: What Is the Evidence? Retina. 2015; 35(5):841-58.

12. Nariani A, Williams B, Hariprasad SM. Long-term effect of anti-vascular endothelial growth factor injections on intraocular pressure. Indian J Ophthalmol. 2016; 64(9): 643-7.

13. Yu AL, Seidensticker F, Schaumberger M, Welge-Lussen U, Wolf A. Evaluation of intraocular pressure elevation after multiple injections of intravitreal ranibizumab. Clin Ophthalmol. 2014; 8:743-7.

38 case repOrt



Esclerite posterior bilateral simultânea e unilateral recorrente

Simultaneous bilateral and unilateral recurrent posterior scleritis

Ana Paula da Silva Maganhoto1, Sara Correia1, Letícia Oliveira Squillace1, Roberto Ivo Pasquarelli Neto1

1 Department of Ophthalmology, Santa Casa de Misericórdia de Santos, Santos, SP, Brazil.

AbstrAct

Posterior scleritis is an ocular inflammatory disease that affects the sclera e whose diagnosis is difficult. The main clinical manifestations are worsening of visual quality, ocular pain and finding in the posterior segment, such as serous retinal detachment, choroidal folds, optic disc edema and sclera thickening. We should award for systemic findings, because it is often accompanied by rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease and infections, such as syphilis and tuberculosis.This paper aims to describe two cases: one patient with simultaneous bilateral posterior scleritis without systemic alterations correlated with the disease. Bilateral presentation is uncommon in this pathology; and another case of recurrent unilateral anterior and posterior scleritis.

Keywords: Scleritis; Sclera; Posterior eye segment; Funds oculi; Retinal detachment; Case reports

Resumo

Esclerite posterior é uma doença inflamatória ocular que acomete a esclera e cujo diagnóstico é difícil. A clínica da doença envolve a piora da qualidade visual com dor ocular e achados do segmento posterior, como descolamento de retina seroso, dobras de coroide, edema de disco óptico e espessamento escleral. Deve-se ficar atento aos achados sistêmicos, pois, muitas vezes, está associada a doenças como artrite reumatoide, lúpus eritematoso sistêmico, doença inflamatória intestinal e doenças infecciosas, como sífilis e tuberculose. Este trabalho objetiva descrever dois casos: uma paciente com quadro de esclerite posterior bilateral simultânea, sem alterações sistêmicas correlacionadas com a doença. A apresentação bilateral é incomum nesta patologia; e outro caso de esclerite anterior e posterior unilateral recorrente.

Descritores: Esclerite; Esclera; Segmento posterior do olho; Fundo de olho; Descolamento de retina; Relatos de casos

39

IntRoductIon

Posterior scleritis is an inflammatory ocular disease affecting the sclera and which is often underdiagnosed,(1) which may compromise the patients’ final visual outcome.

This disease may occur alone or along with rheumatologic diseases, such as rheumatoid arthritis and systemic lupus erythematosus; infectious diseases such as tuberculosis and syphilis; and inflammatory bowel diseases.(2)

It is most commonly found unilaterally but can occur in both eyes simultaneously.(3-5) It usually occurs with ocular pain, low visual acuity, serous retinal detachment, and optic disc edema.(3-6)

Its diagnosis is difficult to perform because the presentation and findings are not always classic. Currently, the clinical findings associated to findings of complementary exams, mainly ocular ultrasonography, are used. Other tests may be used to assist in the diagnosis of associated systemic diseases, as well as to exclude differential diagnoses.

Our objective is to describe the case of a 32-year-old patient with simultaneous bilateral posterior scleritis with no association so far to systemic diseases; and a 34-year-old patient with recurrent unilateral scleritis, also without associated systemic diseases.

cAse RepoRt 1

A 35-year-old female patient, black, was admitted to the emergency service of ophthalmology at Irmandade Santa Casa de Misericórdia de Santos, Brazil, with headache and nausea for a month and low visual acuity (VA) in the left eye (LE) for a week ago, with discomfort in the ocular region. With no other systemic symptoms, joint pain, dermatological changes nor previous ocular surgeries. She presented systemic arterial hypertension as comorbidity, controlled with losartan 50 mg.

At the ophthalmologic exam, she presented VA in the right eye of 20/30, and in the LE of 20/200 according to the Snellen table. Biomicroscopy, direct and consensual pupil reflexes and swing light test, extrinsic ocular movement and normal ectoscopy in both eyes (BE). The intraocular pressure was 14 mmHg in BE.

Funduscopy showed papillary edema with hyperemia, 360º blurring and optic disk elevation, with peripapillary hemorrhages and choroidal folds in the macular region in the RE; LE with 360° papillary edema with hyperemia and border blurring, peripapillary haemorrhages and serous retinal detachment in the lower and temporal regions, partially affecting the macula.

The patient was hospitalized at the ophthalmology care for etiological investigation. We asked for laboratory tests, chest X-ray, opinion of the infectious team (to rule out infectious diseases) and neurology (for CEREBROSPINAL FLUID collection), as well as imaging tests.

Our main diagnostic hypotheses at the initial stage were malignant hypertension (personal history of hypertension), intracranial hypertension (due to bilateral papillary edema), Vogt-Koyanagi-Harada syndrome (bilateral papillary edema and serous retinal detachment) and posterior scleritis (papillary edema, serous retinal detachment and ocular discomfort).

Laboratory tests revealed normal blood count; negative serologies; positive inflammatory activity tests (PCR 13.01 mg/L and ESR 63 mm 1st hour); anti-ENA-SM antibodies, anti-JO-1, anti-RNP, anti-nuclear SSA (Ro), P-ANCA and C-ANCA negative;


computed tomography of the skull within the limits of normality and of orbits with internal contouring thickening of the posterior chamber of the left ocular globe in the posteromost quadrant and lateral to the left (Figure 1). Infectology ruled out infectious causes. CEREBROSPINAL FLUID was normal (clear, 0.3/mm³ leukocytes, glucose 60mg/dL, protein 38mg/dL, bacterioscopy and culture negative, opening pressure 56mmHg). Nuclear magnetic resonance of the skull was within normality, and of the orbits evidenced a hyperintense laminar area in T2 with 0.2 cm thickness in the posterior region of the vitreous chamber of the LE.

Figure 1: Tomography of the skull and orbits with thickening of the posterior chamber of the left eye in the posteromost quadrant and lateral to the left.

The first exams ruled out malignant hypertension, since the patient’s blood pressure control ranged from 120x80 to 140x90 mmHg throughout the hospitalization; intracranial hypertension, because tomography was normal and CEREBROSPINAL FLUID presented opening pressure within normality; and Vogt-Koyanagi-Harada syndrome, because although the ocular findings were congruent with the syndrome, we did not have systemic findings present, such as pleocytosis in cerebrospinal fluid, dermatological and neurological changes (headache alone is not considered enough to fit the change criteria in the central nervous system). Thus, we only had bilateral posterior scleritis as the main hypothesis for the case.

Ultrasonography showed a choroidal thickening of the RE (Figure 2) in the lower wall of the nasal cavity, and serous retinal detachment of inferior wall with temporal wall choroidal thickening in the LE (Figure 3). These findings were congruent with our main diagnostic hypothesis. We did not perform angiofluoresceinography due to the unavailability of the exam during the follow-up period. We also disregard the hypothesis of Harada’s disease (isolated ocular form), as it usually presents as a panuveitis, which was not the initial manifestation described in the case, as well as the sclerocoroid thickening of the ultrasound exam being more characteristic of scleritis (localized and greater than 2 mm) than that of Harada (where thickening is usually diffuse).


40

Figure 2: . Ultrasonography of the right eye showing choroidal thickening in the nasal portion of the inferior wall.

Figure 3: Ultrasonography of left eye showing serous retinal detachment in the inferior wall and choroidal thickening in temporal wall.

cAse RepoRt 2

AFF, female, brown, 34 years old, was admitted to the ophthalmology emergency department of Irmandade Santa Casa de Misericórdia de Santos complaining of pain and hyperemia in the right eye (RE) for 8 days, followed by low visual acuity (VA). The patient had no co-morbidities nor continuous-use medication.

She had a history of similar ocular episodes since 2007. She had previously been treated for central serosal chorioretretinopathy in 2007, 2008 and 2013, and in 2014 she was diagnosed with anterior and posterior scleritis, being treated with indomethacin 50 mg every 8 hours, prednisone 20 mg/day topical ecorticoid.

The ophthalmological exam presented VA in the RE of finger counts (FC) at 1 meter, and of 20/20 in the left eye (LE) in the Snellen table. Biomicroscopy presented diffuse hyperemia without improvement after the test of phenylephrine in the RE; LE without changes. Intraocular pressure (IOP) of 10 mmHg in both eyes. Fundoscopy of the RE revealed diffuse retinal edema

Figura 4: Ultrasonography of the right eye with the “T” sign and retinal detachment.


Maganhoto APS, Correia S, Squillace LO, Pasquarelli Neto RI

Thus, we reached the diagnosis of simultaneous bilateral posterior scleritis and promptly started treatment with methylprednilosone pulse therapy 1g/day for five days,followed by gradual reduction of oral corticosteroid. The patient showed reduction of the retinal detachment and improvement of final visual acuity, with 20/20 in RE and 20/40 in LE at hospital discharge. The patient is being followed up in an outpatient ambulatory with oral corticosteroid regression, and was referred for rheumatologic follow-up in order to investigate systemic diseases.

41



giant cell arteritis, and inflammatory bowel disease (ulcerative colitis and Crohn’s disease).(2-4,7) Therefore, there is a need to perform complementary tests to confirm or exclude such pathologies, as well as appointments with experts in the area. Among the exams, we counted CBC, X-ray of the chest, and FTA-ABS and VDRL as the initial screening.(5) Further examinations and investigations should be requested according to the table presented by the patient.

Patients in our clinical cases had low VA, optic disc edema, and serous retinal detachment, which are commonly found in this disease. To date, there are no other systemic diseases related to this ocular condition. However, they were referred for rheumatologic ambulatory follow-up, as there are reports in the literature of a subsequent development of the diseases mentioned above.

The diagnosis of posterior scleritis is still a challenge. Clinical findings (intense ocular pain, serous retinal detachment, optic disc edema) are combined with complementary exams for the diagnosis to be confirmed. Ultrasonography showed the scleral thickening (classic, but not pathognomonic, “T” sign representing liquid in the Tenon’s capsule and in the optic nerve sheath)(1,2,4), sclerocoroid thickening (greater than 2 mm)(3,4,6), and serous retinal detachment.

In case 1, the patient had clinical scleritis, which was confirmed after ocular ultrasonography, showing scleral thickening in the right eye and serous retinal detachment in the left eye; as well as exclusion of other differential diagnoses after the normal range of exams, such as computed tomography of the skull and cerebrospinal fluid. In case 2, the patient already had a history of the disease, a clinical characteristic, and an ultrasound exam with the classic T sign, making the diagnosis more evident.

Treatment includes the use of non-steroidal anti-inflammatory drugs and systemic corticosteroids from 60 to 80 mg / day, with gradual reduction of medication.(1,2) In some cases, pulse therapy with methylprednisolone 1g / day for three days is necessary.(3) In the case of recurrence of the disease with reduction of the oral medication, the use of immunosuppressive drugs may be of great value, such as cyclosporine and azathioprine.(3)

Scleritis may have severe complications such as permanent low visual acuity.(3) Early diagnosis as well as the onset of therapy can promptly decrease visual sequelae.

Patients were treated with methylprednisolone pulse therapy 1 g / day for five days, followed by gradual reduction of oral corticosteroids. Both showed improvement of the ocular changes, as well as clinical improvement. Currently, they are being followed up in the ophthalmologic and rheumatologic ambulatory, without evidence so far of relapses or complications.

RefeRences

1. Kellar JZ, Taylor, BT. Posterior scleritis with inflammatory retinal detachment. West J Emerg Med. 2015; 16(7):1175-6.

2. Machado DO, Curi ALL, Fernandes RS, Bessa TF, Campos WR, Oréfice F. Esclerite: características clínicas, associação sistêmica, tratamento e evolução de 100 pacientes. Arq BrasOftalmol. 2009; 72(2): 231-5.

3. Machado DO, Curi AL, Bessa TF, Campos WR, Oréfice F. Esclerite posterior: características clínicas, associação sistêmica, tratamento e evolução de 23 pacientes. Arq BrasOftalmol. 2009; 72(3):321-6.

4. Lavric A, Gonzalez-Lopez JJ, Majumder PD, Bansal N, Biswas J, Pavesio C, et al. Posterior scleritis: analysis of epidemiology, clinical factors, and risk of recurrence in a cohort of 114 patients.OculImmunolInflamm. 2016;24(1):6-15.

in the posterior pole, optic disc edema, choroidal folds, serous retinal detachment (RD) in the posterior pole; LE within the normal range.

We can infer the diagnosis of scleritis in the RE from the ophthalmologic findings and the patient’s history. The patient was hospitalized at the ophthalmology care for complementary exams and therapy onset.

Laboratory tests and serologies were within the normal range (hemoglobin 13.6 mg/dL, leucocytes 12880 mg/dL, platelets 224000 mg/dL, C-reactive protein 2.51, VDRL and HIV 1 and 2 negative, toxoplasmosis IgG positive and IgM negative, cytomegalovirus IgG positive and IgM negative, FAN negative, rheumatoid factor negative), except for the erythrocyte sedimentation rate, which was above the reference value (40 mm in the 1st hour). Chest X-ray showed no changes. Computed tomography (CT) of the skull showed no abnormalities, and of orbits revealed parietal thickening of the right eyeball on the posterior projection, with apparent thickening of the choroid and retina and extension to the ipsilateral optic nerve. Ultrasonography (US) of the RE revealed the classic “T” sign, which indicates fluid in Tenon’s capsule and optic nerve sheath, and inferior serous RD (Figure 4).

The patient received pulse therapy with methyl-prednisolone 1mg/day for five days, followed by regression with oral prednisone and indomethacin 50mg every 8 hours. Currently, we are undergoing ambulatory follow-up at our service, with VA of 20/35 in the RE and 20/20 in the LE, and fundoscopy with decreased macular glow in the RE. She was referred for rheumatologic follow-up in order to investigate systemic diseases.

dIscussIon

Scleritis is a scleral inflammatory disease, and can be divided according to Watson’s 1976 classification into five types: anterior diffuse, anterior nodular, anterior necrotizing without inflammation, anterior necrotizing with inflammation, and posterior.(1,2,5)

Posterior scleritis is the most uncommon form of this disease, found in 2 to 12% of cases.(1,4,6) The average age of the patients is the fourth decade, and is more common in females.(2,3-7) Involvement may be unilateral or bilateral, with unilateral being the most common form.(3-5) In the study of Machado et al.,(3) 73.9% of cases were unilateral and 26.1% of cases were bilateral.

Both cases reported in this study show posterior scleritis in middle-aged women, which correlates with the literature data. The patient in case 1 presented a simultaneous bilateral condition, which is not the most usual presentation of the disease; in case 2, the condition was anterior and posterior unilateral.

The most frequent symptoms are low visual acuity (VA), periocular / orbital pain, headache, and pain at ocular movement.(1,3-6) Signs found on ophthalmologic exam include ciliary injection, anterior uveitis, optic disc edema, serous retinal detachment, retinal striae, subretinal infiltrates, choroidal folds, proptosis, limitation of extraocular movement.(1,3-6)

The condition may occur alone or be associated with systemic or infectious diseases such as tuberculosis, herpes simplex or zoster, syphilis, rheumatoid arthritis, systemic lupus erythematosus, polyarteritis nodosa, Wegener’s granulomatosis,

42

5. Watson PG, Hayreh SS. Scleritis and episcleritis. Br J Ophthalmol. 1976;60(3):163-91.

6. Biswas J, Mittal S, Ganesh SK, Shetty NS, Gopal L. Posterior scleritis: clinical profile and imaging characteristics. Indian J Ophthalmol. 1998;46(4):195-202.

7. Watson P, Romano A. The impact of new methods of investigation and treatment on the understanding of the pathology of sclera inflammation. Eye (Lond). 2014;28(8):915-30.

Corresponding author: Ana Paula da Silva Maganhoto Dr. Claudio Luis da Costa, 50, Jabaquara - Department of Ophthalmology, Hospital Irmandade de Santa Casa de Misericórdia de Santos, Santos, SP, Brazil. ZIP Code: 11075-900 Phone No.: +55 13 3202-0600 E-mail: [email protected]


Maganhoto APS, Correia S, Squillace LO, Pasquarelli Neto RI

43

AbstrAct

Multiple myeloma (MM) leads to disorderly proliferation of plasma cells clones, producing monoclonal immunoglobulin and commonly presents osteolytic lesions. In some cases, however, masses called plasmocytomas are found. Ocular and orbital involvement is unusual in this pathology. In this paper, we describe a case of a 63 year-old patient with previous diagnostic of MM that evolved an intraconal plasmocytoma in the right eye, as well as a vascularized mass in the anterior chamber from uveal infiltration. These lesions were correlated to MM e lead to visual loss in the affected eye. Reports of intraconal plasmocytoma have not been found in literature.

Keywords: Multiple myeloma; Plasmacytoma; Eyeneoplasms; Orbital neoplams; Case reports

case repOrt



Plasmocitoma intraconal e infiltração uveal em paciente portadora de mieloma múltiplo

Intraconal plasmocytoma and uveal infiltration in a patient with multiple myeloma

Ana Paula da Silva Maganhoto1, Sara Correia1, Roberto Ivo Pasquarelli Neto2

1 Residency Program, Ophthalmology Serviceb, Irmandade Santa Casa de Misericórdia de Santos, Santos, SP, Brazil. 2 Ophthalmology Service, Santa Casa de Misericórdia de Santos, Santos, SP, Brazil.

Resumo

Mieloma múltiplo (MM) é uma neoplasia que cursa com a proliferação desordenada de clones de plasmócitos, produzindo imunoglobulina monoclonal e normalmente se apresenta como lesões osteolíticas. Em alguns casos, porém, esta doença apresenta-se como massas, chamadas de plasmocitomas. O acometimento ocular e orbitário é incomum nesta patologia. Neste trabalho, descrevemos o caso de uma paciente de 63 anos com diagnóstico prévio de MM que evoluiu com um plasmocitoma intraconal em olho direito, bem como uma massa vascularizada câmara anterior proveniente de infiltração uveal. Essas lesões foram correlacionadas MM e culminaram com a perda visual no olho acometido. Não foi encontrado na literatura relatos de plasmocitoma intraconal.

Descritores: Mieloma múltiplo; Plasmocitoma; Neoplasias oculares; Neoplasias orbitárias; Relatos de casos

44

IntRoductIon

Multiple myeloma (MM) is an hematologic neoplasia that courses with proliferation of plasma cells.(1-2) Its main manifestations occur in the bones, in the form of osteolytic lesions. However, it may also be in the form of isolated bone or extramedullary plasmacytomas.(1)

Ocular and orbital involvement in this pathology is rare. Published articles mention retinal changes due to the state of hypercoagulability, extraconal masses (plasmocytomas), and ciliary body and iris cysts.

The objective of the present study is to report the case of a patient with previous diagnosis of MM, whose development proceeded with intraconal plasmacytoma in the right eye, as well as mass in the anterior chamber suggestive of uveal infiltration secondary to the underlying disease. There are no reports in the literature of cases similar to those presented in the present study.

cAse RepoRt

E.N.O., 63, female, white, was admitted to the emergency department of Ophthalmology at Irmandade Santa Casa de Misericórdia de Santos, Brazil, complaining of low visual acuity (LVA) in the right eye (RE) initiated one day before of the appointment, preceded by diplopia, unilateral headache and increased RE volume three days before.

She had a history of multiple myeloma (MM) diagnosed in December 2015, and underwent five chemotherapy sessions with velcade, cyclophosphamide and zometa in April 2016.

At the time of the appointment, she was taking acyclovir 200mg and antidepressant medications.

The patient had exams corroborating the diagnosis of MM: bone scintigraphy with 99m-Tc with heterogeneous uptake in the skullcap, thoracic and lumbar columns, basal bones and proximal thirds of the femurs; magnetic resonance imaging (MRI) of the pelvis with expansive lesion in the anterior region of the left iliac bone, with soft parts component, measuring 5.0x4.8cm and multiple scattered nodular lesions in the basin bones; myelogram with 35% of plasma cells with moderate degree of atypia (Table 1A); protein electrophoresis with a monoclonal component migrating in the gamma globulin region (Table 1 B).

The ophthalmologic exam showed uncorrected visual acuity (VA) in the RE with no light perception (NLP) and in the left eye (LE) of 20/200 in the Snellen table (the patient had cataract, without improvement with correction in the LE); intraocular pressure (IOP) of 10 mm Hg in both eyes.

Ectoscopy showed proptosis in the RE and change of ocular movement in several positions, mainly at abduction of the RE (Figure 1).


Table 1 Lab exams

A - Myelograml

Puncture: sternal

Celularity: slightly increased

Leuco/erythroblasts: 4,0Red series: moderate hypoplasia, predominance of orto and polycromatic erythroblasts, deviation to the right, discrete anisocytosis.

Granulocyte series: discrete neutropenia with mild deviation to the right; relative basophilia. No evidence of eosinophils or atypia.

Lymphocytes and plasma cells: about 35% nucleated elements are plasma cells with moderate atypia. Some cell nests and rare Mott cells.

Megalocytic series: normoplasia.

B - Protein electrophoresis

Total proteins: 10.6 g/dLAlbumin/globulin: 0,72Albumin: 4.44 g/dLAlpha 1 globulin: 0.29 g/dLAlpha 2 globulin: 1.08 g/dLBeta 1 globulin: 0.43 g/dLBeta 2 globulin: 0.20 g/dLGamma globulin: 4.16 g/dL

Figure 1: A) showing the right eye proptosis; B) with change of the ocular movement of right eye.

Biomicroscopy of the RE showed the presence of a vascularized mass in a lower iridocornean angle, causing corectopia. Fundoscopy was within the normal range in both eyes.

The patient was hospitalized at the ophthalmology care unit for sudden LVA investigation. Computed tomography (CT) of the skull and orbits was performed, presenting a soft tissue density mass with limits partially defined in the right intraconal projection without cleavage plane measuring 2.6x1.3cm (Figure 2A); and MRI of the skull and orbits showing a right retro-orbitary expansive lesion measuring 3.6cm, which conditioned the optic nerve medial displacement and proptose of the ocular globe (Figure 2B).

Maganhoto APS, Correia S, Pasquarelli Neto RI

45Intraconal plasmocytoma and uveal infiltration in a patient with multiple myeloma

Ultrasonic biomicroscopy of the RE (figure 3) was performed, showing inferior hernoma, 360º narrow angle, anterior synechia, topical crystalline and uveal infiltrate invading the anterior chamber. Ultrasonography of the RE revealed a tumor in the region of intraconal orbital fat, with no evidence of direct intraocular invasion.

The head and neck surgery team performed endonasal biopsy of the intraconal lesion. Histopathology revealed small cell neoplasm with invasion of skeletal and muscular tissue, and immunohistochemistry was compatible with infiltration by multiple myeloma / plasmacytoma (CD138 and CD99 positive).

Patients and their families were advised for visual prognosis. The patient was referred to the hematology sector for treatment of the underlying disease, restarting chemotherapy with cyclophosphamide, bortezomid and dexamethasone. We chose not to surgically intervene in the ophthalmologic lesions due to the patient’s clinical condition, absence of symptoms (such as pain) and lack of possibility of visual rehabilitation in the RE (vision with NLP). We did not biopsy the lesion in the anterior chamber for the same reasons.

Figure 2: A) superior: tomography of orbits with intraconal mass on the right; B) inferior: magnetic nuclear resonance of orbits with right intraconal mass.

Figure 3: Ultrasonic right-sided biomicroscopy.

dIscussIon

The irreversible proliferation of a clone of plasma cells producing monoclonal immunoglobulin in the bone marrow is characterized as a neoplasm of plasma cells. This can occur in two forms: an isolated lesion called plasmacytoma, or multiple lesions known as multiple myeloma (MM).(1)

Plasmacytomas are histologically similar to MM, and may be bony (solitary bone plasmocytoma) or soft tissue (extracellular plasmacytoma).(1)

MM represents 1% of malignant neoplasms and 10% of hematological neoplasms in the United States. Its incidence is 4:100.000.(2) Epidemiologically, it is discreetly more frequent in men over 50 years and black. It presents as multiple osteolytic lesions, impairment of bone marrow function, and production and release of monoclonal protein into the bloodstream.(2-5) These changes cause skeletal changes (bone pain, fractures, hypercalcemia), normocytic and normochromic anemia (fatigue, weakness), renal insufficiency, infections, thrombocytopenia, amyloidosis (in 10% of cases) and extramedullary plasmacytomas.(2,5)

The diagnosis is made by bone marrow biopsy with more than 10% of plasma cells or presence of plasmacytoma and at least one of the following: M monoclonal protein in serum or urine; osteolytic lesions (by activation of osteoclasts).(3) The presence of hypercalcemia, renal failure and lesions related to plasma cell proliferation corroborate the diagnosis. (6) Anemia in this disease occurs due to decreased erythropoiesis.

The patient in the case discussed already had a previous diagnosis of MM, with a myelogram showing 35% of plasma cells with a moderate degree of atypia and imaging tests showing bone lesions.

Ocular and orbital involvement is uncommon in this type of neoplasm. The ocular findings described in the literature are iris and ciliary body cysts, plasmacytoma in the lacrimal gland and vascular alterations in the retina(3,7) due to the state of hypercoagulability. Involvement of the orbit is rare, but may occur in three ways: isolated plasmacytoma, extramedullary plasmacytoma (usually from the paranasal s inuses) and orbital involvement, being the cl inical manifestations most found in these cases the proptosis and alteration of the ocular movement.(3,6) The onset of an orbital lesion in a patient with MM already treated suggests recurrence of the lesion and insufficient chemotherapy. The most common site of orbital mass is extraconal, superior temporal. (6) Uveal infiltration by MM is very rare.

In the case reported, the patient presented two ophthalmological manifestations: intraconal plasmacytoma related to the underlying disease, and a mass of uveal infiltrate in the anterior chamber which we can infer to have direct relation with the same due to the history and progression of the MM. In the literature, we did not find other studies correlating two lesions from the MM in a single patient, nor did we find an intraconal mass description, as discussed in the present study.

The patient presented was followed by the hematology team without surgical treatment by the ophthalmology team, since the right eye had no visual prognosis or symptoms, and therefore did not require intervention at the time.


46

RefeRences

1. Cardoso I, Secioso P, Moreira, M. Plasmocitoma solitário ósseo. Relato de caso. RevBrasClin Med. 2010;8(2):183-6.

2. Goldman L, Ausiello D. Cecil: Tratado de Medicina Interna. 23aed. Rio de Janeiro: Elsevier; 2010.

3. Pinho AR, Pinho EA, Alessandri EF, Pereira LS. Tumor orbitário como primeira manifestação clínica de mieloma múltiplo: relato de caso.ArqBras Oftalmol. 2009;72(1):106-8.

4. Silva RO, Brandão KMA, Pinto PVM, Faria RMD, Clementino NCD, Silva CMF et al. Mieloma múltiplo: características clínicas e laboratoriais ao diagnóstico e estudo prognóstico. RevBrasHematolHemoter. 2009; 31(2):63-8.

5. Klaus DG, Carvalho DC, Baldessar MZ. Caso clássico de mieloma múltiplo: uma revisão. ACM ArqCatarin Med. 2009; 38(4): 110-3.

Corresponding author: Ana Paula da Silva Maganhoto Dr. Claudio Luis da Costa, 50, Jabaquara - Department of Ophthalmology – Irmandade de Santa Casa de Misericórdia de Santos - Santos (SP) – 11075-900 Phone No.: +55 13 3202-0600 E-mail: [email protected]

6. Gentile MC, Vigo RR, Basso TO, Fantl D. Compromisoorbitarioenmielomamúltiple. OftalmolClin Exp. 2010: 3(4):151-54

7. Romero IL, Campos FA, Damsceno RW, Vital Filho J, Bison SH. Plasmacytoma of the orbit involving lacrimal gland with secondary transformation into multiple myeloma: case report. Arq BrasOftalmol. 2009;72 ;(2):236-8.


Maganhoto APS, Correia S, Pasquarelli Neto RI

47case repOrt



Rev Bras Oftalmol. 2018; 77 (1):47-9

Neuropatia óptica tóxica por inalação de metanol

Optic neuropathy toxic after methanol inhalation

Frederico Gustavo Telles e Souza1, Vanessa Veloso Eleutério Nogueira2, Luana Inostrosa Maynart 2, Rafael Leite de Oliveira2, Thatiane Célia dos Santos Mendonça3, Pablo Dias Oliveira3

1 Santa Casa Olhos, Montes Claros, MG, Brazil. 2 Faculdades Integradas Pitágoras, Montes Claros, MG, Brazil. 3 Faculdades Integradas do Norte de Minas, Montes Claros, MG, Brazil.

AbstrAct

The methanol toxicity is considered rare event , especially when taken by inhalation . It was portrayed in the present study a case report of a patient who developed toxic optic neuritis after exposure to methanol and acetic acid by inhalation in the workplace . It was described for the therapies from the literature as well as the clinical manifestations and management in this patient.

Keywords: Methanol/adverse effects; Methanol/poisoning; Optic neuritis/chemically induced; Case reports

Resumo

A intoxicação por metanol é um evento considerado raro, principalmente quando feita por via inalatória. Retratou-se neste presente estudo um relato de caso de um paciente que desenvolveu neurite óptica tóxica após exposição ao metanol e ácido acético por via inalatória em seu ambiente de trabalho. Foi descrito sobre as terapias obtidas na literatura, bem como as manifestações clínicas e o manejo a este paciente.

Descritores: Metanol/efeitos adversos; Metanol/envenenamento; Neurite óptica/induzida quimicamente; Relato de casos

48

IntRoductIon

Methanol is a volatile alcohol used commercially in a wide variety of products, and may have inhalation, ingestion and absorption by the skin a routes of entry into the

human body. The toxicity caused by this substance is interlinked with its metabolites, mainly formic acid. (1) Several symptoms and signs may arise, with the most common ones being related to the central nervous system, the eyes and the gastrointestinal tract. (2) Among the clinical manifestations and alterations that occur are confusion, ataxia, visual impairment, metabolic acidosis, brain injury and even death. (3) Visual changes may range from blurred vision and visual field deficits to total blindness(4) associated to headache, nausea, vomiting, and dizziness. The ocular toxicity caused by formic acid worsens acidosis, which allows a greater spread of formic acid in the cells, causing optic disc edema, dysfunction of the myelin sheaths, and injury of the optic nerve. (2)

We reported a case of a patient with intoxication due to accidental inhalation of methanol due to labor exposure. The early detection of the symptomatology and the institution of the therapy allowed a favorable development of the clinical condition.

cAse RepoRt

Patient G. A. R. S, male, 43 years old, born in Montes Claros, MG, laboratory instructor. He reports being exposed to methanol and acetic acid solution for four consecutive mornings, and consequently inhaling these substances during labor activities. He was admitted at the emergency with a significant reduction of visual acuity, paresis of lower limbs, generalized paraesthesia, vomiting and general malaise. As a pathological antecedent, he reported only poorly controlled systemic arterial hypertension. He had arterial gasometry and acidotic respiratory pattern: Ph: 7.05, PCO2 11 and HCO3 3.0.

Due to the unavailability of the antidote Fomepizol or ethanol, 40 ml of Whiskey was administered orally every 4h, with sodium bicarbonate and vigorous venous hydration. After four days of stabilization of the clinical condition, the patient was admitted to the ophthalmology department with significant low visual acuity and bitemporal scotoma. Figure 1 shows the progression of automated campimetry for central scotoma. He presented corrected visual acuity of 20/400 in the RE and 20/200 in the LE at the first examination. The retinal mapping exam showed margins of the optic disc with inaccurate limits, peridiscal flame shaped hemorrhages in both eyes.

Fluorescent angiography (Figure 2) revealed hyper-fluorescence due to superficial and deep optical disk extravasation in the intermediate and late phases, hypofluorescence due to blockage corresponding to superficial retinal hemorrhage points, the and macula was preserved in both eyes. Color and redfree retinography (Figure 3) after 45 days of development showed excavation progression and significant pallor of the optic nerve. MRI of the orbits was requested (Figure 4), and presented a focus of enhancement in the distal orbital portion of the optic nerve bilaterally, suggesting toxic optic neuritis by methanol.

The patient was referred to the neurology service to continue the treatment. Initially, weekly doses of intramuscular injectable B complex were given. After 30 days of treatment, the patient showed significant improvement of vision to 20/40 in the RE and 20/30 in


the LE. However, funduscopy revealed diffuse pallor of the optic nerve and visual campimetry with tubular constriction in both eyes.

Figure 4: Nuclear magnetic resonance

Figure 1: Automated campimetry performed within 45 days.

Figure 2: Angiography 04/12/2016

Figure 3: Red Retinography and Red Freee 05/25/2016

Souza FGT, Nogueira VVE, Maynart LI, Oliveira RL, Mendonça TCS, Oliveira PD

49Optic neuropathy toxic after methanol inhalation


dIscussIon

The vast majority of methanol intoxications are due to their ingestion, and the other forms are considered rare. (5) However, when it comes to labor exposure, inhalation is the most important route, as the patient reported, followed by absorption through the skin. Given this, it is worth mentioning that in the case of labor exposure it can be prevented by the proper use of Personal Protective Equipment (PPE). Serious intoxications with a high mortality rate are always present. (8,9)

The specific diagnosis of methanol intoxication is given by the measurement of this alcohol in the blood. However, such practice is not available in the clinical routine. In the absence of clinical history, the diagnosis is supported by acidemia with Gap anion and increased osmolar Gap, that is, the osmolality measured is greater than the one calculated.(10) In the patient above the diagnosis was facilitated by the clinical history and characteristic laboratory findings.

The recommended dose is 0.6 to 0.8 g/kg IV, maintaining 130 mg/kg/hour or 10 g/hour, with 1 ml of 100% ethanol being equal to 0.8 g.

It is also possible to use Fomepizol (4-methylpyrazole) to delay the production of toxic metabolites. Although more expensive, this drug should replace the use of ethanol, particularly in cases involving children or people with pancreatitis, and also when there is no laboratory support for a rapid determination of the blood levels of ethanol (for monitoring of the treatment). In addition, ethanol has a higher risk of adverse effects, such as hypoglycemia. The loading dose is 15 mg/kg, followed by 4 doses of 10 mg/kg every 12 hours, and then 15 mg/kg every 12 hours, always via IV in a 30-minute infusion until the serum levels of methanol are below 20mg/dl.

Other measures include favoring the metabolism of the already formed toxin with the administration of folinic acid, which increases the elimination of formic acid (50 to 75 mg every 4 hours, IV for 24 hours).(11) 4-methylprednisolone is a competitive inhibitor of alcoholic dehydrogenase as alternative oral therapy. (12) Correction of acidosis with sodium bicarbonate using 1 to 3 mEq/kg, IV, reducing visual changes in order to hinder the penetration of formic acid in the CNS. In severe cases, hemodialysis to remove methanol and toxic metabolites that are circulating.

As mentioned, in this case the alternative oral administration of 40 ml of whiskey every 4 hours is instituted to mimic the effect of ethanol and compete with formic acid for the affinity with the alcoholic dehydrogenase enzyme, along with the use of sodium bicarbonate for correction of acidosis. Despite the slight change of the standard treatment, the clinical development was satisfactory, considering the improvement of symptoms and stabilization of the laboratory findings.

The initial treatment proposal consisted of multidisciplinary and psychological support, since the patient’s work capacity was drastically impaired by the deleterious effects on the visual system and the peripheral nervous system.

The weekly follow-up at the ambulatory was fundamental for clinical support. Progressive visual loss was important, and the campimetric restriction was greatly reduced in both eyes due to peripheral scotoma. The visual acuity developed to improvement in contrast to 20/40 in both eyes with better correction.

RefeRences

1. Christopher SL, Bradley LD, Jerrold BL. Fatality after inhalation of methanol-containing paint stripper. Clin Toxicol (Phila). 2015; 53(4):411.

2. Barceloux DG, Bond GR, Krenzelok EP, Cooper, Vale JA. The American Academy of Clinical Toxicology Ad Hoc Committee on the Treatment Guidelines for Methanol Poisoning. Clin Toxicol (Phila). 2002; 40(4):415–46.

3. Ernstgard L, Shibata E, Johanson G. Uptake and disposition of inhaled methanol vapor in humans. Toxicol Sci. 2005; 88(1):30–8.

4. Givens M, Kalbfleisch K, Bryson S. Comparison of methanol exposure routes reported to Texas Poison Control Centers. West J Emerg Med 2008; 9(3):150-5.

5. Badolato ESG, Duran MC. Risco de intoxicação por metanol pela ingestão de bebidas alcoólicas. Rev Psiquiatr Clín. 2000; 27(2):90-2.

6. Nogué S, Marruecos L. Guía clínica para eltratamiento de lasintoxicaciones por metanol y etilenglicol. Indicacionesdelfomepizol. Reunión de Consenso. Barcelona; 2006.

7. Trujillo M, Pérez OL, Cerdeiriña DZ, Xarau MN, Junyent SG, Munné Mas JM. Tratamiento com fomepizol de una intoxicación aguda por metanol. Ver Toxicol. 2004; 21(1):41-3.

8. Castellanos JL, Limón AB, Hernández AR, Rojas DEF. Intoxicación por metanol, reporte de un caso. Arch Med Urgencia México. 2009; 1(2):67-73.

9. Krause IA. Metanol poisonings. Inensive Care Med. 1992; 18(7): 391-7.

10. Barceloux DG, Bond GR, Krenzelok EP, Cooper, Vale JA. The American Academy of Clinical Toxicology Ad Hoc Committee on the Treatment Guidelines for Methanol Poisoning. Clin Toxicol (Phila). 2002; 40(4):415–46.

11. Rezende CS, Rezende WW. Intoxicações exógenas. Rev Bras Med. 2002; 59(1/2):17-25.

Corresponding author: Frederico Gustavo Telles e Souza E-mail: [email protected]

50 relatO de casO




Retinopatia vaso-oclusiva por lúpus eritematoso sistêmico associada à síndrome do anticorpo antifosfolipídeo

Vaso-occlusive retinopathy by systemic lupus erythematosus associated with the

antiphospholipid antibody syndrome

Bruna Costa Monteiro Hadler¹, Humberto Borges²

1 Residency Program in Ophthalmology, Centro de Referência em Oftalmologia, Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, GO, Brazil. ² Department of Retina and Vitreous, Centro de Referência em Oftalmologia, Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, GO, Brazil.

Study carried out at Centro de Referência em Oftalmologia of Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, GO, Brazil.

AbstrAct

To report the case of a patient with vaso-occlusive retinopathy due to systemic lupus erythematosus (SLE) associated with antiphospholipid antibody syndrome (APAS), which started with signs and symptoms of autoimune hemolytic anemia accompanied by sudden monocular visual loss. Few cases of SLE manifestation primarily involving ocular changes have been reported in the Brazilian and international literature. Screening for antiphospholipid antibodies is of the greatest importance for patients with lupus retinopathy, so that immediate therapy with anticoagulants may be instituted in order to prevent vascular thrombosis, which worsens the visual prognosis.

Keywords: Lupus erythematosus, systemic; Antiphospholipid syndrome; Antibodies; Anemia, hemolytic, autoimmune; Case reports

Resumo

Relatar um caso de paciente com Retinopatia vaso-oclusiva por Lúpus Eritematoso Sistêmico (LES) associado à Síndrome do Anticorpo Antifosfolipídeo (SAF), que se iniciou com um quadro de anemia hemolítica autoimune acompanhado por baixa visual súbita monocular. Poucos casos foram descritos na literatura nacional e mundial em que o LES se manifeste primeiramente com alterações oculares. O screening dos Anticorpos antifosfolípideos (APAs) é de suma importância para pacientes com retinopatia lúpica para que seja instituída a terapia imediata com anticoagulantes como forma de prevenir a trombose vascular, o que piora o prognóstico visual.

Descritores: Lúpus eritematoso sistêmico; Síndrome antifosfolipídica; Anticorpos; Anemia hemolítica autoimune; Relatos de casos

51

IntRoductIon

Systemic Lupus Erythematosus (SLE) is an autoimmune, multisystemic disease which may affect any part of the human body, including the eye. SLE affecting the eye may reflect the systemic activity of the disease, and thus take to the search of other body systems that might have been affected.(1)

The Antiphospholipid Antibody Syndrome (AAS) is an autoimmune disease defined by the presence of antiphospholipid antibodies (APA) along with a clinical manifestation of the disease: arterial/venous thromboses and recurrent fetal loss.(2) Despite the recurrent condition of arterial and/or venous thrombosis, other findings may be seen, such as: false VDRL and thrombocytopenia.(3) APA affect the segments of the blood vases over the body and may lead to hypercoagulability.(4) Ocular affection is most frequently manifested with the occurrence of retinal thrombosis, mainly among the youngsters.(5)

According to recent studies, AAS occurs in 34% 42% of SLE patients.(6) Retinal vascular occurrence will depend on the patient having or not APA associated to SLE.(6) As an example, retinal vascular occlusion is more frequent in APA patients (13.9%) than in those without APA (0.9%). Occurrences with extra ocular thrombosis in lupus patients with APA were 69.2% of cases compared to 22.8% without APA.(7)

SLE complications developing to a worse visual prognosis include occlusion of the central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), retinal displacement (RD), vaso-occlusive retinopathy, and occurrence of the optic nerve with isquemic optic neuropathy and optic neuritis.(1)

The presence of APA is a risk factor for a worse ocular prognostic.(8)

The objective of the present study is to report the case of a patient with vaso-oclusive retinopathy by SLE associated to AAS with the first manifestation being sudden low vision of the left eye associated to symptoms characteristic of autoimmune hemolytic anemia. The patient was admitted to the Rheumatology Department of Hospital das Clínicas (HC) of Goiânia to investigate the cause of hemolytic anemia along with the investigation by Centro de Referência em Oftalmologia (CEROF) to evaluate sudden visual loss, with the correct diagnosis and anticoagulation being performed.

cAse RepoRt

Female patient, 24 years old, white, from the State of Goiás, during her second day of hospitalization at the Rheumatology service of HC de Goiânia, requested the ophthalmology service of the hospital to assess her complaint of sudden low vision of the left eye since the first day of hospitalization. She was hospitalized due to a strong asthenia for a week, along with epigastric pain. She had isolated episodes of fever (37.6°C), besides dark-color urine and light feces. She was investigating a condition of autoimmune hemolytic anemia. She denied having thrombosis of other systems, and had never tried to get pregnant. She received a transfusion of 2U of red blood cells bag two months before, and presented jaundice 3+/4+. Her family history included one sister with AAS and amaurosis fugax for four years and one cousin with SLE. The physical examination of the abdome showed hepatosplenomegaly and at ectoscopy only yellowish sclera. Biomicroscopy and intraocular pressure of both eyes were


normal. The fundoscopy of the right eye (RE) showed intra-retinal hemorrhages and associated roth spots, and the left eye (LE) showed pre and intra retinal hemorrhages in the 4 quadrants and peridiscal candle flame-shaped hemorrhage, in addition to diffuse roth spots. Corrected VA was RE 1.0 and LE 0.1. We requested colored (Figure 1) and fluorescent (Figure 2) retinography, OCT (OpticalCoherenceTomography) of the macula (Figure 3) as soon as she came to the service.

Laboratory exams carried out at the Rheumatology service showed anemia (Hb: 10.3 g/dL), thrombocytopenia (143,000), positive direct coombs, anticardiolipin (IgM = 70.01), lupus anticoagulant (1.6), VDRL: 1/64 and FtA-Abs negative (false positive), hematic cylinders in the urinary sediment. Besides that, after the fifth day of hospitalization the patient complained of arthralgia and alopecia. Thus, laboratory and clinical tests proved the presence of SLE associated to AAS. The patient was subjected

Figure 3: OCT of the macula of the right eye (no changes) and left eye with macular edema, entra-retinal cysts and hyperreflective points compatible with exsudates, respectively.

Figure 1: Retinography of the right eye (A) and left eye (B).

Figure 2: Fluorescent retinography of the right eye (A) and left eye (B)

Vaso-occlusive retinopathy by systemic lupus erythematosus associated with the antiphospholipid antibody syndrome

52


to pulse therapy since the first day of hospitalization with 1g of methylprednisolone/day for 3 days for hemolytic anemia, and then continued with prednisone (1g/kg) in immunosupressive dose. Besides, oral therapy with Warfarin 5 mg 1x/day was used as anticoagulation for AAS and hydroxychloroquine 400mg/day for SLE. After a week, as there was no improvement of the VA and macula edema seen in the OCT of the LE, 10 mg of subtenonian triamcinolone were precribed. Ten days after the subtenonian injection of triamcinolone, the VA of the LE changed to 0.2 (improvement of 2 lines in the Snellen table), and a new colored retinography was performed (Figure 4), showing changes only in the left eye with areas of subtenonian hemorrhage.

The condition was followed up, two months later the macula edema was completely cured in the OCT (Figure 5), and the VA of the LE evolved to 0.6.

In addition, the hemorrhage areas of both eyes disappeared. Anticoagulation was kept with warfarin 5mg/day, hydroxychloroquine 400 mg/day and dose regression of prednisone to 10 mg/day to estibilize the disease from the systemic point of view.

dIscussIon

The incidence of SLE varies from 1.8 to 20 or more cases per 100,000 individuals per year. Of these patients, from 80% to 90% are childbearing-age women of about 30 years of age, as in the case described.(9)

SLE may affect various structures of the eyes and annexes, with no preference for the anterior or posterior segment.(1) The ocular occurrence of SLE, despite less frequent, may be the first manifestation of the disease.(10) The most frequent retinal findings are: cottony exudates, retinal hemorrhages and vascular tortuosity.(11,12)

In the presence of antiphospholipid antibodies, there is a greater tendency to hypercoability of systemic blood vases and the onset of retinal thrombosis(5), as described in the patient studied. Such antibodies are also associated to a greater severity of retinopathy and vascular occlusion in the lupus patient.(2)

Figure 4: Retinographies of the right (A) and left (B) eyes 10 days after the subtenonian injection of triamcinolone.

Figure 5: OCT of the macula of the left eye (with the cure of the condition).

Besides, Ermakovaet al. associated amaurosis fugax and essential hypertension to episodes of vascular occlusion in SLE.(7)

In the presence of antiphospholipid antibodies, anti-coagulation with warfarin is important in the secondary prevention of new episodes of thrombosis, in addition to allowing a better visual prognosis. Thus, it must be done in long term.(13)

However, aspirin and immunosuppressive agents do not yet have scientific evidence for such prophylaxis.(14)

Thus, in the case described, we preferred to institute the therapy only with warfarin 5mg per day, maintaining the medication even after the improvement of the patient’s clinical and ocular condition as a way of avoiding recurrences.

Bajwa et al. report that in case of retinal vasculitis it is also necessary to use infusion of methylprednisolone as an emergency treatment. And also, there are patients in need of therapy with a daily dose of oral corticosteroids. And in case the oral corticosteroid therapy lasts a long time, immunosuppressive agents such as azathioprine and cyclophosphamide must be used.(15)

Subtenonian deposition corticosteroids (triamcinolone acetate) are widely used for the treatment of ocular inflammatory conditions which are refractory to topical and systemic corticoid treatment.(16)

The use of the subtenonian pathway leads to increased intraocular concentration of the drug by transcleral absortion, allowing the reduction of the systemic therapy and minimizing the side effects of the prolonged corticotherapy.(17)

The main indications for this route of administration of corticosteroids are the low visual acuity associated to chronic intravitreal inflammation and/or the presence of cystoid macular edema.(18) The improvement of visual acuity after this type of treatment varies from 65 to 85%,(17) and is an effective treatment for low visual acuity secondary to retinal vasculitis.(18)

In this case, subtenonian triamcinolone was used as the VA was stable to improve the macular edema, intra-retinal cysts, and above all the VA of the LE.

We conclude that the case report on the development of the clinical case and visual prognosis with the adequate therapy in patients with vaso-occlusive retinopathy for Systemic Lupus Erythematosus associated to the Antiphospholipid Antibody Syndrome helps improve the treatment of similar cases in the ophthalmology services in the country. Thus, it is extremely valuable to carry out studies on the subject, since the visual prognosis in patients with antiphospholipid antibodies associated to lupus retinopathy is still low.

RefeRences

1. Arevalo JF, Lowder CY, Muci-Mendoza R. Ocular manifestations of systemic lupus erythematosus. Curr Opin Ophthalmol. 2002;13(6):404-10.

2. Durrani OM, Gordon C, Murray PI. Primary anti-phospholipid antibody syndrome (APS). Surv Ophthalmol. 2002;47(3):215-38.

3. Provenzale JM, Ortel TL. Anatomic distribution of venous thrombosis on patients with antiphospholipid antibody: imaging findings. AJR Am J Roentgenol. 1995;165(2):365-8.4. Giordano N, Senesi M, Battisti E, Traversi C, Mattii G, Palumbo

F, et al. Antiphospholipid antibodies in patient with retinal vascular occlusion. Acta Ophthalmol Scand. 1998;76(1):128-9.

5. Hartnett ME, Laposata M, Van Cott E. Antiphospholipid antibody syndrome in a six-year-old female patient. Am J Ophthalmol.

2003;135(4):542-4.

Hadler BCM, Borges H

53Vaso-occlusive retinopathy by systemic lupus erythematosus associated with the antiphospholipid antibody syndrome


6. Galli M, Luciani D, Bertolini G, Barbui T. Lupus anticoagulants are stronger risk factors for thrombosis then anticardiolipin antibodies in the antiphospholipid syndrome: a systematic review of the literature. Blood. 2003;101(5):1827-32.

7. Ermakova NA, Alekberova ZS, Reshetniak TM, Kalashnikova LA, Kosheleva NM. [Retinal vascular lesions in systemic lupus

erythematosus and secondary antiphospholipid syndrome]. Vestn Oftalmol. 2005;121(5):31-6. Russian.

8. Asherson RA, Mony P, Acheson JF, Harris EN, Hughes GR. Antiphospholipid syndrome: a risk factor for occlusive ocular vascular disease in systemic lupus erythematosus and the primary antiphospholipid syndrome. Ann Rheum Dis.1989;48(5):358-61.

9. Nguyen QD, Foster CS. Systemic lupus erythematosus and the eye. Int Ophthalmol Clin. 1998;38(1):33-60.

10. Davies JB, Rao PK. Ocular manifestations of systemic lupus erythematosus. Curr Opin Ophthalmol. 2008;19(6):512-8.

11. Ushiyama O, Ushiyama K., Koarada S. Retinal disease in patients with systemic lupus erythematosus. Ann Rheum Dis. 2000;59(9):705-8.

12. Coppeto J, Lessel S. Retinopathy in systemic lupus erythematosus. Arch Ophthalmol. 1977;95(5):794-7.

13. Hong-Kee N, Mei-Fong C, Azhany Y, Zunaina E. Antiphospholipid syndrome in lupus retinopathy. Clin Ophthalmol. 2014;8:2359-63.

14. Au A, O’Day J. Review of severe vaso-occlusive retinopathy in systemic lupus erythematosus and the antiphospholipid syndrome: associations, visual outcomes, complications and treatment. Clin Experiment Ophthalmol. 2004;32(1):87-100.

15. Bajwa A, Foster FC. Ocular manifestations of systemic lupus erythematosus. J Clin Cell Immunol. 2014; 5:191. doi: 10.4172/2155-9899.1000191.

16. Helm CJ, Holland GN. The effects of posterior subtenon injection of triamcinolone acetonide in patients with intermediate uveitis. Am J Ophthalmol. 1995;120(1):55-64.

17. Mueller AJ, Jian G, Banker AS, Rahhal FM, Capparelli E, Freeman WR. The effect of deep posterior subtenon injection of corticosteroides on intraocular pressure. Am J Ophthalmol. 1998;125(2):158-63.

18. Finamor LP, Dimantas MAP, Campos VE, Prata Jr JA, Muccioli C. Efeitos da injeção subtenoniana posterior de corticóide em pacientes com uveíte. Arq Bras Oftalmol. 2003; 66(3):289-91.

Corresponding author: Bruna Costa Monteiro Hadler Centro de Referência em Oftalmologia do Hospital das Clínicas da UFG, 1ª Avenida, 355-447 - Setor Leste Universitário,Goiânia-GO, Brazil ZIP:74605-020 E-mail: [email protected]

54


case repOrt


Pseudoxantoma elástico

Pseudoxanthoma elastic

Luiza Pinto Lindenberg Braga1

1 Centro Oftalmológico do Iguaçú, Nova Iguaçu, RJ, Brazil; Universidade do Grande Rio, Rio de Janeiro, RJ, Brasil.

AbstrAct

The pseudoxanthoma elasticum is a generalized disease of the connective tissue involving the skin, eyes and cardiovascular system triggering the fragmentation and calcification of elastic fibers. Usually occurs after puberty, the manifestations characteristics are small spots, circumscribed, yellowish, located on the neck, axilla and inguinal folds. Angioid streaks in the retina, tendency to hemorrhage and arterial insufficiency are the most common complications. This disease can be inherited as autosomal dominant or recessive. The treatment of ocular manifestations is through the conventional phototherapy laser preventing the occurrence of local hemorrhages. However, new therapeutic approaches are being developed as the long-term use of drugs antiangiogenic, which act by inhibiting the ocular neovascularization. Despite not having yet effectively replaced the original treatment, recent research already show benefits of new technique. The objective of this study is to report on a case of a patient of 37 years, the carrier of the Pseudoxanthoma Elasticum, with angioid streaks and ocular hemorrhage, and the effective treatment with antiangiogenic therapy at the clinic of Ophthalmology in Nova Iguaçu, Rio de Janeiro.

Keywords: Pxeudoxantoma elastic, angioid streaks; Antiangiogenic therapy; Ocular manifestations; Connective tissue disease; Eye diseases; Case reports

Resumo

O pseudoxantoma elástico é uma doença generalizada do tecido conjuntivo envolvendo a pele, olhos e sistema cardiovascular desencadeando a fragmentação e calcificação das fibras elásticas. Geralmente ocorre após a puberdade, as manifestações características são manchas pequenas, circunscritas, amareladas, localizadas no pescoço, axila e pregas inguinais. Estrias angioides na retina, tendência à hemorragia e insuficiência arterial são as complicações mais comuns. Esta doença pode ser herdada como autossômica dominante ou recessiva. O tratamento das manifestações oculares convencional é através da fototerapia a laser impedindo a ocorrência de hemorragias locais. Entretanto, novas abordagens terapêuticas estão sendo desenvolvidas como a utilização em longo prazo de drogas antiangiogênicas, as quais atuam inibindo a neovascularização ocular. Apesar de não ter ainda efetivamente substituído o tratamento original, pesquisas recentes já evidenciam benefícios da nova técnica. O objetivo deste estudo é relatar sobre o caso de uma paciente de 37 anos, portadora do pseudoxantoma elástico, com estrias angioides e hemorragia ocular, e o tratamento eficaz com a terapia antiangiogênica no ambulatório de oftalmologia em Nova Iguaçu, Rio de Janeiro.

Descritores: Pxeudoxantoma elástico; Estrias angioides; Terapia antiangiogênica; Manifestações oculares; Doença de tecido conjuntivo; Oftalmopatias; Relatos de casos.

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IntRoductIon

Pseudoxanthoma Elastic is an extremely rare and hereditary disease concentrated in the connective tissue characterized by calcification of the elastic fibers, being responsible

for cutaneous, ophthalmological and vascular involvement.(1) Pseudoxanthoma elastic is low in the general population, with an undifferentiated frequency between men and women and a prevalence still uncertain. However, the variation was estimated in 1:25,000 - 1:100,000, being statistically more prevalent in South Africa.(2)

Although it is a hereditary disorder, a large number of patients do not present very evident or characteristic symptoms of the disease. However, non-pruritic plaques, low visual acuity and vascular alterations such as pulse asymmetry or angina pectoris are manifestations that already signal an important development of the disease, since it manifests slowly and gradually.(2)

Diagnosis can be made with the presence of ocular changes associated to skin changes, which may include biopsy of the injured region and the presence of the genetic mutation.(2)

The treatment for pseudoxanthoma is still not curative, only palliative of the several affected areas of the organism.(3)

This study aims to report a case of diagnosed pseudoxanthoma elastic followed and treated at Centro Oftalmológico de Iguaçu, in addition to presenting the ophthalmologic treatment methods and other areas of action of the disease that are currently being used by physicians.

cAse RepoRt

Female patient, 37 years old, white, single, merchant. Natural of and resident in the city of Rio de Janeiro (RJ) and patient of pxeudoxanthoma elastic in an asymptomatic form, however diagnosed 10 years ago. Since then, she has been regularly followed by physicians of three main specialties: cardiology, ophthalmology and dermatology. She denies other allergies, previous hospitalizations, previous surgeries or other comorbidities. Family history is not worth noting.

On 04/20/2015, the patient went to the ophthalmology office in Nova Iguaçu with urgency. At the appointment, she complained of low visual acuity in the left eye, which began one month before. On examination, there was a slight decrease in the visual acuity in the right eye 20/30, and a great decrease in the visual acuity in the left eye 20/80. Optical biomicroscopy of the anterior segment was normal, and tonometry showed 13/12 in the left eye. Fundoscopy showed angioid striae and hemorrhages in the temporal and juxtapupillary arcade in both eyes (which were not able to be evident in the image exam requested below). The decision was to request an angiofluoresceinography (fluorescence retinography) for a better and more detailed evaluation of the vascular changes observed in the retina. The exam was performed and showed the presence of mild angioid and “peau d’orange” striae in the right eye, in addition to the more exuberant angioid and drusen striae in the left eye.

The patient was then referred to the retina specialist who works at the clinic mentioned above, with the onset of treatment being recommended, and the one chosen was the antiangiogenic therapy with the drug Bevacizumab. The treatment started on 06/10/2014, and the patient already had a worsening of the image, as will be observed. For three consecutive months, intravitreal injections of Bevacizumab were given to the patient, which did

not show a significant improvement of the initial condition, and it can be demonstrated in the following images. In the first month, there were multiple angioid striae and hemorrhages still seen in the left eye. In the second month, even more striae were seen, but no improvement in the hemorrhagic area. At the third month of treatment, the exam still showed no regression of the ocular changes.

Unsatisfied with the result that the patient was presenting after three months of treatment with the vitreous injections of Bevacizumab, we discussed with the team and then chose to

Figure 1: Right eye showing mild angioid and “peau d’orange”.striae

Figure 2: Left eye showing more exuberant and drusen angioid striae.

Figure 3: Month 1: presence of multiple angioid striae and haemorrhages in the left eye


Pseudoxanthoma elastic

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continue with the antiangiogenic therapy as it was the current most promising treatment, but changing the drug used in the treatment, with Ranibizumab being then used. The patient had so far three intravitreal injections of Ranibizumab and showed a significant improvement of the initially presented clinical condition, with improvement of visual acuity - before it was 20/80 and now it is 20/40 - and imaging, as can be seen below, which demonstrates the importance of the early treatment with the right drug.

In the fourth month of treatment, after changing therapeutic drug, promising changes have already begun to be observed. A regression in the caliber of the preexisting angioid striae and mainly the control of the hemorrhagic foci. Were observed During the following month, the size of the striae reduced significantly, and the hemorrhage became even more devastating. In the last application, the changes observed continued to progress

Figure 4: Month 2: presence of more calibrated angioid striae and no improvement of the hemorrhagic condition.

Figure 5: Month 3: maintenance of angioid striae and hemorrhage

Figure 6: Month 4: mild decrease in the size of the striae and involution of the hemorrhagic condition.

satisfactorily, and the course of the ocular disease seems to have been controlled.

The patient is still under ophthalmologic follow-up at Centro Oftalmológico de Iguaçu, and has not yet taken the next intravitreal injection, and improvement is expected to be even more significant than what has been achieved so far.

Figure 7: Month 5: improvement of angioid striae already present, and important involution of the hemorrhagic foci.

Figure 8: Month 6: significant recovery of ocular changes and restraint of the appearance of new striae, approaching a normal retinography.

dIscussIon

As observed and described before, the patient reported presents exclusive clinical manifestations of ocular origin, being emphasized in this topic this specialty of treatment. The patient in question was treated with antiangiogenic therapy instead of the traditional laser photocoagulation, first using Bevacizumab and from the third session on using Ranibizumab, with satisfactory development in both cases, but presenting better results with the second drug.

For three decades, treatment with laser photocoagulation was the treatment of choice for choroidal neovascularization, especially in those with extrafoveal location.(4) Georgalas et al.(2) found that 73% of patients deteriorated vision after photocoagulation to the point of becoming legally blind. Clarkson et al.(5) observed the same visual results, but in all patients studied. In spite of this, photocoagulation showed recurrence rates of 77%, generally occurring in the first three months.(6)


Braga LPL

57Pseudoxanthoma elastic

Antiangiogenic therapy has been studied since 2014, and lesion stabilization, choroidal neovascularization, and even improvement of the patient’s visual acuity are expected if the treatment is initiated in the early diagnosis period.(7) This treatment is based on intravitreal injections with agents that inhibit endothelial and vascular growth factor, these agents being mainly Ranibizumab and Bevacizumab.(8) Comparing the two drugs, Ranibizumab has subconjunctival hemorrhage, mild ocular pain and scintillating scotomas as the most common side effects, and less than 1% of patients can develop them. After 2 years of injection, endophthalmitis, and systemic events were not significant, but it is a drug with a higher cost.(9) On the other hand, Bevacizumab is more likely to develop systemic effects, but it is still more widely used because of its low cost.(2,8)

In a case report study by Savastano et al.(10) it was possible to observe development in the treatment of ocular manifestations of the pseudoxanthoma elastic. In this case, a 54-year-old patient with a history of heart disease had visual loss in the right eye. Ophthalmologic exam revealed neovascularization and decreased visual acuity, and normal left eye, being diagnosed with angioid striae associated to pseudoxanthoma elastic. Treatment with intravitreal Bevacizumab once a month was discontinued due to lack of efficacy. After 9 months, the patient reported the same symptomatology in the left eye, and an ophthalmologic exam revealed the same diagnosis. Treatment in the left eye started with one a dose (one intravitreal Ranibizumab injection per month for a period of three months) followed by treatment. After 21 injections, the right eye showed deterioration of the retinal layer. The left eye had a small foveal scar, with other areas preserved. Finally, the visual acuity remained stable in the left eye, but deteriorated in the right eye. Therefore, the sight function was maintained, and the patient tolerated the treatment well over a period of 6 years, which in turn had pseudoxanthoma elastic and high cardiovascular risk. When compared to the administration of both drugs, the early use of Ranibizumab preserved moderate visual function, a result that was different in the right eye. As justification, we can observe the progression of the disease that was already in different stages in the eyes, suggesting that in order to achieve the best results antiangiogenic therapy should be started as soon as possible.

Another case report study by Savastano et al.(10) showed another 51-year-old patient using Ranibizumab as the treatment of choice for 5 years with complete stabilization of the disease by having 12 injections during the first year. Over the next 4 years, he received two additional injections only in cases of mild recurrence; in the left eye the vision remained stable. The patient was treated with a regimen other than Ranibizumab, and showed the efficacy of a regimen with longer interval time between doses.

conclusIon

Taking into account what was stated, we can conclude that although the diagnosis is difficult it should be made as soon as possible in order to avoid the irreversibility of the clinical consequences as shown above.

According to the articles studied, the treatment of ocular manifestations still needs to be better elucidated, since there is still a great difficulty in the choice of treatment, as there is no unanimity in which conduct is performed and that it is in fact effective in the long term. The greater difficulty in defining the treatment encompasses the very recent findings on antiangiogenic therapy, thus waiting for agreement on therapy to be defined from the results of future studies, since no comparative study could be found for treatment techniques.

RefeRences

1. Sherer DW, Bercovitch L, Lebwohl M. Pseudoxanthoma elasticum: significance of limited phenotic expression in parents of affected offspring. J Am Acad Dermatol. 2001; 44(3):534-7.

2. Georgalas I, Tservakis I, Papaconstaninou D, Kardara M, Koutsandrea C, Ladas I. Pseudoxanthoma elasticum, ocular manifestations, complications and treatment. Clin Exp Optom. 2011; 94(2):169-80.

3. Minelli L, Silva HC, Garcia RM, Pontello R, Santi E. Pseudoxantoma elástico: relato de caso. An Bras Dermatol. 1991;66(6):307-8

4. Offret G, Coscas G, Orsoni-Dupont C. Photo-coagulation des stries angioides aprés angiographie fluorescéinique. Arch Ophtalmol Rev Gen Ophtalmol. 1970; 30(5):419-22.

5. Clarkson JG, Altman RD. Angioid streaks. Surv Ophthalmol. 1982; 26(5):235-46.

6. Lim JI, Bressler NM, Marsh MJ, Bressler SB. Laser treatment of choroidal neovascularization in patients with angioid streaks. Am J Ophthalmol. 1993;116(4):414-23.

7. Adelberg DA, Del Priore LV, Kaplan HJ. Surgery for subfoveal membranes in myopia, angioid streaks, and other disorders. Retina. 1995;15(3):198-205.

8. Teixeira A, Moraes N, Farah ME, Bonomo PP. Choroidal neovascularization treated with intravitreal injection of bevacizumab (Avastin) in angioid streaks. Acta Ophthalmol Scand. 2006;84(6):835-6.

9. Pedersen R, Soliman W, Lund-Andersen H, Larsen M. Treatment of choroidal neovascularization using intravitreal bevacizumab. Acta Ophthalmol Scand. 2007;85(5):526-33.

10. Savastano MC, Minnella AM, Zinzanella G, Falsini B, Caporossi A. Successful long-term management of choroidal neovascularization secondary to angioid streaks in a patient with pseudoxanthoma elasticum: a case report. J Med Case Rep. 2014; 8:458.

Corresponding author: Luiza Pinto Lindenberg Braga E-mail: [email protected]


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Instruções aos autores

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Artigos de Periódicos:Dahle N, Werner L, Fry L, Mamalis N. Localized, central

optic snowflake degeneration of a polymethyl methacrylate intraocular lens: clinical report with pathological correlation. Arch Ophthalmol. 2006;124(9):1350-3.

Arnarsson A, Sverrisson T, Stefansson E, Sigurdsson H, Sasaki

H, Sasaki K, et al. Risk factors for five-year incident age-related macular degeneration: the Reykjavik Eye Study. Am J Ophthalmol. 2006;142(3):419-28.

Livros: Yamane R. Semiologia ocular. 2a ed. Rio de Janeiro: Cultura

Médica; 2003.

Capítulos de Livro:Oréfice F, Boratto LM. Biomicroscopia. In: Yamane R.

Semiologia ocular. 2ª ed. Rio de Janeiro:Cultura Médica; 2003.Dissertações e Teses:Cronemberger S. Contribuição para o estudo de alguns

aspectos da aniridia [tese]. São Paulo: Universidade Federal de São Paulo; 1990.

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vias lacrimais excretoras nos bloqueios funcionais ou síndrome de Milder. Rev Bras Oftalmol [periódico na Internet]. 2003 [citado 2006 jul 22];62(1):[cerca de 5p.]. Disponível em: www.sboportal.org.br

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Oftalmologia

RBO-Jan-Fev-2018 Inglês Revisão 01 · 1 Associada a José Ricardo Carvalho L. Rehder- São Paulo-...

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