Long ciliary processes with no ciliary sulcus and appositional angle closure assessed by ultrasound biomicroscopy.

PURPOSE: Nonpupil block mechanisms and appositional angle closure after laser iridotomy (LI) have been reported as common findings in Asians. We evaluated the presence of these findings in a cohort of Brazilian patients using ultrasound biomicroscopy (UBM). METHODS: This observational case-control study included 22 open angle eyes and 31 eyes with occludable angles on gonioscopy (defined by 2 examiners). UBM radial scans through a typical ciliary process were obtained in both light and dark conditions, at 6 and 12-o'clock positions. Long ciliary processes with no ciliary sulcus were determined on the basis of a reference line drawn perpendicular to the iris plane passing through a point located 750 mum from scleral spur. Trabecular ciliary processes distance was measured on 6-o'clock UBM images. RESULTS: After LI, 52% of occludable angle eyes had appositional angle closure in both 6 and 12-o'clock UBM images. We also observed this finding in 14% and 23% of the control eyes (in 6 and 12-o'clock UBM images, respectively). A long ciliary process with no ciliary sulcus was observed in 61% of occludable angle eyes, and also in 32% of control eyes (6-o'clock UBM images). Control eyes had longer trabecular ciliary processes distance than occludable angle eyes (P<0.001). CONCLUSIONS: The UBM finding of long ciliary processes associated with the absence of ciliary sulcus is not necessarily related to an anterior positioning of the ciliary processes. Whether UBM appositional angle closure after LI is associated with further angle closure process and/or poor intra-ocular pressure control remains to be evaluated.

Use of amniotic membrane in trabeculectomy for the treatment of glaucoma: a pilot study.

PURPOSE: To compare the safety and efficacy of human preserved amniotic membrane (AM) in the trabeculectomy for treatment of primary open-angle glaucoma. METHODS: A prospective, randomized clinical trial compared primary trabeculectomy with amniotic membrane (study group) and without amniotic membrane (control group) in the treatment of the glaucoma. Intraocular pressure (IOP), number of glaucoma medications and appearance of the bleb were compared between the two groups. Thirty-two patients divided into two groups of 16 patients were followed for a period of 12 months. RESULTS: The difference of the mean postoperative intraocular pressure between groups was not statistically significant (15.19 +/- 3.33 in the control group and 12.81 +/- 2.48 in the study group p=0.297) at one year follow-up. Postoperative number of medications decreased in both groups (p<0.001 and p=0.007, study group and control respectively). At the end of a 12-month follow-up period, nine eyes (56.25%) showed thin, avascular blebs in the study group as compared to only one eye (6.25%) in the control group. CONCLUSIONS: Trabeculectomy with amniotic membrane and standard trabeculectomy promote lower postoperative intraocular pressure although results showed no statistically significant difference between groups regarding postoperative intraocular pressure after one year follow-up.

Correlation between genotype and phenotype in primary open angle glaucoma of Brazilian families with mutations in exon 3 of the TIGR/MYOC gene.

PURPOSE: To investigate the phenotype of primary open-angle glaucoma (POAG) in Brazilian families with mutation in exon 3 of TIGR/MYOC. METHODS: Seventy-eight POAG patients with a positive family history and eighteen unrelated patients with POAG were screened by automated DNA sequencing for mutations in exon 3 of the TIGR/MYOC gene. The pedigrees of POAG patients with mutations that lead to amino acid change were built. All available relatives of the index cases were also examined and genotyped by sequencing. RESULTS: Four sequence variants were identified in exon 3 of the TIGR/MYOC gene (Tyr347Tyr, Pro370Pro, Lys398Arg and Cys433Arg) from the 96 initially screened patients. The Lys398Arg mutation was previously described as a polymorphism and in our study did not segregate with POAG. The most prevalent mutation was Cys433Arg, affecting 3 index cases (3.1% or 3/96). In two different families, 8/56 subjects presented Cys433Arg mutation and had POAG, 5/56 had ocular hypertension and 8/56 had no disease manifestation. POAG patients had a median age at diagnosis of 43.25 yr (17-58 yr) and intraocular pressure (IOP) with a mean of 36.3 +/- 3.8mmHg for the right eye and 37.6 +/- 9.75 mmHg for the left eye. The group of patients with Cys433Arg mutation had significantly higher IOP (p<0.0007) and vertical cup/disc ratio when compared to the patients without mutation (p<0.023). CONCLUSIONS: Cys433Arg mutation in exon 3 of the TIGR/MYOC gene is related to juvenile-onset POAG (J-POAG) in Brazilian families and autosomal dominant inheritance. The phenotype of this mutation is characterized by varied ages at diagnosis, causing J-POAG and late-onset POAG, associated with high IOP.

The prevalence of ocular surface complaints in Brazilian patients with glaucoma or ocular hypertension.

PURPOSE: To examine the prevalence of ocular surface complaints in Brazilian patients with glaucoma or ocular hypertension who used topical intraocular pressure (IOP)-lowering regimens. METHODS: In this multicenter, noninterventional, single-visit study, adults with glaucoma or ocular hypertension treated with an IOP-lowering regimen were administered the 12-item ocular surface disease index (OSDI) questionnaire. Each response was scored on a 5-point scale, with 0 indicating symptom present none of the time and 4 indicating symptom present all of the time. The average of the 12 item responses for each patient was transformed to a scale from 0 to 100, with higher scores representing worse disabilities. OSDI results then were categorized as absence of OSD (scores of 0-12), mild OSD (scores of 13-22), moderate OSD (scores of 23-32), or severe OSD (scores of 33100). RESULTS: The 173 enrolled patients had a mean age of 61.2 years, were women in 65.3% of cases, and had glaucoma in 89.0% of cases and ocular hypertension in 11.0% of cases. OSDI scores for 158 patients using 1 IOP-lowering therapy indicated no OSD in 37.3% of patients (59/158), mild OSD in 20.9% (33/158), moderate OSD in 17.1% (27/158), and severe OSD in 24.7% (39/158). For the 120 patients using 1 IOP-lowering medication and having a known duration of diagnosis of glaucoma or ocular hypertension, mean OSDI scores were numerically higher (worse) for the 39 patients with a diagnosis ≥6 years long (score 25 [± 20], indicating moderate OSD) than for the 81 patients with a diagnosis lasting <6 years (score 22 [± 20], indicating mild OSD); however, no significant differences in OSDI scores by duration of diagnosis were evident in means (P=0.49), distributions (P≥0.26), or correlation (P=0.77). CONCLUSIONS: A large proportion of Brazilian patients treated with 1 IOP-lowering therapy had some ocular surface complaints.

Nerve fiber layer in glaucomatous hemifield loss: a case-control study with time- and spectral-domain optical coherence tomography.

PURPOSE: To evaluate the retinal nerve fiber layer measurements with time-domain (TD) and spectral-domain (SD) optical coherence tomography (OCT), and to test the diagnostic ability of both technologies in glaucomatous patients with asymmetric visual hemifield loss. METHODS: 36 patients with primary open-angle glaucoma with visual field loss in one hemifield (affected) and absent loss in the other (non-affected), and 36 age-matched healthy controls had the study eye imaged with Stratus-OCT (Carl Zeiss Meditec Inc., Dublin, California, USA) and 3 D OCT-1000 (Topcon, Tokyo, Japan). Peripapillary retinal nerve fiber layer measurements and normative classification were recorded. Total deviation values were averaged in each hemifield (hemifield mean deviation) for each subject. Visual field and retinal nerve fiber layer "asymmetry indexes" were calculated as the ratio between affected versus non-affected hemifields and corresponding hemiretinas. RESULTS: Retinal nerve fiber layer measurements in non-affected hemifields (mean [SD] 87.0 [17.1] µm and 84.3 [20.2] µm, for TD and SD-OCT, respectively) were thinner than in controls (119.0 [12.2] µm and 117.0 [17.7] µm, P<0.001). The optical coherence tomography normative database classified 42% and 67% of hemiretinas corresponding to non-affected hemifields as abnormal in TD and SD-OCT, respectively (P=0.01). Retinal nerve fiber layer measurements were consistently thicker with TD compared to SD-OCT. Retinal nerve fiber layer thickness asymmetry index was similar in TD (0.76 [0.17]) and SD-OCT (0.79 [0.12]) and significantly greater than the visual field asymmetry index (0.36 [0.20], P<0.001). CONCLUSIONS: Normal hemifields of glaucoma patients had thinner retinal nerve fiber layer than healthy eyes, as measured by TD and SD-OCT. Retinal nerve fiber layer measurements were thicker with TD than SD-OCT. SD-OCT detected abnormal retinal nerve fiber layer thickness more often than TD-OCT.

Bilateral nonarteritic anterior ischemic neuropathy following acute angle-closure glaucoma in a patient with iridoschisis: case report.

A 55-year-old woman was referred to our clinic because of a one-week history of visual loss and raised intraocular pressure in the left eye followed 4 days later by visual loss in the right eye. Slit-lamp examination showed bilateral conjunctival hyperemia, slight diffuse corneal edema, shallow anterior chamber and fixed and dilated pupil in both eyes. Splitting of the anterior layers of the iris with fibrillar degeneration extending for approximately one quadrant inferiorly was presented in each eye. Fundus examination showed optic disc edema with no vascular tortuosity and no cup in both eyes. The condition was treated as bilateral acute angle-closure glaucoma in a patient with irisdoschisis. After medical treatment and improvement of visual acuity, perimetry revealed a significant visual field defect especially in left eye; this case represents a rare concurrence of acute angle-closure glaucoma and bilateral nonarteritic ischemic optic neuropathy. Although most cases of elevated intraocular pressure, including acute angle-closure glaucoma, do not result in optic disc edema and irreversible vision loss, variations in the vascular supply of the nerve optic head along with others ocular systemic risk factors, may predispose certain individuals to nonarteritic ischemic optic neuropathy during periods of elevated intraocular pressure.

Relationship between visual field sensitivity loss and quadrantic macular thickness measured with Stratus-Optical coherence tomography in patients with chiasmal syndrome.

PURPOSE: To correlate visual field sensitivity (VFS) loss on standard automated perimetry (SAP) and quadrantic macular thickness on optical coherence tomography (OCT) in patients with permanent temporal hemianopia from chiasmal compression. METHODS: Forty eyes from 40 patients with chiasmal compression and 40 healthy eyes were submitted to standard automated perimetry and Stratus-OCT scanning. Raw data of the fast macular thickness scanning protocol were exported and macular thickness measurements were recorded and averaged for each quadrant and half of the central area. The correlation between visual field sensitivity loss and optical coherence tomography measurements was tested with Pearson's correlation coefficients and with linear regression analysis. RESULTS: A significant association was found between each macular thickness parameter and the corresponding central VF mean sensitivity. The strongest association was observed between superonasal macular thickness and the inferotemporal mean defect measured both in decibel (R=0.47; p=0.001) and in 1/Lambert (R=0.59; p<0.0001) units. CONCLUSION: Stratus-OCT-measured macular thickness was topographically related with visual field sensitivity loss in patients with temporal hemianopia from chiasmal compression. Such measurements could prove clinically useful in the diagnosis and follow-up of patients with chiasmal compression. ClinicalTrial.gov identifier number: NCT0039122.

Intracameral bevacizumab and mitomycin C Trabeculectomy for eyes with neovascular glaucoma: a case series.

The purpose of this study was to describe the surgical outcomes and safety of intracameral bevacizumab during trabeculectomy in eyes with neovascular glaucoma. Pilot study included four eyes (four patients) with refractory neovascular glaucoma submitted to fornix-based trabeculectomy with adjunctive use of bevacizumab in the anterior chamber during the procedure. Patients were previously treated with panretinal photocoagulation as standard therapy. Variables evaluated were intraocular pressure, bleb appearance, iris neovascularization, intraoperative/postoperative complications, and visual outcomes. No intraoperative complication was observed. The mean follow-up period was 12.75 (range, 12-15 months). All eyes showed significant intraocular pressure control postoperatively. Iris neovascularization reduced significantly within 1 month after surgery. Mild anterior chamber inflammation was observed during follow-up in all eyes. No significant postoperative complication was observed, and no patient presented visual acuity deterioration. Intracameral bevacizumab may be used as an adjunctive therapy during trabeculectomy in eyes with neovascular glaucoma.

Comparison between retinal nerve fiber layer and macular thickness measured with OCT detecting progressive axonal loss following traumatic optic neuropathy.

PURPOSE: To compare the optical coherence tomography retinal nerve fiber layer and macular thickness measurements for detection of progressive axonal loss following acute traumatic optic neuropathy in a longitudinal study. METHODS: Three patients with unilateral traumatic optic neuropathy were evaluated sequentially after trauma. Macular and retinal nerve fiber layer thickness measurements were obtained using optical coherence tomography weekly for five weeks and around the twelfth week after trauma. RESULTS: All patients showed progressive macular and retinal nerve fiber layer thickness reduction. The mean retinal nerve fiber layer thickness on the first week was 114 microm and reduced sequentially over the first five weeks and was 46 microm on the twelfth week. For macular parameters, the mean average thickness on the first week was 248 microm and also reduced over the first five weeks and was 218 microm on the twelfth week. When compared to the initial measurement, macular thickness average reduction rate at the 12th week was 14% while peripapillary retinal nerve fiber layer thickness average reduction rate was 59%. CONCLUSIONS: Although both measurements reduce significantly after trauma, retinal nerve fiber layer thickness measurements show greater and faster retinal neural reduction if compared to macular thickness measurements in traumatic optic neuropathy.

Hipertensão venosa episcleral idiopática unilateral em mulher jovem / Unilateral idiopathic elevated episcleral venous pressure in a young woman

O objetivo é relatar o caso de uma paciente de 33 anos, que veio ao Pronto Socorro de Oftalmologia apresentando queixa de redução da acuidade visual à esquerda, de caráter insidioso e progressivo, há dois anos. Ao exame oftalmológico, apresentava ingurgitamento dos vasos da conjuntiva bulbar, pressão intraocular muito elevada e nervo óptico com escavação total à esquerda. Foi submetida à campimetria computadorizada 24:2 WW e SITA-SWAP do olho direito, ambas com resultados dentro da normalidade. As tomografias de crânio e órbitas, bem como ultrassonografia com doppler do globo ocular, artérias oftálmicas e veias supraorbitárias não apresentavam anormalidades. Diante disso, aventou-se a hipótese diagnóstica de hipertensão venosa episcleral idiopática, um diagnóstico de exclusão, visto que patologias intracranianas e intraorbitárias haviam sido excluídas. Paciente foi tratada clinicamente com colírios hipotensores, com redução importante da pressão intraocular à esquerda, porém não o suficiente, evoluindo para trabeculectomia.

The objective is to report a 33 year old female who came to the emergency room of Ophthalmology complaining of reduced visual acuity on the left eye, in a progressive and insidious way, about two years ago. In the ophthalmological examination, she presented dilated tortuous vessels in her left bulbar conjunctiva, very high intraocular pressure and increased cupping of the optic disc. SITA-SWAP and 24:2 computed perimetry were performed on the right eye, both within normal limits. CT scans of the skull and orbits, and ultrasonography of the eyeball and doppler of the ophthalmic artery and the supra-orbital veins had no abnormalities. Thus, it was suggested the possibility of idiopathic elevated episcleral venous pressure, an exclusion diagnosis, since intra-cranial and intraorbital pathologies were excluded. The patient was treated medically with hypotensive eyedrops, with significant reduction of intraocular pressure on the left eye, but not enough, evolving to trabeculectomy.

The prevalence of ocular surface complaints in Brazilian patients with glaucoma or ocular hypertension / Prevalência de sintomas da doença da superfície ocular em pacientes brasileiros com glaucoma ou hipertensão ocular

PURPOSE: To examine the prevalence of ocular surface complaints in Brazilian patients with glaucoma or ocular hypertension who used topical intraocular pressure (IOP)-lowering regimens. METHODS: In this multicenter, noninterventional, single-visit study, adults with glaucoma or ocular hypertension treated with an IOP-lowering regimen were administered the 12-item ocular surface disease index (OSDI) questionnaire. Each response was scored on a 5-point scale, with 0 indicating symptom present none of the time and 4 indicating symptom present all of the time. The average of the 12 item responses for each patient was transformed to a scale from 0 to 100, with higher scores representing worse disabilities. OSDI results then were categorized as absence of OSD (scores of 0-12), mild OSD (scores of 13-22), moderate OSD (scores of 23-32), or severe OSD (scores of 33100). RESULTS: The 173 enrolled patients had a mean age of 61.2 years, were women in 65.3% of cases, and had glaucoma in 89.0% of cases and ocular hypertension in 11.0% of cases. OSDI scores for 158 patients using 1 IOP-lowering therapy indicated no OSD in 37.3% of patients (59/158), mild OSD in 20.9% (33/158), moderate OSD in 17.1% (27/158), and severe OSD in 24.7% (39/158). For the 120 patients using 1 IOP-lowering medication and having a known duration of diagnosis of glaucoma or ocular hypertension, mean OSDI scores were numerically higher (worse) for the 39 patients with a diagnosis ≥6 years long (score 25 [± 20], indicating moderate OSD) than for the 81 patients with a diagnosis lasting <6 years (score 22 [± 20], indicating mild OSD); however, no significant differences in OSDI scores by duration of diagnosis were evident in means (P=0.49), distributions (P≥0.26), or correlation (P=0.77). CONCLUSIONS: A large proportion of Brazilian patients treated with 1 IOP-lowering therapy had some ocular surface complaints.

OBJETIVO: Avaliar a prevalência de sintomas decorrentes de doença de superfície ocular (DSO) em pacientes brasileiros com glaucoma ou hipertensão ocular que utilizam tratamento ocular tópico para redução da pressão intraocular (PIO). MÉTODO: Neste estudo multicêntrico, não intervencional de uma única visita, pacientes adultos com glaucoma ou hipertensão ocular em tratamento para redução da pressão intraocular (PIO) responderam aos 12 itens do questionário "índice de doença da superfície ocular" (OSDI). Cada resposta foi pontuada numa escala de 5 pontos, com 0 (zero) indicando a ausência de sintomas e 4 indicando sintomas presentes todo o tempo. A média de respostas dos 12 itens para cada paciente foi transformada numa escala de 0 a 100, com pontuações mais elevadas representando piores deficiências. Os resultados do OSDI foram categorizados como ausência de DSO (pontuação de 0-12), DSO leve (pontuação de 13-22), DSO moderada (pontuação de 23-32) ou DSO grave (pontuação de 33-100). RESULTADOS: Os 173 pacientes incluídos apresentavam idade média de 61,2 anos, 65,3% eram mulheres (65,3%), tinham glaucoma em 89,0% dos casos e hipertensão ocular em 11,0% dos casos. As pontuações do OSDI para os 158 pacientes utilizando uma medicação para redução da PIO indicaram "DSO ausente" em 37,3% dos pacientes (59/158), "DSO leve" em 20,9% (33/158), "DSO moderada" em 17,1% (27/158) e "DSO grave" em 24,7% (39/158). Para os 120 pacientes utilizando medicação redutora da PIO e com duração conhecida do diagnóstico de glaucoma ou hipertensão ocular, a pontuação média do OSDI foi numericamente superior (pior) para 39 pacientes com diagnóstico realizado há mais de 6 anos (pontuação 25 [± 20] indicando DSO moderado) do que para 81 pacientes com o diagnóstico realizado há menos de 6 anos (pontuação 22 [± 20] indicando DSO leve); no entanto, não houve diferença estatisticamente significativa na média da pontuação OSDI na duração do diagnóstico (P=0.49), distribuição (P≥0,26), ou correlação (P=0,77). CONCLUSÃO: Uma grande proporção de pacientes brasileiros tratados com uma medicação para redução da PIO apresenta sintomas decorrentes de doença da superfície ocular (DSO).

Nerve fiber layer in glaucomatous hemifield loss: a case-control study with time- and spectral-domain optical coherence tomography / Camada de fibras nervosas na perda de hemicampo glaucomatoso: um estudo caso-controle com tomografia de coerência óptica time- e spectral-domain

PURPOSE: To evaluate the retinal nerve fiber layer measurements with time-domain (TD) and spectral-domain (SD) optical coherence tomography (OCT), and to test the diagnostic ability of both technologies in glaucomatous patients with asymmetric visual hemifield loss. METHODS: 36 patients with primary open-angle glaucoma with visual field loss in one hemifield (affected) and absent loss in the other (non-affected), and 36 age-matched healthy controls had the study eye imaged with Stratus-OCT (Carl Zeiss Meditec Inc., Dublin, California, USA) and 3 D OCT-1000 (Topcon, Tokyo, Japan). Peripapillary retinal nerve fiber layer measurements and normative classification were recorded. Total deviation values were averaged in each hemifield (hemifield mean deviation) for each subject. Visual field and retinal nerve fiber layer "asymmetry indexes" were calculated as the ratio between affected versus non-affected hemifields and corresponding hemiretinas. RESULTS: Retinal nerve fiber layer measurements in non-affected hemifields (mean [SD] 87.0 [17.1] µm and 84.3 [20.2] µm, for TD and SD-OCT, respectively) were thinner than in controls (119.0 [12.2] µm and 117.0 [17.7] µm, P<0.001). The optical coherence tomography normative database classified 42% and 67% of hemiretinas corresponding to non-affected hemifields as abnormal in TD and SD-OCT, respectively (P=0.01). Retinal nerve fiber layer measurements were consistently thicker with TD compared to SD-OCT. Retinal nerve fiber layer thickness asymmetry index was similar in TD (0.76 [0.17]) and SD-OCT (0.79 [0.12]) and significantly greater than the visual field asymmetry index (0.36 [0.20], P<0.001). CONCLUSIONS: Normal hemifields of glaucoma patients had thinner retinal nerve fiber layer than healthy eyes, as measured by TD and SD-OCT. Retinal nerve fiber layer measurements were thicker with TD than SD-OCT. SD-OCT detected abnormal retinal nerve fiber layer thickness more often than TD-OCT.

OBJETIVO: Avaliar as medidas da camada de fibras nervosas da retina com a tomografia de coerência óptica (OCT) "time domain" (TD) e "spectral domain" (SD), e testar a habilidade diagnóstica de ambas as tecnologias em pacientes com perda assimétrica glaucomatosa de hemicampo visual. MÉTODOS: Trinta e seis pacientes com glaucoma primário de ângulo aberto com perda de campo visual em um hemicampo (acometido) e ausência de perda no hemicampo oposto (não-acometido), e 36 controles pareados por idade tiveram o olho de estudo examinado com Stratus-OCT (Carl Zeiss Meditec Inc., Dublin, California, USA) e 3 D OCT-1000 (Topcon, Tokyo, Japan). As medidas de espessura da camada de fibras nervosas da retina peripapilar e classificação normativa fornecida pelos aparelhos foram registrados para análise. A média aritmética dos valores do gráfico de desvio total em cada hemicampo foi calculada para cada indivíduo. "Índices de assimetria" para campo visual e camada de fibras nervosas da retina foram calculados como a razão entre hemicampos acometido e não-acometido e hemirretinas correspondentes, respectivamente. RESULTADOS: As medidas da camada de fibras nervosas da retina em hemicampos não-acometidos (média [SD] 87.0 [17.1] µm e 84.3 [20.2] µm, para TD e SD-OCT, respectivamente) foram menores do que em controles (119.0 [12.2] µm e 117.0 [17.7] µm, P<0.001). O banco de dados normativo classificou como alterado 42% e 67% das hemirretinas correspondentes a hemicampos não-acometidos com TD e SD-OCT, respectivamente (P=0.01). As medidas da camada de fibras nervosas da retina foram consistentemente mais espessas com TD comparados com SD-OCT. Índices de assimetria da camada de fibras nervosas da retina foram semelhantes entre TD (0.76 [0.17]) e SD-OCT (0.79 [0.12]) e significantemente maiores do que o índice de assimetria do campo visual (0.36 [0.20], P<0.001). CONCLUSÃO: Os hemicampos normais de pacientes com glaucoma apresentaram camada de fibras nervosas da retina mais fina do que olhos saudáveis. As medidas da camada de fibras nervosas da retina foram mais espessas com TD do que com SD-OCT, que por sua vez detectou anormalidades na espessura da camada de fibras nervosas da retina mais frequentemente do que o TD-OCT.

Bilateral nonarteritic anterior ischemic neuropathy following acute angle-closure glaucoma in a patient with iridoschisis: case report / Neuropatia óptica isquêmica anterior não arterítica bilateral após crise de fechamento angular num paciente com iridosquise: relato de caso

A 55-year-old woman was referred to our clinic because of a one-week history of visual loss and raised intraocular pressure in the left eye followed 4 days later by visual loss in the right eye. Slit-lamp examination showed bilateral conjunctival hyperemia, slight diffuse corneal edema, shallow anterior chamber and fixed and dilated pupil in both eyes. Splitting of the anterior layers of the iris with fibrillar degeneration extending for approximately one quadrant inferiorly was presented in each eye. Fundus examination showed opitc disc edema with no vascular tortuosity and no cup in both eyes. The condition was treated as bilateral acute angle-closure glaucoma in a patient with irisdoschisis. After medical treatment and improvement of visual acuity, perimetry revealed a significant visual field defect especially in left eye; this case represents a rare concurrence of acute angle-closure glaucoma and bilateral nonarteritic ischemic optic neuropathy. Although most cases of elevated intraocular pressure, including acute angle-closure glaucoma, do not result in optic disc edema and irreversible vision loss, variations in the vascular supply of the nerve optic head along with others ocular systemic risk factors, may predispose certain individuals to nonarteritic ischemic optic neuropathy during periods of elevated intraocular pressure.

Paciente de 55 anos, sexo feminino, encaminhada para nosso serviço com história de perda de visão e aumento da pressão intraocular no olho esquerdo há uma semana seguida quatro dias após de perda visual no olho direito. À biomicroscopia hiperemia conjuntival bilateral, edema difuso da córnea, câmara anterior rasa e pupilas fixas e dilatadas em ambos os olhos. Separação do folheto anterior da íris no quadrante inferior estava presente em ambos os olhos. O exame do fundo do olho mostrava edema de disco sem tortuosidade vascular e sem escavação em ambos os olhos. O quadro clínico foi tratado como crise de fechamento angular bilateral num paciente com iridosquise. Após tratamento clínico e iridotomia bilateral com melhora da acuidade visual, a perimetria computadorizada revelou grave perda de campo visual, especialmente no olho esquerdo; este caso representa a rara ocorrência simultânea de crise de fechamento angular e neuropatia óptica isquêmica anterior não-arterítica bilateral. Embora a maioria dos casos com pressão intraocular elevada, incluindo crise de fechamento angular, não resulta em edema de disco e perda visual irreverssível, variações no suprimento vascular da cabeça do nervo óptico associados com outros fatores de risco sistêmicos, podem predispor certos indivíduos à neuropatia óptica isquêmica anterior durante períodos de elevação da pressão intraocular.

Relationship between visual field sensitivity loss and quadrantic macular thickness measured with Stratus-Optical coherence tomography in patients with chiasmal syndrome / Correlação entre defeito de campo visual e espessura macular quadrântica avaliada através da tomografia de coerência óptica em pacientes com compressão quiasmática

PURPOSE: To correlate visual field sensitivity (VFS) loss on standard automated perimetry (SAP) and quadrantic macular thickness on optical coherence tomography (OCT) in patients with permanent temporal hemianopia from chiasmal compression. METHODS: Forty eyes from 40 patients with chiasmal compression and 40 healthy eyes were submitted to standard automated perimetry and Stratus-OCT scanning. Raw data of the fast macular thickness scanning protocol were exported and macular thickness measurements were recorded and averaged for each quadrant and half of the central area. The correlation between visual field sensitivity loss and optical coherence tomography measurements was tested with Pearson's correlation coefficients and with linear regression analysis. RESULTS: A significant association was found between each macular thickness parameter and the corresponding central VF mean sensitivity. The strongest association was observed between superonasal macular thickness and the inferotemporal mean defect measured both in decibel (R=0.47; p=0.001) and in 1/Lambert (R=0.59; p<0.0001) units. CONCLUSION: Stratus-OCT-measured macular thickness was topographically related with visual field sensitivity loss in patients with temporal hemianopia from chiasmal compression. Such measurements could prove clinically useful in the diagnosis and follow-up of patients with chiasmal compression. ClinicalTrial.gov identifier number: NCT0039122.

OBJETIVO: Avaliar a correlação entre o defeito de campo visual ao exame de perimetria computadorizada e a espessura macular quadrântica ao exame de tomografia de coerência óptica (OCT) em pacientes com hemianopsia temporal permanente causada por compressão quiasmática. MÉTODOS: Quarenta olhos de 40 pacientes com compressão quiasmática e 40 olhos de 40 indivíduos controles foram submetidos aos exames de perimetria computadorizada e tomografia de coerência óptica. Dados não processados foram exportados e as medidas de espessura macular foram calculadas para cada quadrante e metade da área macular central. A correlação entre o defeito campimétrico e as medidas de espessura macular foi avaliada por coeficiente de correlação de Pearson e por análise de regressão linear. RESULTADOS: Associação significante foi encontrada entre os parâmetros de espessura macular e seus respectivos defeitos campimétricos. A correlação mais forte foi encontrada entre o parâmetro espessura macular nasal superior e o defeito campimétrico médio temporal inferior medido em decibel (R=0,47; p=0,001) e em 1/Lambert (R=0,59; p<0,0001). CONCLUSÃO: Medidas de espessura macular avaliada através da tomografia de coerência óptica foi topograficamente relacionada ao defeito campimétrico em pacientes com hemianopsia temporal por compressão quiasmática. Estas medidas podem provar a importância clínica no diagnóstico e seguimento dos pacientes com compressão quiasmática. ClinicalTrial.gov identifier number: NCT0039122.

Comparison between retinal nerve fiber layer and macular thickness measured with OCT detecting progressive axonal loss following traumatic optic neuropathy / Comparação entre as medidas da espessura da camada de fibras nervosas da retina e da mácula pela tomografia de coerência óptica na detecção da perda axonal progressiva decorrente à neuropatia óptica traumática

PURPOSE: To compare the optical coherence tomography retinal nerve fiber layer and macular thickness measurements for detection of progressive axonal loss following acute traumatic optic neuropathy in a longitudinal study. METHODS: Three patients with unilateral traumatic optic neuropathy were evaluated sequentially after trauma. Macular and retinal nerve fiber layer thickness measurements were obtained using optical coherence tomography weekly for five weeks and around the twelfth week after trauma. RESULTS: All patients showed progressive macular and retinal nerve fiber layer thickness reduction. The mean retinal nerve fiber layer thickness on the first week was 114 μm and reduced sequentially over the first five weeks and was 46 μm on the twelfth week. For macular parameters, the mean average thickness on the first week was 248 μm and also reduced over the first five weeks and was 218 μm on the twelfth week. When compared to the initial measurement, macular thickness average reduction rate at the 12th week was 14 percent while peripapillary retinal nerve fiber layer thickness average reduction rate was 59 percent. CONCLUSIONS: Although both measurements reduce significantly after trauma, retinal nerve fiber layer thickness measurements show greater and faster retinal neural reduction if compared to macular thickness measurements in traumatic optic neuropathy.

OBJETIVO: Comparar as medidas da espessura da camada de fibras nervosas da retina e macular obtidas pela tomografia de coerência óptica na detecção da perda axonal progressiva após neuropatia óptica traumática aguda e durante o seguimento clínico. MÉTODOS: Três pacientes com neuropatia óptica traumática unilateral aguda foram avaliados sequencialmente após o trauma. Medidas da espessura macular e da camada de fibras nervosas da retina foram obtidas pela tomografia de coerência óptica semanalmente por 5 semanas consecutivas e ao redor da décima segunda semana após o trauma. RESULTADOS: Todos os pacientes apresentaram redução progressiva dos valores da espessura macular e da camada de fibras nervosas da retina. A espessura média da camada de fibras nervosas da retina foi de 114 μm na primeira semana e reduziu sequencialmente ao longo das primeiras cinco semanas e foi de 46 μm na décima segunda semana. Para parâmetros macular, a espessura média foi de 248 μm na primeira semana, e também reduziu ao longo das primeiras cinco semanas e foi de 218 μm na décima segunda semana. Quando comparado às medidas iniciais, a taxa de redução das médias da espessura macular foi 14 por cento na décima segunda semana após o trauma, enquanto que a taxa de redução das médias da espessura da camada de fibras nervosas da retina foi 59 por cento. CONCLUSÕES: Os valores da espessura da camada de fibras nervosas da retina apresentaram uma redução maior e mais rápida se comparada às medidas da espessura macular na neuropatia óptica traumática.

Correlation between genotype and phenotype in primary open angle glaucoma of Brazilian families with mutations in exon 3 of the TIGR/MYOC gene

OBJETIVO: Identificar nos representantes de famílias com glaucoma primário de ângulo aberto (GPAA) mutações no exon 3 do gene TIGR/MYOC e avaliar a expressão fenotípica associada às mutações encontradas em seus respectivos núcleos familiares. MÉTODOS: Setenta e oito pacientes (81,2%), com pelo menos um representante na família com GPAA, e dezoito pacientes (18,7%) com glaucoma esporádico tiveram o exon 3, do gene TIGR/MYOC, submetido a seqüenciamento automático para identificação de mutações. Os pacientes, com mutação não silenciosa identificadas nesta triagem inicial, tiveram os heredogramas de suas famílias construídos. Todos os seus familiares disponíveis foram submetidos a exame oftalmológico e seqüenciamento automático do exon 3, do gene TIGR/MYOC.RESULTADOS: Foram identificados quatro tipos de variações na seqüência do exon 3 do TIGR/MYOC (Cys433Arg, Pro370Pro, Lys398Arg e Tyr347Tyr) nos 96 pacientes inicialmente estudados. A mutação Lys398Arg previamente descrita como polimorfismo não segregou com a doença na família estudada. A mutação Cys433Arg foi a mais prevalente afetando 3,1% da amostra inicial (3/96). Em duas diferentes famílias (56 integrantes disponíveis para exame), 8/56 carregavam a mutação Cys433Arg e tinham GPAA, 5/56 com mutação eram hipertensos oculares e 8/56 com mutação não apresentavam manifestações da doença. Pacientes com GPAA apresentaram mediana de idade de diagnóstico de 43,25 anos, variando entre 17-58, e média de pressão intra-ocular (PIO) de 36,3±3,8 mmHg para olho direito e 37,6±9,75 mmHg para olho esquerdo. O grupo com a mutação Cys433Arg apresentou PIO significantemente mais elevada (p<0,0007) e relação escavação/disco vertical mais comprometida (p<0,023) que o grupo de pacientes sem mutação.CONCLUSÃO: A mutação no exon 3 do gene TIGR/MYOC associa-se com famílias brasileiras portadoras de GPAA de início precoce. O fenótipo desta mutação é caracterizado por variável idade de diagnóstico, causando GPAA-juvenil e GPAA do adulto, PIO bastante elevada, de difícil controle, freqüentemente levando a grave comprometimento visual.

Use of amniotic membrane in trabeculectomy for the treatment of glaucoma: a pilot study

OBJETIVO: Comparar a eficácia e a segurança do uso da membrana amniótica (MA) na trabeculectomia para o tratamento cirúrgico do glaucoma primário de ângulo aberto. MÉTODOS: Estudo prospectivo aberto, randomizado, grupos paralelos de tratamento. Trinta e dois pacientes com indicação de tratamento cirúrgico para glaucoma foram selecionados e aleatoriamente divididos em dois grupos. O primeiro grupo foi submetido a trabeculectomia com o uso intra-operatório da membrana amniótica (grupo estudo) e o segundo grupo foi submetido a trabeculectomia sem o uso da membrana amniótica (grupo controle) comparando o efeito redutor da pressão intra-ocular, número de medicações e aparência da bolha filtrante. Trinta e dois pacientes divididos em dois grupos de 16 pacientes foram acompanhados por 12 meses. RESULTADOS: A média das pressões pós-operatórias no grupo da membrana amniótica 12,81± 2,48 e no grupo controle 15,19±3,33 não apresentaram diferença estatisticamente significante no seguimento de um ano (p=0,297). O número de medicações pós-operatórias diminuiu nos dois grupos (p<0,001 e p=0,007 grupo estudo e grupo controle respectivamente). No final de 12 meses de pós-operatório nove olhos (56,25%) apresentaram bolhas finas e avasculares no grupo estudo comparando com apenas um olho (6,25%) do grupo controle. CONCLUSÃO: A trabeculectomia com membrana amniótica e a trabeculectomia simples mostraram redução da pressão intra-ocular no pós-operatório, embora a diferença entre elas não seja estatisticamente significante.

Efeito da instilação correta de colírios sobre a pressão intra-ocular de pacientes com glaucoma / Effect of correct eyedrop instillation on the intraocular pressure of glaucoma patients

OBJETIVO: Verificar o efeito da instilação correta de colírios hipotensores oculares no comportamento pressórico de pacientes portadores de glaucoma crônico. MÉTODOS: Estudo prospectivo realizado em 90 olhos, de 47 pacientes. Em cada participante era realizada uma minicurva pressórica antes, e outra após lhe ser explicado como proceder à instilação correta de colírios. A seguir, as médias pressóricas obtidas nas duas minicurvas eram comparadas. RESULTADOS: Houve queda significativa de 22,3 por cento na pressão intra-ocular média de 35 (38,9 por cento) olhos. Dos restantes, 35 (38,9 por cento) olhos exibiram pequena queda (-8,2 por cento) em sua média pressórica e, 20 (22,2 por cento), pequeno aumento (+8,4 por cento), ambos não estatisticamente significantes. CONCLUSÕES: Verificou-se que parcela expressiva da população estudada conseguiu obter redução adicional em sua média pressórica por meio da instilação correta de colírios. Portanto, o ensino da técnica adequada da instilação de colírio é necessária a todos os pacientes, podendo resultar em benefício extra para os usuários de medicação hipotensora ocular.

Técnica da instilação de colírios em pacientes portadores de glaucoma crônico / Eye drop instillation technique in chronic glaucoma patients

OBJETIVO: Verificar a técnica da instilação de colírio em pacientes portadores de glaucoma crônico. MÉTODOS: Estudo prospectivo realizado em 193 pacientes glaucomatosos. Para cada participante era entregue um frasco de colírio lubrificante (Dunason®, Laboratório Alcon, São Paulo, Brasil) e solicitado que realizasse uma instilação. RESULTADOS: Os participantes utilizaram, em média, 1,64 ± 1,26 gotas de colírio por instilação e 54,5 por cento dos pacientes fizeram contato do bico do colírio com a superfície ocular. Em 3,1 por cento das instilações nenhuma gota de medicamento atingiu o olho, com o paciente não se dando conta do fato. A oclusão do ponto lacrimal ou a manutenção do olho fechado por dois minutos após a instilação não foi realizada em 87,0 por cento dos participantes, e 61,6 por cento piscaram repetidas vezes imediatamente após instilar a droga. CONCLUSÕES: Verificou-se que a maior parte dos participantes deste estudo efetuou a instilação do colírio de modo incorreto. Isto significa desperdiçar grande parte do conteúdo do frasco, aumentar as possibilidades de toxicidade sistêmica, não aproveitar a plenitude do efeito hipotensor das drogas e contaminar a extremidade do frasco de colírio. Portanto, o ensino da técnica adequada da instilação de colírio é absolutamente necessária para todos os pacientes.