perfil epidemiológico de pacientes com glaucoma congênito ... · revista brasileira de...

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w Perfil epidemiológico de pacientes com glaucoma congênito

Benign concentric annular macular dystrophyw

Evaluation of retinal nerve fiber layer in optic disc drusenw

Intra-ocular lenses and clinical treatment in pediatric cataratw

Vol. 74 - nº 3 - Maio/Junho 2015

Publicação bimestral

ISSN 0034-7280Versão impressa

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Publicação bimestral Rev Bras Oftalmol, v. 74, n. 3, p. 127-196, Mai./Jun. 2015

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OftalmologiaPUBLICAÇÃO OFICIAL:

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129


OftalmologiaPUBLICAÇÃO OFICIAL:

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SOCIEDADE BRASILEIRA DE CIRURGIA REFRATIVA

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www.sboportal.org.br

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Publicação bimestral Rev Bras Oftalmol, v. 74, n. 3, p. 127-196, Mai./Jun. 2015

Editorial131 Quality of life and glaucoma

Qualidade de vida e Glaucoma Ricardo Augusto Paletta Guedes

Originals Articles133 Epidemiological profile of patients with congenital glaucoma treated in the Hospital

Regional de São JoséPerfil epidemiológico de pacientes com glaucoma congênito atendidos no HospitalRegional de São JoséDeyse Bianca Campos Brink, Marília Bastos Quirino Brasil, Günther Bernardes Brink

138 Prevalência de endoftalmite em um hospital universitárioEndophthalmitis prevalence in an university hospitalLetícia Maria Coelho,Thaís Martins de Souza, Marco Antônio Guarino Tanure

141 Comparison of final visual acuity: cataract surgery with intraoperative complicationsversus non intraoperative complicationsComparação de acuidade visual final: cirurgias de catarata com intercorrências versussem intercorrênciasPatrícia Mencaroni Kange, Marcela Costa Cruz, Daniel Martin, Fabio Hara, Renata Magrino Pereira, AndréBerger Emiliano da Silva

152 Evaluation of tear film function, ocular surface and tear film in HIV-seropositivepatientsEvaluation of tear film function, ocular surface and tear film in HIV-seropositive patientsCarolina Ramos Mosena, Marcus Vinicius Vieira Pinheiro, Paula Azevedo Alhadeff, Thyarles Tomich Neiva,Sérgio Felberg

Fundada em 01 de junho de 1942CODEN: RBOFA9

Contents - Sumário

ISSN 0034-7280(Versão impressa)

ISSN 1982-8551(Versão eletrônica)

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160 Variation of intra ocular pressure in resistance exercise performed in two differentpositionsVariação da pressão intraocular no exercício resistido realizado em duas diferentes posiçõesAlex Sander Soares, André Athanazio Caldara, Lucas Ruiz Storti, Luis Felipe Milano Teixeira, João GuilhermeTorniziello Terzariol, Marcelo Conte

164 Difficulties of daily tasks in advanced glaucoma patients - a videotaped evaluationDificuldades no cotidiano dos pacientes com glaucoma avançado - avaliação objetivacom registro em vídeoAna Isabel Martinho Miguel, Cristina Fonseca, Nuno Oliveira, Filipe Henriques, João Filipe Silva

Case Reports

171 Dural sinus thrombosis in pediatric ageTrombose do seio dural em idade pediátricaFilipe Mira Ferreira, Bruno Lourenço Costa, António Mendes, Catarina Paiva, António Roque Loureiro

175 Evaluation of retinal nerve fiber layer thickness in a patient with bilateral opticdisc drusenAvaliação da espessura da camada de fibras nervosas da retina em um paciente com drusasdo disco óptico bilateralmenteAlime Gunes, Seden Demirci, Serpil Demirci, Hasan Rifat Koyuncu

178 Chorioretinitis sclopetariaCoriorretinite esclopetáriaIsaac Carvalho de Oliveira Ramos , Diogo Carvalho Macedo dos Santos, Itamar Soares, Vitor Cerqueira

183 Benign concentric annular macular dystrophyDistrofia macular anular concêntrica benignaLuísa Salles de Moura Mendonça, Luciana Castro Lavigne, Luis Fernando Oliveira Borges Chaves, JoséMaurício Botto de Barros Garcia, David Leonardo Cruvinel Isaac, Marcos Ávila

186 Posterior polychromatic corneal dystrophyDistrofia policromática posterior da córneaLetícia Maria Coelho, Guilherme Kfoury Muinhos, Marco Antônio Guarino Tanure, Homero Gusmão deAlmeida, Reinaldo de Oliveira Sieiro

Review Article

189 Intraocular lenses and clinical treatment in paediatric cataractLentes intraoculares e tratamento clínico na catarata pediátricaCamila Ribeiro Koch Pena , Priscilla Almeida Jorge, Newton Kara-Junior

Instruções aos autores

194 Normas para publicação de artigos na RBO


131EDITORIAL

Rev Bras Oftalmol. 2015; 74 (3): 131-2

Glaucoma is the leading cause of irreversible blindness worldwide.1 The main and most challenging goal of treating glaucomais to maintain the quality of life (QoL) of patients at an acceptable cost.2

QoL is a complex and multidimensional concept that includes the health of the individual, the physical and psychologicalwell-being, as well as a good capacity for social and cognitive performance.3 In medicine, QoL is related to several points: since theconcern of the individual with the disease and its consequences, going through functional disorders caused by the disease, to theundesirable effects of the treatments.2

Individuals diagnosed with glaucoma may have their QoL impaired for many reasons: loss of visual function; difficulty in thedaily routine of treatment; side effects and the treatment costs; and worries, anxiety and fear related to the diagnosis of a chronicdisease that threatens the vision.2

In general, there is evidence in the literature that the more advanced glaucoma is, the worst the QoL.4-5 However, this may beimpaired even at early stages of the disease, as observed in the Los Angeles Latinos Eye Study (LALES).5 The loss of the visualfunction is the main determinant for a worse QoL in glaucoma, and may compromise the patient’s daily activities such as reading,driving, walking, estimating distances and seeing objects approaching from the side.4 The psychological effects (fear of blindness andsocial withdrawal) of glaucoma in the individual are also not negligible and tend to increase with the disease progress. The treatmentitself may have a major impact in the QoL.4

The antiglaucoma medications may influence the quality of life in different ways: the daily use of medications reminds thepatient of their status as the carrier of an incurable disease; eyedrops can be expensive and difficult to be applied; local and systemicside effects, which can affect their vision and the general health; the scheme of doses, which can interfere in their daily life, leaving thepatient anxious (if they are using the medication correctly).6

It has been shown that the greater the number and the prevalence of side effects of the medication, the worse the quality of life7;the greater the system of droplets, the worse the quality of life8-9; the more expensive the treatment, the worse the quality and life8-10.

Few studies compared the different treatments using the patient’s QoL as a result. The QoL, when used as a study outcome isthe ideal way to evaluate a treatment, as this is the most important outcome measure from the point of view of the patient.

For the study of QoL as an outcome, we can use the quantitative method (use of specific instruments such as validatedquestionnaires) and the qualitative methods (open interviews, focus groups, etc.).

The QoL in general can be hard to be quantified. In this attempt, different instruments or methods were developed andvalidated. Some examples are: Visual Function Questionnaire, developed by the National Eye Institute, in the USA (NEI-VFQ);Glaucoma Symptom Scale (GSS), Glaucoma Quality of Life – 25 (GQL-25) and Symptom Impact Glaucoma Score (SIG).

A Cochrane review identified only one randomized controlled study which directly compares different types of glaucoma treatment(medication versus surgery), having as one of QoL outcomes: the Collaborative Initial Glaucoma Treatment Study (CIGTS).11-12

This study assessed 607 patients newly diagnosed with glaucoma, which were randomized for clinical treatment or trabeculectomy.The QoL was assessed by three questionnaires, which lasted approximately 48 minutes to be completed by the patients12.

The results showed that patients who underwent surgical treatment had lower QoL scores in the initial phase of treatment(mainly related to local discomfort from the surgery). This difference disappeared over time. Another important finding was that theQoL in both groups was worse soon after the diagnosis, and that the scores show a trend of improvement over time, showing thatpatients tend to get used to the disease and its symptoms.12

In another study to assess the QoL directly, Guedes et al. evaluated 225 patients interviewed by means of the Brazilian versionof the NEI-VFQ. In this cross-sectional study, patients were divided into 3 groups, group 1 (patients exclusively under clinicaltreatment without ever having been under any filtering surgery); group 2 (patients operated without using any antiglaucomamedication) and group 3 (operated patients, but who needed to return to the use of antiglaucoma medication).

The groups were uniform regarding the following variables: age, sex, race, education and type of glaucoma. When controlled bythe stage of glaucoma (initial, moderate and advanced), there was no difference between the scores of patients undergoing surgicaltreatment or those in medical treatment, except for the initial glaucoma. The results showed that patients who underwent filteringsurgery in early stage of glaucoma had a lower score of QoL compared to the patients with chronic use of eyedrops.13 This differencewas not observed in moderate or advanced glaucoma, and was mainly related to the psychological dimension.

Another study by the same group (Guedes et al.) assessed the QoL in patients with glaucoma under clinical treatment in use ofdifferent prostaglandins (Bimatoprost, Latanoprost and Travoprost).14 In this study, 213 patients were assessed by means of aquestionnaire validated for the Brazilian population. The results showed that Travoprost had similar results of QoL to Latanoprost.Among the 3 prostaglandins, Bimatoprost was the one that showed the lowest score of QoL14, despite the fact already reported in otherstudies, which show that it is the one prostaglandin that further reduces intraocular pressure and is the most cost-effective drug.15-17

Qualidade de vida e glaucoma

Quality of life and glaucoma


132


Guedes RAP

The research with qualitative methodology aims to capture the aspects related to the disease that would be very difficult to beobserves in the quantitative studies of QoL. In the medical literature there are virtually no research studies with a qualitativeapproach which attempted to understand the beliefs and values assigned by patients with glaucoma to the type of treatmentproposed by the doctor (physician or surgeon).

A study by the qualitative method was performed Vieira et al., aiming to search the different perspectives of patients aboutglaucoma and its treatment.18 Two focus groups were conducted, where the interviews were conducted in groups and recorded indigital media (group 1: patients exclusively under clinical treatment in advanced stages of glaucoma, and group 2: patients operatedon both eyes at least 1 year before with no medication and also in advanced stage of glaucoma).18

The results showed that glaucoma raises a deep fear and concern to the patients, not only regarding the loss of vision, but alsothe impact of the disease and its treatment on a daily basis (falls, costs, use of eyedrops in pre-determined times, side effects, etc.).

Both groups had the same level of concern about the disease and blindness. The costs and side effects of the treatment werethe most significant negative factors posed by the patients.18

The patients in the surgical group were unanimous in preferring surgery in relation to chronic use of eyedrops. Operatedpatients with glaucoma seem to have less impact on their daily lives, but the concern about the disease persists.18

The confidence in the doctor and in the correct indication of the treatment, be it clinical or surgical, is a major factor for morepeace of mind and, consequently, a better QoL, reinforcing the need for a good doctor-patient relationship.18

The study of the impact of glaucoma and its treatment on QOL of patients is of fundamental importance because QOL is theultimate goal of any glaucoma therapy, but it is also the most important outcome of the patient’s point of view.

More studies are needed in order to deal better with the decrease of QoL in patients with glaucoma. But from now on we haveto keep in mind that:

• glaucoma has a major impact in the QoL;

• the type of treatment can interfere for better or worse in the QoL;

• the doctor has a key role in maintaining and improving the QoL using the appropriate and personalized treatment, notingthat one way to try to alleviate the burden of disease is to establish a good doctor-patient relationship.

Ricardo Augusto Paletta GuedesResearcher at the Federal University of Juiz de Fora (UFJF). Masters degree in Public Health (UFJF). Doctorate in Health

(UFJF). Glaucoma expert at Centre Hospitalier National d’Ophthalmologie des Quinze-Vingts (University of Paris, France).

REFERENCES

1. Resnikoff S, Pascolini D, Etya’ale D, Kocur I, Pararajasegaram R, Pokharel GP et al. Global data on visual impairment in the year 2002.Bull World Health Organ. 2004; 82:844-851.

2. European Glaucoma Society. Terminology and Guidelines for Glaucoma, 2nd ed. Savona, Italy: Ed Dogma; 2003.3. Zanlonghi X, Arnould B, Bechotille A, Baudouin C, Bron A, Denis P et al. Glaucoma and quality of life. J Fr Ophthalmol. 2003; 26 (HS 2): 2S39-44.4. McKean-Cowdin R, Varma R, Wu J, Hays RD, Azen SP, Los Angeles Latino Eye Study Group. Severity of visual field loss and helath-

related quality of life. Am J Ophthalmol 2007; 143(6): 1013-23.5. Sckalicky S, Goldberg I. Quality of life in glaucoma patients. US Ophthalmic Review. 2013; 6(1): 6-9.6. Emerick GT. Quality of life and glaucoma medications. Do our prescriptions make a difference? Glaucoma Today. 2005; 5:38-39.7. Nordmann JP, Auzannaeu N, Ricard S, Berdeaux G. Vision realated quality of life and topical glaucoma treatment side effects. Health Qual

Life Outcomes. 2003;10:1-75.8. Tsai J. A comprehensive perspective on patient adherence to topical glaucoma therapy. Ophthalmology 2009; 116: S30-6.9. Hong S, Kang SY, Yoon JU, Kang U, Seong GJ, Kim CY. Drug atitude and adherence to anti-glaucoma medication. Yonsei Med J. 2010; 51(2):261-9.10. Silva LMS, Vanconcellos JPC, Temporini ER, Costa VP, Kara-José N. Tratamento clinico do glaucoma em um hospital universitário: custo

mensal e impacto na renda familiar. Arq Bras Oftalmol. 2002; 65:299-303.11. Burr J, Azuara-Blanco A, Avenell A. Medical versus surgical interven tions for open-angle glaucoma (Cochrane Review). The Cochrane

Library, Issue 4, 2007.12. Feiner L, Piltz-Seymour JR, Collaborative Initial Glaucoma Treatment Study Group. Collaborative initial glaucoma treatment study: a

summary of results to date. Curr Opin Ophthalmol. 2003; 14:106-111.13. Paletta Guedes RA, Paletta Guedes VM, Freitas SM, Chaoubah A. Quality of Life of Medically Versus Surgically Treated Glaucoma

Patients. J Glaucoma. 2012; March 7(Epub ahead of print).14. Guedes RA, Guedes VM, Freitas SM, Chaoubah A. Quality of Life of Glaucoma under medical therapy with different prostaglandins.

Clinical Ophthalmol. 2012;6:1749-53.15. Aptel F, Cucherat M, Denis P. Efficacy and tolerability of prostaglandina analogs: a meta-analysis of randomized controlled clinical trials.

J Glaucoma. 2008, 17:667-673.16. Noecker RJ, Walt JG. Cost-effectiveness of monotherapy treatment of glaucoma and ocular hypertension with the lipid class of medica-

tions. Am J Ophthalmol. 2006; 141: S15-S21.17. Guedes RPA, Guedes VMP, Chaoubah A. Custo-efetividade dos análogos de prostaglandinas no Brasil. Rev Bras Oftalmol. 2008; 67:281-6.18. Vieira AA, Guedes, RA, Vieira RC, Guedes, VM. Percepção dos pacientes portadores de glaucoma sobre sua doença e os diferentes tipos

de tratamento (clinico versus cirúrgico). Rev Bras Oftalmol (em submissão).


133ORIGINAL ARTICLE

Perfil epidemiológico dos pacientes com glaucomacongênito atendidos no Hospital Regional de São José

Epidemiological profile of patients withcongenital glaucoma treated in the

Hospital Regional de São José

Deyse Bianca Campos Brink1, Marília Bastos Quirino Brasil1, Günther Bernardes Brink1

1 Hospital Regional de São José Dr. Homero de Miranda Gomes (HRSJ-HMG) – São José (SC), Brasil.

Received for publication 12/05/2013 - Accepted for publication 07/10/2013

The authors declare no conflicts de interest

ABSTRACT

RESUMO

Objetivo: Delinear um perfil epidemiológico de pacientes com glaucoma congênito atendidos no serviço de Oftalmologia do HospitalRegional de São José, bem como a evolução destes pacientes com os tratamentos empregados. Métodos: Foi realizado um estudo longitu-dinal, retrospectivo, descritivo que avaliou 32 pacientes com glaucoma congênito atendidos em ambulatório, desde a primeira consultaquando ingressaram no serviço e consultaram pelo menos duas vezes no período de 1º de março de 2009 até 1º de fevereiro de 2011.Resultados: Houve predominância do sexo feminino (59,37%). Com relação à lateralidade, ambos os olhos foram acometidos em 91%dos casos. A maioria dos pacientes (78,12%) apresentava glaucoma congênito primário. Oitenta e cinco cirurgias foram realizadas para oglaucoma congênito, destes 63,52% foram submetidos à trabeculotomia. A pressão intraocular aferida na primeira e na última consultadiminuiu em 85,93% dos 64 olhos, já em relação à pressão intraocular média houve uma diminuição de 82,81% em relação ao valor naprimeira consulta. Ao realizar a comparação do diâmetro corneano horizontal da primeira consulta em relação à última, bem como daprimeira consulta em relação à média das aferições de todas as consultas, em 25,42% ocorreu aumento. Conclusão: Nos pacientes comglaucoma congênito, houve predomínio do acometimento bilateral e do sexo feminino. A maioria dos pacientes apresentou diminuição dapressão intraocular na última consulta em relação à primeira e em poucos pacientes houve um aumento do diâmetro corneano horizontal.

Descritores: Glaucoma/congênito; Glaucoma/epidemiologia; Trabeculectomia; Hidroftalmia; Pressão intraocular


Objective: To outline an epidemiological profile of patients with congenital glaucoma treated in the ophthalmology service, as well as theevolution of these patients with the treatment adopted. Methods: A longitudinal, retrospective, descriptive study was undertaken inorder to evaluate 32 patients with congenital glaucoma treated in the clinic, from the first consultation in which they entered the serviceand who attended the clinic at least two times in the period from march 1st, 2009 to february 1st, 2011. Results: There was a predominanceof female patients (59.37%). In relation to the lateralization, both eyes were affected in 91% of the cases. Most patients (78.12%)presented primary congenital glaucoma. Eighty-five surgeries were performed for congenital glaucoma, 63.52% of them were submittedto trabeculotomy. The intraocular pressure measured in the first and in the last consultation diminished in 85.93% of the 64 eyes, andin relation to the mean intraocular pressure there was a decrease of 82.81% in relation to the value of the first consultation. Whenmaking the comparison of the horizontal corneal diameter of the first consultation in relation to the last one, as well as of the firstconsultation in relation to the average of the measurements of all consultations, in 25.42% there was an increase. Conclusion: In thepatients with congenital glaucoma, there was a predominance of bilateral involvement and of female patients. Most patients presenteda decrease of intraocular pressure in the last consultation in relation to the first one, and in a few patients there was an increase ofhorizontal corneal diameter.

Keywords: Glaucoma/congenital; Glaucoma/epidemiology; Trabeculectomy; Hydrophthalmos; Intraocular pressure


134

INTRODUCTION

C ongenital glaucoma is a disease with bilateralmanifestation in 75% of cases (1, 2), asymmetric evolution,which reaches males more frequently(1). Most cases are

sporadic. In approximately 10% of cases it is believed that thepattern of inheritance is autosomal recessive(1).

Congenital glaucoma can be separated into three groups(1,

3-6). The first is composed of isolated congenital glaucoma,wherein the abnormal developedment of the angle of the ante-rior chamber leads to an obstruction of aqueous flow inconsistent association with the development of other ocular orsystemic abnormalities. The second one involves developmentglaucoma associated to some abnormality in which adevelopmental abnormality is responsible for glaucoma, butadditional ocular and systemic changes are present. The thirdgroup includes glaucoma acquired during the childhood(secondary glaucoma) in which the flux obstruction mechanismis acquired by means of other events such as inflammation,rather than a change of angle development(1).

Primary congenital glaucoma (PCG) is a rare diseasewhichhas an overall incidence of 1 in every 10,000 births(1, 5, 6) and canvary among populations and continents. Due to consanguinity,GCP is more frequent in isolated populations, such as in SaudiArabia (1:2,500)(2,6), among gypsies in Slovakia (1:1,250)(6) andamong people of Andhra Pradesh, India (1:3300)(6).

The treatment for congenital glaucoma is essentiallysurgical(1, 2, 5-12). Goniotomy is the chosen procedure wheneverthe degree of corneal transparency allows to realize it(1, 5, 6).Trabeculotomy, in turn, is indicated when the camerular vision isimpaired(1, 5, 6). Surgical alternatives are trabeculectomy withadministration of mitomycin C, artificial devices to drain theaqueous humor and the cyclodestructive procedures(1, 5, 13).

To follow the patient with congenital glaucoma, inaddition to the measurement of intraocular pressure, theserial measurement of corneal diameter (1, 2, 5, 7, 8, 14-16), theechobiometry(1,5,7,10,14) and assessment of signs and symptomsshould be included. The reduction of the intraocularpressure decreases corneal edema and therefore thesymptoms related to it.

The present paper aims at outlining an epidemiologicalprofile of patients with congenital glaucoma treated at theOphthalmology service at the Regional Hospital of São José,considered a referral hospital in Santa Catarina, as well as theevolution of said patients to the treatments performed.

METHODS

This was a longitudinal, retrospective, descriptive studywhich evaluated 32 patients diagnosed with congenital glaucomatreated at the glaucoma ambulatory of the Regional Hospital ofSão José (HSRJ) since the first consultation when they joinedthe service and who were consulted at least twice during theperiod from March 1, 2009 to February 1, 2011.

The data assessed were: gender, affected eye, family history,age at the last consultation, age when diagnosed with congenitalglaucoma, who suspected that there was some ocular disease inthe child and suggested to look for a consultation with an expert,

region of origin on Santa Catarina, signs and symptoms presentat the first consultation, eye fundus exam, measuring the axialocular length by ultrasound type A, ocular and systemicassociated changes and type of treatment. We also assessed theextent of the horizontal corneal diameter and the intraocularpressure at every consultation. These data were input in MicrosoftOffice Excel 2007 for the calculation of percentages.

Was considered, during the evaluation of the intraocularpressure and the horizontal corneal diameter, the value in the firstand last consultations, as well as the average value in all consultations.

The measurement of the horizontal corneal diameter wasperformed with a compass, and the intraocular pressure withthe Perkins tonometer.

Regarding the age of diagnosis of congenital glaucoma,patients were divided into seven different age groups: 1) 0 to 9days; 2) 10 days to 1 month; 3) > 1 month to 3 months; 4) > 3 to6 months; 5) > 6 months to 1 year; 6) > 1 year to 3 years; 7) > 3years. Regarding the age at the last consultation, patients weredivided into nine age groups: 1) 6 months to one year; 2) > 1 yearto 2 years; 3) > 2 to 3 years; 4) > 3 to 5 years; 5) > 5 to 7 years; 6)> 7 to 9 years; 7) > 9 to 12 years; 8) > 12 to 16 years; 9) > 16 years.

The region of origin in Santa Catarina was classified intoeight regions following the geographical classification: coast,northeast, Itajaí valley, Planalto Norte, Planalto Serrano, south,midwest and west.

RESULTS

From a total of 32 patients with congenital glaucoma, 19were female (59.37%) and 13 were male (40.62%). The averageage at the last consultation was 7.06 years, with its extremesranging from 7 months to 32 years (Table 1).

Regarding the family history only 16% of patientspresented other cases of congenital glaucoma in the family, andin none of the cases the parents were consanguineous. In 80% ofpatients whose family history was positive the diagnosis wasprimary congenital glaucoma.

Regarding laterality, 29 patients (91%) had glaucoma inboth eyes, and 3 (9%) had unilateral glaucoma.

The municipalities in the south were reported as origin byseven patients (22%). The group comprising the state’s coast asorigin accounted for six cases (19%). Less common, the originwas reported in municipalities of Itajaí valley in two cases (6%).None of the patients in the sample was from cities in PlanaltoNorte (Figure 1).

Regarding the age of diagnosis of congenital glaucoma, itwas observed that the group (0 to 9 days) accounted for 10 cases(31.25%) (Figure 2).

Brink DBC, Brasil MBQ, Brink GB

Figure 1. Distribution of 32 patients, according to the origin.



135Epidemiological profile of patients with congenital glaucoma treated in the Hospital Regional de São José

The person who suspected of some ocular disease in thechildren and sought specialized care was the mother of thesepatients in 60% of cases, the pediatrician was responsible for25% of suspicions and grandparents of 6%. The symptom thatprevailed in the first consultation was photophobia (65.62%),followed by epiphora with 13 cases (40.62%). Regarding signs inthe first consultation 56.25% of the cases showed corneal opacity,and 81.25% an increase in eye size.

The majority of patients (78.12%) had primary congenitalglaucoma, 6.25% had associated ocular changes, and 15.62%systemic changes (Table 1).

The mean time of follow-up of patients in the glaucomaservice at the HRSJ since the first consultation and who stayedat the service until the last one was 41.5 months, with its extremesranging from 2 months to 173 months (Figure 3).

O exame de fundoscopia foi impossível devido à opacidadede meios, na primeira consulta, em 48,43% dos 64 olhos avaliados.

The fundoscopy exam was impossible to be performeddue to media opacity in the first consultation in 48.43% of the 64eyes assessed.

The anteroposterior diameter (APD) in 65% of cases washigher than expected for the age (months) of the patient inrelation to the values expected in the forecast line(1), but in relationto the expected values in the confidence interval(1) this percentage

Table 1

Distribution of the 32 patients in relation to sex,age at the last consultation and the classification

of congenital glaucoma

increased to 76.66%. When we consider only the point valueexpected for the patient’s age in months regardless of the nor-mal range, in 80% APD was higher than expected (Figure 4). In4 eyes measuring the ocular axial length by ultrasound type Awas not performed (in patient 3 it was not performed in botheyes, in patients 15 and 20 in the left eye).

85 surgeries for congenital glaucoma were performed atthe HRSJ, from these 63.52% were trabeculotomy, 20%trabeculectomy + mitomycin C, 8.23% Molteno tube implant,7.05% trabeculotomy associated with trabeculectomy +mitomycin C, 1.17% Ahmed valve implant. In three patients(9.37%) surgical intervention was not necessary, as they hadalready been operated in another hospital and presented a stablecondition (Figure 5). In the last visit 43.75% of the 64 eyesevaluated were not using eyedrops to control intraocularpressure, 20.31% were using only one eyedrops, 21.87% wereusing two eyedrops (Figure 6).

Figure 3. Time of follow-up of each patient from the first consultationto the last in months

Figure 5. Distribution of 32 patients according to the number ofsurgeries for congenital glaucoma

Figure 4. Distribution of 64 eyes of 32 patients who were attendedat the HRSJ-HMG, according to the anteroposterior diameter(APD) (in mm) of the right eye and the left eye compared to theAPD expected for their age in months, with the expected value atthe confidence interval of 95%(1) and the expected value of theprediction line(1).


Figura 2. Distribution of the 32 patients according to the age whenthey were diagnosed with congenital glaucoma

Number %

Sex: Female 19 59.37 Male 13 40.62

Age at the last consultation 6 months up to one year 2 6 > 1 year to 2 years 4 13 > 2 to 3 years 4 13 > 3 to 5 years 6 19 > 5 to 7 years 3 9 > 7 to 9 years 3 9 > 9 to 12 years 2 6 >12 to 16 years 5 16 >16 years 3 9

Congenital glaucoma rating Primary congenital glaucoma 25 78.12 Glaucoma associated with congenital anomalies 7 21.88 Glaucoma acquired in childhood 0 0


136 Brink DBC, Brasil MBQ, Brink GB

Figure 6. Distribution of 32 patients according to the number ofhypotensive eyedrops in use in the last consultation

The intraocular pressure measured in the first and lastconsultation decreased by 85.93% of the 64 eyes, but regardingthe mean intraocular pressure there was a decrease of 82.81%from the value at the first consultation. In 15.62% of the eyes thePIO value increased if we compare the measure in the firstconsutation and the mean of all measurements. It was observedin 10.93% of the cases when comparing only the PIO at the firstand the last consultations

The horizontal corneal diameter can be compared in 59eyes, because in 5 eyes there was no adequate measurement.From these five eyes in which the corneal diameter was notmeasured, four had Phthisis bulbi (patients 15 and 20 in the lefteye and patients 24 and 28 in the right eye), and for this reasonthe serial measurement was not performed. The Phthisis bulbiwas diagnosed in one patient after the surgery performed athethe HRSJ, in two patients it was secondary to trauma, and onewas already presenting the condition when the follow-up at theservice started.

The horizontal corneal diameter in 52.54%, i.e., in 31 eyesremained the same in all consultations. When we compared thehorizontal corneal diameter of the first consultation against thelast one and the first consultation against the mean measurementof all consultations, in 25.42% there was an increased (Figure 8).

The total was, therefore, 15 eyes with increased horizontalcorneal diameter during the follow-up. From these in only 2(13.33%) the mean PIO increased in relation to the measurementof PIO in the first consultation.

Figure 7. Distribution of 64 eyes of 32 patients according to the PIOof the right eye and the left eye during the first and the lastconsultations in numbers (mmHg), and the mean intraocular pressureof all consultations.

Figure 8. Distribution of 64 eyes of 32 patients according to thehorizontal corneal diameter of the right eye and the left eye in thefirst and the last consutations in number (mm), and the meanmeasurement of the horizontal corneal diameter of all consultations.

DISCUSSION

Primary congenital glaucoma occurs in about 1 in 10,000births(1,5,6). In this study, 78.12% of the patients had primarycongenital glaucoma.

There was a predominance of females and bilateraloccurrence in this study. The literature showed a preponderanceof males(1, 5, 17) and a prevalence of bilaterality in 65-80% of thecases(1,2,5,17,18). However, in Japan females are the most affected,with a ratio of girls to boys of 3:2(6). There are no available dataon the epidemiology of congenital glaucoma in the Brazilianpopulation(6).

The region of origin was included in the survey in order totry to delineate the epidemiology, even with limitations and limitedto the patients treated at the Single Health System (SUS) in SantaCatarina. None of the patients in the sample were from cities inPlanalto Norte, which has border with the state of Paraná, withthe possibility of the same being referred to the neighboring state.

The evolution of congenital glaucoma is predominantlyasymmetric(1)

, so the comparative exam between the eyes shallalways be performed. In this study, 61 eyes had congenitalglaucoma, but the follow-up was performed in the 64 eyes. Patients27 and 31 had congenital glaucoma only in the right eye, andpatient 26 only in the left eye.

Regarding the family history, 84% of patients withcongenital glaucoma had no history of disease in the family.However, regardless of family history, parents of children withprimary congenital glaucoma should be aware of the risk oftransmitting this feature to the other children, even with this riskbeing small (assuming the recessive autosomal inheritance)(1,6).All siblings of any child with primary congenital glaucoma shouldtherefore be carefully analyzed to exclude this disease.

The onset of the clinical profile of the disease appearsduring the first year of life in more than 80% of cases, of which25% are diagnosed in the neonatal period and 60% during thefirst 6 months of life(6,17). In the study of the profile of patientswith congenital glaucoma most patients were diagnosed before10 days after birth (31.25%), and only 21.86% of the cases werediagnosed after 6 months, i.e., as described in the literature.

Pediatricians are responsible for the diagnosis andtreatment of the simplest eye diseases, as well as referral to thespecialized eye examination when necessary. In this study, thepediatrician was responsible for 25% of suspicions. A surveyconducted in Porto Alegre about the knowledge of pediatriciansof eye disorders in children (19) showed that 52% of them did notknow that the symptom triad of congenital glaucoma isphotophobia, epiphora and blepharospasm.

In glaucoma that appears after one year of age, it is difficultthat there is photophobia(1). Four patients (12.5%) werediagnosed after 1 year of age; from these 50% had photophobiaat the diagnosis.

When the glaucomatous process sets in the first 3 years oflife, due to the characteristics of eye collagen fibers at this age,the size of the eyeball tends to increase(1). In children over 3years the previous segment shows no signs of increaseddimensions, which makes it more difficult to diagnose glaucoma(1).Three patients (9.37%) were diagnosed after 3 years of age;from them only one had increased ocular dimensions.

The horizontal corneal diameter of a normal newborn ran-ges from 10 to 10.5 mm and reaches values from 11 to 12 mm at1 year of age(1) and it is considered a parameter for the follow-up



137Epidemiological profile of patients with congenital glaucoma treated in the Hospital Regional de São José

of children with congenital glaucoma(1,5,14,19). Kiskis et al. studied31 eyes of 17 children with primary congenital glaucoma andconcluded that the corneal diameter is the most sensitiveparameter (97%) and does not require any expensiveequipment(20). At HRSJ it is the parameter used to follow uppatients with congenital glaucoma along with the measurementof the intraocular pressure.

The measurement of the ocular axial length by ultrasoundtype A is an exam that aids in the diagnosis and follow-up ofcongenital glaucoma (1,5,7,10,14,17). However, it is not a parameterused as a follow-up at HRSJ for all patients due to the non-availability of the same during the exam under sedationperformed in the operating room. To use the anteroposteriordiameter (APD) as a preparatory means in childhood it isnecessary to know the dimensions of the normal eye in this agegroup(1). In the present study, this comparison was conducted bythe table presented in the reference(1), with the correlation beingperformed between the APD (in mm) and the age (in months)in normal eyes and in the patients studied, taking into accountthe mean value as well as the values found in the confidenceinterval of 95%(1) and the values in the existing forecast line(1).

In general the treatment of congenital glaucoma issurgical(1,2,5-7,9,11-13,17,18), and clinical treatment is used only as asupport(1,5,17). The first choice for clinical treatment is the eyedropsof beta-blockers and carbonic anhydrase inhibitors(5,17), and thealpha agonist eyedrops are contraindicated (1.17). In HRSJ whenthere is need for associated clinical therapy there is a preferenceto eyedrops of beta-blockers and topic inhibitors of carbonicanhydrase.

Goniotomy is the procedure of choice in some hospitals.However, it requires the transparency of the cornea andgonioscopic lens of direct observation. In the study presentedherein said procedure was not performed in any patient. Theliterature describes the goniotomy results as very similar to thetrabeculotomy, with a success rate around 90%(1,18).

In the glaucoma service, trabeculotomy is the procedureadopted in patients with primary congenital glaucoma. Theadvantage of said procedure is that it is independent of thetransparency means to be realized. On the other hand, to performthe trabeculotomy, unlike goniotomy, it is necessary to manipulatethe conjunctival, causing a fibrotic scarring(1,17,18).

One patient (24) had Phthisis bulbi after the surgeryperformed at the HRSJ, which is a serious complication thatcauses functional and aesthetic problems. This patient had alreadyundergone 7 surgeries in the eye, which evolved into Phthisisbulbi, and the disease was difficult to be controlled despite thetherapy instituted.

Children with congenital glaucoma whose eyes reachbuphthalmic dimensions are exposed to blunt trauma, whichcan lead to rupture of the eyeball, with the ultimate evolutionbeing atrophy of the ocular bulb(1). Two patients developed intoPhthisis bulbi after trauma.

CONCLUSION

Among the patients with congenital glaucoma, theprevalence was of bilateral involvement and females. Most patientsshowed a decrease in the intraocular pressure during the lastconsultation in compariosn to the first one, and few patients hadan increase of the horizontal corneal diameter.

REFERENCES

1. Dias JF, Almeida HG, Prata Junior AP. Glaucoma. 4a ed. Rio deJaneiro: Cultura Médica; 2010.

2. Elder MJ. Congenital glaucoma in the West Bank and Gaza Strip.Br J Ophthalmol. 1993;77(7):413-6.

3. Dickens CJ, Hoskins Jr HD. Epidemiology and pathophysiologyof congenital glaucoma. In: Ritch R, Shields MB, Krupin T. (edi-tors). The glaucomas. 2a ed. St. Louis: Mosby; 1996.

4. Lopes Filho JG, Betinjane AJ, Carvalho CA. [Automated perim-etry in patients with primary congenital glaucoma]. Arq BrasOftalmol. 2007;70(1):37-40. Portuguese.

5. Shields MB, Allingham RR, Damji KF, Freedman S, Moroi S,Shafranov G. Shields Tratado de Glaucoma. 5a ed. Rio de Janeiro:Cultura Médica; 2008.

6. Paolera MD. Avaliação do gene CYP1B1 em pacientes com glau-coma congênito primário [tese]. São Paulo: Irmandade da SantaCasa de Misericórdia de São Paulo; 2008.

7. Alsheikheh A, Klink J, Klink T, Steffen H, Grehn F. Long-termresults of surgery in childhood glaucoma. Graefes Arch Clin ExpOphthalmol. 2007;245(2):195-203.

8. Cohen R, Almeida GV, Mandia Júnior C. [Congenital glaucoma:relationship among age, stage of evolution and surgical results].Arq Bras Oftalmol. 1988;51(3):113-5. Portuguese.

9. Cronemberger S, Santos DV, Ramos LF, Oliveira AC, MaestriniHA, Calixto N. [Trabeculectomy with mitomycin C in patientswith refractory congenital glaucoma]. Arq Bras Oftalmol.2004;67(3):475-9. Portuguese.

10. Dietlein TS, Jacobi PC, Krieglstein GK. Prognosis of primary abexterno surgery for primary congenital glaucoma. Br JOphthalmol. 1999;83(3):317-22.

11. Fulcher T, Chan J, Lanigan B, Bowell R, O’Keefe M. Long-termfollow up of primary trabeculectomy for infantile glaucoma. Br JOphthalmol. 1996;80(6):499-502.

12. Passos AF, Kiefer K, Amador RC. [Results of trabeculotomy-trabeculectomy in not elderly patients]. Rev Bras Oftalmol.2009;68(4):223-30. Portuguese.

13. Chen TC, Bhatia LS, Walton DS. Ahmed valve surgery for refrac-tory pediatric glaucoma: a report of 52 eyes. J Pediatr OphthalmolStrabismus. 2005;42(5):274-83; quiz 304-5.

14. Betinjane AJ, Carvalho, CA. [Significance of the corneal diam-eter and the axial length of the eye in the evaluation of congeni-tal glaucoma]. Rev Bras Oftalmol. 1994;53(1):35-9. Portuguese.

15. Freitas S, Domingues MF, Cotta JS, Reis FF. Glaucoma congênito:estudo retrospectivo. Acta Oftalmol. 2003;13:23-6.

16. Morin JD, Coughlin WR. Corneal changes in primary congenitalglaucoma. Trans Am Ophthalmol Soc. 1980;78:123-31.

17. Shaarawy TM, Sherwood MB, Hitchings RA, Crowston JG. Glau-coma: medical diagnosis e therapy. United Kingdom: Elsevier; 2009.

18. Meirelles SH, Liporaci SD, Bloise RR, Ávila EG. Resultados emlongo prazo da trabeculotomia no tratamento do glaucomacongênito primário. Rev Bras Oftalmol. 2004;63(5-6):326-33.

19. Manica MB, Côrrea ZM, Marcon IM, Telichevesky N, Loch LF.What do pediatricians know about children’s eye diseases? ArqBras Oftalmol. 2003;66(4):489-92. Portuguese.

20. Kiskis AA, Markowitz SN, Morin JD. Corneal diameter and axiallength in congenital glaucoma. Can J Ophthalmol. 1985;20(3):93-7.

Corresponding author:Deyse Bianca Campos BrinkRua Maria Helena Kretzer, 707 - room 204 – Praia Comprida,ZIP Code: 88103-670 - São José, Santa Catarina, Brazil.



138

Prevalência de endoftalmite em um hospital universitário

Endophthalmitis prevalence in anuniversity hospital

Letícia Maria Coelho1, Thaís Martins de Souza1, Marco Antônio Guarino Tanure1

ORIGINAL ARTICLE


The authors declare no conflicts of interest

Objetivo: Estudo da prevalência de endoftalmite em um hospital universitário, avaliando características epidemiológicas, tempo desintomas, tratamento realizado e evolução clínica. Métodos: Avaliação retrospectiva dos prontuários de pacientes com diagnóstico deendoftalmite, no período de janeiro de 2009 a junho de 2011, quanto às características epidemiológicas do paciente, causa da endoftalmite,tempo de início dos sintomas, tratamento prévio, tempo de internação, tratamento realizado, resultados de culturas, evolução clínica eacuidade visual final. Resultados: Sessenta e oito pacientes, sendo 44 mulheres e 24 homens, com idade média de 56,99 anos, foramavaliados. A maioria foi referenciada de outro serviço (27,94%), já tinha sido submetida a algum tratamento clínico e/ou cirúrgico(45,59%) e possuía alguma comorbidade (60,29%) que decorreu de trauma (35,29%) ou pós-cirurgia (22,06%). O tempo médio deinício dos sintomas foi de 5,76 dias e o de internação de 12,40 dias. A acuidade visual inicial e a final foram para ambas igual ou pior quepercepção luminosa em 64,71% dos casos. A maior parte dos pacientes (58,82%) foi submetida apenas a tratamento clínico e, em 69,12%dos casos, a cultura foi negativa ou não foi realizada. Conclusão: A endoftalmite é uma das complicações mais graves e de pior resultadofuncional entre as afecções oftalmológicas. Seu diagnóstico rápido e correto é fundamental para um tratamento adequado e precoce, afim de melhorar o prognóstico visual do paciente, garantindo sua qualidade de vida e posterior inserção socioeconômica.

Descritores: Endoftalmite; Infecções oculares; Epidemiologia; Prevenção e controle; Transtornos da visão

ABSTRACT

RESUMO

Purpose: To study endophthalmitis prevalence in an university hospital, assessing its epidemiological characteristics, symptomsonset, treatment and clinical outcome. Methods: We retrospectively reviewed medical records of patients diagnosed withendophthalmitis, from january 2009 to june 2011, identifying patient epidemiological characteristics, endophthalmitis cause, onset ofsymptoms time, previous treatment, hospital stay, treatment, culture results, clinical outcome and final visual acuity. Results: Sixty-eight patients, 44 women and 24 men, with a mean age of 56,99 years, were evaluated. Most were referred from other services(27,94%), had already undergone to any medical treatment and/or surgery (45,59%), presented some comorbidity (60,29%) andresulted from trauma (35,29%) or post-surgery (22,06%). The average duration of onset of symptoms was 5,76 days and ofhospitalization was 12,40 days. Initial and final visual acuity were both equal to or worse than light perception in 64,71% of cases.Most of patients (58,82%) undergone to clinical treatment only and 69,12% of cases presented no results in culture. Conclusion:Endophthalmitis is one of the most serious and worst functional outcome between ophthalmologic disorders. Its rapid and accuratediagnosis is essential for appropriate and early treatment, in order to improve patient visual prognosis, ensuring better quality of lifeand socioeconomic reintegration.

Keywords: Endophthalmitis; Eye Infections; Epidemiology; Prevention and Control; Vision Disorders

1 Hospital São Geraldo, Hospital das Clínicas, Federal University of Minas Gerais, Minas Gerais, MG, Brasil.

Study conducted at Hospital São Geraldo, Hospital das Clinicas, Federal University of Minas Gerais, Minas Gerais, MG, Brazil.



139

INTRODUCTION

Endophthalmitis is an inflammation of the intraoculartissues1, and is one of the most serious complicationsand with worst functional outcome among ophthalmic

diseases2. Although it is a rare condition, it is potentiallydestructive since it creates irreversible damage to the delicatephotoreceptor layer of the retina, and even with properintervention results in partial or complete loss of vision, or evenof the eye in a few days3.

It can be classified as postoperative (acute, chronic or latepresentation), post-traumatic or endogenous4.

The etiopathogenesis, clinical presentation and developmentare variable depending on the type of endophthalmitis and thecausative microorganism. Generally, the patient has decreasedvision, pain and inflammatory signs of the anterior and/or poste-rior segment of the eye associated with a history of surgery, trau-ma, or systemic and debilitating diseases such as diabetes,neoplasms or immunosuppression5.

As it is a devastating condition6, the rapid and accurate diagnosisis essential for a proper and early treatment, which is initiallyestablished empirically, until there are the culture results and thenecessary adjustments2.

The present study aimed to study the prevalence ofendophthalmitis in a university hospital, assessing the epidemiologicalcharacteristics of the patients, the onset time of symptoms, thetreatment performed and the clinical development, comparing thefinal visual acuity to the visual acuity present on admission.

METHODS

This work is a descriptive observational study of theuniverse of all patients admitted at Hospital São Geraldo, Hos-pital das Clinicas, Federal University of Minas Gerais with adiagnosis of endophthalmitis from January 2009 to June 2011.

The record books of the surgical services were analyzed inorder to detect all patients who were diagnosed withendophthalmitis, the date and the procedure performed. Fromthis information and the registration number, the medical recordsof every patient were assessed.

The epidemiological characteristics of each patient werestudied, such as age, gender, profession, origin and presence ofcomorbidities. The cause of endophthalmitis, the time from onsetof symptoms to consultation at the health service, prior treatmenthistory and visual acuity at hospital admission were assessed.Then, hospitalization, the treatment performed, the results ofmicrobiological cultures performed and the clinical developmentof the patient and their final visual acuity at hospital dischargewere considered.

The project was submitted to the Ethics Committee of theFederal University of Minas Gerais (CAAE: 0534.0.203.000-11) andthe authorities of the institution where the research was conductedanswered the consent term to carry out the present work.

As it was an epidemiological study, patients were not identifiedand the institution where the research was conducted could decideon dropping out to participate. All provisions on Research Ethicswere observed, according to the resolution 196/96.

The tabulation of the data obtained was done by theprogram Excell, and the statistical analysis by the statisticalprogram SPSS 13.0 for Windows. To assess if there was any

correlation between the time from onset of symptoms, age, initialvisual acuity or time of hospitalization and the final visual acuitythe Spearman’s correlation test was employed. To compare thefinal visual acuity among the different groups of patientsseparated by culture, cause, prior treatment, comorbidities andtreatment, the non-parametric test of Kruskal-Wallis was used.

RESULTS

68 patients were evaluated, of which 44 were male and 24female, with a mean age of 56.99 years (7-88 years). Regardingthe merits, 14.71% were already patients of the hospital, 27.94%were sent from another hospital, and 22.06% sought the healthservices on their own. Of all the patients, 42.65% had alreadyundergone some type of medical treatment, and 2.94% to somesurgical treatment. Regarding the presence of comorbidities,29.41% of the patients had some systemic disease, 22.06% someocular disease, and 8.82% some kind of immunodeficiency.Regarding the probable etiology, 10.29% were due to blebitis,19.12% after cataract extraction, 2.94% post-penetratingkeratoplasty, 35.29% post-trauma, 14.71% post-keratitis, 1.47%after removal of stitches, 11.76% were considered endogenous,and in 4.41%, the cause has not been identified (Figure 1).

The mean time from onset of symptoms was 5.76 days (1-30 days), and the mean time of hospitalization was 12.40 days (2-35 days). Regarding initial visual acuity (VA), 26.47% of thepatients had no light perception (LP), 38.24% had LP, 30.88%had VA less than or equal to 20/400, and only 4.41% better than20/400. Regarding the final VA, 39.71% of the patients had no LP,25.00% had LP, 29.41% had VA less than or equal to 20/400, andonly 5.88% better than 20/400 (Figure 2).

Of all the patients, 58.82% underwent only clinical treatment,19.12% to some kind of surgical treatment, and 22.06%progressed to evisceration. Regarding the microbiological results,gram-positive bacteria were identified in 19.12% of the cases,and gram-negative in 5.88% of them. In 1.47% of them therewas mixed growth, and in 4.41% there was the growth of fungi.In 69.12% of the cases, the culture was negative or was notperformed. There was no relation between the final VA and thetime to seek the health service, nor between the final VA and thetime of hospitalization. There was a weak positive correlationbetween the patient’s age and the final VA, and a substantiallypositive correlation between the initial VA and the final VA.There was no significant difference in the final visual acuity among

Endophthalmitis prevalence in an university hospital

Figure 1. Distribution of patients (%) according to the probable causeof endophthalmitis.



140 Coelho LM, Souza TM, Tanure MAG

the different groups of patients, separated by culture, cause, pri-or treatment, comorbidities and treatment.

DISCUSSION

As in other studies2,7,8, there was a predominance of malesamong the patients, which may have resulted from the largenumber of cases of post-traumatic endophthalmitis, usuallypredisposed by the type of economic occupation of the patient,more common among men.

Regarding the cause, post-traumatic infections were morefrequent than those following surgery, differing from most ofthe literature3,9,10. This can be explained by the large number ofcases referred in the countryside of the state, especially fromrural areas, related to severe trauma, which require care in morespecialized hospitals like ours.

As in other work2, there was a great delay in seeking thehealth system, which might have resulted from lack of informationof the patient and the reference of other more distant services.This may also account for the large number of patients who hadalready undergone some treatment, either clinical or surgical,which in turn may explain the large number of patients who didnot have material collected for culture when getting to the ourservice, or who presented a negative result of culture. Amongthe positive cultures, there was a predominance of gram positivemicroorganisms, as in other studies1,2,4,6. The delay in the diagnosisand appropriate treatment can also justify the longhospitalization and the poor visual outcome found in our study.

The large number of cases of postoperative infectionobserved may have resulted from more complicated surgeries,due to the learning curve of surgeons in a teaching hospital, aswell as inadequate preoperative preparation of the patients, sincethey were found referred in most cases from other services. Inorder to reduce this number, it is essential to identify and controlthe preoperative risk factors, institute appropriate antibioticprophylaxis and maintain the appropriate postoperative follow-up. During surgery, care for the integrity of the incision preventinginflux of microorganisms is a crucial factor in preventingendophthalmitis11.

The lack of correlation between variables (low statisticalsignificance found) probably resulted from the small number ofpatients included in this sample. This draws attention to the needfor further studies, and also of a better filling of the medicalrecords.

Figure 2. Distribuição of patients (%) according to initial and finalvisual acuities.

CONCLUSION

Because it is a serious disease, the patient orientationregarding the main signs and symptoms of endophthalmitis, itsearly diagnosis and proper medical management are key toimprove the visual prognosis of the patient, guaranteeing theirquality of life and later socioeconomic integration.

REFERENCES

1. Bispo PJ, Höfling-Lima AL, Pignatari AC. [Molecular biologyapplied to thelaboratory diagnosis of bacterial endophthalmitis].Arq Bras Oftalmol. 2009;72(5):734-40. Review. Portuguese.

2. Schirmbeck T, Romão E, Rodrigues ML, Figueiredo JF.[Endophthalmitis: an analysis of 58 cases]. Arq Bras Oftalmol.2000;63(1):39-44. Portuguese.

3. Bispo PJ, Melo GB, d’Azevedo PA, Hõfling-Lima AL, Yu MC,Pignatari AC. [Culture proven bacterial endophthalmitis: a 6-year review].Arq Bras Oftalmol. 2008;71(5):617-22. Portuguese.

4. Kresloff MS, Castellarin AA, Zarbin MA. Endophthalmitis. SurvOphthalmol. 1998;43(3):193-224. Review.

5. Adan CB, Blay D, Yu MC, Freitas D, Allemann N. [Ultrasoundfindings in clinical suspected of endophthalmitis]. Arq BrasOftalmol. 2001;64(5):423-8. Portuguese.

6. Melo GB, Bispo PJ, Regatieri CV, Yu MC, Pignatari AC, Höfling-Lima AL.Incidence of endophthalmitis after cataract surgery(2002-2008) at a Brazilianuniversity-hospital. Arq Bras Oftalmol.2010;73(6):505-7. Portuguese.

7. Norregaard JC, Thoning H, Bernth-Petersen P, Andersen TF, JavittJC, Anderson GF. Risk of endophthalmitis after cataract extrac-tion: results from theInternational Cataract Surgery Outcomesstudy. Br J Ophthalmol. 1997;81(2):102-6.

8. Duch-Samper AM, Menezo JL, Hurtado-Sarrió M. Endophthalmitisfollowingpenetrating eye injuries. Acta Ophthalmol Scand.1997;75(1):104-6.

9. Bohigian GM, Olk RJ. Factors associated with a poor visual resultinendophthalmitis. Am J Ophthalmol. 1986;101(3):332-41.

10. Chaib AR, Freitas D, Scarpi MJ, Guidugli T. [Laboratory find-ings in endophthalmitis]. Arq Bras Oftalmol. 1997;60(3):250-7.Portuguese.

11. KashiwabuchiI FK, Khan YA, Rodrigues Jr MW, Wang J,McDonnell PJ, Daoud YJ. [Efficacy of three different methodsfor side port incision wound sealing]. Rev Bras Oftalmol.2013;72(6):379-82. Portuguese.

Correspondending author:Letícia Maria CoelhoAv. Alfredo Balena, 190 - room 3005 - Santa Efigênianeighborhood - Belo Horizonte, MG, BrazilZIP code: 30130-100.E-mail: [email protected]



141

Comparação de acuidade visual final: cirurgias de cataratacom intercorrências versus sem intercorrências

Patrícia Mencaroni Kange1, Marcela Costa Cruz1; Daniel Martin1, Fabio Hara1, Renata Magrino Pereira1, André BergerEmiliano da Silva2

Received for publication 14/10/2014 - Acceptrd for publication em 05/01/2015

RESUMO

ABSTRACT


ORIGINAL ARTICLE

Comparison of final visual acuity: cataractsurgery with intraoperative complicationsversus non intraoperative complications

1 Residency Program in Ophthalmology, Institute Service Suel Abujamra, São Paulo, SP, Brazil.2 Cataract Surgery Section, Medical Residency Program in Ophthalmology University of Santo Amaro, São Paulo, SP, Brazil.

Objetivo: Comparar a acuidade visual (AV) final dos pacientes submetidos à cirurgia de catarata com e sem complicações intraoperatóriase possíveis fatores que contribuíram para o resultado ao final do pós-operatório. Métodos: Análise dos prontuários de 179 pacientes,retrospectivo, longitudinal, operados de fevereiro a julho de 2013 no Instituto Dr. Suel Abujamra, pela técnica de facoemulsificação (FACO),divididos em dois grupos: com e sem complicações intraoperatórias. Os dados obtidos foram analisados pelos métodos teste-t para duasamostras ou Análise de Variância (ANOVA). Os critérios de exclusão foram pacientes com cirurgia ocular prévia, retinopatia diabéticaproliferativa ou não proliferativa grave, outras retinopatias, escavação do disco óptico igual ou maior que 0,7x0,7 ou uso de mais de doishipotensores oculares, olho único, catarata secundária à uveíte, traumática ou congênita. Resultados: Dos 179 pacientes, 37 (20,7%)tiveram complicações intraoperatórias e 142 (79,3%) não tiveram complicações intraoperatórias. A média da idade dos pacientesfoi de 70,33 anos. O olho direito foi o operado em 49,7% dos casos, e o olho esquerdo em 50,3%. O diabetes mellitus estava presenteem 29,05% dos casos, sendo 29,73% de pacientes com complicação e 28,87% sem complicações. Do total, 77,65% atingiram uma AV final20/40 ou melhor, sendo que nos pacientes com complicação a média para esta AV foi de 59,46% e no grupo sem complicações foi de 82,40%.A principal complicação foi ruptura de cápsula posterior. Conclusão: Após toda a análise, verificamos que os fatores que implicaram comsignificância estatística em menor AV final foram as complicações intraoperatórias e a idade dos pacientes.

Descritores: Cristalino; Catarata; Extração de catarata; Procedimentos cirúrgicos oftalmológicos; Facoemulsificação; Acuidade visual

Objective: Compare visual acuity (VA) of patients after cataract surgery with and without intraoperative complications regardingpossible factors that contributed to the outcome on postoperative follow-up. Methods: Longitudinal, retrospective study that evaluated179 medical records of patients who underwent cataract surgery under the technique Phacoemulsification (PHACO) in the SuelAbujamra Institute from february to july 2013. Patients were divided into two groups concerning presence or absence of intraoperativecomplications. Data were analyzed using t-test methods for two samples or (ANOVA) Analysis of Variance. Exclusion criteria were:patients with previous ocular surgery, retinopathy related to diabetes, either proliferative or severe non proliferative, other retinopathies,optic disc cup equal to or greater than 0,7x0,7, use of more than two ocular hypotensive medications, only one eye, cataract due to uveitis,trauma or congenital. Results: 37 (20.7%) patients had intraoperative complications and 142 (79.3%) had not. Average age of patientswas 70.33 years. There were 49.7% surgeries of the right eye and 50.3% of the left eye. There were 29.05% diabetic patients, of which29.73% had intraoperative complications and 28.87% had not. From the 179 patients, 77.65% reached a final VA of 20/40 or better,considering that patients with intraoperative complications reached a VA of about 59.46% and patients without intraoperativecomplications of about 82.40%. The main complication was posterior capsular tear. Conclusion: After entire evaluation, we realized thatfactors that influenced lower final VA, with statistical significance, were intraoperative complications and patient age.

Keywords: Crystalline; Cataract; Cataract extraction; Eye surgical procedures; Phacoemulsification; Visual acuity



142 Kange PM, Cruz MC, Martin D, Hara F, Pereira RM, Silva ABE

INTRODUCTION

Cataracts are the leading cause of reversible blindness inthe developing countries. WHO estimated in 2010 thatthere are almost 18 million people bilaterally blind from

cataract in the world, representing almost half of the causesof blindness due to eye diseases. The blindness ratio due tocataract in relation to all other eye diseases ranges from 5%in Western Europe, North America and in the more developedcountries in the Western Pacific region, to 50% or more inpoorer regions(1) It may be from senile, congenital, traumaticor secondary etiology.

The gradual increase of life expectancy in our countrycaused a subsequent increase in the prevalence of this diseasein the last decades.(1) Despite popular belief, the majority ofthe population believes that cataract surgery is a definitivetreatment to restore the vision(2,3), thus allowing animprovement in the quality of life and reintegration into thelabor market(4).

Cataract extraction is the most commonly performedsurgery in the USA, with 1.7 million surgeries perfomedannually, and phacoemulsification (FACO) is the chosentechnique(5). Studies carried out worldwide in the past 20 yearshave shown that the phacoemulsification is a safe and effectiveprocedure to treat patients with mild to advanced cataracts(6,7).

A complication feared during the cataract surgery is theloss of barrier between the anterior segment and the vitreous,which may be due to the posterior capsule rupture (PCR) orzonular detachment(8). However, other intraoperativecomplications can be added, such as vitreous prolapse, vitreousloss and core in the vitreous, which remain significant adverseevents in the cataract surgery(9), decreasing the likelihood ofachieving good postoperative final visual acuity(8,9).

Posterior capsule rupture is the most common intra-operative complication during the ophthalmologist learningphase (9), despite being potentially serious in the cataractsurgery, and may be associated to vitreous loss, poor visualacuity, retinal detachment, endophthalmitis, among others(7,9).In the literature limited to studies with over 1,000 surgeries,they show a PCR rate of 1.9% to 5.2% and vitreous lossbetween 1.1% and 5.0%(8). Other risk factors forintraoperative complications described in other studies includeadvanced age(9) and previous ocular pathology (7,10).

Thus, the present study aimed to compare the final visu-al acuity of patients undergoing cataract surgery by thephacoemulsification technique separating them into twogroups: those with and without intraoperative complications,assessing possible factors that influence the final visual acuityat the end of the postoperative period.

METHODS

A study was conducted in the Medical Residency Servicein Ophthalmology at Institute Suel Abujamra, retrospective,longitudinal, by the analysis of medical records of 179 patientsundergoing cataract surgery by the second and third yearresidents between the months of February and July 2013 bymeans of the phacoemulsification technique. The patients weredivided into 2 groups, the first group of patients with

intraoperative complications and the second one withoutintraoperative complications. The primary assessment wasthe development of visual acuity, and the presence or absenceof intraoperative complications. Other variables analyzedwere age, the presence of diabetes mellitus, the year ofmedical residency and the type of apparatus used for theprocedure (Legacy®- Surgical Series 20000 Legacy-STTL;Alcon Laboratories, California - USA, Universal®- Alcon –Universal II; Alcon Laboratories, California - USA andVizual®- Vizual - American Optisurgical Inc; Lake Forest,California – USA). It should be noted that the resident wassupervised by an experienced surgeon (preceptor), presentin the operating room and always available for any king ofcomplications. In case of intraoperative complications, thepreceptor would take the surgery over and deal with thecomplication the best possible way.

As inclusion criteria for the study patients wereaccepted with cataract and presenting preoperative visualacuity worse than 20/60. As exclusion criteria, the patientsexcluded from the study were the ones with previousintraocular surgery, severe proliferative or non-proliferativediabetic retinopathy, severe hypertensive retinopathy, otherretinopathies, excavation of the optical disc bigger than orequal to 0.7 x 0.7 or the use of 2 or more ocular hypotensive,single eye, cataract secondary to uveitis, traumatic orcongenital. The patients with postoperative complicationssuch as cases of resuture and corneal edema were alsoexcluded from the study.

The measures of visual acuity were made according tothe Snellen scale, with values of 20/20 to 20/400 and includingthe patient counting fingers (CF), perception of hand motion(HM) and light perception (LP).

We classified the measures on a number scale, and weconsidered how the development in how many lines in theSnellen scale the individual had changed, for example:

• If before surgery the visual acuity was 20/100 and aftersurgery was 20/80 there was 1 point in improvement(Evolution = +1).

• If before surgery the visual acuity was 20/100 and aftersurgery was 20/20 there were 8 points in improvement(Evolution = +8).

• If before surgery the visual acuity was 20/60 and aftersurgery was 20/200 there were 6 points in worsening(Evolution = -6).

The analysis mainly used the t test for two samples orANOVA - Analysis of Variance, to compare the means ofdevelopments (for these tests we checked the statisticalhypotheses for safe use and they were met). The test for twoproportions was used to compare the percentages.

RESULTS

From the 179 patients analyzed in the period, 37 hadintraoperative complications (20.7%) and 142 did not haveintraoperative complications (79.3%), as shown in Graph 1.



143

The mean age of the patients was 70.33 years. The right eyewas operated in 49.7% of the cases, and the left eye in 50.3% ofthem. Diabetes mellitus was present in 29.05% of the cases, and29.73% of the patients presented some complication and 28.87%of the patients did not present any complication. From the totalof patients, 77.65% achieved a final visual acuity of 20/40 or better,and the mean for this visual acuity was 59.46% in patientspresenting complication and 82.40% of the patients in the groupwith no complication. The main complication was posteriorcapsule rupture. Patients were followed for an average period of61 days and 66 days in the group with complications and 57 daysin the group without complications.

Table 1 and Graph 2 show the visual acuity of the patients.

Comparison of final visual acuity: cataract surgery with intraoperative complications versus non intraoperative complications

Graph 1

Percentage distribution of patients

Preoperativevisualacuity

HP

LM

CF

20/400

20/200

20/160

20/130

20/120

20/100

20/80

20/60

20/50

20/40

20/33

20/30

20/25

20/20

Total

Table 1

General distribution of pre and post operative visual acuity

Total

2

4

16

29

58

3

1

4

40

16

6

0

0

0

0

0

0

179

2 2 2 2 2 2

0 0 0 0 0 0 2 2 2 2 2 2 2 2

/ / / / / / 0 0 0 0 0 0 0 0

P 4 2 1 1 1 1 / / / / / / / /

P M C 0 0 6 3 2 0 8 6 5 4 3 3 2 2

L M D 0 0 0 0 0 0 0 0 0 0 3 0 5 0

Postoperative visual acuity

1 1

1 1 2

1 1 1 1 1 4 4 3

2 5 2 3 4 5 7 1

1 1 1 2 1 1 3 4 6 19 11 8

1 2

1

1 2 1

1 5 4 2 6 8 7 7

1 1 2 6 5 1

1 2 2 1

2 0 1 0 3 0 1 0 9 6 9 10 11 22 47 36 22



144

Graph 2

General distribution of pre and post operative visual acuity

Note that the great majority of patients showed improvement. This is best seen in Graphs 3 and 4 which show the developmentof each patient and also the general mean development.

Graph 3

Individual development of patients

Kange PM, Cruz MC, Martin D, Hara F, Pereira RM, Silva ABE



145

Graph 4

Mean development of patients

Comparing the visual acuity among patients presenting and not presenting intraoperative complication we realized that themean developments were different, with a significant difference between the mean development in both groups (Graph 5). In graph6 we have the distribution of visual acuity development for patients with and without complication. Note that the patients presentingcomplication have a higher variability of outcomes.

Graph 5

Mean development of patients - Complication x no complication




146

Graph 6

Percentage distribution of development scores - Complication x no complication

The assessment of patients in the Diabetes Mellitus group shows that the development of visual acuity in patients with diabetesand without diabetes was very similar, with the diabetes group having a slightly higher mean development, but there is no significantdifference between mean developments. (Graphs 7 and 8).

Graph 7

Percentage distribution of evolution scores - Diabetes




147

Graph 8

Mean development of patients - Diabetes

Graph 9

Percentage distribution of evolution scores - Resident

The analysis of visual acuity development separated by the type of apparatus used for the procedure (Legacy®, Universal®and Vizual®) shows that the mean development with the three apparatuss was very similar, with Legacy® showing a slightly highermean development and no patient worsening the visual acuity. All worsening occurred in Vizual® (Chart 10). The statistical tests letus conclude that there was no significant difference between the variability and the mean development of the groups.



Considering the group of second and third year residents, it is noted that the devlopment of visual acuity in both groups (groupR2 and group R3) was very similar, with no significant difference between mean developments (Chart 9).


148

Graph 10

Percentage distribution of evolution scores - Apparatus

Age is a factor of a continuous variable. The table shows a tendency of decreased visual acuity as the age increases. Graph 11presents the dispersion between the two measures, and a certain decrease in the development is noticed as the age increases, butthere is also a great dispersion in the results.

Graph 11

Graph of dispersion between age and development of visual acuity

All the results above were presented by indivudual analysis of the factors in comparison with visual acuity.From now on we present a comparative analysis of the factors and the visual acuity.Diabetes mellitus as a cause of poor development in the comparison between the groups was low, i.e., the difference in

development between having or not diabetes is about the same in both groups of complication. We note that the lines are almostparallel in chart 12 indicating statistical irrelevance.




149

Graph 12

Mean development of patients - Diabetes

When comparing the scores between the years of each resident, the means were similar when there were no complications, butthere was a difference when there were complications with the third-year residents (R3), with a lower mean development than thesecond-year residents ( R2) (Chart 13).



Graph 13

Mean development of patients - Resident


150

Table 2

ANOVA for the develoment of complication and apparatus scores

Source Degree of freedon Sum of squares Mean squares F-statistics Descriptive level

Complication 1 102.89 102.89 8.18 0.005Apparatus 2 33.41 16.70 1.33 0.268Complication xApparatus 2 23.40 11.70 0.93 0.397Residue 173 2.176.64 12.58

Total 178 2.402.18

Regarding the factor age, in order to check if the relationship between the groups was different we made a Regression Analysis,and we obtained the results shown in table 3 in which we conclude that the Complication does not significantly affect the relationshipbetween Development and Age (p-value = 0.058 for the interaction Age x Complication).

Table 3

ANOVA for regression between the development of the scores and age considering the complications

Regarding the interaction between the groups and the apparatus used, we noted that the group of the apparatus Legacy®presented complication and alowe mean development than the others. The most important information for our analysis is thedescriptive level of the interaction Complication x Apparatus®, which was 0.397 indicating no significant interaction, i.e., the differencebetween visual acuity developments in the three apparatus can be considered the same in both groups (Table 2).



DISCUSSION

The intraoperative complication rate in the present studywas 20.7%, with the great majority being due to the posteriorcapsule rupture. Compared to the published works in which theposterior capsule rupture rates were found around 1.9 to 5.2%(8),we can considere the complication rate as high, even comparedto the procedure studies performed only by resident doctors(6,11).However, the vast majority of patients showed improvement ofvisual acuity, regardless of complications. When the variables areanalyzed separately, the factors involved with the statisticalsignificance in a worse final visual acuity were the intraoperativecomplications and the patient age; no other variable was studiedwith statistical significance. The facts of patients having diabetesmellitus, the device used for the procedure and the year ofresidency in ophthalmology alone were not statistically significant.

This finding is consistent with most works in the art, whichshow that the intraoperative complications were more relatedto a worse final visual acuity(8, 9). Age has also been shown inother studies to be a risk factor associated with a poorer finalvisual acuity, because the vision of the elderly usually declineswith age, especially after 70 years old, even without pathologicalfindings(12).

Source Degree of freedon Sum of squares Mean squares F-statistics Descriptive level

Age 1 128.97 128.97 11.10 0.001Complication 1 25.94 25.94 2.23 0.137Age x Complication 1 42.21 42.21 3.63 0.058Residue 175 2.033.66 11.62

Total 178 2.402.18

In the comparisons between groups with and withoutcomplications, besides the fact already presented that the groupwith complications presented worse final visual acuity than thegroup without complication, we realized that the factor wichinfluenced the group with complication is the resident surgeon.Although it has no statistical significance alone, as already foundin other studies(9,11), in the comparison of final visual acuity inthe group with complications R3 had a worse development thanR2. This result is possibly due to the fact that in our servicegenerally R3 performs the surgery alone, only being taught duringcomplications, but trying to solve them, while R2 is in the learningphase and always followed by the preceptor. Another possibleexplanation is based on the current phacoemulsification teachingmethod, which requires a specific theoretical charge for the useof the phacoemulsification in order to improve the performanceand reliability of the surgical technique. Probably the second-year residents have more conditions to study the theoreticalpart than the third-year residents, whise focus is to effectivelyperform surgeries(13). The resident’s learning curve for thephacoemulsification technique has been described to decreasethe vitreous loss rates, with the gain of surgeon expertise(9), andthus the resident who will start learning phacoemulsificationshall have an experienced preceptor by his side to minimize therisk of complications(6).


151

Corresponding author:Patricia Mencaroni KangeRua Tamandaré, 693 - 9th floor – Aclimação – São Paulo – SPZip Code 01525-001E-mail: [email protected]

Rev Bras Oftalmol. 2015; 74 (3): XXX-XXX Rev Bras Oftalmol. 2015; 74 (3): 141-51


The other variables were not statistically significant in thecomparison between the two groups.

Although no statistically significant, the fact of having agreater number of complications with the apparatus Vizual® isprobably due to the service has 2 units of this apparatus, thereforeperforming a higher total number of surgeries in them.

CONCLUSION

Despite the high complication rate found in the currentstudy, the great majority of patients had a better final visualacuity than the preoperative one. However, intraoperativecomplications and the advanced age of the patients accountedfor a lower final visual acuity than expected with the cataractsurgery. In patients with intraoperative complications, theexperience of the resident doctor was a significant factor for aworse result than expected. Thus, it is unquestionable that thelearning curve by the resident in the current chosen technique -phacoemulsification - is the main obstacle to be overcome inorder to avoid low visual acuity in the patients operated, as wellas the detection and intervention of possible risk factors duringthe preoperative procedure.

REFERENCES

1 Carlos Eduardo Leite Arieta, Marco Antônio Rey de Faria. SérieOftalmologia Brasileira – Cristalino e Catarata. 3º ed. Rio deJaneiro: Cultura Médica; 2013 – 2014.

2 Edméa Rita Temporini, Newton Kara Júnior, Newton Kara José,Nilo Holzchuh. Popular beliefs regarding the treatment of senilecataract. Rev Saúde Pública. 2002; 36(3):343-9.

3 Newton Kara Júnior, Edméa Rita Temporini, Newton Kara José.Cataract surgery: expectations of patients assisted during a com-munity Project in São Paulo, State of São Paulo, Brazil. RevHosp Clin Fac Med Sao Paulo. 2001;56(6):163-8.

4 Newton Kara Júnior, Marcony Rodrigues Santhiago, Tais RenataRibeiro Parede, Rodrigo França Espindola, Maysa Godoy GomesMazurek, Renato Germano, Newton Kara Jose. Influência dacorreção cirúrgica da catarata na percepção laborativa. Arq. Bras.Oftalmol. 2010;73(6):491-3.

5 Christakis PG, Braga-Mele RM. Intraoperative performance andpostoperative outcome comparison of longitudinal, torsional, andtransversal phacoemulsification machines. J Cataract RefractSurg. 2012; 38(2):234-41.

6 Ana Catarina Delgado de Souza, Alexandre Ventura, CatarinaVentura, João Eudes Tavares, Carlos Teixeira Brandt. One yearlearning curve in 160 facoemulsifications performed by a thirdyear resident. Rev Bras Oftalmol. 2005; 64(3):156-61.

7 Chan FM, Mathur R, Ku JJ, Chen C, Chan SP, Yong VS, et al. Short-term outcomes in eyes with posterior capsule rupture during cata-ract surgery. J Cataract Refract Surg. 2003; 29(3):537-41.

8 Lundström M, Behndig A, Kugelberg M, Montan P, SteneviU, Thorburn W. Decreasing rate of capsule complications in cata-ract surgery: eight-year study of incidence, risk factors, and datavalidity by the Swedish National Cataract Register. J CataractRefract Surg. 2011; 37(10):1762-7.

9 Blomquist PH, Morales ME, Tong L, Ahn C. Risk factors for vit-reous complications in resident-performed phacoemulsificationsurgery. J Cataract Refract Surg. 2012; 38(2):208-14.

10 Blomquist PH, Rugwani RM. Visual outcomes after vitreous lossduring cataract surgery performed by residents. J Cataract Re-fract Surg. 2002; 28(5):847-52

11 Jackson Barreto Junior, Helio Primiano Junior, Rodrigo Françade Espíndola, Renato Antunes Schiave Germano, Newton Kara-Junior. Cirurgia de catarata realizada por residentes: avaliaçãodos riscos. Rev Bras Oftalmol. 2010; 69(5):301-5

12 Lundström M, Barry P, Henry Y, Rosen P, Stenevi U. Visual out-come of cataract surgery: study from the European Registry ofQuality Outcomes for Cataract and Refractive Surgery. J Cata-ract Refract Surg. 2013; 39(5):673-9.

13 Newton Kara Junior. A situação do ensino da facoemulsificaçãono Brasil. Rev Bras Oftalmol. 2011;70(5):275-77.


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ORIGINAL ARTICLE

Avaliação da função lacrimal, da superfície ocular edo filme lacrimal em pacientes soropositivos para o HIV

Evaluation of tear film function, ocular surfaceand tear film in HIV-seropositive patients

1 Sector of Cornea and External Diseases, State Public Health Service Hospital “Francisco Morato de Oliveira”, SP, Brazil.2 Sector of Glaucoma, State Public Health Service Hospital “Francisco Morato de Oliveira”, SP, Brazil3 Sector of Retina and Vitreous, State Public Health Service Hospital “Francisco Morato de Oliveira”, SP, Brazil.

Study conducted at the State Public Health Service Hospital “Francisco Morato de Oliveira”, SP, Brazil.



ABSTRACT

RESUMO

Objective: Evaluate tear function, tear film and ocular surface in patients with positive serology for HIV. Methods: Observational,cross-sectional, quantitative and analytical study, performed between june and october 2011, in the HSPE-FMO, SP, OphthalmologyDepartment, including 32 patients. Sixteen were HIV-positive patients and 16 HIV-negative. Results: There was no significantstatistical difference in the middle age between both groups (p=0.083). The ferning test was statistically different in HIV group (withpredominance of III and IV) compared to the control group (in which predominated the patterns I and II), both in the right and theleft eye (p = 0.019 and p=0.001, respectively). Other parameters were not statistically significant between the groups. Conclusion:HIV-positive patients had no changes in lacrimal function and ocular surface, however, samples of tears showed differences consideredstatistically significant in the crystallization test, compared with samples obtained from controls.

Keywords: keratoconjunctivitis sicca; HIV; Dry eye

Objetivo: Avaliar a função lacrimal, a superfície ocular e o filme lacrimal de pacientes com sorologia positiva para o vírus HIV. Métodos:Estudo observacional, transversal, quantitativo e analítico, realizado entre junho e outubro de 2011, no Departamento de Oftalmologiado Hospital do Servidor Público Estadual “Francisco Morato de Oliveira”, com 32 pacientes no total, sendo 16 soropositivos para oHIV e 16 soronegativos. Resultados: Não houve diferença estatística significante na média de idade entre os grupos estudados (p =0,083). O padrão do teste de cristalização da lágrima foi estatisticamente diferente no grupo de pacientes HIV (com predomínio dospadrões III e IV) em relação ao grupo controle (no qual predominaram os padrões I e II), tanto no olho direito como no esquerdo (p= 0,019 e p < 0,001, respectivamente). As demais variáveis estudadas não mostraram-se estatisticamente relevantes entre os grupos.Conclusão: Os pacientes soropositivos para o HIV não apresentaram alterações da função lacrimal e da superfície ocular, porémamostras de lágrimas evidenciaram diferenças consideradas estatisticamente significantes nos padrões dos testes de cristalização do filmelacrimal, quando comparadas com amostras obtidas de pacientes controles.

Descritores: Ceratoconjuntivite seca; HIV; Olho seco

Carolina Ramos Mosena1, Marcus Vinicius Vieira Pinheiro1, Paula Azevedo Alhadeff 2, Thyarles Tomich Neiva3, Sérgio Felberg1


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INTRODUCTION

The acquired immunodeficiency syndrome (AIDS) wasfirst recognized in the United States in the eighties, and itis assumed that the human immunodeficiency virus (HIV)

originates from primates of Africa(1,2).. The transmission of theretrovirus to humans may be due to bites, scratches or any kindof contact with the blood of these animals. However, the AIDSpandemic has followed the use in a large-scale of primates forbiological experiments, including xenotransplantation(3).

According to the World Health Organization (WHO), it isestimated that there are 33.3 million people infected with HIV inthe world, and in Brazil more than 590,000 cases have beenidentified from 1980, when HIV was discovered, until June 2010(4).

The systematic classification for the AIDS definition wasproposed in 1982 by the Centers for Disease Control (CDC), andrevised in 1997. Currently, the classification is based on thequantification of CD4+ T-lymphocytes, since the drop in the levelsof these lymphocytes is a major characteristic of the disease(5,6).

Regarding the ocular changes of the anterior segment inAIDS, before the era of combined antiretroviral therapy(HAART), Kaposi’s sarcoma, Burkitt’s lymphoma, conjunctivalmicrovasculopathy, non-specific conjunctivitis, keratoconjunctivitissicca and iridocyclitis were frequent. The main changes of theposterior segment were the cotton wool spots, cytomegalovirusretinitis, herpes simplex and varicella zoster, HIV, toxoplasmosis,syphilitic retinitis and infectious endophthalmitis(7,8).

Among the external eye diseases, several studies in patientswith positive HIV serology report a significant prevalence of dryeye in patients with AIDS in the period before HAART (9,10).

Dry eye syndrome refers to a disease of the ocular surfacewith different etiologies which often coexist. The preciseprevalence of dry eye syndrome in a certain population is difficultto be established precisely due to the lack of accurate diagnosticcriteria and the subjectivity of symptoms. To make the diagnosismore objective, clinical tests are established, such as assessmentof the tear film breakup time (TFBUT), surface staining withvital dyes (fluorescein, rose bengal and lissamine green),Schirmer’s test and tear crystallization test (ferning test). Othertests used, such as osmolarity of the tear film, measurement ofprotein concentration in the film, interferometry andevaporimetry, are of little use in the daily practice due to the lowpracticality and the high cost of implementation.

In 2007, the results of the International Dry Eye Workshop(DEWS (11) were published, wherein dry eye was defined as amultifactorial disease of the tears and the ocular surface, resultingin discomfort, visual blurring and tear film instability with potentialdamage to the ocular surface, and associated to an increase intear osmolarity and ocular surface inflammation.

The etiology of the dry eye associated with HIV is not wellestablished yet, but the tear reduction may be associated withlymphocytic infiltration and eventual destruction of the aciniand ducts of the lacrimal gland, generating the Sjogren-likesyndrome, not just due to the clinical appearance, but also thehistopathological one(12). The prevalence of dry eye in HIV-infected patients in previous studies ranged from 7.79% to 38.8%,and the symptoms of dry eye have an important impact on thequality of life of these patients(13-17). Early in the HIV epidemic,SJ cases were reported as secondary to the infection(18). However,a few years later, the sicca syndrome associated with HIV wasdefined as a clinical entity that was called diffuse infiltrativelymphocytosis syndrome (DILS). Present in 0.85 to 3% of HIV-

positive patients, the DILS is characterized by lymphocytic infiltrationin various organs and peripheral lymphocytosis at CD8+ costs,clinically manifested as sicca syndrome and increased parotid, thussimulating a condition similar to Sjogren’s syndrome ( Sjogren-like). Tear reduction may be associated with this lymphocyticinfiltration and eventual destruction of acinar and ducts of the lacri-mal gland(18). In SJ lymphocytic infiltration is by CD4+ and serologicaltests (anti-RO and anti-LA) are positive(19, 20).

OBJECTIVES

Assess the lacrimal function, the ocular surface and thetear film in patients with positive serology for HIV.

METHODS

This is an observational, cross-sectional, quantitative andanalytical study carried out between June and October 2011, onthe premises of the Department of Ophthalmology of the StatePublic Health Service Hospital of São Paulo. The study protocolwas approved by the Ethics and Research Committee of theinstitution under number 079/11.

Two groups named “study group” and “control group”were defined.

Study group

Inclusion criteria: positive serology for humanimmunodeficiency virus (HIV), legal majority and signature ofthe consent form.

Exclusion criteria: positive serology for hepatitis B or C,use of ocular medication or contact lenses during the seven daysprior to the assessment, patients with previously diagnosed eyediseases that compromise the lacrimal production or drainage(Sjögren’s syndrome, Stevens-Johnson syndrome, ocularpemphigoid, ocular chemical burns, trachoma, peripheral facialparalysis), continuous use of medication with anticholinergiceffect, pregnant and lactating women.

Control group

Inclusion criteria: negative serology for humanimmunodeficiency virus (HIV), legal majority and signature ofthe consent form.

Exclusion criteria: positive serology for hepatitis B or C,use of ocular medication or contact lenses during the seven daysprior to the assessment, patients with previously diagnosed eyediseases that compromise the lacrimal production or drainage(Sjögren’s syndrome, Stevens-Johnson syndrome, ocularpemphigoid, ocular chemical burns, trachoma, peripheral facialparalysis), continuous use of medication with anticholinergiceffect, pregnant and lactating women.

Sixteen patients with HIV and 16 patients without the virusinfection were selected according to the proposed criteria.

In the Study Group, 5 patients were male and 11 werefemale. The mean age was 44.94 years (± 10.33). In the ControlGroup, 5 patients were male and 11 were female, and the meanage was 55.50 years (± 20.81). Tables 1 and 2 summarize the data,demonstrating no statistically significant differences betweenboth groups with respect to age (p = 0.083) and sex (p> 0.999),respectively. Table 3 summarizes the data of patients in the studygroup, including the period of HIV infection.


Evaluation of tear film function, ocular surface and tear film in HIV-seropositive patients


154

Table 4

Record of temperature (°C) and relativehumidity (%) values

T. míno C T. máxo C R.H. min % R.H.max %

Minimum 20.7 21.9 43 49Maximum 23.2 25.8 68 73Média 22.05 23.8 53.5 60.6DP 0.96 1.54 7.81 7.52

Caption: T = temperature; R.H. = relative humidity; min. = minimum;max. = maximum; SD = Standard deviation.

Mosena CR, Pinheiro MVV, Alhadeff PA, Neiva TT, Felberg S


Sequence of exams

After consulting the relevant literature, we did not findconsensus regarding the optimal sequence for the realization ofdry eye tests, so that the proposal in this study was created toavoid the maximum that the realization of a test would influencethe performance of the next one.

Both patients in the study group and in the control groupunderwent the same assessment sequence. Initially, astandardized questionnaire was presented about the knownduration of the infection and the likely form of contagion, as wellas about the antiretroviral therapy in use, when present.

After obtaining said information, the parameters studiedand the interval between each exam are as follows:

Table 1

Assessment of the groups regarding sex

Group

Variable Control HIV+ Total p-Value n % n % N %

Sex >0.999#Female 11 68.8 11 68.8 22 68.8Male 5 31.3 5 31.3 10 31.3

Total 16 100 16 100 32 100

Table 2

Assessment of the groups regarding age

Variable Group Mean SD Median Minimum Maximum N p-Value

Age Control 55.50 20.81 55.5 18 85 16 0.083(years) HIV+ 44.94 10.33 44 18 72 16

Table 3

Study Group Data (HIV+)

Patient Sex Age ΔΔΔΔΔt Infection

1 F 46 132 2 M 41 7 3 F 44 96 4 M 43 96 5 M 41 120 6 M 51 168 7 F 50 168 8 M 50 24 9 F 45 156 10 F 72 228 11 F 43 144 12 F 42 108 13 F 44 168 14 F 18 84 15 F 43 84 16 F 46 168

Legend: F = female; M= male; Age = in years;ΔΔΔΔΔt infection = in months

The questionnaire “dry eye - specific” was initially applied:Ocular Surface Disease Index® (OSDI); immediately after, a tearsample was collected to perform the tear film crystallization test;afterwards, the observation of the tear film breakup time wasobserved, and the cornea was assessed with fluorescein dye 1%.After at least thirty minutes of the previous exam, the Schirmer’stest I was performed. After that, the ocular surface was studiedonce again, but this time using the rose bengal dye 1%. Finally,after at least thirty minutes from the previous test, the sensitivityof the cornea was measured with a Cochet-Bonet esthesiometer.

Location of exams

The questionnaires, measurements of tear film breakuptime, ocular surface staining with fluorescein dye 1%, Schirmer Itest, ocular surface staining with rose bengal dye 1%,esthesiometry, and the collection of tear samples were performedin the same room of the Cornea and External DiseasesAmbulatory of the Department of Ophthalmology of IAMSPE,with doors and windows closed.

In times of collections, the temperature and relativehumidity in the room were recorded with a digital thermo-hygrometer (Barigo®, Barometerfabrik, Villingen-Schwenningen,Germany). The apparatus records the minimum and maximumtemperature in a given period of time, as well as minimum andmaximum relative humidity. Table 4 summarizes the measuresrecorded on days when the patients were assessed.

Parameter Description

• Questionnaire OSDI

All patients underwent a dry eye questionnaire - specific“Ocular Surface Disease Index” (OSDI®, Allergan, Irvine,California, USA), composed of twelve questions asked by the


155Evaluation of tear film function, ocular surface and tear film in HIV-seropositive patients


researcher to the respondents. To answer them, they shouldconsider the seven days preceding the interview. The questionscover three areas: ocular symptoms, possible environmentalstimuli causing ocular discomfort, and finally limitations in dailyactivities of patients according to the ocular clinical profile. Inthis questionnaire, in order to measure the intensity of theanswers provided the patients refer to each question one answeron a scale ranging from 0 to 4 points, with 0 being minimumcommitment and 4 maximum commitment. In the end, an overallscore is generated, taking into account both the indexes providedin each response and the total number of questions that couldbe answered. This score ranges from 0 to 100, with 0 being absenceof eye discomfort, and 100 maximum eye discomfort. Thequestionnaire was administered to patients at all stages, alwaysby the same researcher (CM).

• Tear film crystallization test

In such assessment, also known as ferning test, the patientswere accommodated in a conventional way at the slit lamp andwith non-heparinized capillary glass tube, and the tear samplewas collected from the right eye fornix. A droplet with diameterranging between two and three millimeters was deposited onthe surface of a clean glass slide in the center of a circle previouslymarked with blue or red pen. The tear was allowed to dry atroom temperature for about ten minutes before being stored inthe appropriate box for transportation. The analysis of the slideswas made later, with the help of a light microscope Zeiss Axistar,with which digital pictures of the location corresponding to drytear droplet were obtained, with the camera attached to themicroscope (Sony CybershotÒ model DSC-W120) in zooms of 5,10 and 40 times and resolution of 3 megapixels. The material wascollected and the pictures were taken by the same researcher(CM). The pictures obtained were examined in a separatemoment and in an independent way by another researcher withprevious experience in test reading (SF).

For the classification, the findings of the tear filmcrystallization test were characterized in four patterns, accordingto the model proposed by Rolando, with patterns I and II beingconsidered normal and patterns III and IV abnormal(21).

• Tear film breakup time (TFBUT)

The exam was performed with a slit lamp, and lighting beingcobalt blue. One droplet of 1% fluorescein was instilled in thelower fornix of both eyes of the patients. The patients were askedto blink a few times, and then stop blinking when the timer wasimmediately triggered. The time to the appearance of the first tearfilm breakup point was observed on the cornea surface. Threemeasures were recorded so that the average was obtained.

The test was conducted at all stages by the same researcher (CM).

• Cornea exam with fluorescein dye 1%

Taking advantage of the same volume of fluoresceininstilled for TRFL checking, immediately afterwards the corneaof each eye was assessed according to the following scoreproposed by the researchers:

Score 0: cornea without changes; does not stain with fluorescein.

Score 1: punctate keratitis, with sparse points evidenced by the dye.

Score 2: punctate keratitis, with nearby points evidenced by the dye.

Score 3: severe keratitis, with confluent points evidenced by the dye.


• Schirmer’s Test I

The Schirmer’s test I, also called a Schirmer’s test withouttopical anesthesia, was performed simultaneously on both eyesby placing a standardized and millimetric strip of Wathmannfilter paper number 41 (Ophthalmosâ, São Paulo, Brazil) to theside third of each one of the lower eyelids. The patients wereinstructed to remain with their eyes closed for five minutes. Soonafter, the value corresponding to the wetting of the paper ineach eye was observed and recorded.


• Exam of the ocular surface with rose bengal dye 1%

The assessment of damage to the ocular surface wasanalyzed with rose bengal dye 1%. A droplet of the dye wasinstilled in the upper bulbar conjunctiva of both eyes of thepatients. Then they were assessed at the slit lamp with lightingand green filter. The eyes were classified according to theproposal of van Bjesterveld(22), in which each eye has the ocu-lar surface area exposed by the naturally open slit divided intothree thirds: side bulbar conjunctiva, cornea and medial bulbarconjunctiva. Each third receives from the examiner a scoreranging from 0 to 3, in which:

Score 0: does not stain with rose bengal.

Score 1: dyes slightly, with sparse points.

Score 2: dyes moderately, with nearby points.

Score 3: dyes intensely, with confluent points.The scores of the three thirds are summed to generate a

final score ranging from 0 to 9 points, with 0 being consideredthe absence of damage to the surface and 9 the maximum damage.The exam was conducted at all stages by the same researcher (CM).

• Esthesiometry

In the assessment of the central cornea sensitivity, the patientreported a minimum sensitivity to touch when stimulated in thecentral region of the cornea by the Cochet-Bonnet esthesiometer(Luneau Ophthalmologie, Paris-France), according tostandardization proposed by Norn(23). The exam was performedin both eyes, always by the same examiner (CM), which initiatedthe test in the right eye, touching the central cornea with a nylonthread in maximum exposure (level 6). If the touch was notperceived, the thread was reduced to level 5.5 and so on, 0.5 by 0.5,to level 0. If the touch was perceived, the amount correspondingto the level of exposure of the wire was registered.

Statistical analysis

To meet the goals of the study, first the measures assessedwere described by group using a summary of measures (mean,standard deviation, median, minimum and maximum), then thevalues were compared between the groups using the Mann-Whitney tests, except for ages, which were comparedusing thewith Student’s t-test.

Sex, the OSDI and crystallization classification weredescribed according to the groups using absolute and relativefrequencies, and the existance of an association between thegender and the groups was verified using the chi-square test,and the scale degree among the groups was compared usingtests Mann-Whitney tests.

The tests were conducted at a significance level of 5%.


156 Mosena CR, Pinheiro MVV, Alhadeff PA, Neiva TT, Felberg S


Table 5

Description of the numerical scale values of the second groups and the results of the comparative tests

Results of the Mann-Whitney test(*) Result of t-Student test

Variable Group Mean SD Median Minimum Maximum N p-Value

Age (years) Controle 55.50 20.81 55.5 18 85 16 0.083*HIV+ 44.94 10.33 44 18 72 16

OSDI absolute Controle 13.79 17.13 7.15 0 70 16 0.926HIV+ 13.18 13.16 7.67 0 41,6 16

BUT RE (seconds) Controle 7.94 2.67 10 3 10 16 0.224HIV+ 6.56 3.27 7 2 10 16

BUT LE (seconds) Controle 7.81 2.59 9 3 10 16 0.224HIV+ 6.31 3.26 5 2 10 16

Schirmer RE (mm) Controle 14.81 9.84 15 2 35 16 0.838HIV+ 15.56 9.75 14.5 1 35 16

Schirmer LE (mm) Controle 15.25 8.24 13.5 6 35 16 0.809HIV+ 15.25 9.83 11.5 3 35 16

Esthesio RE Controle 5.13 0.81 5.5 3,5 6 16 0.171HIV+ 4.34 1.55 4.5 1 6 16

Esthesio LE Controle 5.25 0.71 5.5 3,5 6 16 0.210HIV+ 4.41 1.54 4.75 1,5 6 16

Fluorine RE Controle 0.19 0.54 0 0 2 16 0.752HIV+ 0.06 0.25 0 0 1 16

Fluorine LE Controle 0.19 0.54 0 0 2 16 0.780HIV+ 0.25 0.58 0 0 2 16

Rose RE Controle 0.13 0.34 0 0 1 16 >0.999HIV+ 0.13 0.34 0 0 1 16

Rose LE Controle 0.19 0.40 0 0 1 16 0.780HIV+ 0.25 0.45 0 0 1 16

RESULTS

Table 5 shows that the mean age of the control group isstatistically equals to the HIV+ group (p = 0.083), and the teststhat take scores (fluorescein and rose bengal) also did not differbetween the control and the HIV+ groups (p > 0, 05).

Table 6 shows that the standard of tear crystallization testis statistically different in the group of HIV+ patients (with apredominance of patterns III and IV) in relation to the controlgroup (in which the predominant patterns are I and II), both inthe right and the left eyes (p = 0.019 and p < 0.001, respectively).

Charts 1 and 2 illustrate the results in Table 5, but the tearcrystallization scores in both eyes were statistically higher in HIV+patients.

DISCUSSION

The data presented in this study showed that assessmentsof the lacrimal function tests (Schirmer test and tear film breakuptime) and the status of the ocular surface (tests with the dyesfluorescein and rose bengal and sensitivity of the cornea) ofHIV seropositive patients did not show significant differencescompared with the control patients in the conditions studied.

Factors that limit the interpretation of the data are the smallnumber of patients in the study group, the heterogeneity oftime between viral infection and ocular assessment, and indi-vidual characteristics of both antiretroviral treatment and theconsequent clinical spectrum of HIV infection. Initially weplanned to describe the findings using the absolute numberof eyes (64 eyes); however, as the disease studied involvesboth eyes similarly, we chose to use the number of patientsand not eyes, although both have undergone all tests. Thus,the fact that we found no changes that characterizekeratoconjunctivitis sicca in the study group allows us to inferonly that, unlike the findings of other researchers, the groupof selected patients did not present dry eye at the very momentthat our assessment was made.

If we assume that the clinical profile of ocular drynessassociated with HIV infection observed by other authors is infact similar to that observed in the Sjögren’s syndrome, it ispossible to conclude that the damage caused in the secretoryexocrine tissue occur in the first group in a gradual way as well,with slow and gradual installation of the symptoms. In this regard,it is not possible to ignore the possibility of the group studiedherein develop further changes of the lacrimal function andconsequently the ocular surface, and is therefore recommendedto evaluate it periodically.


157

Table 6

Description of qualitative scales and accordingto groups and results of the association test

and comparative tests of scales.

Group

Variable Control HIV+ Total p-Value n % n % N %

OSDIclassification 0.809

Normal 11 68.8 12 75.0 23 71.9Mild 2 12.5 1 6.3 3 9.4Moderate 3 18.8 3 18.8 6 18.8

Cristal RE 0.019

I 6 37.5 2 12.5 8 25.0II 6 37.5 3 18.8 9 28.1III 3 18.8 7 43.8 10 31.3IV 1 6.3 4 25.0 5 15.6

Cristal LE <0.001

I 10 62.5 2 12.5 12 37.5II 4 25.0 1 6.3 5 15.6III 2 12.5 5 31.3 7 21.9IV 0 0.0 8 50.0 8 25.0

Total 16 100 16 100 32 100

Chart 1

Percentage of crystallization in the right eyeobserved according to groups.

Chart 2

Percentage of crystallization in the left eyeobserved according to groups



The etiology of keratoconjunctivitis sicca related to HIVinfection is not well established yet. Evidence derived fromstudies of patients with Sjögren’s syndrome shows the presenceof a cross-sectional reaction of serum antibodies with retroviralproteins, and the occurrence of reverse transcriptase activity inthe salivary glands(18). Furthermore, the detection of retroviralantigens, retrovirus-like particles or retroviral sequences in thesalivary glands of patients with systemic retrovirus infection(EBV, HIV and HTLV) corroborate the theory that the infectioncould represent the trigger for the development of manifestationscaused by underactivity of the exocrine glands, although to dateno study has evidenced that these findings present in the salivaryglands are reproduces in the lacrimal ones, but clinical evidencesuggest that the pathogenic mechanism is similar(24).

That is, both the presence of the virus live in glandularmicroenvironment and the immune dysfunction leading thedefense system to consider non-self proteins of the ducts andglandular acini in a cross-section reaction with viral proteins canlead to inflammation and local destruction, justifying theabnormalities of the lacrimal function described above andobserved by other authors in HIV-positive patients. This means,therefore, that some HIV-infected patients who develop dry eyeare in fact genetically predisposed to this cross-section reaction,and it is unclear exactly in which percentage they represent thegroup of patients developing dry eye by this mechanism in theuniverse of seropositive. It is possible to believe that in suchcases keratoconjunctivitis sicca is installed later than in thosedetermined solely by the presence of the virus in the acinartissue. The sample reduced from patients in the present studyfavors the selection bias, and the group may have been composedof patients predisposed to long-term changes.

Rodrigues et. al. observed a significant increase in thefrequency of the dry eye syndrome in patients with the disease

developed for over four years, especially among those who wereon HAART, but the decrease in tear production was not relatedto the severity or time of infection(25). In the group studied, allpatients were using HAART, and the time of infection was nottaken into account; however, we did not consider the relevant factdue to not observing differences between them and the controls.If changes were detected in the infected group in the performanceof the tests, there would be a doubt whether the use of systemicmedication might account for the findings. Presumably, HAARTscheme can eliminate the manifestations of the Sjögren-likesyndrome; however, no study has clearly shown the action ofantiretroviral drugs alone or in combination, or if they may have adeleterious effect on some of the tear film components, regardlessof the infection. On the other hand, in order for the influence ofantiretroviral therapy be concluded as a protective factor in theprevention of keratoconjunctivitis sicca, an event that may haveoccurred to the patients studied herein, a new study would beneeded comparing HIV-positive patients under treatment withother without any treatment or systemic comorbidities.


158 Mosena CR, Pinheiro MVV, Alhadeff PA, Neiva TT, Felberg S


Again, the samples will tend to be reduced because of thefrequent association of HIV infection with other virusespotentially triggering dry eye, including the HCV and HVB(considered as an exclusion criteria of the present study, beingone of the responsible for the restriction on the size of the samplethat was formed).

Colombo et. al. described the dissociation between signsand symptoms of dry eye in patients with Sjögren’s syndrome,i.e., the weak relation between the intensity of complaints (alsoassessed by questionnaire of dry eye - specific - OSDI) and thestatus of the ocular surface, especially in chronic and severe ca-ses(26). One explanation proposed by the authors was that chronicinflammation caused by dry eye and the local release ofinflammatory mediators would lead to cornea hypoesthesia, withsubsequent reduction of perception of nuisance, despite asignificantly changed ocular surface. We believe, however, thatthe normal values observed in OSDI questionnaire in our studyand that indicate the absence of ocular discomfort represent theabsence of complaints due to the lack of eye damage, verified bythe sequence of the other tests and confirmed by the sensitivityof the normal corneas assessed.

It is possible to consider that biochemical changes of thetear film responsible for the mucous component under certainconditions can be earlier signs of lacrimal dysfunction thanchecking the deficit in water production or the presence ofdamage to the ocular surface. This justifies the inalteredSchirmer’s test. The test of crystallization in the tear samplescollected showed that HIV-infected patients tend to have a worsequality than normal patients. Seropositive patients presentpatterns III and IV of Rolando more often than individualswithout the infection. In these, the patterns I and II were moreprevalent. The relative humidity above 50% can reduce the testreproducibility; however, the pioneer studies describing this testdo not measure the humidity and not to mention it as an influenceparameter(27), while other studies in order to assess only this testdid it with humidity between 48-69%(28). The classification systemof the crystallization test works as an evaluation index of theoverall quality of the tear film, since so as to form each of thepaterns considered in the classification the mucus, glycoproteins,and electrolytes concentrations are fully determinant.

Another important test, although not conducted in ourstudy, is the osmolarity measure of the tear film. The role ofhyperosmolarity is known as a key mechanism in thephysiopathogenesis of dry eye, as demonstrated in numerousstudies and increasingly discussed(29). Hyperosmolarity occursas a consequence of the reduction in aqueous production and/or the increase of tear evaporation. It is also responsible forreducing the density of goblet cells of the bulbar conjunctiva.The loss of goblet cells may be responsible for the unstable tearfilm and the reduction of mucin(30), showing changes in thebiochemical component of the tear. As the test and crystallization,due to evaluating the first affected component in the Sjögren-like cases, probably the measure of osmolality was also changedin our study.

This finding confirms the need for the present study follow-up, with new assessments of the patients observed under thesame conditions described here, in addition to its developmentwith different tests, such as the tear osmolarity measure itself inthis group.

CONCLUSION

Under the conditions studied, the HIV seropositive patientsshowed no changes in lacrimal function nor in the ocular surface;however, the tear samples showed differences consideredstatistically significant in the patterns of the tear film crystallizationtests when compared with the samples obtained from controlpatients.

REFERENCES

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2. McClure MO, Schulz, TF. Origin of HIV. BMJ. 1989; 298 (6883):1267-8.

3. Mendes NF. Simian viruses, organ xenotransplantation and a hy-pothesis about the origin of AIDS. Braz J Med Biol Res. 1993;26(3): 231-3.

4. UNAIDS. Resumo mundial da epidemia de HIV/SIDA – janeirode 2011 [Interne]. [citado 2014 Set 30]. Disponível em: URL:http://www.unaids.org.

5. Garry RF. Potential mechanisms for the cytopathic properties ofHIV. AIDS. 1989;(11):683-94.

6. Update: acquired immunodeficiency syndrome – United States,1992. MMWR Morb Mortal Wkly Rep. 1993; 42(28):547-51,557.

7. Freitas JA, Soranz Filho JE, Soranz JF, Barbosa ML, Gonçalves VL.Achados oftalmológicos em pacientes com Síndrome deImunodeficiência Adquirida. Rev Bras Oftalmol. 1997;56(11): 837-41.

8. Kadhem M; Kalisch SB, Goldsmith J, Fetkenhour C, O’Grady RB,Phair JP, Chrobak M. Ophthalmologic findings in acquired immuno-deficiency syndrome (AIDS). Arch Ophthalmol. 1984;102(2): 201-6.

9. Raskin RH, Justo DM, Torres LM, Picetti E, Cattani S, BocaccioFJL, Rymer S. Avaliação de olho seco em pacientes com testeanti-HIV positivo [resumo]. Arq Bras Oftalmol. 1993;56(4).

10. Steck AD, Abreu MT, Muccioli C, Lottenberg C, Belfort Júnior R.Prevalência de olho seco em população de pacientes HIV positivos[resumo]. Arq Bras Oftalmol. 1994;57(4).

11. The definition and classification of dry eye disease: report of thedefinition and Classification Subcommittee of the InternationalDry Eye Workshop (2007). Ocul Surf. 2007;5(2):75-92.

12. Pflugfelder SC, Wilhelmus KR, Osato MS, Matoba AY, Font RL.The autoimmune nature of aqueous tear deficiency. Ophthal-mology. 1986; 93(12):1513-7.

13. Kordossis T, Paikos S, Aroni K, Kitsanta P, Dimitrakopoulos A,Kavouklis E, et al. Prevalence of Sjögren-like syndrome in acohort of HIV-1 positive patients: descriptive pathology and im-munopathology. Br J Rheumatol. 1998: 37(6):691-5.

14. DeCarlo DK, Penner SL, Schamerloh RJ, Fullard RJ. Dry eyeamong males infected with the human immunodeficiency virus. JAm Optom Assoc. 1995; 66(9):533-8.

15. Geier SA, Libera S, Klauss V, Goebel FD. Sicca syndrome inpatients infected with the human immunodeficiency virus. Oph-thalmology. 1995; 102(9):1319-24.

16. Lucca JA, Kung JS, Farris RL: Keratoconjunctivitis sicca in fe-male patients infected with human immunodeficiency virus. CLAOJ. 1994; 20(1):49-51.

17. Lucca JA, Farris RL, Bielory L, Caputo AR. Keratoconjunctivitissicca in male patients infected with human immunodeficiencyvirus type 1. Ophthalmology.1990; 97(8):1008-10.

18. Sipsas NV, Gamaletsou MN, Moutsopoulos HM. Is Sjögren’s syn-drome a retroviral disease? Arthritis Res Ther. 2011; 13(2):212-19.


159

Corresponding author:Carolina Ramos MosenaRua Borges Lagoa, 1755 - Ophthalmology, 3rd floor - VilaClementino - ZIP Code: 704038-034. São Paulo - SP - BrazilPhone: (11) 5549-2937/ (11) 5088-8167 / Fax: (11) 55492937Email: [email protected]



19. Panayiotakopoulos GD, Aroni K, Kyriaki D, Paikos S, VouyioukasN, Vlachos A, Kontos AN, Kordossis T: Paucity of Sjögren’s -likesyndrome in a cohort of HIV-1-positive patients in the HAARTera. Part II. Rheumatology (Oxford). 2003, 42(10):1164-7.

20. Felberg S, Dantas PE. Diagnóstico e tratamento da síndrome deSjögren. Arq Bras Oftalmol. 2006; 69(6):959-63.

21. Rolando M. Tear mucus ferning test in normal and keratoconjuntivitissicca eyes. Chibret Int J Ophthamol. 1984; 2(4):32-41.

22. van Bijsterveld OP. Diagnostic tests in the Sicca syndrome. ArchOphthalmol. 1969 Jul;82(1):10-4.

23. Norn MS. Conjuntival sensivity in pathological cases, with simul-taneous measurement of corneal and lid margin sensitivity. ActaOphthlmol (Copenh). 1975; 53(3):450-7.

24. Talal N, Dauphinée MJ, Dang H, Alexander SS, Hart DJ, GarryRF. Detection of serum autoantibodies to retroviral proteins inpatients with primary Sjögren’s syndrome (autoimmuneexocrinopathy). Arthritis Rheum. 1990, 33(6):774-781.

25. Rodrigues ML, Rodrigues ML, Holanda de Freitas JA. Estudoda síndrome de ceratoconjuntivite seca de pacientessoropositivos para o vírus da imunodeficiência adquirida humanatipo 1 e com síndrome da imunodeficiência adquirida, em uso ounão de terapia anti-retroviral combinada (HAART). Arq BrasOftalmol. 2004; 67(2):283-7.

26. Barboza MN, Barboza GN, de Melo GM, Sato E, DantasMC, Dantas PE, Felberg S. Correlation between signals and symp-toms of dry eye in Sjögren’s syndrome patients. Arq BrasOftalmol. 2008;71(4):547-52.

27. Tabbara KF, Okumoto M. Ocular ferning test. A qualitative testfor mucous deficiency. Ophthalmology. 1982; 89(6):712–4.

28. Felberg S, Cordeiro H, Sato E, Martini D, Dantas MC, Endo RM,Dantas PE. Reprodutibilidade na classificação do teste decristalização do filme lacrimal em pacientes com síndrome deSjögren. Arq Bras Oftalmol. 2008;71 (2):228-33.

29. Baudouin C, Aragona P, Messmer EM. Role of hyperosmolarityin the pathogenesis and management of dry eye disease: pro-ceedings of the OCEAN Group Meeting. Ocul Surf2013;11(4):246-58.

30. Liu H, Begley C, Chen M, Bradley A, Bonanno J, McNamara NA,et al. A link between tear instability and hyperosmolarity in dryeye. Invest Ophthalmol Vis Sci. 2009; 50(8):3671-9.


160


ORIGINAL ARTICLE

RESUMO

ABSTRACT

Variação da pressão intraocular no exercícioresistido realizado em duas diferentes posições

Variation of intraocular pressure in resistanceexercise performed in two different positions

Alex Sander Soares1, André Athanazio Caldara1, Lucas Ruiz Storti1, Luis Felipe Milano Teixeira1, João Guilherme TornizielloTerzariol1, Marcelo Conte1

1 BOS Fit, Center for Studies and Research in Sports Sciences, Ophthalmology Hospital of Sorocaba, Sorocaba, SP, Brazil.

The authors declare no conflict of interest


Objetivo: Verificar a variação da PIO no exercício resistido na posição sentada e em decúbito dorsal. Métodos: Foram avaliados 14voluntários do Centro de Atividades Físicas do Banco de Olhos de Sorocaba (BOS Fit). Os critérios de exclusão adotados foram: I)opacidade de meios; II) alteração de volume do bulbo ocular ou ausência de bulbo ocular; III) PIO maior do que 21mmHg; IV) idadeinferior 20 e superior a 40 anos; V) tempo de prática de treinamento resistido inferior a 30 dias. Inicialmente foi realizado o teste depredição no exercício leg press para determinar o percentual de carga para o respectivo exercício durante o experimento. Os voluntáriosforam submetidos a duas intervenções separadas em um intervalo de 72 horas, ambas com o mesmo volume e intensidade no exercícioleg press, ou seja, 3 séries de 15 repetições com 60% 1RM, tempo de intervalo entre as séries de 60 segundos e velocidade moderada, deacordo com as seguintes posições: P1) leg-press executado na posição sentada e P2) leg press na posição em decúbito dorsal. A PIO foiobtida utilizando o tonômetro de Perkins em três momentos: M1) imediatamente antes do exercício; M2) imediatamente após a terceirasérie; M3) três minutos após a finalização da terceira série. Resultados: Em ambas as posições houve queda significativa da PIO apóso exercício (M2), permanecendo significativamente reduzida após três minutos de recuperação (M3). Contudo, não houve diferença daPIO segundo a posição (P1 e P2), independentemente do momento de aferição (M1, M2 e M3). Conclusão: Houve queda da PIOdecorrente ao exercício resistido e não foi verificada resposta diferencial da PIO de acordo com a posição do exercício.

Descritores: Pressão intraocular/fisiologia; Exercício; Treinamento de resistência; Postura

Objective: To verify the variation in IOP in the resistance exercise performed in the sitting and supine. Methods: A 14 volunteers ofthe Center for Physical Activities of the Sorocaba Eye Bank (BOS Fit). Exclusion criteria were adopted: I) media opacity; II) changein volume of the eyeball or no eyeball; III) IOP greater than 21mmHg; IV) age 20 and over 40; V) time practice of resistance trainingless than 30 days. Initially the test was performed to predict the leg press exercise to determine the percentage charge for the exercisethereof during the experiment. The volunteers underwent two interventions separated by an interval of 72 hours, both with thesame volume and intensity in the leg press exercise, 3 sets of 15 repetitions with 60% 1RM, interval time between sets 60 seconds andmoderate speed, according to the following positions: P1) leg press performed in the sitting position and P2) leg press in supineposition. IOP was obtained using the Perkins tonometer in three moments: M1) immediately before exercise; M2) immediately afterthe third series; M3) three minutes after completion of third grade. Each sequence was obtained by measuring the position of theirexercise performance. Results: We found that in both positions there was a significant drop in IOP after exercise (M2), remainedsignificantly reduced after three minutes of recovery (M3). However, there was no difference in IOP second position (P1 and P2),regardless of time of measurement (M1, M2 and M3). Conclusion: There was a decrease in IOP due to resistance exercise and wasnot observes differential response of IOP of IOP according to the position of the exercise.

Keywords: Intraocular pressure/physiology; Exercise; Resistance training; Posture


161

INTRODUCTION

The intraocular pressure (IOP) is determined by theproduction, circulation and drainage of aqueous humorthrough trabecular and uveoscleral outflow, and also by

the episcleral venous pressure(1). The vitreous volume, choroidalblood volume, scleral rigidity, orbicular muscle tension of the eyeand the external pressure may also affect the IOP(2). Besidesthat, the IOP can be varied due to several factors such as circadianrhythm(3), body position(4), physical exercise(5), among others.

In relation to the circadian rhythm there is an IOP peak inthe early morning hours and the value becomes lower in the lateafternoon, with floating of 4 to 6 mmHg. Said variation is relatedto the activity of the autonomic nervous system, humoral controland change muscle tone(3,4,6,7). However, it was found thatregardless the body position there is a significant increase in theIOP at night that is kept until the early morning hours, but thedaily curve of IOP shows differences according to age(8).

As for the body position, the IOP lying down is higherthan sitting, and possibly the hydrostatic changes such as theelevated episcleral venous pressure which occur from oneposition to another may explain said differences(9). Regardingphysical exercises, both aerobic and anaerobic activities - includingweightlifting (resistance training) - show a reduction in the IOPdue to the reduction of plasma osmolality, hyperventilation,increased nitric oxide synthesis, reduction in plasma pH, amongother mechanisms(10,11).

On the other hand, it is known that there is an IOP variationdue to the change in body position, patients in supine positionhave higher blood pressure values in relation to themeasurements obtained in the sitting position, and the increasedepiscleral venous pressure(12) may be considered as an importantfactor for IOP fluctuation resulting from the change in posture.In fact, studies have demonstrated the hypotensive effect ofresistance training in IOP. However, it is not defined in theliterature if exercises performed in different positions also havedifferent effects on IOP.

In this sense the objective of the present study was toverify the IOP variation in the resistance training in the sittingposition and in the supine position.

METHODS

Sample

This experimental study was conducted in healthy patientssubmitted to two resistance training sessions. By conveniencethe sample consisted of 20 patients (10 male and 10 female). Theexclusion criteria adopted were: i) media opacity; ii) volumechange of ocular bulb or absence of ocular bulb iii) age below 20or over 40 years old, and iv) time practicing resistance trainingbelow 30 days. The inclusion criteria considered was a medicalcertificate corresponding to clinical and laboratory assessmentand electrocardiogram. The experimental procedures werecarried out on the premises of the Physical Activities Center ofthe Eye Bank if Sorocaba (BOS Fit).

The protocol was conducted following the ethical principlesestablished in the Declaration of Helsinki proposed by the World

Medical Association. The project was sent to approved by theResearch Ethics Committee of the Ophthalmology Hospital ofSorocaba (opinion No.101.533). All participants were informedabout the research and their respective degree of involvement,and then asked to sign the Informed Consent, consisting ofexplanation about the following aspects: i) justification, objectivesand procedures used; ii) discomfort, possible risks and expectedbenefits; iii) form of follow-up and assistance and their guardians;iv) information on the possibility of inclusion in the control group;v) freedom to refuse to participate or withdraw their consent atany stage of the research, without penalty or loss and vi)guarantee of confidentiality in relation to the data collected.

Instruments and procedures

To determine the training loads, the prediction test(13)

initially performed was the leg-press exercise, which aims toestimate the maximum load for resistance training by means ofthe application of submaximal loads to exhaustion. According tothe relevant protocol, a random load is applied, and thevolunteers as asked to exercise to fatigue. The repetitions arerecorded and related to a specific table to check the estimatedload to be used in the experiment, here 60% of one maximumrepetition (1MR).

The volunteers underwent two interventions separated byan interval of 72 hours, both with the same volume and intensity inthe leg-press exercise, i.e., 3 sets of 15 repetitions with 60% 1MR, atime interval between series of 60 seconds and moderate speed,according to the following positions: P1) leg-press performed in asitting position and P2) leg-press in the supine position. The IOPwas obtained using the Perkins tonometer, always by the sameophthalmologist with experience in this technique, in threemoments: M1) immediately before the exercise, M2) immediatelyafter the third set and M3) three minutes after the completion ofthe third set. Each measurement sequence was obtained in therespective performance position of the exercise, watching a distantobject with the contralateral eye, after instillation of a droplet ofproparacaine eyedrops and a droplet of fluorescein eyedrops.Although the Goldman applanation tonometer is considered thegold standard for the measurement of IOP, other tonometersshoe good mesurement correlation(14,15). In this study, the use ofthe Perkins tonometer is justified by the practicality of employmentin field situations of physical exercise, allowing it to be takenanywhere and that the measure is made with minimal displacementof the patient assessed, as well as allowing the measurement in thesupine position(16).


The mean and the standard deviation were descriptivelycalculated, and the data were presented in the tabular form andin box diagram (Box-plot). We used ANOVA with repeatedmeasures and Bonferroni post-test, adopting a significance levelof 5% to compare to the measures for the variables studied. Thesoftware used was GraphPadPrism®.

RESULTS

Table 1 shows the IOP response in both positions at threedifferent moments, and demonstrates the significance in reducingthe IOP after the beginning of the exercise.


Variation of intraocular pressure in resistance exercise performed in two different positions


162


It was observed that in both positions there was a significantdecrease in IOP after the exercise (M2), remaining significantlyreduced after three minutes of recovery (M3). However, therewas no difference in IOP according to the position (P1 and P2),regardless of the moment of measurement (M1, M2 and M3).

Figures 1 and 2 show the variation of IOP in the right eye(RE) and left eye (LE) according to the position in the momentspre-exercise (M1), post-exercise (M2) and three minutes afterexercise (M3).

DISCUSSION

In a study of boxing athletes who underwent resistancetraining sessions, values significantly lower in the IOP were found

Table 1

IOP response according to the position of the exercise and according to the assessment moment

Figure 1. Changes in the IOP in the RE according to the position,second moment.

Figure 2. Change in the IOP in the LE according to the position, secondmoment

a= p<0.001; b= p<0.01; c = p<0.05

a= p<0.001; b= p<0.01; c = p<0.05

after performing the exercises, regardless the body position ofthe volunteers(17).

However, a survey was conducted with 82 patients notsubject to physical exercise which presented the followingconditions: primary open angle glaucoma (POAG), normalpressure glaucoma (NPG) and individuals with normal eyes (NE).It was observed that the IOP was higher in the supine positionthan in the sitting position(18), regardless of the condition. Themean difference in IOP between the supine and the sittingpositions in the POAG was 3.41mmHg. However, the NPG groupwas 2.77mmHg, and finally in volunteers with NE the differencefound was 2.45mmHg. The authors consider that the respectivedifference may be associated with increased episcleral venouspressure.

It is also pointed out that the exercises performed with thelegs positioned above the head can result in elevation of IOP(19).On the other hand, this increase may be due to increasedchoroidal vasculature and episcleral venous pressure, in whichthe flow of ocular tissues becomes committed, and the choroid isa very vascularised tissue which can cause dynamic changes inthe aqueous humor liquid, causing increased IOP(20).

Another study(21) which also found that the variation inthe aqueous humor drainage according to the body positionfound that the average IOP in 21 volunteers in the sitting andsupine positions was significantly different, i.e., respectively,17.8+1.7mmHg and 19.9+1.6mmHg. On the other hand, therewas no significant difference in the aqueous humor drainageaccording to the body position, with observed values of 0.30+0.31(seatting) and 0.28+0.09l/min/mmHg (supine)

Regarding the volume and intensity of training(17,22) it isobserved that the resistance training causes a decreased IOPregardless of the load used during the exercise session, with agreater change in the method which calls for the development ofmuscle strength. In fact, in these conditions the total volume oftraining and the time in which the muscles remain under tensionare higher than in other methods of resistance training. However,the supine exercise performed with maximum load for fourrepetitions in voluntary apnea caused a mean increased IOP of4.3±4.2mmHg in young healthy volunteers(23).

Hypothetically, exercises performed in the supine positionwould naturally increase the IOP levels. However, the hypotensiveeffects of resistance training(7,11,17,24) seems to interfere in thisprocess, antagonizing the potential increase in IOP by mechanismsthat promote the reduction of the formation and/or increasedaqueous humor outflow.

Soares AS, Caldara AA, Storti LR, Teixeira LFM, Terzariol JG T, Conte M

Moment

Position M1 M2 M3

RE LE RE LE RE LE

Sitting (P1) 12.85 + 1.91 12.21 + 1.80 a9.28 + 1.97 b9.35 + 2.02 a9.28 + 2.36 b9.00 + 2.48

Supine (P2) 12.35 + 2.30 11.78 + 1.42 c9.57 + 1.22 b8.78 + 1.18 b9.14 + 1.91 a8.35 + 1.78

a=p<0.001; b=p<0.01; c =p<0.05


163

CONCLUSION

There was a drop in the IOP due to resistance training,and the differential response of IOP according to the position ofthe exercise was not verified. In practical terms, these results cancontribute to the selection of resistance training for people withrisk factors for ocular hypertension or glaucoma, since it wasfound that exercises in both the sitting and the supine positionpromote the reduction of the IOP.

REFERENCES

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2. Talieri IC, Honsho CS, Nunes N, Souza AP, Duque JC. [Behavior ofintraocular pressure according to cardiorespiratory and hemodynamiceffects induced by desflurane in dogs subjected to experimental hy-povolemia]. Arq Bras Oftalmol. 2005;68(4): 521-6. Portuguese.

3. Jaén-Díaz JI, Cordero-García B, López-de-Castro F, De-Castro-Mesa C, Castilla-López-Madridejos F, Berciano-Martínez F. [Di-urnal variability of intraocular pressure]. Arch Soc Esp Oftalmol.2007;82(11):675-9.

4. Shuba LM, Doan AP, Maley MK, Zimmerman MB, Dinn RB,Greenlee EC, et al. Diurnal fluctuation and concordance of in-traocular pressure in glaucoma suspects and normal tension glau-coma patients. J Glaucoma. 2007;16(3):307-12.

5. Dane S, Koçer I, Demirel H, Ucok K, Tan U. Effect of acutesubmaximal exercise on intraocular pressure in athletes and sed-entary subjects. Int J Neurosci. 2006;116(10):1223-30.

6. Asejczyk-Widlicka M, Pierscionek BK. Fluctuations in intraocu-lar pressure and the potential effect on aberrations of the eye. BrJ Ophthalmol. 2007;91(8):1054-8.

7. Conte M, Scarpi MJ, Rossin RA, Beteli HR, Lopes RG, MarcosHL. [Intraocular pressure variation after submaximal strengthtest in resistance training]. Arq Bras Oftalmol. 2009;72(3):351-4.Portuguese.

8. Mansouri K, Weinreb RN, Liu JH. Effects of aging on 24-hourintraocular pressure measurements in sitting and supine bodypositions. Invest Ophthalmol Vis Sci. 2012;53(1):112-6.

9. Rodrigues LD, Silva MR, Schellini SA, Jorge EN. [Intraocularpressure peaks: comparison between the circadian curve, diurnalcurve and the 6 a.m. measurement]. Arq Bras Oftalmol.2004;67(1):127-31. Portuguese.

10. Ashkenazi I, Melamed S, Blumenthal M. The effect of continuousstrenuous exercise on intraocular pressure. Invest OphthalmolVis Sci. 1992;33(10):2874-7.

11. Harris A, Malinovsky VE, Cantor LB, Henderson PA, Martin BJ.Isocapnia blocks exercise-induced reductions in ocular tension.Invest Ophthalmol Vis Sci. 1992;33(7):2229-32.

12. Weber AK, Price J. Pressure differential of intraocular pressuremeasured between supine and sitting position. Ann Ophthalmol.1981;13(3):323-6.

13. BrzyckI M. Strength testing: predicting a one-rep max from reps-to-fatigue. J Phys Educ Recreation Dance. 1993;64(1):88-90.

14. Andrada Márquez MT, Fesser Oroz I, Antón López A. [Compara-tive study of two portable tonometers: Tono-Pen XL and Perkins].Arch Soc Esp Oftalmol. 2003;78(4):189-96. Spanish.

15. dos Santos MG, Makk S, Berghold A, Eckhardt M, Haas A. In-traocular pressure difference in Goldmann applanation tonom-etry versus Perkins hand-held applanation tonometry in over-weight patients. Ophthalmology. 1998;105(12):2260-3.

16. Favarato M, Almodin J, Almodin F, Cvintal T. [Intraocular pres-sure and exotalmometer evaluation before and after peribulbaranaesthesia in cataract surgery]. Rev Bras Oftalmol.2011;70(3):68-173. Portuguese.

17. Conte M. Associação entre exercícios resistidos e pressão intra-ocular [tese]. São Paulo: Universidade Federal de São Paulo; 2009.

18. Meirelles SH, Mathias CR, Brandão G, Frota AC, Yamane R.[Postural influence on intraocular pressure and visual field de-fects in open angle glaucoma and normal tension glaucoma].Rev Bras Oftamol. 2008;67(1):19-24. Portuguese.

19. Hilton E. Exerc-eyes: effects of exercise on ocular health[Internet]. Anstey: Sportvision, 2003 [cited 2013 Set 10]. Avail-able from: www.sportvision.co.uk/pdf/articleexerceyes.pdfý

20. Prata TS, De Moraes CG, Kanadani FN, Ritch R, Paranhos A Jr.Posture-induced intraocular pressure changes: considerations re-garding body position in glaucoma patients. Surv Ophthalmol.2010;55(5):445-53. Review.

21. Selvadurai D, Hodge D, Sit AJ. Aqueous humor outflow facility bytonography does not change with body position. Invest OphthalmolVis Sci. 2010;51(3):1453-7.

22. American College of Sports Medicine. American College of SportsMedicine position stand. Progression models in resistance train-ing for healthy adults. Med Sci Sports Exerc. 2009;41(3):687-708.Review.

23. Vieira GM, Oliveira HB, de Andrade DT, Bottaro M, Ritch R.Intraocular pressure variation during weight lifting. ArchOphthalmol. 2006;124(9):1251-4.

24. Avunduk AM, Yilmaz B, Sahin N, Kapicioglu Z, Dayanir V. Thecomparison of intraocular pressure reductions after isometric andisokinetic exercises in normal individuals. Ophthalmologica.1999;213(5):290-4.

Variation of intraocular pressure in resistance exercise performed in two different positions


Corresponding author:Alex Sander SoaresZIP Code: 18190-000 - Araçoiaba da Serra-SP, Brazil,


164

ABSTRACT

Objective: The purpose of this study was to perform an objective videotaped evaluation of the difficulties of eyedrop instillation anddaily tasks in patients with advanced glaucoma with visual impairment. Methods: A prospective observational study was performed inadvanced glaucoma patients with visual impairment, during 5 months. Patients completed a survey (with demographic questions, qualityof life, compliance and eyedrop instillation) with interview and video recording in specific daily tasks (eyedrop instillation, climbingstairs, walking in a crowded room and in an irregular floor). Ophthalmologic evaluation was performed and its results registered in aform. Correlation was searched between limitation in quality of life, tasks’ performance and visual fields. Results: 25 patients wereincluded, corresponding to 12h of videotaping. All patients reported being capable of self-instilling eyedrops. 68% of them reported nodifficulty instilling the eye drops at home, however 20% of the patients were unable to instill a drop in the eye in the objective evaluation.72% of the patients stated never touching the eye with the bottle but 40% touched the ocular surface with the bottle. There was amoderate difficulty in the other tasks, with some patients exhibiting proprioceptive mechanisms of adaptation to impaired vision. Therewas a tendency of correlation between limitation in tasks and visual field defects, but no statistically significant. Conclusion: Patients withadvanced glaucoma and visual impairment have marked difficulty in eye drop instillation and daily tasks, with a poor awareness of theirinabilities. Some patients have proprioceptive adaptations that allow them to perform better than expected in tasks.

Keywords: Glaucoma; Video recording; Quality of life; Patient compliance; Activity of daily living


ORIGINAL ARTICLE



Dificuldades no cotidiano dos pacientes com glaucomaavançado - avaliação objetiva com registro em vídeo

Difficulties of daily tasks in advancedglaucoma patients - a videotaped evaluation

Ana Isabel Martinho Miguel1, Cristina Fonseca2, Nuno Oliveira2, Filipe Henriques2, João Filipe Silva2

1 Polyclinique de la Baie, Avranches, França.2 Hospital and University Center of Coimbra, Portugal.

This work was partially presented at the 55th Portuguese Congress of Ophthalmology, December 6, 2012, in Lisbon.


165

INTRODUCTION

It is estimated that glaucoma is the 2nd largest global cause ofblindness1. In the case of a chronic disease whose treatmentusually includes self-administration of hypotensive eyedrops,

treatment adhesion is essential to reduce the risk of progressionof glaucomatous damage2.

Treatment adhesion refers to all the aspects whichdistinguish the correct administration of treatment prescribed2,3,beyond the correct compliance with the use of medication bythe patient and the appropriate persistence (continuedtreatment over time).

In glaucoma, non-adhesion to treatment is associated withthe progression of glaucomatous damage4,5, leading to visualloss6. Studies estimate that adhesion occurs in 25 to 39% ofpatients with initial glaucoma2,7-9. But patients with advancedglaucoma, by noticing some visual impairment, are moremotivated to therapeutic adhesion; however, these patientshave greater difficulty in self-administering eyedrops10. Suchdifficulty may be responsible for involuntary non-adhesion andnot perceived by the patient, as suggested in recent studies ofthe capacity of eye-drop administration in patients withadvanced glaucoma11,12.

The correct placement of a droplet in the conjunctivalfornix depends on several factors, such as the ability to see13

and squeeze the bottle14 or to detect whether the droplet hasfallen in or out of the eye15. Only three studies used videotapingto objectively assess the difficulty of patients with advancedglaucoma in self-administering hypotensive eyedrops11,12,15.

Besides the difficulty in using eyedrops, the patients withadvanced glaucoma reported greater difficulties in many dailytasks16,17. Thus, these patients have a lower quality of life thanpatients without glaucoma and patients with inicialglaucoma18,19.Cowdin et al. confirmed that the visual field defectstranslate into negative impact on quality of life20-22, and thatpatients with advanced glaucoma are at a higher risk for falls23.However, there is no study objectively assessing with videorecording the abilities and difficulties of patients to performdaily tasks.

The aim of our study was to assess objectively and withvideo recording the performance on specific daily tasks ofpatients with advanced glaucoma. The secondary objectivesincluded estimating the quality of life of these patientsidentifying the relation between visual field defects and thelimitation in performing daily activities and quality of life.

METHODS

Study design

We conducted a prospective unicentric observational study.The study lasted 5 months (from April 1 to August 31, 2012).

Selection of participants

A systematic sample of the patients selected was obtainedin a glaucoma consultation during the study period at the Hospi-tal and University Center of Coimbra, Portugal, sector ofOphthalmology, subspecialty Glaucoma. The first three patientsof each consultation day that met the inclusion criteria wereinvited to take part in the study. The study was explained to thepatients, who filled a written and oral informed consent. Theinclusion criteria in the study were:

• Primary open angle glaucoma (POAG) diagnosis bytonometry, gonioscopy, assessment of the optical disc andvisual field

• Diagnosis made by the ophthalmologist at least in theconsultation prior to the consutation to select the participant

• Participant’s age e” 18 years old• Experience in self-administration of hypotensive eyedrops

for tat least 6 months• Visual acuity (VA) d” 20/60 or moderate to severe campimetric

defect in at least one eye11

The exclusion criteria were:

• Other types of glaucoma• Suspected glaucoma• VA d+ perception of hand bilateral movements• Disagreement in taking part in the study• Patients with dementia, psychiatric or neurological

pathologies impeditive from answering the questions

RESUMO

Objetivo: O objetivo deste trabalho foi avaliar objetivamente, com registro em vídeo, as dificuldades dos pacientes com glaucomaavançado na colocação de colírios hipotensores e na realização de tarefas do cotidiano. Métodos: Realizou-se um estudo prospectivoobservacional em pacientes com glaucoma avançado e perda visual. Os dados foram coletados durante 5 meses e posteriormenteaplicados questionários (questões demográficas, qualidade de vida, autoadministração de colírios e aderência ao tratamento) erealizadas entrevistas e gravações das tarefas em vídeo (autoadministração dos colírios, leitura, subir e descer escadas, deambular emespaços apertados e pavimentos irregulares). Realizou-se avaliação oftalmológica com registro em formulário pré-definido e pesquisou-se a correlação entre os defeitos de campos visuais e as limitações dos pacientes. Resultados: Com 25 participantes foram abtidos umtotal 12 horas de vídeo.Todos os doentes afirmaram ser capaz de colocar os colírios hipotensores e 68%afirmaram nunca ter falhadona instilação do colírio. No entanto, 20% não conseguiram instilar uma única gota no olho. Setenta e dois por cento (72%) dospacientes afirmaram nunca tocar o frasco no olho, porém 40% afirmaram tocar. Houve dificuldade moderada nas atividades,especialmente ao deambular em espaços com obstáculos e em pavimentos irregulares. Alguns pacientes apresentaram mecanismosproprioceptivos de adaptação à baixa visão (como tatear o degrau com o pé). Houve uma correlação entre a severidade dos defeitosde campo visual e maior limitação nas atividades. Conclusão: Os portadores de glaucoma avançado têm considerável dificuldade nasatividades da vida diária e na instilação de colírios, frequentemente com percepção deficiente. Alguns pacientes apresentam adapta-ções proprioceptivas para superar parte da limitação visual.

Descritores: Glaucoma; Gravação em vídeo; Qualidade de vida; Cooperação do paciente; Atividades cotidianas

Difficulties of daily tasks in advanced glaucoma patients - a videotaped evaluation



166 Miguel AIM, Fonseca C, Oliveira N, Henriques F, Silva JF


• Patients who claimed to be unable to self-administer theeyedrops

• Patients with other eye diseases responsible for visual loss.

Data collection methods

A questionnaire was applied and interviews were held bynurses and secretaries (after prior training) with variousdemographic, social, treatment adhesion and quality of lifequestions (using the validated instrument Glaucoma Quality ofLife 15, GQL15). Each patient had a complete ophthalmologicexamination with recordings in a previously created form: eyeand surgical history, ophthalmic medication in use, VA,biomicroscopy, Goldmann applanation tonometry, fundoscopyincluding assessment of the optic disc, gonioscopy, results of vi-sual field exams and optical coherence tomography (OCT).

Quality of life assessment - GQL 15

The GQL15 (Glaucoma Quality of Life 15) is a validatedinstrument for measuring the quality of life that includes 15questions that can be aggregated into a single summary measurethrough the sum of the values of answers to the 15 variables. Thehigher the value in this scale, the lower the quality of life appliedto vision. The questionnaire assesses difficulties in:

• Reading newspapers or magazines• Walking in the dark• Seeing at night• Walking in floor with differences in level• Adapting to an environment with intense lighting• Adapting to an environment with poor lighting• Going from a lighted room to a dark one or vice versa• Avoiding tripping over objects• Seeing objects approaching from the side• Crossing the street• Going up or down the stairs• Walking without bumping into objects• Estimating the distance from the foot to a step• Finding fallen objects• Recognizing faces

Video recording

The recording of each task was performed by the authorAM, who did not witness the results of the questionnaire andophthalmologic evaluation to avoid bias. The duration plannedfor the recording was 5 minutes per task.

1. Self-administration of eyedrops

To assess the performance in the self-administration ofhypotensive eyedrops, we asked the patients to put one dropletin each eye, using their hypotensive eyedrops (if the patient hadnot brought it, we offered a bottle). We do not use artificial tears(unlike the study held by Hennessyet al.11 in order to createmost of the conditions of normal use of the patient. We recordedall patient attempts, but evaluated the 1st so that the resultswould not get crossed with the patient’s training. Each patientwas allowed to use their usual technique to put on eyedrops,whether it involved the use of a mirror, a reclining chair or evena stretcher for the administration in supine position. The followingvariables were registered: successfully putting on at least onedroplet in the eye (defined as “partial success”, and the respectivetime in seconds) successfully putting on only a droplet in the eyewithout touching the ocular surface (defined as the “completesuccess” and the respective time in seconds) number of attemptsuntil success, number of drops administered.

2. Reading

An updated correction was prescribed to the patients forclose vision and a scale for close vision and a magazine wereprovided. The reading capability at about 40 cm distant wasrecorded on video.

For the tasks described below the patients who had majormotor and mobility difficulties were excluded.

3. Walking around in spaces with obstacles

Only one room was used and the obstacles were preparedthe same way: the room had an area of 6m2 and the patientswere asked to follow a pathway of 2m lined with obstacles sothat the free area of the pathway was only 50cm long. Thus, it waspossible to detect how the visual defects interfered in the abilityto identify side obstacles (some located on the floor and others70 cm tall).

The following outcome variables were recorded (after thevideo recording): number of touches or bumps into the obstacles,number of proprioceptive aid (such as the use of hands or elbowsto feel the obstacles instead of seeing them) and overall rating ofthe difficulty to complete of the task.

4. Walking on uneven flooring

Patients were sent to a specific inpatient ward, where theywere invited to walk 5m of uneven flooring and climb a poorlyvisually marked step. This task was video recorded, as well as theclassification of difficulty of each patient in performing it.

5. Climbing stairs

The patients were asked to climb 8 steps of a stair in wichedges were not visually marked. It was recorded in video, theoverall performance was classified and the proprioceptive aidwas identified.

6. Going down the stairs

The procedure was the same as in the previous task, withthe evaluation of the difficulties to go down the stairs.


We used the program SPSS version 20 for the statisticalanalysis. In the continuous variables of normal distribution weused the t-test to identify the differences between two groups; inthe non-normal distribution we used the Mann-Whitney test. Incategorical variables with normal distribution we used the chi-square test, and in the non-normal distribution we used theKruskal Wallis test. The multivariate logistic regression modelswere built to predict factors of difficulty and the success in eachof the tasks. The significance considered was 0.05.

RESULTS

Characterization of the population

In this study, interviews and objective evaluation wereperformed with videos of 25 patients, with a duration of totalrecording of approximately 12 hours. The mean age ofparticipants was 73 years old. Nine participants (36%) werefemale; 68% were retired (Table 1).

The 25 participants said they heve been using thehypotensive eyedrops for more than 6 months and instill theeyedrops by themselves. Twenty-four patients (96%) reportedto follow the glaucoma treatment correctly. Fifty-five percent of


167Difficulties of daily tasks in advanced glaucoma patients - a videotaped evaluation


Table 1

Socio-demographic characteristics of the participants

Caracteristcs Number % or standardor mean deviation (sd)

Female 9 36%

Age (mean) 73 years sd: 9.11

Caucasian 25 100%

Education 35% without education65% with primary educaion only

Systemic diseases 40% systemic arterial hipertension15% osteoarticular pathology20% diabetics20% smoker /ex-smoker35% hyphoacusis20% cardiovascular pathology25% pulmonary pathology

Table 2

Examples of participants’ responses to the questionnaire

* Response to “Rate your vision from 0% to 100%, with 0% beingtotal blindness and 100% normal vision. * Response to the question:“Rate your treatment adhesion from 0% to 100%, with 0% beinghaving never put a droplet and 100% having never failed or forgottento put any droplets of the treatment”

Caracteristics Percentage Standard deviation and number (sd)

Self-assessment 46.1% sd: 22.2of vision*

Self-assessment of 96.8% sd: 11.3treatment adhesion**

Patients who reportednever had difficulties 17 (68%)in putting eyedrops

Patients who reportednever touched the eye 18 (72%)with the bottle

Table 3

Summary of the objective assessment with video ofpatients self-administering the eyedrops

Self-administration of the eyedrops Mean or %

Partial sucess (> 1droplet in the eye) 80%

Partial sucess time 10.4 segundos

Total sucess (put just one dropletinto the conjunctival fornix without 40%touching the ocular surface)

Total sucess time 10.5 segundos

Number of attempts before sucess 1.65

Number of droplets put in the eye 2.45

Patientes who touched the ocularsurface with te bottle 40%

the patients (55%) reported having difficulties in instillingeyedrops, and 30% reported occasionally not being able to instilleyedrops by themselves, needing help. Seventeen patients (68%)reported never having failed to instill even a droplet of eyedrops,and 18 patients (72%) said they had never touched the ocularsurface with the bottle (Table 2).

Ophthalmologic assessment

The mean VA of the patients was 1.03 logMAR (equivalentto 1/10 in decimal notation). The mean tonometry was 13 mmHg,the excavation of the optic disc in average 8/10 (there were somepatients with a total excavation and VA for unilateral lightperception). The mean deviation of all visual fields was -22dB(severe campimetric loss). Patients were treated with an average

of 2 bottles hipotensorese eyedrops, and 92% had undergoneglaucoma surgery.

Self administration of eyedrops and adhesion to treatment

Forty percent of the patients managed to put a droplet ofeyedrops in the eye with an appropriate technique. Twenty percentof the patients were unable to self-administer even a droplet,even after several attempts. Patients placed on average 2.45droplets in the eye (one patient put 7 droplets), and it took themon average 10.4 seconds to put the droplet in the eye (themaximum was 38 seconds). Seven patients (28%) were unableto detect whether the droplet entered eye: 1 patient put thedroplet in the eye but did not detect it and instilled 2 moredroplets; the other 6 patients put the droplet out of the eye andfinished the task for thinking that they had put the dropletcorrectly. (Table 3)

Table 3 describes the assessment results with video of thepatients self-administering the eyedrops.

Objective reading assessment

18 patients (70%) had little or no difficulty.

Objective assessment of daily activities

Five patients (20%) were excluded from the assessment ofthese activities for presenting important locomotor difficulties,in order to avoid selection bias.

Regarding the performance of the patients to go up anddown the stairs, 8 participants showed proprioceptive adjustmentmechanisms like using their foot to feel the position of the stepbefore supporting their weight on the step or touching thehandrail to go up or down the stairs. Three of the patients hadmarked difficulties to go up and/or down the stairs.

We did not have enough sample of patients to completelogistic regression models and predict the factors for success orfailure in putting eyedrops or performing motor tasks that werestatistically significant, but there was a trend to failure in patientswith greater visual field defects and worse visual acuity, and atrend to success in daily activities in patients who hadproprioceptive adaptation mechanisms which allowed them topartially compensate for their low visual function.


168 Miguel AIM, Fonseca C, Oliveira N, Henriques F, Silva JF


There was a trend to correlate a worse quality of life in eachof the GQL 15 questions to a greater visual field defect (meandeviation), being it statistically significant only for the issue ofdifficulties to see at night (Pearson’s correlation, p = 0.042).

Figure 1. Objective rating of the ability to walk in a room with severalside obstacles

Figure 2. Difficulties of the patients with advanced glaucoma to walkon an uneven floor

DISCUSSION

After a literature review with several databases (PubMed,Scopus, Cochrane Central, Ovid, and Google Scholar), we notedthat the current study was the 4th one to objectively assesswith video self-administration of hypotensive eyedrops inadvanced glaucoma, and the only one to objectively assess theperformance of various daily tasks10-12.

The objective assessment with video recording ofvarious daily tasks allowed to characterize the performanceand difficulties of the patients with advanced glaucoma,which information can help to improve the quality of life ofthese patients.

In this study we observed that the patients did not realizetheir visual impairments: they did not estimate their visioncorrectly, did not realize their difficulties in administering eyedropsand in walking.

The concern for the self-administration of eyedrops isrelatively new and important, since the wrong operation isresponsible for non-adhesion to treatment, which can lead tothe progression of glaucomatous damage. Our results are simi-lar to previous studies12, but the Portuguese patients seem tohave poorer perception of their limitations: 68% of the patientsin our study denied failure to instill the eyedrops, but 20% failedto put at least one droplet, while in the american study11 36% ofthe patients stated that and 35% failed to instill.

From the 72% of Portuguese patients (and 69% ofAmericans) who said they never touched the eye with the bottle,only 40% did not touch (versus 24% of Americans). We shouldwarn patients about the potential risk of contamination of thebottles when they touch the ocular surface24 and risk of ocularinjuries25. Subjective observational studies estimated thatpatients failed by 50% in putting eyedrops (the droplet fell outof the eye)26,27.

Seven patients (28%) did not notice if the droplet wasinstilled into or out of the eye. One of the patients instilled thedroplet into the eye but did not realize it and put several otherdrops, causing an increase to the cost of the treatment28. And theother 6 patients put the droplet out of the eye and thought it wasinstilled in it, generating concerns of therapeutic poor complianceand the possibility of progression of an already advanceddisease6,15.

It is important that the ophthalmologist check theinstillation technique of hypotensive eyedrops in the patientswith glaucoma, to guide them regarding the proper handling ofthe medication, as signaled in the Brazilian study29 which showedthat only 2.5% of new cases of glaucoma presented occlusion ofthe lacrimal point after instillation, and that 23.3% with glaucomarecurrence instilled the eyedrops with the eye closed, drawingattention to the problem of correctly instilling the eyedrops.Patients should be supervised or a chaperone can instill theeyedrops to the patient in rder to increase the chance to instill ofdroplet in the eye.

In the present study, the poor perception of the patientsregarding their limitations was widespread, occurring inpredicting the ability to perform tasks such as walking on unevensurfaces, and also in the self-assessment of VA, where the meanself-assessment of VA was 0.46 whereas the mean VA measuredby the ophthalmologist was 0.1.

Performing tasks like walking in spaces with obstacles anduneven surfaces was very difficult and had some “near-falls”,which justifies the increased fear of falls among patients withglaucoma21 and the reduced quality of life proved in this andother studies17. It would be interesting to train patients withadvanced glaucoma regarding orientation and mobility to preventaccidents and improve the quality of life. In this study, severalpatients had conscious or unconscious adaptive proprioceptionmechanisms that allowed them a better performance thanexpected for their visual function. It would be helpful to teachthese simple mechanisms to all patients with advanced glaucomato increase their quality of life. Some of these mechanisms include:touching the step with the foot to identify it, touching the handrail(before going up or down the stairs and on uneven floors),


169Difficulties of daily tasks in advanced glaucoma patients - a videotaped evaluation


walking with the arms bent and protruding elbow (in tight spaces,to identify side obstacles), touching or stretching the arms intight spaces (not to collide with little visible obstacles).

Although the results were interesting, it was complex andtime consuming to have this full assessment in each patient, whichhad limited the size of our sample. It would be useful to developprotocols with video technicians, as the ones developed in otherstudies11,12 instead of having the ophthalmologist tape the patients.And also to develop protocols along with other hospitals, evenin national level, in order to have a multicentric study identifyingpeculiarities in different patient populations and increasing thecapacity for possible construction of logistic regression models.

The performance of daily tasks is also a challenge forpatients with low visual function by other eye diseases, so it isinteresting to expand the objective assessment of tasks for thesepatients, as done in the study comparing glaucoma to retinalpathology12 in the self-administration of eyedrops, with poorperformance being found in both groups.

CONCLUSION

Patients with advanced glaucoma have a marked difficultyin daily activities, often with poor perception of their limitations.There was a correlation between the severity of the visual fielddefects and a higher limitation in the activities.

Many patients failed to self-administer the hypotensiveeyedrops and did not detect said failure.

Some patients presented proprioceptive adaptations toovercome part of the visually impairment in locomotor daily tasks.

THANKS

To the secretary (Paula Ramos) and nurses of theOphthalmology consultation for the effort during the interviewsand questionnaires. to the technicians of the Ophthalmologyconsultation for their support during this work.

SUPPLEMENTARY MATERIAL

Some videos will be available in a protected internet pageas a complementary part of this work for consultation by healthprofessionals, provided that users comply with the principles ofethics and the Declaration of Helsinki in: http://www.eyerobot.pt/glaucoma.php

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8. Schwartz GF, Platt R, Reardon G, Mychaskiw MA. Accountingfor restart rates in evaluating persistence with ocular hypotensives.Ophthalmology. 2007; 114(4):648-52.

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

11. Hennessy AL, Katz J, Covert D, Protzko C, Robin AL. Video-taped evaluation of eyedrop instillation in glaucoma patientswith visual impairment or moderate to severe visual field loss.Ophthalmology. 2010;117(12):2345–52.

12. Hennessy AL, Katz J, Covert D, Kelly CA, Suan EP, SpeicherMA, et al. A video study of drop instillation in both glaucoma andretina patients with visual impairment. Am J Ophthalmol.2011;152(6): 982–8.

13. Winfield AJ, Jessiman D, Williams A, Esakowitz L. A study of thecauses of non-compliance by patients prescribed eyedrops. Br JOphthalmol.1990;74(8):477– 80.

14. Brown MM, Brown GC, Spaeth GL. Improper topical self-admin-istration of ocular medication among patients with glaucoma.Can J Ophthalmol 1984;19(1):2–5.

15. Stone JL, Robin AL, Novack GD, Covert DW, Cagle GD. Anobjective evaluation of eyedrop instillation in patients with glau-coma. Arch Ophthalmol. 2009;127(6):732–6.

16. Miguel A, Silva JF, Azevedo L, Henriques F, Andrês R, Lopes N,Rito F, Loureiro AR. Qualidade de vida no glaucoma.Oftalmologia. 2012; 36(1Supl): 33-40.

17. Varma R, Wu J, Chong K, Azen SP, Hays RD; Los Angeles LatinoEye Study Group. Impact of severity and bilaterality of visualimpairment on health-related quality of life. Ophthalmology.2006;113(10):1846-53.

18. Patino CM, Varma R, Azen SP, Conti DV, Nichol MB, McKean-Cowdin R; Los Angeles Latino Eye Study Group. The impact ofchange in visual field on health-related quality of life: the losangeles latino eye study. Ophthalmology. 2011;118(7):1310-7.

19. Wilson MR, Coleman AL, Yu F, Bing EG, Sasaki IF, Berlin K,etal. Functional status and well-being in patients with glaucoma asmeasured by the Medical Outcomes Study Short Form-36 ques-tionnaire. Ophthalmology. 1998; 105(11):2112– 6.

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Corresponding author:Ana Isabel Martinho MiguelE-mail: [email protected]


171CASE REPORT

Trombose do seio dural em idade pediátrica

Dural sinus thrombosis in pediatric age

1 Intern of the Ophthalmology Complementary Internship at the General Hospital of the Hospital and University Center of Coimbra, Coimbra, Portugal.2 Intern of the Neurosurgery Complementary Internship at the General Hospital of the Hospital and University Center of Coimbra, Coimbra, Portugal.3 Ophthalmology Hospital Assistant at the General Hospital of the Hospital and University Center of Coimbra, Coimbra, Portugal.4 Director of the Ophthalmology Service at the General Hospital of the Hospital and University Center of Coimbra, Coimbra, Portugal.

Received for publication 29/10/2012 - Accepted for publication xx/xx/20xx

The authors declare have no conflict of interest

A trombose do seio dural é uma situação clínica rara, que resulta normalmente da complicação de processos infecciosos dos seiosperinasais. Os sintomas e sinais são extremamente variados e inespecíficos sendo o diagnóstico feito através da ressonância magnéticanuclear. Esse trabalho relata a ocorrência de trombose do seio dural em um paciente com idade pediátrica. Paciente com 10 anos de idade,sexo masculino, foi enviado ao serviço de urgência devido à diplopia e endotropia no olho esquerdo. No exame oftalmológico foi detectadopapiledema bilateral, diplopia binocular e endotropia do olho esquerdo. Apresentava acuidade visual de 10/10 bilateralmente. Diante dasuspeita de lesão ocupando espaço do sistema nervoso central, foi realizada ressonância magnética nuclear que confirmou o diagnósticode TSD. Para avaliar a pressão intracraniana foi efetuada uma punção lombar com manometria, e esta demonstrou uma pressão intracranianade 20mmHg (normal: <15mmHg). Perante isto a criança ficou internada para tratamento médico (enoxaparina de baixo peso molecular 1,5mg/kg/dia subcutâneo (60 mg/dia), prednisolona 35 mg/dia oral e acetazolamida 250 mg/dia oral) durante 10 dias. Após 1 mês de follow-up verificou-se agravamento oftalmológico. A realização de nova punção lombar apresentou uma pressão intracraniana de 40 mmHg quenão cedia ao tratamento médico. Após discussão multidisciplinar do caso optou-se pela realização de derivação lombo-peritoneal. Anecessidade de uma grande dose de suspeição clínica, tanto para o diagnóstico inicial quanto para a monitorização das complicações,tornam a abordagem da trombose do seio dural um processo singular.

Descritores: Trombose dos seios intracranianos/diagnóstico; Hipertensão intracraniana; Imagem por ressonância magnética;Relatos de casos

RESUMO

ABSTRACT

Dural sinus thrombosis is a rare condition, usually results from a late complication of an infection of the paranasal sinuses. The signsand symptoms are extremely varied and nonspecific, being the diagnosis made through magnetic resonance imaging. Ten-year-oldmale patient that was sent to our emergency department with left endotropia and diplopia. Ophthalmic examination was performedand showed papilledema with margin blurred right and left eye, binocular diplopia and left eye endotropia. Visual acuity was 10/10bilaterally. Given the suspected space occupying lesion of the central nervous system, the MRI was performed and confirmed thediagnosis of DST. For evaluating the intracranial pressure (IP), a lombar puncture (LP) with manometry was carried out andrevealed IP of 20 mmHg (normal values: <15mmHg). Towards this, the child’s was admitted for medical treatment (low molecularweight enoxaparin subcutaneous 1,5 mg/kg/day (60 mg/day), prednisolone 35 mg/per day and acetazolamide 250 mg/per day) over10 days. After 1 month of follow-up there was deterioration of the ophthalmologic condition. A new LP was made and showed IP of40 mmHg resilient to medical treatment. After multidisciplinary discussion of the case, it was decided for conducting lumboperitonealshunt. The need for a great deal of suspicion for both the initial diagnosis and for monitoring complications make DST approach aspecial process.

Keywords: Sinus thrombosis, intracranial/diagnosis; Intracranial hypertension; Magnetic resonance imaging; Case reports

Filipe Mira Ferreira1, Bruno Lourenço Costa2, António Mendes1 Catarina Paiva3, António Roque Loureiro4



172 Ferreira FM, Costa BL, Mendes A, Paiva C, Loureiro AR


INTRODUCTION

Dural sinus thrombosis (DST) comprises the sagittal,transverse and sigmoid sinuses, and in about one thirdof the cases it comprises multiple sinuses(1,2).

The estimated incidence of DST in pediatric age isapproximately 0.67 per 100,000 children per year(3).

TSD typically results from a complication of infectious pro-cesses of the paranasal sinuses and the middle ear, but theremay be aseptic forms associated to predisposing medicalconditions for thromboembolic events such as: haematologicaldisorders, trauma, anemia and dehydration(3-5).

The clinical presentation is nonspecific and may manifestas coma, headaches, vomiting, lethargy with ocular paresis anddiplopia, which often leads to a late diagnosis.

The diagnosis is made by nuclear magnetic resonance(NMR) alone or in association with cerebral angiography(6).This paper reports the case of occurrence of DST in a pediatricpatient.

CASE REPORT

A 10-year old male patient is sent to the emergency roomdue to endothropy of the left eye (LE) and binocular diplopia.As relevant systemic background there was a flu syndrome since1 month before, and binocular diplopia with a development ofabout fifteen days.

The ophthalmological exam showed intermittent binoculardiplopia, endothropy of the left eye of about 15° (HirschbergMethod) and limitation of abduction in levoversion of the LE. Itpresented best visual acuity (VA) corrected bilaterally of 10/10.Biomicroscopy without changes. Goldmann applanation tonometry:12mmHg in both eyes, and in fundoscopic observation: optical discswith undefined boundaries in both eyes by exuberant bilateralpapilledema. Macular regions were normal in both eyes (Figure 1).

The decision was to perform a retinal fluorescein

Figure 1. Retinography

angiography which showed late hyperfluorescence with dye leakin both eyes.

An MRI was performed in association with the cerebralangiography (Figure 2) which revealed: exclusion, in the venousstudy, of all the right sigmoid sinus, the distal portion of thetransverse sinus and the proximal segment of the internal jugularvein, which is followed by isosignal on T1 and a discretehypersignal on the remaining ponderations, and after the use ofcontrast an enhancement that is predominantly peripheral was

observed. The expansion of the optic nerve sheath is alsoobserved. These aspects are suggestive of venous thrombosis.

Given the suspicion of DST, the decision was to requestthe Neurology to observe, and no neurological disorders weredetected. Nevertheless, a lumbar puncture was performed andthe result revealed an intracranial pressure (PIC) of 20 mmHg.

Before the clinical profile, the child was hospitalized formedical treatment with low molecular weight enoxaparin 1.5mg/kg/day subcutaneously (60 mg/day), prednisolone 35 mg/day orally and acetazolamide 250 mg/day orally.

During hospitalization the tests of blood count,biochemistry, microbiology, serology, a study of prothromboticfactors, autoimmunity and a study of the cerebrospinal fluid(CSF) were performed.

The child was discharged after ten days of hospitalization,with no complaints, treated with enoxaparin 60 mg/day and aregressive scheme of oral corticosteroids. The follow-up wasperformed at the end of 1 month and showed: VA RE: 4/10 andVA LE: 1/10. In the fundoscopy: less exuberant papilledema,but associated with bilateral pallor of the optic disc. Theperformance of a control NMR showed a profile similar tothe previous one. The performance of visual fields showedsevere bilateral loss of the visual field, more intense in the LE,with preservation of central islands of vision (Figure 3).Furtherevaluation has been requested by the Neurology, and a newlumbar puncture was performed with manometry, whoseresult revealed PIC of 40 mmHg. The clinical case was thendiscussed with the Neurosurgery which indicated externallumbar drainage with monitoring of the CSF pressure bycontinuous manometry. Despite the decrease in the PIC, thedecision was to have a lumboperitoneal shunt. The child wasdischarged after 48 hours, with no complaints, PIC between 8-12 mmHg and decreased bilateral papilledema.

After 1 month, the child was asymptomatic and with thefollowing eye exam results: VA RE: 9/10 and VA LE: 5/10. Thefunduscopy showed an improvement of the edema of the opticdisc, however associated to pallor in the RE and optic atrophyin LE (Figure 4). The performance of new visual fields showedam improvement (Figure 5).

Figure 2: NMR angiography - subtraction image within the rightsigmoid sinus


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Figure 3: Visual field 24-2 SITA Fast

Figure 5: Visual field RLE 24-2 SITA Fast

Figure 4: Retinography RLE

DISCUSSION

The DST usually involves the sagittal, transverse andsigmoid sinuses, showing an incidence of 0.67 cases per 100,000children per year(3).

The clinical presentation is nonspecific, often leading to alate diagnosis or even to its omission. Symptoms can range fromheadache, decreased VA, diplopia to lethargy, coma and death,having Sébire et al.(7) concluded that headaches, fever and changesof the cranial nerves were the most common form of presentation.

This clinical situation typically results from infectious pro-cesses of the paranasal sinuses or prothrombotic conditions,being acquired such as anemia and dehydration, or genetic suchas increased factor VIII, increased fibrinogen, decreased proteinsC and S, factor V Leiden mutation, homozygosity of thermolabilegene variant of methylenetetrahydrofolate reductase (t-MTHFR). In the same study of Sébire et al.(7), anemia andincreased factor VIII were the most commonly found laboratoryfindings. In about 25% of the cases there is no predisposingfactor identified(8).

In the present clinical case, a comprehensive study ofinfectious causes was performed by serology to screen adenovirus,mycoplasma, pneumonia, cytomegalovirus, herpes simplex 1 and2, Epstein-Barr virus, and all the results were negative. Bloodcultures for anaerobic, aerobic and fungi also presented negativeresults. The research of prothrombotic risk factors includingfibrinogen, protein C and S, anti-thrombin, anti-cardiolipin, lupusanticoagulant, plasminogen, homocysteine, prothrombin, factorV Leiden, homozygosity for t-MTHFR, factor VIII and factorXII have all had negative results.

Electrocardiogram, echocardiogram, carotid Doppler werealso performed - all without changes.

Given the results of the supplementary diagnostic examsperformed, it was concluded that this is an idiopathic condition,fitting in the 25% of cases without an etiologic diagnosis. Itcould also be supposed that the flu-like illness occurred a monthbefore has triggered the current situation, but there is no clinicaldata to prove this relationship. There is some controversyregarding the use of enoxaparin, but several studies have shownthat its use is associated with a decreased mortality and anincreased recovery rate(9,10).

The diagnosis of DST requires a large initial clinicalsuspicion, and the confirmation is established through the use ofNMR angiography (6). This method allows the identification ofthe thrombus and the involved sinus completing deficit, currentlybeing considered as the gold standard.

The incidence of intracranial hypertension arises in thework of Sébire et al. in 62% of cases, yet the convulsions andthe appearance of new thrombotic events are the most frequentcomplications(7). As there was no initial response to the medicaltherapy and there was a worsening of PIC, there was a needfor neurosurgical therapy with the placement oflumboperitoneal shunt.

Permanent complications such as blindness and focalneurological deficits are described in about 6-20% of the ca-ses(1,11,12), and a mortality rate between 4.3 and 30%. The prognosisseems to be related to the extent and location of the parenchymallesion, hemoglobin level, age, and most likely the rapid diagnosisand treatment.

Dural sinus thrombosis in pediatric age



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CONCLUSION

The dural sinus thrombosis is a rare but fatal clinicalsituation in some cases. Often the ophthalmologist becomes thekey element both in the diagnosis and monitoring of thesepatients, therefore being important to alert the ophthalmiccommunity to its importance.

REFERENCES

1. Stam J. Thrombosis of the cerebral veins and sinuses. N Eng JMed. 2005;352(17):1791-8. Comment in N Engl J Med. 2005;353(3):314-5.

2. Renowden S. Cerebral venous sinus thrombosis. Eur Radiol.2004;14(2):215-26. Review.

3. deVeber G, Andrew M, Adams C, Bjornson B, Booth F, BuckleyDJ, Camfield CS, David M, Humphreys P, Langevin P, MacDonaldEA, Gillett J, Meaney B, Shevell M, Sinclair DB, Yager J; Cana-dian Pediatric Ischemic Stroke Study Group. Cerebral sinovenousthrombosis in children. N Eng J Med. 2001;345(6):417-23. Com-ment in N Engl J Med. 2001;345(24):1777-8.

4. Carvalho KS, Bodensteiner JB, Connolly PJ, Garg BP. Cerebralvenous thrombosis in children. J Child Neurol. 2001;16(8):574-80.

5. Heller C, Heinecke A, Junker R, Knöfler R, Kosch A, Kurnik K,Schobess R, von Eckardstein A, Sträter R, Zieger B, Nowak-Göttl U; Childhood Stroke Study Group. Cerebral venous throm-bosis in children: a multifactorial origin. Circulation.2003;108(11):1362-7.

6. Medlock MD, Olivero WC, Hanigan WC, Wright RM, Winek SJ.Children with cerebral venous sinus thrombosis diagnosed withmagnetic resonance imaging and magnetic resonance angiogra-phy. Neurosurgery. 1992;31(5):870-6; discussion 876.

7. Sébire G, Tabarki B, Saunders DE, Leroy I, Liesner R, Saint-MartinC, et al. Cerebral venous sinus thrombosis in children: risk factors,presentation, diagnosis and outcome. Brain. 2005;128(Pt 3):477-89.

8. Bousser MG, Barnett HJM. Cerebral venous thrombosis. In: BarnettHJ, editor. Stroke: pathophysiology, diagnosis and management.2nd ed. New York: Churchill Livingstone; 1992.

9. Einhäulpl KM, Villringer A, Meister W, Mehraein S, Garner C,Pellkofer M, et al. Heparin treatment in sinus venous thrombosis.Lancet.1991;338(8767):597-600. Erratum in Lancet. 1991;338(8772):958. Comment in Lancet. 1991;338(8775):1154.

10. Stam J, de Bruijn S, deVeber G. Anticoagulation for cerebral sinusthrombosis. Stroke. 2003;34(4):1054-5.

11. Ferro JM, Canhão P, Stam J, Bousser MG, Barinagarrementeria F;ISCVT Investigators. Prognosis of cerebral vein and dural sinusthrombosis: results of the International Study on Cerebral Veinand Dural Sinus Thrombosis (ISCVT). Stroke. 2004;35(3):664-70.

12. Stolz E, Trittmacher S, Rahimi A Gerriets T, Röttger C, SiekmannR, et al. Influence of recanalization on outcome in dural sinusthrombosis: a prospective study. Stroke. 2004;35(2):544-7.

Ferreira FM, Costa BL, Mendes A, Paiva C, Loureiro AR

Corresponding author:Filipe Mira FerreiraE-mail: [email protected]


175CASE REPORT



RESUMO

ABSTRACT

Evaluation of retinal nerve fiber layer thicknessin a patient with bilateral optic disc drusen

Avaliação da espessura da camada de fibras nervosas da retinaem um paciente com drusas do disco óptico bilateralmente

Alime Gunes, Seden Demirci, Serpil Demirci, Hasan Rifat Koyuncu

1 Departments of Ophthalmology, Süleyman Demirel University Faculty of Medicine, Isparta, Turkey.2 Departments of Neurology, Süleyman Demirel University Faculty of Medicine, Isparta, Turkey.

As drusas do disco óptico (DDO) são depósitos de material hialino calcificado dentro da substância da cabeça do nervo óptico. Drusasdo disco óptico, especialmente se for bilateral, podem apresentar o quadro clínico de edema de papila. Usualmente o espessamento dacamada de fibras nervosas da retina (RCFN) podem estar presentes em DDO. Neste relato apresentamos o caso de um homem com 17anos de idade que foi encaminhado por um outro centro, com o diagnóstico de edema do disco óptico. A acuidade visual do paciente, oexame de lâmpada de fenda e a pressão intraocular foram normais em ambos os olhos. No exame de fundo de olho havia discoselevados de forma irregular bilateralmente e os nervos ópticos com margens de disco nebulosas. Ele não tinha defeitos do campo visualem perimetria computadorizada. Drusas do disco óptico (DDO) bilateral foram identificados e confirmados pela ultrassonografia B-scan e tomografia de coerência óptica (TCO) que demonstraram 4 horas de relógio de RCFN com espessamento. As drusas do discoóptico podem ser diagnosticadas como papiledema. Assim, a suspeita clínica de DDO é importante a fim de evitar intervenções desneces-sárias. Embora a maioria dos olhos com DDO têm espessura normal ou thinner RCFN, alguns desses olhos podem ter camada maisgrossa na RCFN.

Descritores: Drusas do disco óptico; Papiledema; Nervo óptico/patologia; Fibras nervosas/patologia

Optic disc drusen (ODD) is the accumulations of calcified hyaline-like material within the substance of the optic nerve head. Opticdisc drusen, especially if it is bilateral, may mimic the clinical presentation of papilledema. Usually retinal nerve fiber layer (RNFL)thinning can be present in ODD. In this report we present uncommon RNFL changes in a patient with bilateral ODD. A 17-year-oldmale was referred by another center with a diagnosis of optic disc edema. The patient’s visual acuity, the slit-lamp examination andthe intraocular pressures were normal in both eyes. On fundus examination, there were irregularly elevated discs bilaterally and theoptic nerves appear with hazy disk margins. He did not have visual field defects in automated perimetry. Bilateral ODD wereidentified and confirmed by B-scan ultrasonography and optical coherence tomography (OCT) demonstrated 4 clock hours ofRNFL thickening. Optic disc drusen may be misdiagnosed as papilledema. Thus, clinical suspicion of ODD is important in order todiagnose papilledema and prevents unnecessary interventions. Although most of eyes with ODD have normal or thinner RNFLthickness, some of these eyes can have thicker RNFL thickness.

Keywords: Optic disc drusen; Papilledema; Optic nerve/pathology; Nerve fiber/pathology



176 A Gunes, S Demirci, S Demirci, HR Koyuncu


INTRODUCTION

Optic disc drusen (ODD) is the accumulations of calcifiedhyaline-like material within the substance of the opticnerve head(1). Compression of ganglion cells by calcified

hyaline structures results in alteration in axoplasmic flow andcell death and so retinal nerve fiber layer (RNFL) defects areseen in ODD(2).

Patients with ODD are often asymptomatic, with thecondition being found incidentally during fundus examination.Visual acuity is well preserved but the visual fields of thesepatients can be abnormal and may deteriorate over time(3).

The mechanism of visual field loss from ODD isspeculative, and there is no known treatment. Atrophy of theRNFL can be appreciated as RNFL thinning, thereforemeasurement of RNFL thickness can be used as an objectiveindex of optic nerve damage(2).

In this report we present uncommon RNFL changes in apatient with bilateral ODD.

CASE REPORT

A 17-year-old male was referred by another center with adiagnosis of optic disc edema. The patient’s visual acuity, the slit-lamp examination and the intraocular pressures were normal inboth eyes. On fundus examination, there were irregularly elevateddiscs bilaterally and the optic nerves appear with hazy diskmargins (figures 1, 2). He did not have visual field defects inautomated perimetry with the Humphrey Visual Field Analyzer(Zeiss Humphrey Systems, Dublin, California USA). BilateralODD were identified and confirmed by B-scan ultrasonography(BVI Compact) (figures 3, 4) and optical coherence tomography(OCT) (Spectral OCT SLO, OPKO/OTI Instrumentation, Miami,FL, USA) demonstrated 4 clock hours of RNFL thickening (fi-gure 5). The average RNFL thickness were 135 µm in right eyeand 138 µm in left eye. His neurological examination was withinnormal limits except for the appearance of the optic discs. Hiscranial magnetic resonance imaging and Visual evoked potentialshowed no abnormality. Hence, the patient was diagnosed withbilateral ODD.

Figure 1. Fundus photography of the patient’s right eye reveal,irregularly elevated optic discs and the optic nerve appear with hazydisk margin

Figure 2. Fundus photography of the patient’s left eye reveal,irregularly elevated optic discs and the optic nerve appear with hazydisk margin

Figure 3. B-scan ultrasonography of the patient’s right eye identifiedthe optic disc drusen

Figure 4. B-scan ultrasonography of the patient’s left eye identifiedthe optic disc drusen


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Corresponding author:Alime Gunester, Assistant professorDepartment of Ophthalmology, Süleyman Demirel UniversityFaculty of Medicine, Isparta, TurkeyPhone: +905054828345E-mail: [email protected]

Figure 5. Optical coherence tomography showing 4 clock hours of RNFL thickening

DISCUSSION

Optic disc drusen occurs in 0.3-2.0% of the population, isbilateral in 75% of cases, and have no sex predilection(3).Impairment of visual acuity is rare in ODD, but insignificantvisual field defects may occur in up to half of cases(4).

Usually RNFL thinning can be present in ODD. Roh etal. (5) reported that superior and inferior RNFL weresignificantly thinner in the eyes with visible ODD, and OCT issensitive and early indicator of RNFL thinning.

Noval et al.(6) studied 28 eyes with ODD in children andclassified as type 1 (buried), type 2 (ringed), and type 3 (superfici-al) ODD. They found that RNFL thickness was higher in type 1and 2 ODD although RNFL thickness was lower in type 3 ODD.Similarly, our patient had buried ODD and had higher RNFLthickness in both eyes. Optic disc drusen can cause an increase inRNFL thickness but in the following years ODD can lead todecrease in RNFL thickness by damaging the optic nerve fibers.

Optic disc drusen may be misdiagnosed as papilledema.Thus, clinical suspicion of ODD is important in order to diagnosepapilledema and prevents unnecessary interventions. Althoughmost of eyes with ODD have normal or thinner RNFL thickness,some of these eyes can have thicker RNFL thickness. Patientwith ODD should be followed for further RNFL damage orvisual field defects although they have thicker RNFL.

REFERENCES

1. Larentzen SE. Drusen of the optic disc: a clinical and geneticstudy. Acta Ophthalmol. 1966; Suppl 90:l-180.

2. Katz BJ, Pomeranz HD. Visual field defects and retinal nervefiber layer defects in eyes with buried optic nerve drusen. Am JOphthalmol. 2006;141(2):248-53.

3. Auw-Haedrich C, Staubach F, Witschel H. Optic disk drusen. SurvOphthalmol. 2002;47(6):515-32.

4. Antcliff RJ, Spalton DJ. Are optic disc drusen inherited? Oph-thalmology. 1999;106(7):1278-81.

5. Roh S, Noecker RJ, Schuman JS, Hedges TR 3rd, Weiter JJ, MattoxC. Effect of optic nerve head drusen on nerve fiber layer thick-ness. Ophthalmology. 1998;105(5):878-85.

6. Noval S, Visa J, Contreras I. Visual field defects due to optic diskdrusen in children. Graefes Arch Clin Exp Ophthalmol.2013;251(10):2445–50.

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1 Ophthalmologist at Hospital Nossa Senhora da Saúde – Gamboa, Rio de Janeiro – RJ, Brazil.2 Ophthalmologist at Hospital Municipal Souza Aguiar – Rio de Janeiro – RJ, Brazil.3 Masters in Ophthalmology, Federal University of Rio de Janeiro - UFRJ, Brazil; Professor at Estacio de Sá University - UNESA, Rio de Janeiro - RJ, Brazil; Ophthalmologist at Federal State Public Servant Hospital - HFSE, Rio de Janeiro - RJ, Brazil.

CASE REPORT

Received for publication 09/07/2012 - Accepted for publication xx/xx/20xx

Os autores declaram não haver conflitos de interesse

Isaac Carvalho de Oliveira Ramos1,2 , Diogo Carvalho Macedo dos Santos1,2, Itamar Soares1,2, Vitor Cerqueira3

Chorioretinitis sclopetaria

Coriorretinite esclopetária

RESUMO

O objetivo deste trabalho é relatar um caso de trauma ocular por projétil de arma de fogo, que atingiu e se alojou na cavidade orbitária,desenvolvendo coriorretinite esclopetária. Foram abordados o mecanismo fisiopatológico, os principais achados clínicos e de examescomplementares, além das opções de tratamento. As características do caso relatado reforçam a importância de uma abordagemmultidisciplinar no trauma ocular.

Descritores: Coriorretinite/fisiopatologia; Coriorretinite/terapia; Ferimentos por arma de fogo; Ferimentos oculares penetrantes;Coroide/lesões; Ruptura; Relatos de casos

ABSTRACT

The objective of this study is to report a case of ocular trauma by gunshot bullet, which struck and lodged in the orbit, developingchorioretinitis sclopetaria. We also addressed the pathophysiological mechanism, the main clinical findings and laboratory tests, andtreatment options. The characteristic of this case enhances the importance of a multidisciplinary approach in the ocular trauma.

Keywords: Chorioretinitis/physiopathology; Chorioretinitis/therapy; Gunshot wounds; Penetrating eye injuries; Choroid/injuries; Rupture; Case reports

Study conducted at the Municipal Hospital Souza Aguiar, Rio de Janeiro - RJ, Brazil, and Hospital Nossa Senhora da Saúde – Gamboa, Rio deJaneiro – RJ, Brazil.


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INTRODUCTION

Chorioretinitis sclopetaria is the term used to characterizean eye injury in which a firearm projectile (FAP) passesnearby the globe without perforating it, causing damage

to the retina and choroid(1-15). It was first described in 1901 byGoldzieher(3,6,14,15), but Kempster et al. mention Graefe as firstreporting it in 1954(16). This syndrome has received a variety ofnames which include proliferative chorioretinitis, proliferative plasticchorioretinitis and proliferative Lagrange chorioretinitis(14,15).

The pathophysiological mechanism of the injury is causedby the energy release resulting from the high speed of theprojectile when reaching the orbital cavity and passing close tothe eyeball in its path(1-3,5,6,13-15). Although there is no perforation,there is direct damage to the retina and/or choroid, orimmediately adjacent to that path, generally parallel to the oraserrata. Indirect injury may be due to kickback mechanism, i.e.,the shock waves propagate through the eyeball until reachingthe posterior pole. Choroidal ruptures by kickback aregenerally concentric, vertical, and unique to the optic nerve,and can seriously compromise the macula(14,16-20). In cases ofmultiple lesions, they are often parallel with the largest onebeing central and the smallest one peripheral. A compressionmechanism (Commotio retinae) may also be involved, leadingto Berlin edema(21-27).

Changes in motility, either by restriction or by direct injuryof the extraocular muscles, may be present. The involvement ofvisual acuity is variable because it depends on the location andthe extent of the injury. In the anterior segment, pupillary andphoto-motor reflection changes may be present, and theintraocular pressure (IOP) can be altered as a result of ocularinflammation.

Although classically associated to FAPs, quite similarsiuations have been described with compressed air projectilesand even with fishing equipment(6).

The objective of this study is to report a case ofchorioretinitis sclopetaria attended the emergency service of theMunicipal Hospital Souza Aguiar (HMSA), and with ambulatoryfollow-up at Hospital Nossa Senhora da Saúde - Gamboa. Thepathophysiological mechanism, the main clinical findings, possiblecomplications and the treatment options will be discussed.

CASE REPORT

A 35 year old man, brown, was admitted tat the emergencyservice of HMSA on August 19, 2010, stating “gunshot in the righteye and blurred vision” two hours before in a robbery. Theectoscopy showed hematoma and bi-eyelid edema, besidescontusion measuring a centimeter in the lower eyelid. Motility waspreserved and the uncorrected visual acuity (VA) was 20/200 (RE)and 20/20 (LE). Biomicroscopy showed intact eyeball, conjunctivalhyperemia, intense subconjunctival hemorrhage, transparentcornea, anterior chamber formed and wide, photo-reactive pupiland transparent lens. The IOP measurement with Goldmannapplanation tonometry (GAT) was 13mmHg both eyes.

We requested a CT scan of skull and orbit, showing thatthe central nervous system was preserved and the presence ofFAP in the right orbit cavity located below (Figure 1). The opinionof a neurologist was requested, which said it was normal, andalong with the BMF the procedure was hospitalization for

monitoring. The patient condition progressed to side abscessand subsequent restriction of adduction. The eye fundus showedimportant rupture of choroid, mild retinal whitening and discretemacular edema with cherry aspect, showing the Berlin edema.He then underwent surgery with a multidisciplinary approach(ophthalmology and BMF) to drain the abscess. It progressed toinert FAP in the inferior orbital cavity post surgery, and thepatient was discharged for ambulatory follow-up.

Figure 1. Computed tomography of skull and orbit, showing the cen-tral nervous system preserved and the presence of a FAP in the rightorbit located inferiorly.

Figure 2. Simple retinography of the right eye showing choroidalrupture temporally reaching the macula and saving the foveal region.



Four weeks after the trauma the patient went toinspection with right dystopia and reflection of Hirshberg andnormal pupils. He reported mild pain and diplopia to abductionin the RE. The corrected visual acuity was 20/100, and he had nochanges in biomicroscopy. The IOP was 7 and 11mmHg in theRE and LE, respectively. Retinotopy showed an important lowervitreous hemorrhage; subretinal hemorrhage and choroidalrupture in the periphery of the retina; as well as peri-macular(temporal) choroidal rupture concentric with the optic nerve.Said findings were confirmed by retinography and ecography(Figures 2 and 3). The procedure was expectant and the patientwas followed up monthly with VA and GAT measurements,retinal mapping and visual field exams. He showed animprovement of the dystopia and moderate absorption of thevitreous hemorrhage, evolving to visual acuity of 20/40 and examof macular acuity potential of 20/30 partial. He was stable for 18months, with a small visual field defect in the nasal region (Figu-re 4) consistent with the topography of the peri-macular lesion.Optical coherence tomography showed no edema in the poste-rior pole, but it is noticed an expected disorder of the retinal


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pigment epithelium cells in the damaged area (Figure 5). Thepatient is still under follow-up every six months, undergoing theroutine exams already mentioned, in addition to the fluoresceinangioretinography in order to assess the possible onset ofneovascularization.

de coerência óptica não apresenta edema no polo posteri-or, porém é notado um esperado desarranjo das células doepitélio pigmentar da retina na região da lesão (figura 5). Opaciente segue em acompanhamento semestral, submetendo-seà rotina dos exames já citados, além da angioretinografiafluoresceínica, a fim de avaliar possível aparecimento deneovascularização.

DISCUSSION

The chorioretinitis sclopetaria was introduced in theliterature by Goldzieher in Germany in 1901(3,6,14,15), and refersto the retinal and choroidal lesions secondary to a trauma byFAP passing adjacent to the eyeball. Although there is noperforation, ruptures in the retina and choroid, as well as macularedema may be present and seriously impair the visual acuity(1-15).

The multidisciplinary approach should always beconsidered in cases of ocular trauma. In this report, the patienthad no injury of the extrinsic muscles, but it progressed withlimitation of adduction by restriction subsequent to theformation of lateral abscess. The procedure adopted along withneurosurgery and oral and maxillofacial surgery was the surgicaldrainage of the abscess, which was successfully performed.

Computed tomography showed no optic nerve lesion, butthis is a condition that may occur in part or in its entirety, leadingto significant losses of visual field and amaurosis(7).

In the acute phase of chorioretinitis sclopetaria,hemorrhages (vitreous, retinal and/or subretinal), and choroidaland retinal ruptures can be seen, besides retinal edema(3,15). These

Figure 3. Eye ultrasonography of the right eye showing the lowervitreous hemorrhage.

Figure 4. Computerized visual field of the right eye showing a defectof the superior nasal visual field consistent with the topography ofthe injury.

Figure 5. Optical coherence tomography (OCT) of the right eye showingthe disorder of the retinal pigment epithelium near the macula.

Ramos ICO , Santos DCM, Soares I, Cerqueira V


181

findings were observed in our patient with the choroidalrupture, partially reaching the macular region and consequentlypermanently impairing the visual field. It is known that thechoroid ruptures are associated with blunt trauma, either bydirect or indirect mechanism(19,28-32). Retinal and maculawhitening with a cherry aspect (Berlin edema) have also beenreported after eye injuries, a condition that is known ascommotio retinae(21-27). Both can appear in chorioretinitissclopetaria, as it also has a blunt component in itspathophysiology. In our case the edema was lightly tomoderately present in the acute phase, and was regressing withparallel recovery of the visual acuity (20/200 to 20/40).

In eyes with chorioretinitis sclopetaria, it is tempting tointervene in some way because of the often scary size and theposterior location of the retinal rupture. However, the retina rarelydesplaces in this situation, presumably because of an inflammationin the edges of the necrotic retina leading to a firm chorioretinaladhesion. Furthermore, it is believed that the retina and choroidare retracted as a single unit, with the posterior hyaloid remainingintact from rupture, preventing the entrance of the vitreous intothe subretinal space(1,3,15). If a retinal detachment occurs, it is usuallyat another site. Therefore, it is not necessary to perform prophylacticcryopexy or photocoagulation.

The late complication of the chorioretinitis sclopetaria isthe same choroidal rupture in another situation, i.e., the possibilityof developing neovascularization from the choroid andfibrovascular proliferation. This occurs in 25 to 50% after oneyear of the choroid ruptures(6,28-32). Our patient is currently inthe 18th month after injury, and is being closely monitored withfluorescein angioretinography, getting normal results so far.

It is important to mention that there is no exact model inthe chorioretinitis sclopetaria injuries; the extent of the injurywill vary according to the type of gun, projectile caliber, distancefrom the weapon to the target, pathway and interaction withvarious ocular structures that have varied tissue resistances. Itcan be found from small peripheral retinal injuries to optic nerveavulsion. Supplementary exams are needed to elucidate thediagnosis. The tomography of skull and orbit is enlightening tolocate the projectile, in addition to assess the impairment level ofthe central nervous system. In ambulatory level follow-up is donewith retina mappings, fluorescein angioretinography, ecography,optical coherence tomography (OCT) and visual field. Followingthe same reasoning, the treatment and the visual prognosis arevariable and depend on the extent and location of the lesion.

CONCLUSION

This paper aims at alerting ophthalmologists so thatwhenever treating a patient with ocular trauma by FAP they areaware of the diagnosis of chorioretinitis sclopetaria. Due to themultidisciplinarity of the trauma, it is of great importance the theassessment is made along other medical specialties.

REFERENCES

1. Ahmadabadi MN, Karkhaneh R, Roohipoor R, Tabatabai A,Alimardani A. Clinical presentation and outcome of chorioretini-tis sclopetaria: a case series study. Injury. 2010;41(1):82-5.

2. Beatty S, Smyth K, Au Eong KG, Lavin MJ. Chorioretinitissclopetaria. Injury. 2000;31(1):55-60.

3. Dubovy SR, Guyton DL, Green WR. Clinicopathologic correla-tion of chorioretinitis sclopetaria. Retina. 1997;17(6):510-20.

4. Germani L, Viale C. [Unusual ocular traumatic syndrome: choriore-tinitis sclopetaria]. Minerva Oftalmol. 1970;12(3):100-2. Italian.

5. Hart JC, Natsikos VE, Raistrick ER, Doran RM. Chorioretinitissclopetaria. Trans Ophthalmol Soc U K. 1980;100(Pt 2):276-81.

6. Katsumata S, Takahashi J, Tamai M. Chorioretinitis sclopetariacaused by fishing line sinker. Jpn J Ophthalmol. 1984;28(1):69-74.

7. Mohammadpour M, Soheilian M. Concomitant optic nerve transec-tion and chorioretinitis sclopetaria. BMC Ophthalmol. 2005;5:29.

8. Otto CS, Nixon KL, Mazzoli RA, Raymond WR 4th, AinbinderDJ, Hansen EA, et al. Chorioretinitis sclopetaria from BB exmemoria. Ophthalmic Surg Lasers. 2001;32(2):152-5.

9. Pérez-Carro G, Junceda-Moreno C. [Dual cause of blindness: chori-oretinitis sclopetaria and homonymous hemianopsia]. Arch SocEsp Oftalmol. 2006;81(2):119-22. Spanish.

10. Perry HD, Rahn EK. Chorioretinitis sclopetaria: choroidal andretinal concussion injury from a bullet. Arch Ophthalmol.1977;95(2):328-9.

11. Ahmadabadi MN, Rajabi MT. Evolution of retinitis sclopetariaafter blunt trauma: comment. Clin Experiment Ophthalmol.2010;38(7):737-8; author reply 8. Comment on Clin ExperimentOphthalmol. 2009;37(9):896-7.

12. Georgalas I, Koutsandrea C, Papaconstantinou D, KampougerisG, Ladas I. Evolution of retinitis sclopetaria after blunt trauma.Clin Experiment Ophthalmol. 2009;37(9):896-7. Comment in ClinExperiment Ophthalmol. 2010;38(7):737-8; author reply 738.

13. Maguluri S, Hartnett ME. Radial choroidal ruptures in sclopetaria.J Am Coll Surg. 2003;197(4):689-90.

14. Martin DF, Awh CC, McCuen BW 2nd, Jaffe GJ, Slott JH,Machemer R. Treatment and pathogenesis of traumaticchorioretinal rupture (sclopetaria). Am J Ophthalmol.1994;117(2):190-200.

15. Richards RD, West CE, Meisels AA. Chorioretinitis sclopetaria.Am J Ophthalmol. 1968;66(5):852-60.

16. Kempster RC, Green WR, Finkelstein D. Choroidal rupture. Clini-copathologic correlation of an unusual case. Retina. 1996;16(1):57-63. Retina. 1996;16(1):57-63.

17. Grosso A, Panico C. Surgical management of sclopetaria associ-ated with macular hole in a young patient: long term results. Eye(Lond). 2009;23(9):1875-6.

18. Kunjukunju N, Navarro A, Oliver S, Olson J, Patel C, Garcia G, etal. Bilateral macular hole formation secondary to sclopetariacaused by shockwaves transmitted by a posterior vector: casereport. BMC Ophthalmol. 2010;10:6.

19. Neame H. Multiple ruptures of choroid with retention of goodvision. Br J Ophthalmol. 1940;24(8):399-400.

20. Williams DF, Mieler WF, Williams GA. Posterior segment manifes-tations of ocular trauma. Retina. 1990;10 Suppl 1:S35-44. Review.

21. Itakura H, Kishi S. Restored photoreceptor outer segment incommotio retinae. Ophthalmic Surg Lasers Imaging. 2011;42Online:e29-31.

22. Liem AT, Keunen JE, van Norren D. Reversible cone photore-ceptor injury in commotio retinae of the macula. Retina.1995;15(1):58-61.

23. Morita C, Preti RC, Ferraz DA, Maia Júnior OO, Takahashi WY.Tomografia de coerência óptica na commotio retinae: relato decaso. Arq Bras Oftalmol. 2009;72(4):533-6.

24. Park JY, Nam WH, Kim SH, Jang SY, Ohn YH, Park TK. Evalua-tion of the central macula in commotio retinae not associatedwith other types of traumatic retinopathy. Korean J Ophthalmol.2011;25(4):262-7.

25. Souza-Santos F, Lavinsky D, Moraes NS, Castro AR, Cardillo JA,Farah ME. Spectral-domain optical coherence tomography inpatients with commotio retinae. Retina. 2012;32(4):711-8.




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Corresponding author:Isaac Carvalho de Oliveira Ramos. Rua General Goes Monteiro,number 8, Block E, Apt.: 1803, Botafogo, ZIP Code: 22290-030, Rio de Janeiro - RJ, BrazilE-mail: [email protected]

26. Umeed S, Shafquat S. Commotio-retinae and central retinal ar-tery occlusion after blunt ocular trauma. Eye (Lond).2004;18(3):333-4.

27. Kohno T, Ishibashi T, Inomata H, Ikui H, Taniguchi Y. Experimen-tal macular edema of commotio retinae: preliminary report. JpnJ Ophthalmol. 1983;27(1):149-56.

28. Artunay O, Rasier R, Yuzbasioglu E, Sengül A, Bahcecioglu H.Intravitreal bevacizumab injection in patients with choroidalneovascularization due to choroid rupture after blunt-headtrauma. Int Ophthalmol. 2009;29(4):289-91.

29. Mennel S, Hausmann N, Meyer CH, Peter S. Photodynamictherapy and indocyanine green guided feeder vessel photoco-agulation of choroidal neovascularization secondary to choroidrupture after blunt trauma. Graefes Arch Clin Exp Ophthalmol.2005;243(1):68-71.

30. Oya Y, Yoshizawa T, Aoki S, Kurihara A, Abe H. [A case of chor-oidal rupture due to blunt ocular trauma healed with prolifera-tive tissue protruding into the vitreous cavity]. Nihon GankaGakkai Zasshi. 2002;106(11):721-7. Japanese.

31. Takahashi M, Kinoshita S, Saito W, Kase M, Ishida S. Choroidalneovascularization in a patient with blunt trauma-caused trau-matic retinopathy without choroidal rupture. Graefes Arch ClinExp Ophthalmol. 2011;249(1):137-40.

32. Wyszynski RE, Grossniklaus HE, Frank KE. Indirect choroidalrupture secondary to blunt ocular trauma. A review of eight eyes.Retina. 1988;8(4):237-43.

Ramos ICO , Santos DCM, Soares I, Cerqueira V


183CASE REPORT

Benign concentric annular macular dystrophy

Distrofia macular anular concêntrica benigna

Luísa Salles de Moura Mendonça1, Luciana Castro Lavigne1, Luis Fernando Oliveira Borges Chaves1, José MaurícioBotto de Barros Garcia1, David Leonardo Cruvinel Isaac1, Marcos Ávila1

1 Universidade Federal de Goiás, Goiânia (GO), Brazil.


The authors no conflicts of interest

RESUMO

O objetivo dos autores é detalhar o quadro clínico de um paciente com distrofia macular anular concêntrica benigna, quadro raro, quecompõe o diagnóstico diferencial das maculopatias em alvo. Realizou-se avaliação oftalmológica com auxílio de testes de percepção decores, angiofluoresceinografia e eletrofisiologia ocular.

Descritores: Doenças retinianas/diagnóstico; Angiofluoresceinografia; Eletrofisiologia; Mácula lútea/patologia; Diagnóstico dife-rencial; Relatos de casos

ABSTRACT

The purpose of the authors is to show clinical findings of a patient with benign concentric annular macular dystrophy, which is anunusual condition, and part of the “bull’s eye” maculopathy differential diagnosis. An ophthalmologic examination with colorperception, fluorescein angiography, and ocular electrophysiology was performed.

Keywords: Retinal diseases/diagnosis; Fluorescein angiography; Electrophysiology; Macula lutea/pathology; Diagnosis,differential; Case reports



184 Mendonça LSM, LavigneLC, Chaves LFOB, Garcia JMBB, Isaac DLC, Ávila M


INTRODUCTION

Benign concentric annular macular dystrophy (BCAMD)(OMIM 153870; Online Mendelian Inheritance in Man,http://www.ncbi.nlm.nih.gov/omim) is an uncommon

disorder, initially characterized by paracentral ring scotoma with acentral hyperpigmentation of the retinal pigment epithelium (RPE)and relatively good visual acuity(1-3). The first report of BCAMD waspublished in 1974, in a family with an autosomal dominant trait(4).

A ringlike hyperfluorescence is typically found in fluoresceinangiographic images. It is a result of a window defect in the atrophicmacular pigment which provides the characteristic “bull’s eye”maculopathy(1,4). Electroretinogram (ERG) is usually normal orslightly abnormal(1,2). Studying the patients’ color perception, someof them show predominant defects in the blue yellow axis, thoughthis finding is not constant(1,5,6).

The differential diagnosis of a “bull’s eye” maculopathyincludes chloroquine and hydroxychloroquine toxicity,Stargardt’s disease, central areolar choroidal atrophy, chronicmacular hole and cone dystrophy. Patients with BCAMD do nothave a prior history of regular chloroquine intake or symptomsrelated to photoreceptors dystrophy, such as photophobia andseverely defective color vision(1).

The present study reports a case of a patient with typicalclinical findings of BCAMD.

CASE REPORT

A 41-year-old male, native of Rio de Janeiro, Brazil,presented at CEROF-UFG complaining about nyctalopia andgradual deterioration of visual acuity, in the last 4 years. His pastmedical history and family medical history were unremarkable.He did not refer photophobia or history use of regular oralmedications. He was initially treated in another clinic in Rio deJaneiro, where the disorder was diagnosed as cone rod dystrophy.

His initial examination showed a best corrected visual acuityof 20/50 in the OD and 20/30 in the OS. Anterior segmentbiomicroscopy was normal in OU. Intraocular pressure was 15mmHg in the OD and 13 mmHg in the OS. Fundoscopy evaluationhad shown bilateral area of perifoveal hypopigmentation withan annular conformation and a concentric aspect in the macularregion, but sparing the center of the fovea (figure 1). Fundusperiphery was normal. Fluorescein angiography had showntypical “bull’s eye” maculopathy pattern (figure 2). TheFarnsworth-Munsell D15 color test was performed, whichpresented no visual dysfunction.

Figure 1. Fundus photographs showing an annular and concentricarea of hipopigmentation in the macular region, with a central, irre-gular and hyperpigmented area

Figure 2. Fundus imaging (top row) and angiography with fluorescein(bottom row), demonstrating a typical bull’s eye maculopathy image

The standard ERG was normal (figure 3). The parameters wereabnormal on the pattern Visual evoked potential (VEP), presentingdecreased amplitude and prolongation of the latency (figure 4).

Figure 3. Standard ERG and 30Hz Flicker with normal findings

Figure 4. Pattern VEP with decreased amplitude and prolongation ofthe latency


185

After evaluating all this clinical features, the patient wasdiagnosed with BCAMD. In 3 years of follow up, he did notshow any changes in visual acuity, maintaining the samefundoscopy and angiographic findings and ERG withoutabnormalities. After that, he did not return to an appropriatefollow-up in our service.

DISCUSSION

BCAMD is a highly unusual disorder(3). A search on theterms “annular” “macular” and “dystrophy” on PubMed websitefound 11 original related articles. After the initial report byDeutman in 1974, the term “benign” was applied to a generalcondition of a good visual acuity as part of one of the mainclinical features of the BCAMD(1, 3).

Recently, a mutation in the IMPG1 was related to BCAMD,but this relation is not confirmed(1, 2). The IMPG1, residing at theBCAMD locus, in the chromosome 6 might result in a Leu579Proamino acid substitution, playing a major role in its pathogenesis(2).

Fundus retinography typically shows a “bull’s eye”configuration with a RPE’s annular ring atrophy, corresponding tothe fluorescein angiography of a circular hyperfluorescence(1, 3).

While patients frequently show a “benign” course with goodvisual acuity for a long time, others may present a pronouncedinvolvement of the peripheral retina associated with a severephotoreceptor dysfunction(1, 3). A long term follow-up study of anaffected Dutch family showed that there was a pronouncedinvolvement of the peripheral retina, increased photoreceptordysfunction, waxy optic disc, arteriolar attenuation and furtherdecline of the ERG, as found in retinitis pigmentosa(2, 3).

Regarding color vision defects in BCAMD, the existenceof defects in the blue yellow axis is predominant, though notconstant. Some studies showed mild defects only, without anypredominant axis of confusion(1,5,6).

The ERG is typically normal or slightly abnormal(1, 3). Thenormal findings obtained on ERG suggest that this is a focaldysfunction rather than a generalized fundus disorder, but sometesting revealed a photoreceptor dysfunction with a slightpredominance of rod dysfunction above cone dysfunction(1,2, 7).A study showed a “bulls’ eye” maculopathy, associated with anegative ERG in four unrelated patients who had normal visioninitially, but with progressive loss of visual acuity, preserved coneresponse in ERG, and mild to moderate color deficiency. It wasthought that they had a similar condition with BCAMD, but nosigns at all of an autosomal dominantly disease(8). The VEPfindings, to our knowledge, have not been described previouslyin patients with BCAMD.

The optic coherence tomography (OCT) findings in thiscondition may suggest new pathological abnormalities. Alimitation of our case report is the absence of the OCT images,because the patient was examined prior to OCT introduction inclinical practice, and, after that, he did not return to anappropriate follow-up. However, OCT alterations are mild and,to our knowledge, have been described only in one case reportin 2005, in which they did not contribute to establish thediagnosis(3). The abnormalities include high and low reflectivityareas under the RPE, similar to the OCT findings seen in adultvitelliform macular dystrophy. The relatively normalneurosensory retina at the fovea probably explains the goodvisual acuity and mild ERG abnormalities(3).

The angiographic aspect, family history and hereditarypattern are the most relevant data when determining adifferential diagnosis among variable clinical conditions(1).Retinopathy secondary to anti malarial drugs requires a historyof sustained intake of chloroquine or hydroxychloroquine. It isdifficult to differentiate BCAMD and photoreceptorsdystrophies. Symptoms and clinical signs, such as photophobia,progressive central vision loss, important defect in color visionand an extremely altered photopic electroretinogram are foundin cone rod dystrophy(1, 2). Stargardt’s disease has an autosomalrecessive inheritance and shows a marked reduction in centralvisual acuity, although, in the initial stages, the fundus imagingmay appear normal. The characteristic “silent” choroidalangiographic and the altered electrooculogram are alsoimportant to its diagnosis(1).

In the reported case, regarding the good visual acuity, afterstudying the fluorescein angiography with correspondingretinographies, and the results of the standard ERG and VEP,BCAMD was diagnosed. The differential diagnosis include allconditions with the “bull’s eye” maculopathy configuration(1, 6).

REFERENCES

1. Gomez-Faiña P, Alarcón-Valero I, Buil Calvo JA, Calsina-Prat M,Martín-Moral D, Lillo-Sopena J, et al. Distrofia macular anularbenigna concéntrica. Arch Soc Esp Oftalmol. 2007; 82(6):373-76.

2. van Lith-Verhoeven JJ, Hoyng CB, van den Helm B, DeutmanAF, Brink HM, Kemperman MH, et al. The benign concentricannular macular dystrophy locus maps to 6p12.3-q16. InvestOphthalmol Vis Sci. 2004; 45(1):30-5.

3. Burton BJ, Holder GE, Duguid G, Gregory-Evans K. Opticalcoherence tomography findings in benign concentric annulardystrophy. Eye. 2005; 19(6):699-701.

4. Deutman AF. Benign concentric annular macular dystrophy. AmJ Ophthalmol. 1974; 78(3):384-96.

5. van den Biesen PR, Deutman AF, Pinckers AJ. Evolution of be-nign concentric annular macular dystrophy. Am J Ophthalmol.1985; 100(1):73-8.

6. Sadowski B1, Rohrbach JM, Partsch M, Schiefer U. Benign con-centric annular macular dystrophy. Klin Monbl Augenheilkd. 1994;205(3):173-5.

7. Coppeto J, Ayazi S. Annular macular dystrophy. Am J Ophthalmol.1982; 93(3):279-84.

8. Miyake Y, Shiroyama N, Horiguchi M, Saito A, Yagasaki K. Bull’seye maculopathy and negative electroretinogram. Retina.1989;9(3):210-5.

Corresponding author:Luísa Salles de Moura MendonçaRua 9, nº 663, apto 602 – Setor OesteZip code 74120-010 – Goiânia (GO), BrazilE-mail: [email protected]

Benign concentric annular macular dystrophy



186


CASE REPORT

Distrofia policromática posterior da córnea

Posterior polychromatic corneal dystrophy

Letícia Maria Coelho1, Guilherme Kfoury Muinhos1, Marco Antônio Guarino Tanure2, Homero Gusmão de Almeida1 ,Reinaldo de Oliveira Sieiro3

1 Eye Institute of Belo Horizonte, Belo Horizonte, MG, Brazil.2 Cornea and Cataract Service of São Gerardo Hospital, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil; São Gerardo Hospital, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil; Medicine College, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil; Cataract and Glaucoma Service, Eye Institute of Belo Horizonte, Belo Horizonte, MG, Brazil.3 Medicine School, College of Medical Sciences of Minas Gerais, Belo Horizonte, MG, Brazil.

Received for publication 16/09/2014 - Aceito for publication 27/11/2014

The autohrs declare no conflicts of interest

RESUMO

Os autores descrevem dois casos de distrofia policromática posterior da córnea, uma distrofia pré-Descemet, pouco descrita nasliteraturas nacional e mundial, em que se observam pontos policromáticos difusos no estroma posterior da córnea, sem aparentecomprometimento da visão.

Descritores: Distrofias hereditárias da córnea; Córnea/patologia; Lâmina limitante posterior/anormalidades; Substância própria/anormalidades; Relatos de casos

ABSTRACT

The authors describe two cases of posterior polychromatic corneal dystrophy, a pre-Descemet dystrophy, poorly described innational and world literatures, characterized by diffuse polychromatic points on the posterior corneal stroma, without visual impairment.

Keywords: Corneal dystrophies; Cornea/pathology; Descemet membrane/abnormalities; Corneal stroma/abnormalities; Casereports

Institution: Eye Institute of Belo Horizonte - IOBH - Belo Horizonte, MG, Brazil.


187

INTRODUCTION

The term corneal dystrophy is used to describe hereditary,bilateral, symmetrical and progressive corneal diseasesnot related to environmental or systemic conditions1.

Polychromatic dystrophy was described as a posterior stromacorneal dystrophy, pre-Descemet, characterized by punctate,polychromatic, uniform, diffusely distributed opacities with noapparent impairment of visual acuity2.

Despite the probable dominant autosomal inheritance1,2 ithas been described few times until today: only once ininternational2 literature and once in national literature3, remainingstill unknown by many ophthalmologists.

The aim of this article is to describe two cases of posteriorpolychromatic corneal dystrophy considering their features, theirrecognition in the ophthalmic practice and their clinicalmanagement.

CASE REPORT

CASE 1: DMS, 30 years old, female, leucoderma, married,economist, born and living in Belo Horizonte/MG, searchedroutine ophthalmologic evaluation due to ametropia. She woreglasses and soft contact lenses. She complained of recentdiscomfort from contact lenses. She reported that anophthalmologist had already contraindicated the use of contactlenses a few years ago due to a “problem in the cornea” whichshe could not specify, but she decided to wear them againwithout medical supervision a few months ago. She deniedhaving other previous eye diseases. She mentioned vitiligowithout clinical manifestations and without the administrationof medications at the time, and fibromyalgia with theadministration of Cyclobenzaprine. She had no history ofconsanguinity and/or eye diseases in the family. The examrevealed static refraction in the right eye (RE) of -2.50 (VA =20/25) and in the left eye (LE) of -2.50 (VA = 20/25). Thebiomicroscopy revealed mild hyperemia, mild papillary reaction,transparent corneas, with reduced BUT (break up time), diffusepuntactas and fine, uniform, polychromatic, diffusely distributedopacities in the posterior stroma (Figure 1). The intraocularpressure (IOP) was 11/10 mmHg at 5pm. The fundoscopyshowed no abnormalities. The non-contact specular microscopy(Konan® NONCON ROBO) showed cell count in RE = 2655cells/mm2 and LE = 2510 cells/mm2, with discrete pleomorphism/ polymegathism and numerous bright spots corresponding tothe posterior stromal opacities seen at the slit lamp. The centralultrasonic pachymetry (Alcon® OcuScan RxP) was equal to495 mm in the RE and 486 mm in the LE. Computerized cornealtopography (Tomey® TMS-4) showed normal keratometricvalues, with a mild asymmetrical irregular astigmatism,suggestive of tear film changes.

The tomography exam of optical coherence (Visante®OCT) showed hyperreflective images in the posterior stroma,without other changes (Figure 1). The patient was advised todiscontinue the use of contact lenses to restore the ocular surface,using lubricating eyedrops without preservatives and anti-allergyeyedrops. After that, use silicone hydrogel contact lenses withhigh oxygen permeability for a reduced time, with more frequentdisposal, proper eye lubrication and periodic medical follow-up.

CASE 2: MOG, 23 years old, female, leucoderma, single,administrative assistant, born and living in Belo Horizonte / MG,searched routine ophthalmologic assessment due to ametropia.She wore glasses. She denied previous eye and/or systemicdiseases. She had no history of consanguinity, and reported agrandfather with glaucoma. The exam revealed static refractionin the right eye (RE) of -1.50 -0.50 x 125° (VA = 20/20) and in theleft eye (LE) of -2.00 -1.00 x 80° (VA = 20/20). The biomicroscopypresented mild meibomitis, mild hyperemia, mild papillaryreaction, transparent corneas, with a little reduced BUT, discreteinferior puntactas and fine, uniform, polychromatic, diffuselydistributed opacities in the posterior stroma (Figure 2). The IOPwas 14/14 mmHg at 8pm. The fundoscopy showed noabnormalities. The non-contact specular microscopy (Konan®NONCON ROBO) showed cell count in the RE = 3243 cells/mm2 and LE = 2930 cells/mm2, without pleomorphism /polymegathism and with numerous bright spots correspondingto the posterior stromal opacities (Figure 2). The central ultrasonicpachymetry (Alcon® OcuScan RxP) was equal to 561 mm in theRE and 570 mm in the LE. Computerized corneal topography(Tomey® TMS-4) showed normal keratometric values, withnegligible astigmatism in both eyes (BE). The optical correctionwas prescribed, and the patient was advised to maintain regularmedical follow-up (Figure 2).

Figure 1 (patient 1): biomicroscopic images of punctate, fine, diffuse,polychromatic opacities in the posterior corneal stroma (above andbelow on the right) and optical coherence corneal tomography showinghyper-reflective points in the posterior stroma (below on the left).

Figure 2 (patient 2): biomicroscopic images of punctate, fine, diffuse,polychromatic opacities in the posterior corneal stroma (on the left)and specular corneal microscopy showing hyper-reflective pointscorresponding to the opacities seen in the slit lamp (on the right).


Posterior polychromatic corneal dystrophy


188


DISCUSSION

The pre-Descemet dystrophies are not a well-definedclinical entity yet, and do not have a clarified pattern of geneticinheritance. For this reason, they are included in category 4 ofthe classification of the International Committee of CornealDystrophies Classification (IC3D), which includes new orpreviously documented corneal dystrophies with evidence thatthey are separate entities, although they are not well proven1.

They usually manifest after 30 years old, but they havealready been observed in children up to 3 years. Patients areusually asymptomatic, without vision impairment. And the clinicalappearance of these dystrophies is thin, focal opacities locatedon the deep corneal stroma, prior to the Descemet’s membrane,central, annular or diffuse, with different shapes and sizes1.

Histological studies conducted showed only keratocytesincreased in the posterior stroma containing cytoplasmicinclusions and vacuoles of lipid-like material, and the studieswith electron microscopy showed vacuoles with electron-densematerial suggestive of secondary lysosomes and lipofuscin1. Forthis reason, some of them were related to a degenerative processand aging1,2.

The studies with confocal microscopy showed onlyhiperrefletivas particles in the posterior corneal stroma,immediately prior to the Descemet membrane1,5,6.

The differential diagnosis of these dystrophies should bedone with the granular opacities of the Bowman’s membrane(Reis-Bucklers), the stromal deposits of macular dystrophy, theguttatas of endothelial dystrophy7, the deposits ofmucopolysaccharidosis7,8 and mucolipidoses7 and deposits in themonoclonal gammopathy7,8-11.

The first author to describe the corneal dystrophies of thepre-Descemet type was Vogt in 1923, abd he called them farinatadystrophy4. Since then, several morphologies of pre-Descemetopacities have been described in the literature.

The first description of posterior polychromatic cornealdystrophy was made by Fernandez-Sasso et al in 1979 in Argen-tina, from the observation of 8 patients of the same family whohad punctate, polychromatic, uniform, diffusely distributedopacities in the posterior corneal stroma. It was considered anew type of pre-Descemet corneal dystrophy, with probabledominant autosomal genetic inheritance2.

Since then, only four extra clinical cases of two differentfamilies have been described by Tzelikis et al in 2007 in Brazil3.

These two present reports seem to be the third descriptionin the literature to date.

The main features of posterior polychromatic cornealdystrophy, and which differs it from other pre-Descemet cornealdystrophies, are the variety of opacity colors both in direct lightingand in indirect lighting of the slit lamp, and the uniform anddiffuse distribution of opacities of the same size, from limbo tolimbo of the cornea, without forming aggregate areas, leavingtransparent spaces between the opacities greater than their ownopacities2,3.

The diagnosis of this dystrophy is made by ophthalmologicexam in slit lamp, by means of observation of their morphologicalcharacteristics. It does not seem to interfere with the quality ofvision of the patients, nor worsen with time2,3.

There are few cases reported in the literature so far, and itis believed that this is due to lack of symptoms reported by thepatients and the lack of knowledge about this entity by most

ophthalmologists. Therefore, many patients must not have beendiagnosed yet.

Although it does not seem to require treatment over time,it is important to recognize this dystrophy, avoiding confusionwith other clinical conditions which require specific care andtreatment.

Studies to elucidate the gene responsible for this conditionand the way of genetic inheritance are still needed so that theposterior polychromatic corneal dystrophy can be recognized asa well defined corneal dystrophy.

CONCLUSION

The posterior polychromatic corneal dystrophy is still notconsidered a well-defined clinical entity, and was described a fewtimes, although it is believed to be more prevalent. The diagnosisis made primarily by eye examination at slit lamp. Althoughpatients do not seem to have symptoms and/or progression ofthe disease, they should be correctly diagnosed for properophthalmologic advice and follow-up which allows greaterknowledge about this condition.

REFERENCES

1. Weiss JS, Møller HU, Lisch W, Kinoshita S, Aldave AJ, Belin MW,et al. The IC3D classification of the corneal dystrophies. Cornea.2008;27 Suppl 2:S1-83.

2. Fernandez-Sasso D, Acosta JE, Malbran E. Punctiform and poly-chromatic pre- Descemet’s dominant corneal dystrophy. Br JOphthalmol. 1979; 63:336-8.

3. Tzelikis PF, Santos UR, Tanure MA, Trindade FC. Distrofia corneanapolicromática posterior. Rev Bras Oftalmol. 2007; 66 (4):262-6.

4. Vogt A. Cornea farinata. Schweiz Med Wochenschr.. 1923; 53:991.5. Ye YF, Yao YF, Zhou P, Pan F. In vivo confocal microscopy of pre-

Descemet’s membrane corneal dystrophy. Clin ExperimentOphthalmol. 2006 ;34(6):614-6.

6. Kontadakis GA, Kymionis GD, Kankariya VP, Papadiamantis AG,Pallikaris AI. Corneal confocal microscopy findings in sporadiccases of pre-descemet corneal dystrophy. Eye Contact Lens.2014;40(2):e8-e12.

7. Klintworth GK. Corneal dystrophies. Orphanet J Rare Dis.2009;4:7. Review.

8. Villas-Bôas FS, Fernandes Filho DJ, Acosta AX. [Ocular findingsin patients with mucopolysaccharidosis]. Arq Bras Oftalmol.2011;74(6):430-4. Portuguese.

9. Tzelikis PF, Laibson PR, Ribeiro MP, Rapuano CJ, HammersmithKM, Cohen EJ. Ocular copper deposition associated with mono-clonal gammopathy of undetermined significance: case report.Arq Bras Oftalmol. 2005;68(4):539-41.

10. Koo H, Oh DH, Chun YS, Kim JC. A case of crystalline keratopathyin monoclonal gammopathy of undetermined significance(MGUS). Korean J Ophthalmol. 2011;25(3):202-5.

11. Foo FY, Khng C, Voon LW. Bilateral polychromatic crystallinekeratopathy as the initial manifestation of IgG-lambda multiplemyeloma. Ann Acad Med Singapore. 2013;42(2):93-4.

Corresponding author:Letícia Maria CoelhoRua Padre Rolim, 541 - Santa Efigenia - Belo Horizonte - MG -ZIP Code: 30130-090.E-mail: [email protected]

Coelho LM, Muinhos GK, Tanure MAG, Almeida HG, Sieiro RO


189 REVIEW ARTICLE

Lentes intraoculares e tratamentoclínico na catarata pediátrica

Intraocular lenses and clinicaltreatment in paediatric cataract

Camila Ribeiro Koch Pena 1, Priscilla Almeida Jorge 2, Newton Kara-Junior2

1 Instituto Brasileiro de Prevenção à Cegueira, Hospital Humberto Castro Lima, Salvador (BA), Brazil;2 Universidade de São Paulo (USP), São Paulo (SP), Brazil.



RESUMO

A catarata pediátrica é a causa mais comum de cegueira tratável em crianças. Prevalência, etiologia e morfologia variam conforme odesenvolvimento sócioeconômico. O tratamento tem como objetivo diminuir a ambliopia, sendo de difícil manejo principalmente emcasos unilaterais. A decisão sobre afacia ou implante primário de lente intraocular deve ser individualizado, assim como a correção comlente de contato ou óculos. As lentes intraoculares acrílicas hidrofóbicas de peça única são as mais implantadas em crianças compreferência de implante no saco capsular. A fórmula biométrica Sanders-Retzlaff-Krafftheoretic (SRK/T) é a mais precisa em pacientespediátricos, seguida de Holladay I e SRK II, com recomendação de sob correção de +6 a +8.0 dioptrias, devido ao esperado crescimentorápido do globo ocular. A opacidade de cápsula posterior é a complicação mais frequente e varia com o material da lente a serimplantada e o glaucoma é a complicação pós-operatória mais grave e depende da idade da criança na cirurgia, implante primário deLIOs e da duração do acompanhamento pós-cirúrgico. A adesão ao tratamento oclusivo é fundamental para o prognóstico visual,sendo determinado de acordo com a idade da criança e a lateralidade da catarata. Mesmo com a melhora do tratamento cirúrgico e daslentes intraoculares o prognóstico visual final ainda não é o desejável.

Descritores: Catarata/congênito; Catarata/etiologia; Afacia/cirurgia; Lentes de contato; Lentes intraoculares

ABSTRACT

Pediatric cataract is the most common treatable cause of blindness in children. Prevalence, etiology and morphology vary with thesocioeconomic development. The treatment goal is to reduce amblyopia, being difficult management especially in unilateral cases.The decision on aphakia or primary intraocular lens should be individualized as well as correction with contact lens or spectacles. Theintraocular lens single-piece hydrophobic acrylic are the most implanted in children and the preferably is in the capsular bag. TheSanders-Retzlaff-Kraff theoretic (SRK/T) stressing that is described as more predictable, following Holladay I and SRK II and therecommendation is to under correction +6.0 or +8.0 dioptrias expecting the growth of the eye. The posterior capsule opacity is themost frequent complication and varies with the material choice of the lens. Glaucoma is the most serious postoperative complicationand depends on the timing of the surgery, primary lens implantation and time of post surgical follow-up. The adherence to occlusiontherapy with patching is critical to the visual prognosis and is determined by the child’s age and laterality of the cataract. There wassignificant improvement in the surgery and in IOLs, however the final visual prognosis is still not desirable.

Keywords: Cataract/congenital; Cataract/etiology; Aphakia/surgery; Contact lenses; Lenses intraocular



190 Pena CRK, Jorge PA, Kara-Junior N


INTRODUCTION

Blindness in children is a high-priority goal of the WorldHealth Organization until 2020. In 1992, dates showed1.5 million cases of childhood blindness in the world, in

2002 around 1.3 million and in 2010 around 1.4 million(1,2).The literature reports about 75% of avoidable blindness inchildren in the world, and 30% of them are due to PediatricCataract (PC)(2). Other important causes are refractive error,corneal opacities and retinopathy of prematurity(3).Furthermore, socioeconomic development influence in theprevalence and etiology of PC. More than 85% of blindchildren live in Africa, Asia and Latin America(4). In Brazil, theprevalence of low vision due to PC is still high, 5.5 to 12% of thepatients(5). It is known about the difficulty in obtaining accurateprevalence data on blindness in children due to very large samplespopulation-based, besides the high cost, demands trainedprofessionals and specific equipment.

The final goal of PC is successful visual rehabilitation. However, the controversy over the best correction of aphakiaresulting from cataract surgery and primary intraocular lens(IOL) implantation, especially in newborns, remains under study.The purpose of this review is to report the prevalence causes,and treatment of pediatric cataract.

DEVELOPMENT

Morphology, Etiology and Clinical Findings

The classification of PC depends on morphological analysisof lens opacity, its etiology and time of emergence.

The morphological types are according to the location ofthe lens opacity. They are Polar, Zonular, Coronary, Total (white),Membranous and Persistent Fetal Vasculature (PFV). TheZonular is the most common and according to the location mayhave subtypes: Nuclear, Lamellar, Capsule Plaque and Sutural(3).Often there is an association between the subtypes. Most of thestudies the Nuclear is the most common varying from 10 to 54%,followed by lamellar. Usually nuclear is non progressive andalmost all had an association with posterior capsule plaque(6,7).

There is a socioeconomic influence in the other etiologiesand morphology. Retrospective studies in developing countriesasserted congenital infections, especially Rubella in the firsttrimester of pregnancy as one of the most prevalent etiologiesand total cataract as one of the most common morphologies found,opposing the rarity in developed countries(8). The vaccinationcampaigns against rubella have been reduced its prevalence(2).Others intrauterine infections (toxoplasmosis, herpes, syphilis,varicella, cytomegalic), birth dates (prematurity and low birthweight), syndromes (Down, Turner, Lowe, Hallermann-Streiff-Francois, Nance-Horan) and systemic diseases (galactosaemia,hypocalcaemia) are recognized as PC causes(3,6,7). As regardsetiology more than 50% of cases are idiopathic and one third ofcases are hereditary, most of them autosomal dominant.(3,5,7,9)

Nuclear cataract have inheritance in 30-50% and lamellarcommonly have pattern of inheritance too(3,7,8).

Chronological classification depends on the time onset ofthe opacity. Congenital Cataract (CC) when detected beforethree months of life, Infantile Cataract (IC) when detected afterthree months and PC which includes all types. Trauma is themajor cause of acquired cataracts in infants, however, traumatic

is a type of cataract with management, implications and differentexpectations from CC.(7) Most of the available studies affirmthat 57-81% of PC are bilateral and is associated with systemicdisorders or hereditary factors(7,9). Available studiesdemonstrated PFV in 94-100% of eyes with unilateral CC, and itmay have association with microphthalmia, aniridia, iris colobomaand lens coloboma(6,8). Another peculiarity is its association withstrabismus, nystagmus and fixation instabilities. The esotropia isfound more and will generally follow deprivation amblyopia.The nystagmus is an indicator that vision is affected significantly.The importance of recognizing these signs is due to the fact thatthey were related to visual prognosis(4,10).

Decision about the treatment

The decision about the treatment in children with PCdepends on extension of lens opacity, through of the examinationof the red reflex, retinoscopy and biomicroscopy or using a hand-held slitlamp when possible or undergoing examination underanesthesia if necessary(3,4). The red reflex in newborn detect earlysuspects of CC and has a low cost, reasons that made itmandatory in many hospitals(11). The CC without risk toamblyopia shouldn’t be an indication for surgery. Monitoring ispreferred, in addition using mydriatic drops, occlusion of thedominant eye and postponing surgery to avoid surgicalcomplications. The presence of dense opacities with morethan 3 mm in diameter in the center of the lens brings lowvision and should be removed(3,7,12). The ideal is to performsurgery between 1-4 months of life. Before 4 weeks risks outweighthe benefits(13). Glaucoma is the most serious complication, thesooner the surgery the higher the risk, besides, the calculation ofbiometrics is more prone to errors and inflammation is morefrequent.(3,7,9) Thus, after 4 weeks of life surgery should beperformed and the vision can be developed in the best possibleway. At birth the visual system is immature and is still developingin early months of life. The newborn has poor fixation, verylimited ability to discriminate colors, limited visual fields and anestimated visual acuity between 20/200 and 20/400(14). During thegrowth, the acuity reaches the healthy adult standard of 20/20 at6 months. The development of the visual stimulus depends onthe integrity of a complex network which includes retina, opticnerve, optic radiations, visual pathway and visual cortex. Thedevelopment of the cortex depends on the phenomenon calledplasticity, manipulated by changes in stimuli, for example presenceof CC or treatment using patching(12). In general the imagesprovided by the better eye will be recorded. Knowing this, studiesrecommend early surgery with the aim of reducing the risk ofamblyopia, principally in unilateral IC(12,14).

Surgery and complications

The child’s eye has some details that make technically moredifficult the cataract surgery than adults(3,7,15). The anterior capsuleis more elastic, the vitreous pressure is larger, the sclera is thinner,small pupil is often and the hydrodissection should be morecareful in posterior polar because in 40% of the surgeries it maybe stuck in the posterior capsule(3,16).

The femtosecond laser in infants began to be realized withsuccess helping principally in the capsulotomy, with a specificdiameter without risk for capsular tears. The difference betweenadults and children is the size of the eye which is impossible toaccommodate the laser’s interface. So it is necessary in childrencreate a small lateral cantholysis of less than 2 mm to realize the


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procedure(17). Probably in the future the laser will be a moreconsolidated step in children’s cataract surgery.

Posterior capsule opacification (PCO) is an expectedcomplication, requiring additional treatment with NeodymiumYAG-laser or intraocular reoperation in order to recovery theoptical transparency because of the risk of amblyopia. To avoidthis postoperative complication, some surgeons perform a pos-terior capsulotomy with anterior vitrectomy(3,5). PCO incidencevaries depending on IOL materials(18). Reports show thathydrophobic acrylic IOLs apparently have more PCO thanpolymethyl methacrylate (PMMA) IOLs, even then, theprevalence is high, reaching 50%(18,19). Glaucoma is the mostsevere complication after IC surgery. It may occur several yearsafter primary surgery, being more frequent the developmentaround 3 years of age and needs long-term follow-up(20). Theprevalence varies from 3.5% to 58% and the exact etiology is stillunknown(13,21). This large variation in prevalence of glaucomamay be related to the length of time of post operative follow-upof children ranging in the studies, since the risk continues to risewith time(20,21). Bilateral cataract is associated with a higher riskof glaucoma(13,20). Furthermore, the literature is contradictoryon primary IOL implantation and glaucoma development. Thetheoretical explanation for the IOL to prevent glaucoma is toavoid the vitreous contacting the trabecular meshwork. On theother hand intact posterior capsule may be associated with alower risk of development glaucoma(22).

Other less frequent adverse events can occur after PCsurgery, such as pupillary membranes, corectopia, phimosis ofthe anterior capsule, lens reproliferation, vitreous hemorrhage,retinal detachment, endophthalmitis, phithisis bulbi, cornealabrasion, corneal edema, dilated pupil and capsular phimosis(15,23).

IOLs

IOLs implantation in children after two years old isaccepted by most pediatric surgeons. In the 1980s, theintroduction of PMMA IOLs and vitrectomy instrumentationgot an improvement in surgical results, and the introduction ofhydrophobic acrylic IOLs in 1990’s made it better(24). Even withincreasing costs, the hydrophobic acrylic single-piece lensimplanted in the capsular bag became the favorite amongsurgeons, due to the possibility to introduce the IOLs in smallincision, with less trauma and less PCO(24).

Three piece IOLs can be deformed in small eyes andocclusion the pupil, but are indicated for sulcus fixation. Siliconeand hydrophilic acrylic IOLs are not the first choice for children,because more PCO and capsule contraction was foundrespectively. However some studies show good results withhydrophilic acrylic IOLs compared to PMMA IOLs(25).

From birth to maturity, the eye increases three times itssize. One third of the eye’s growth in diameter occurs in the firstyear of life. The axial length (AL) is extremely short, most ofthem less than 20mm and the refractive power of the cornea ishigh, about 51 dioptries (D), consequently the prediction errorin IOL calculation is expected. Every 1mm of increase in ocularlength results in approximately 2.50 D of myopic shift. An axiallength measurement error is increased at 4 to 14 D/mm in childrencompared with 3 to 4 D/mm error in adults(26). Some reportssuggest under correction in 20-30%, hyperopia of +6.0 or +8.0 D,expecting this growth of the eye, especially in bilateral cataractand correction with contact lenses in the first months after thesurgery(27,28). AL measurements are possible under anesthesiawith A-scan ultrasonography, being contact or immersion with

equivalent results(29,30). With respect to biometric formulas, theycan be used the same as in adults, stressing that Sanders-Retzlaff-Kraff theoretic (SRK/T) is described as more predictable,following Holladay I and SRK II(24,28,31).

There is no agreement about the best time for surgery andIOL implantation. It is advisable to leave aphakia infants lessthan seven months of life, especially for families who can affordand properly perform the treatment with contact lens(32).However, we expect complications in the eyes of these childrento be subjected to secondary implant later and this should beweighed. The primary implant is an option in cases where thereis risk of decreasing visual acuity of the child for inappropriateuse of contact lens. According to some studies, the correctionwith primary IOL implantation unilateral results in improvedvisual acuity, improved binocular vision outcome, but higher rateof complications requiring reoperation(5). Recently, a multicenterclinical trial compared cataract surgery in children less than sevenmonths of age with unilateral CC with and without IOLimplantation following in the first 5 years. The long-termmonitoring showed no statistical difference in the outcome ofvisual acuity between groups(33).

Aphakia rehabilitation

Beyond the diagnostic difficulty, intrasurgical complications,decisions on IOL implantation and postoperative adverse events,the IC requires a rigorous treatment of visual correction andrefraction requires more attention, preferably with pediatricophthalmologist, psychological monitoring and expert fitting ofcontact lens in children.

Contact Lens/Spectacles

The infantile aphakia visual rehabilitation is possible withcontact lens (CL), soft (SE) or rigid gas permeable (RGP), orspectacles. The recommendation is CL in monocular aphakiaand spectacles in bilateral aphakia, but the financial conditionsand the family support must be taken into account. The literatureshows some successful cases in monocular aphakia with spectablesand patching and CL in bilateral aphakia and nystagmusCC(10,34).The CL in children are harder to fit than in adults, butfollow the same principles. The rapid growth of the eye duringthe first 18 months of life requires frequent monitoring(35). Atbirth the horizontal corneal diameter (HCD) is about 10mm innormal eyes and the corneal curvature between 47 D (7.18mm)and 48.50 D (6.96mm) and close to two years of age isapproximately 43,5D and the HCD increases to 11,5mm between3 and 4 years old(36).

The suggestion in newborns with a normal eye is to startwith a specifically RGP designed for aphakia infants in flattercurve of the cornea (K), about 7.00 to 7.5 mm and increasefrequently about every three months for the infant’s first 12months. The total diameter fitting in RGP depends on the infant’sage; usually of 10.0 mm, vary 8.3 to 11.2mm and refraction +26 Dto +32 D(35,37). The SE about 2.5 to 3.0mm larger than the hori-zontal visible iris diameter. Newborns should be overcorrectedby about +2,50 to +3,00D to focus them at this near viewingpoint correction at 50 cm and at 18 to 24 months of age should bereduced to +1,00 to +1,50 D, when children starts to becomemore aware of distant objects and at 3 to 4 years should haveappropriate distance correction, with the reading correction thenincorporated into a pair of spectacles, usually bifocals ormultifocal, to be used over the contact lenses(37). The lens will beremoved once a week in particular leaving it in solution.

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The silicone hydrogel SE is the type more fitting inpediatrics, is easy to fit, because it is a logical way withoutkeratometry, very stable on the eye and has a good oxygen supplyeven in a high plus power(32). On the other hand, it does notcorrect the significant corneal astigmatism, it is more difficult toinsert by the parents and loss is not uncommon(35). RGP is evenmore stable, able to correct for any corneal astigmatism, easierhandling and some complications are less common, such asmicrobial keratitis, corneal vascularisation and pappillaryconjunctivitis. However, RGP requires more medical expertise,is more prone to foreign bodies and more easily ejected.Apparently, there are no differences in visual acuity between SEand wearing RGP(38).

Secondary IOL implantation

In the aphakic infants an elective secondary IOLimplantation appears to provide a safe and effective alternative,like in some cases the inability to wear contact lens successfully.The secondary IOL implantation around 2 years in bilateral ICmay show better visual prognosis than early primary IOLimplantation and can contribute to lowering glaucomaincidence(39). The IOL can be inserted in the capsular bag or in theciliary sulcus, with/without iris or scleral fixation, depending onthe situation(40). Possible complications should be taken intoaccount, such as macular edema and elevated intraocularpressure(15).

Ambliopy treatment

The risk of amblyopia is greatest during the first year oflife. The occlusion therapy with patching should be prescribedsoon after the surgery in unilateral or bilateral cataract, around2-4 weeks at the same time starting the most accurate refractiveerror correction possible in pseudophakic or aphakia either withspectacles or contact lens(3). If none of these forms work, thechoice in those cases is IOL secondary implantation. The periodof use the treatment with patch has relation with the age of thepatient(3,7,12). Up to 12 months of life in infants that are left withunilateral aphakia, occlusion of the eye not operated for 1 hourdaily is recommended and after, a half of awaking hours isindicated, that way forcing the brain to use the suppressed eye(33).In bilateral cases if one eye is more amblyopic than the other theocclusion therapy is necessary and is important alternation thepatching among the eyes. In general, the success of occlusiontherapy for amblyopia will depend on the age of the patient, thedegree of visual impairment and adherence to treatment(41).Theduration will depend on recovery of vision during the first decadeof life. There must be careful monitoring, to avoid sensorydeprivation amblyopia in the eye occluded. A recent studycompared children with unilateral IC treatment with IOLimplanted at the time of the surgery or corrected aphakia withcontact lens showed incidence of nystagmus and fixationinstabilities about 60% overall(10).

Visual acuity

Reports about visual results after cataract surgery in thechildren must have careful consideration when compared to eachother, because the visual outcome depends on the age of thepatient, type of cataract, laterality, the delay until surgery andvisual rehabilitation treatment. The chance of amblyopia is higherin unilateral IC, dense lens, delayed surgery and irregulartreatment with occlusion or contact lens/spectacle.

The best choice to measure the best corrected visual acuityin children is the Teller acuity card. It is accurate, is possibleestimates of the VA in about 5 minutes and can be use withchildren starting at one month of age(42). The Visual evokedpotentials (VEP) is relatively simple and noninvasive but it is atime consuming procedure. The electrical activity in the brain ismeasured in response to stimulation of sight and should beindicated as a supplement in special cases(43).

Reports shown in unilateral IC with or without IOLimplantation underwent surgery before 1 year age, visual acuityabout 40 to 50% with poor visual acuity ≤ 20/200.The bettervision around 20/32 the vast majority without primary IOLimplantation(44). Primary IOL implantation in bilateral CCimplantation underwent surgery before 1 year of age mostly liesbetween 20/25 to 20/100. Secondary IOL implantation around 2years in bilateral CC implantation underwent surgery before 1year age mostly lies between 20/100 to 20/40, the latter 40% ofthe children(45). Almost all these children will be able to attend anormal school.

Conclusions and recommendations

IC is still a major cause of blindness in the world even withgovernment investments. The prognosis is worse in congenitalcataract with associated disorders or unilateral. The timing ofsurgery is critical, therefore the importance of the red reflex testat birth and forwarding to a reference center. The lens implant isconsolidated starting from the age of two, however before thisage it is questionable because the literature shows no statisticaldifference in visual acuity and a greater number of surgicalinterventions, especially until 12 months of life. Glaucoma is theworst complication and PCO the most common. All methods ofvisual acuity correction have their limitations and advantages,and the choice must be made individually. The suggestion is todelay IOL implantation if the families can manage contact lenscare and expense. The long-term safety remains a consideration.Cataract surgery offers children with this condition the bestchance for a full life.

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Correspondente author:Camila Ribeiro Koch PenaRua Hilton Rodrigues nº 71, apto. 903 – Ed Torre Molinos,Bairro PitubaCEP 41830-630 – Salvador (BA), BrasilEmail:[email protected]


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Instruções aos autores

A Revista Brasileira de Oftalmologia (Rev Bras Oftalmol.) - ISSN0034-7280, publicação científica da Sociedade Brasileira de Of-talmologia, se propõe a divulgar artigos que contribuam para oaperfeiçoamento e o desenvolvimento da prática, da pesquisa e doensino da Oftalmologia e de especialidades afins. Todos os ma-nuscritos, após aprovação pelos Editores, serão avaliados por doisou três revisores qualificados (peer review), sendo o anonimatogarantido em todo o processo de julgamento. Os comentários dosrevisores serão devolvidos aos autores para modificações no textoou justificativa de sua conservação. Somente após aprovações fi-nais dos revisores e editores, os manuscritos serão encaminhadospara publicação. O manuscrito aceito para publicação passará aser propriedade da Revista e não poderá ser editado, total ou parci-almente, por qualquer outro meio de divulgação, sem a préviaautorização por escrito emitida pelo Editor Chefe. Os artigos quenão apresentarem mérito, que contenham erros significativos demetodologia, ou não se enquadrem na política editorial da revista,serão rejeitados não cabendo recurso.

Os artigos publicados na Revista Brasileira de Oftalmologiaseguem os requisitos uniformes proposto pelo Comitê Internaci-onal de Editores de Revistas Médicas, atualizado em fevereiro de2006 e disponível no endereço eletrônico http://www.icmje.org

APRESENTAÇÃO E SUBMISSÃO DOS MANUSCRITOS

O artigo enviado deverá ser acompanhado de carta assinadapor todos os autores, autorizando sua publicação, declarandoque o mesmo é inédito e que não foi, ou está sendo submetido àpublicação em outro periódico e foi aprovado pela Comissão deÉtica em Pesquisa da Instituição em que o mesmo foi realizado.

A esta carta devem ser anexados:• Declaração de Conflitos de Interesse, quando pertinente. A

Declaração de Conflitos de Interesses, segundo Resolução doConselho Federal de Medicina nº 1595/2000, veda que em arti-go científico seja feita promoção ou propaganda de quaisquerprodutos ou equipamentos comerciais;

• Informações sobre eventuais fontes de financiamento dapesquisa;

• Artigo que trata de pesquisa clínica com seres humanosdeve incluir a declaração de que os participantes assinaram Ter-mo de Consentimento Livre Informado.

Todas as pesquisas, tanto as clínicas como as experimentais,devem ter sido executadas de acordo com a Declaração deHelsinki.

A Revista Brasileira de Oftalmologia não endossa a opiniãodos autores, eximindo-se de qualquer responsabilidade em rela-ção a matérias assinadas.

Os artigos podem ser escritos em português, espanhol, inglêsou francês. A versão “on-line” da revista poderá ter artigos apenasem inglês.

A Revista Brasileira de Oftalmologia recebe para publicação:Artigos Originais de pesquisa básica, experimentação clínica oucirúrgica; Divulgação e condutas em casos clínicos de relevanteimportância; Revisões de temas específicos, Atualizações; Cartasao editor. Os Editoriais serão escritos a convite, apresentandocomentários de trabalhos relevantes da própria revista, pesquisasimportantes publicadas ou comunicações dos editores de inte-resse para a especialidade. Artigos com objetivos comerciais oupropagandísticos serão recusados. Os manuscritos deverão obe-decer as seguintes estruturas:

Artigo Original: Descreve pesquisa experimental ou investi-gação clínica - prospectiva ou retrospectiva, randomizada ou duplocego. Deve ter: Título em português e inglês, Resumo estruturado,Descritores; Abstract, Keywords, Introdução, Métodos, Resulta-dos, Discussão, Conclusão e Referências.

Artigo de Revisão: Tem como finalidade examinar a biblio-grafia publicada sobre um determinado assunto, fazendo umaavaliação crítica e sistematizada da literatura sobre um determi-nado tema e apresentar as conclusões importantes, baseadasnessa literatura. Somente serão aceitos para publicação quandosolicitado pelos Editores. Deve ter: Texto, Resumo, Descritores,Título em Inglês, Abstract, Keywords e Referências.

Artigo de Atualização: Revisões do estado-da-arte sobredeterminado tema, escrito por especialista a convite dos Editores.Deve ter: Texto, Resumo, Descritores, Título em Inglês, Abstract,Keywords e Referências.

Relato de Caso: Deve ser informativo e não deve conterdetalhes irrelevantes. Só serão aceitos os relatos de casos clíni-cos de relevada importância, quer pela raridade como entidadenosológica, quer pela não usual forma de apresentação. Deveter: Introdução, Descrição objetiva do caso, Discussão, Resu-mo, Descritores, Título em Inglês, Abstract e Keywords e Refe-rências.

Cartas ao Editor: Têm por objetivo comentar ou discutirtrabalhos publicados na revista ou relatar pesquisas originais emandamento. Serão publicadas a critério dos Editores, com a res-pectiva réplica quando pertinente.

Preparo do Manuscrito:A) Folha de Rosto deverá conter:• Título do artigo, em português e inglês, contendo entre dez

e doze palavras, sem considerar artigos e preposições. O Títulodeve ser motivador e deve dar idéia dos objetivos e do conteúdodo trabalho;

• Nome completo de cada autor, sem abreviaturas, porém seo autor já possui um formato utilizado em suas publicações,deve informar à secretaria da revista;

• Indicação do grau acadêmico e/ou função acadêmica e aafiliação institucional de cada autor, separadamente. Se houvermais de uma afiliação institucional, indicar apenas a mais rele-vante. Cargos e/ou funções administrativas não devem serindicadas.

• Indicação da Instituição onde o trabalho foi realizado;• Nome, endereço, fax e e-mail do autor correspondente;• Fontes de auxílio à pesquisa, se houver;• Declaração de inexistência de conflitos de interesse.

B) Segunda folhaResumo e Descritores: Resumo, em português e inglês,

com no máximo 250 palavras. Para os artigos originais, deveráser estruturado (Objetivo, Métodos, Resultados, Conclusão), res-saltando os dados mais significativos do trabalho. Para Relatos deCaso, Revisões ou Atualizações, o resumo não deverá serestruturado. Abaixo do resumo, especificar no mínimo cinco eno máximo dez descritores (Keywords) que definam o assunto dotrabalho. Os descritores deverão ser baseados no DeCS -Descritores em Ciências da Saúde - disponível no endereço ele-trônico http://decs.bvs.br/

Abaixo do Resumo, indicar, para os Ensaios Clínicos, o núme-ro de registro na base de Ensaios Clínicos (http://clinicaltrials.gov)*

C) TextoDeverá obedecer rigorosamente a estrutura para cada catego-

ria de manuscrito.Em todas as categorias de manuscrito, a citação dos autores

no texto deverá ser numérica e sequencial, utilizando algarismosarábicos entre parênteses e sobrescritos. As citações no texto de-verão ser numeradas sequencialmente em números arábicos so-brepostos, devendo evitar a citação nominal dos autores.

Introdução: Deve ser breve, conter e explicar os objetivos eo motivo do trabalho.


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Métodos: Deve conter informação suficiente para saber-se oque foi feito e como foi feito. A descrição deve ser clara e suficien-te para que outro pesquisador possa reproduzir ou dar continui-dade ao estudo. Descrever a metodologia estatística empregadacom detalhes suficientes para permitir que qualquer leitor comrazoável conhecimento sobre o tema e o acesso aos dados origi-nais possa verificar os resultados apresentados. Evitar o uso determos imprecisos tais como: aleatório, normal, significativo, im-portante, aceitável, sem defini-los. Os resultados da pesquisa de-vem ser relatados neste capítulo em seqüência lógica e de manei-ra concisa.

Informação sobre o manejo da dor pós-operatório, tanto emhumanos como em animais, deve ser relatada no texto (Resolu-ção nº 196/96, do Ministério da Saúde e Normas Internacionaisde Proteção aos Animais).

Resultados: Sempre que possível devem ser apresentadosem Tabelas, Gráficos ou Figuras.

Discussão: Todos os resultados do trabalho devem ser dis-cutidos e comparados com a literatura pertinente.

Conclusão: Devem ser baseadas nos resultados obtidos.Agradecimentos: Devem ser incluídos colaborações de pes-

soas, instituições ou agradecimento por apoio financeiro, auxíli-os técnicos, que mereçam reconhecimento, mas não justificam ainclusão como autor.

Referências: Devem ser atualizadas contendo, preferencial-mente, os trabalhos mais relevantes publicados, nos últimoscinco anos, sobre o tema. Não deve conter trabalhos não referi-dos no texto. Quando pertinente, é recomendável incluir traba-lhos publicados na RBO. As referências deverão ser numeradasconsecutivamente, na ordem em que são mencionadas no textoe identificadas com algarismos arábicos. A apresentação deveráseguir o formato denominado “Vancouver Style”, conforme mo-delos abaixo. Os títulos dos periódicos deverão ser abreviadosde acordo com o estilo apresentado pela National Library ofMedicine, disponível, na “List of Journal Indexed in Indexmedicus” no endereço eletrônico: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=journals.

Para todas as referências, citar todos os autores até seis. Quan-do em número maior, citar os seis primeiros autores seguidos daexpressão et al.

Artigos de Periódicos:Dahle N, Werner L, Fry L, Mamalis N. Localized, central optic

snowflake degeneration of a polymethyl methacrylate intraocularlens: clinical report with pathological correlation. ArchOphthalmol. 2006;124(9):1350-3.

Arnarsson A, Sverrisson T, Stefansson E, Sigurdsson H, SasakiH, Sasaki K, et al. Risk factors for five-year incident age-relatedmacular 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 as-

pectos da aniridia [tese]. São Paulo: Universidade Federal de SãoPaulo; 1990.

Publicações eletrônicas:Herzog Neto G, Curi RLN. Características anatômicas das vias

lacrimais excretoras nos bloqueios funcionais ou síndrome de

Milder. Rev Bras Oftalmol [periódico na Internet]. 2003 [citado2006 jul 22];62(1):[cerca de 5p.]. Disponível em:www.sboportal.org.br

Tabelas e Figuras: A apresentação desse material deve serem preto e branco, em folhas separadas, com legendas e res-pectivas numerações impressas ao pé de cada ilustração. Noverso de cada figura e tabela deve estar anotado o nome domanuscrito e dos autores. Todas as tabelas e figuras tambémdevem ser enviadas em arquivo digital, as primeiras preferenci-almente em arquivos Microsoft Word (r) e as demais em arqui-vos Microsoft Excel (r), Tiff ou JPG. As grandezas, unidades esímbolos utilizados nas tabelas devem obedecer a nomenclatu-ra nacional. Fotografias de cirurgia e de biópsias onde foramutilizadas colorações e técnicas especiais serão consideradaspara impressão colorida, sendo o custo adicional de responsa-bilidade dos autores.

Legendas: Imprimir as legendas usando espaço duplo, acom-panhando as respectivas figuras (gráficos, fotografias e ilustra-ções) e tabelas. Cada legenda deve ser numerada em algarismosarábicos, correspondendo as suas citações no texto.

Abreviaturas e Siglas: Devem ser precedidas do nome com-pleto quando citadas pela primeira vez no texto ou nas legendasdas tabelas e figuras.

Se as ilustrações já tiverem sido publicadas, deverão vir acom-panhadas de autorização por escrito do autor ou editor, constan-do a fonte de referência onde foi publicada.

O texto deve ser impresso em computador, em espaço duplo,papel branco, no formato 210mm x 297mm ou A4, em páginasseparadas e numeradas, com margens de 3cm e com letras detamanho que facilite a leitura (recomendamos as de nº 14). Ooriginal deve ser encaminhado em uma via, acompanhado deCD, com versão do manuscrito, com respectivas ilustrações,digitado no programa “Word for Windows 6.0.

A Revista Brasileira de Oftalmologia reserva o direito de nãoaceitar para avaliação os artigos que não preencham os critériosacima formulados.

Versão português-inglês: Seguindo os padrões dosprincipais periódicos mundiais, a Revista Brasileira de Oftalmologiacontará com uma versão eletrônica em inglês de todas as edições.Desta forma a revista impressa continuará a ser em português e aversão eletrônica será em inglês.

A Sociedade Brasileira de Oftalmologia, Sociedade Brasileirade Catarata e Implantes Intraoculares e Sociedade Brasileira deCirurgia Refrativa, se comprometem a custear a tradução dosartigos para língua inglesa, porém seus autores uma vez quetenham aprovado seus artigos se disponham a traduzir a versãofinal para o inglês, está será publicada na versão eletrônicaantecipadamente a publicação impressa (ahead of print).

* Nota importante: A “Revista Brasileira de Oftalmologia”em apoio às políticas para registro de ensaios clínicos daOrganização Mundial de Saúde (OMS) e do IntemationalCommittee of Medical Joumal Editors (ICMJE), reconhecendo aimportância dessas iniciativas para o registro e divulgaçãointernacional de informação sobre estudos clínicos, em acessosomente aceitará para publicação, a partir de 2008, os artigosde pesquisas clínicas que tenham recebido um número deidentificação em um dos Registros de Ensaios Clínicos validadospelos critérios estabelecidos pela OMS e ICMJE, disponível noendereço: http://clinicaltrials.gov ou no site do Pubmed, no item<ClinicalTrials.gov>.

O número de identificação deverá ser registrado abaixo doresumo.

Os trabalhos poderão ser submetidos pela Internet, pelo site -rbo.emnuvens.com.br



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Declaração dos Autores (é necessária a assinatura de todos os autores)

Em consideração ao fato de que a Sociedade Brasileira de Oftalmologia está interessada em editar o manuscrito a ela

encaminhado pelo(s) o(s) autor(es) abaixo subscrito(s), transfere(m) a partir da presente data todos os direitos autorais para a

Sociedade Brasileira de Oftalmologia em caso de publicação pela Revista Brasileira de Oftalmologia do manuscri-

to............................................................. . Os direitos autorais compreendem qualquer e todas as formas de publicação, tais como na

mídia eletrônica, por exemplo. O(s) autor (es) declara (m) que o manuscrito não contém, até onde é de conhecimento do(s)

mesmo(s), nenhum material difamatório ou ilegal, que infrinja a legislação brasileira de direitos autorais.

Certificam que, dentro da área de especialidade, participaram cientemente deste estudo para assumir a responsabilidade por

ele e aceitar suas conclusões.

Certificam que, com a presente carta, descartam qualquer possível conflito financeiro ou de interesse que possa ter com o

assunto tratado nesse manuscrito.

Título do Manuscrito___________________________________________________________________________

Nome dos Autores_______________________________________________________________________________

_____________________________________________________________________________________________

Minha assinatura abaixo indica minha total concordância com as três declarações acima.

Data____________Assinatura do Autor____________________________________________________________


Data____________Assinatura do Autor_____________________________________________________________





Oftalmologia

Rev Bras Oftalmol. 2015; 74 (3): 196


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