Perimetría computadorizada no estandarizada / Unstandardized Computed Perimetry

La perimetría tradicional estándar es la base de la introducción de innovaciones no convencionales, que continúan considerándola como punto de referencia para comparar su eficiencia y señalar sus desventajas. Aunque la mayoría de estas contribuciones se centran en el glaucoma, también existen informes significativos sobre resultados satisfactorios en otras enfermedades. El propósito de esta revisión es abordar la tendencia emergente de las pantallas y monitores de última generación que se integran con las computadoras. Estos avances resaltan la accesibilidad mejorada, la introducción de nuevos equipos y la incorporación de nuevos pasos, variables y grupos etarios. La búsqueda de información se concentró en la literatura publicada en línea, especialmente en inglés, de los últimos 5 y 17 años. En total, se identificaron y recuperaron 24 artículos: 17 de los últimos cinco años y 7 de los últimos 17 años. Se registraron 18 tecnologías diferentes que compararon sus resultados con la perimetría estándar. Estas tecnologías se clasificaron, para los propósitos del estudio, en dos categorías: aquellas basadas en computadora (en línea y fuera de línea) y aquellas asistidas por el monitor y acopladas a simulación(AU)

Standardized traditional perimetry is the basis for the introduction of unconventional innovations, which continue to be considered as a benchmark to compare its efficiency and point out its disadvantages. Although most of these contributions focus on glaucoma, there are also significant reports of successful results in other diseases. The purpose of this review is to address the emerging trend of state-of-the-art screens and displays integrated with computers. These advances highlight improved accessibility, the introduction of new equipment, as well as the incorporation of new steps, variables and age groups. The search for information focused on the literature published online, especially in English, between the last 5 to 17 years. A sheer number of 24 articles were identified and retrieved, 17 from the last 5 years and 7 from the last 17 years. Eighteen different technologies were identified, whose results were compared to those of standardized perimetry. These technologies were classified, for the purposes of the study, into two categories: computer-based (online and offline), or display-assisted and simulation-coupled(AU)

Glaucoma suspects referred by general ophthalmologists to a tertiary center in Brazil: outcomes of the glaucoma specialist assessment.

PURPOSE: To characterize patients with suspected glaucoma who were referred to the clinic for suspected glaucoma in a tertiary public hospital in southern Brazil and to evaluate differences in functional and structural damages between patients diagnosed with different types of glaucoma, those with normal eye examination results, and those who remained as glaucoma suspects. METHODS: This is a cohort study of patients referred by general ophthalmologists to the clinic for suspected glaucoma at Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil, between March 2016 and December 2018. The patients were followed up until they had undergone reliable examinations (eye examination, visual field screening, and optic coherence tomography for classification as normal and having a suspected glaucoma, glaucoma with an elevated intraocular pressure, normotensive glaucoma, or ocular hypertension. RESULTS: A total of 135 patients were included in this study. Of the patients, 117 subjects completed all examinations and met the inclusion criteria. Most patients were normal (36.8%), followed by those with suspected glaucoma (25.64%), normal tension glaucoma (18.8%), glaucoma with elevated intraocular pressure (12%), and ocular hypertensive (6%). The main reason for referral was increased optic nerve head cupping. The patients with normal tension glaucoma were older than the other subjects on average (p=0.03). In addition, the normal tension glaucoma group had a significantly worse baseline visual field index and mean deviation of the visual field than the normal, glaucoma suspect, and ocular hypertensive groups. The circumpapillary retinal nerve fiber layer on OCT was thinner on average in the normal tension glaucoma group than in the normal and glaucoma suspect groups (p<0.002) but did not significantly differ between the glaucoma group with elevated intraocular pressure and the other groups. CONCLUSIONS: Patients with normal tension glaucoma tend to be diagnosed later because of their normal intraocular pressures; thus, the optic nerve cupping must be greater to raise the suspicion of glaucoma. In this study, we found that the patients with normal tension glaucoma had worse disease at the time of diagnosis.

Pupillary response to chromatic light stimuli as a possible biomarker at the early stage of glaucoma: a review.

Glaucoma is a multifactorial neurodegenerative disease of the optic nerve currently considered a severe health problem because of its high prevalence, being the primary cause of irreversible blindness worldwide. The most common type corresponds to Primary Open-Angle Glaucoma. Glaucoma produces, among other alterations, a progressive loss of retinal ganglion cells (RGC) and its axons which are the key contributors to generate action potentials that reach the visual cortex to create the visual image. Glaucoma is characterized by Visual Field loss whose main feature is to be painless and therefore makes early detection difficult, causing a late diagnosis and a delayed treatment indication that slows down its progression. Intrinsically photosensitive retinal ganglion cells, which represent a subgroup of RGCs are characterized by their response to short-wave light stimulation close to 480 nm, their non-visual function, and their role in the generation of the pupillary reflex. Currently, the sensitivity of clinical examinations correlates to RGC damage; however, the need for an early damage biomarker is still relevant. It is an urgent task to create new diagnostic approaches to detect an early stage of glaucoma in a prompt, quick, and economical manner. We summarize the pathology of glaucoma and its current clinical detection methods, and we suggest evaluating the pupillary response to chromatic light as a potential biomarker of disease, due to its diagnostic benefit and its cost-effectiveness in clinical practice in order to reduce irreversible damage caused by glaucoma.

The rates of visual field progression in glaucoma and its clinical importance / Taxas de progressão do campo visual em glaucoma e sua importância clínica

ABSTRACT The rate of visual field progression is an essential factor in determining risk of visual disability or blindness in glaucoma patients. Knowledge of the rate of progression of a particular patient, in combination with an estimation of their longevity and other clinical factors, allows clinicians to optimize management by providing appropriately aggressive treatment. Despite decades of research on the treatment of glaucoma, the natural history of glaucomatous visual field progression in untreated and treated patients remains unclear. The purpose of this review is to provide a comprehensive summary of the literature surrounding the rate of visual field progression in glaucoma. Most of the available data pertains to primary open angle glaucoma, but we will also review progression rates in other subtypes of open angle glaucoma, such as pseudoexfoliative glaucoma and normal tension glaucoma, as well as in primary angle closure glaucoma. Specifically, we will cover methods to identify rates of progression, rates of progression in treated versus untreated patients, factors that may influence progression, and lastly, suggest some parameters that might help clinicians in determining acceptable rates of visual field deterioration in patients with glaucoma.

RESUMO A taxa de progressão do campo visual é um fator essencial para determinar o risco de incapacidade visual ou cegueira em pacientes com glaucoma. Conhecer a taxa de progressão de um determinado paciente, em combinação com uma estimativa de sua longevidade e outros fatores clínicos, permite que os médicos otimizem a conduta, fornecendo um tratamento adequadamente agressivo. Apesar de décadas de pesquisa sobre o tratamento do glaucoma, a história natural da progressão do campo visual glaucomatoso em pacientes não tratados e tratados permanece pouco clara. O objetivo desta revisão é fornecer um resumo abrangente da literatura sobre a taxa de progressão do campo visual do glaucoma. A maioria dos dados disponíveis diz respeito ao glaucoma de ângulo aberto primário, mas também revisaremos as taxas de progressão em outros subtipos de glaucoma de ângulo aberto, como o glaucoma pseudoexfoliativo e o glaucoma de tensão normal, bem como o glaucoma primário de ângulo fechado. Especificamente, iremos cobrir métodos para identificar taxas de progressão, taxas de progressão em pacientes tratados versus não tratados, fatores que podem influenciar a progressão e, finalmente, sugerir alguns parâmetros que podem ajudar os médicos a determinar taxas aceitáveis de deterioração do campo visual em pacientes com glaucoma

Aneurisma de la arteria carótida interna como lesión compresiva de la vía visual / Internal carotid artery aneurysm as a compressive lesion of the visual pathway

El diagnóstico temprano de las lesiones compresivas del nervio óptico adquiere cada vez mayor importancia. La descompresión precoz de este o del quiasma puede resultar una mejora significativa de la función visual, mientras que el diagnóstico erróneo puede ocasionar pérdida visual irreversible, disfunción neurológica o la muerte. Las causas de la compresión de la vía visual anterior son increíblemente variadas. Los meningiomas, los tumores hipofisarios y los aneurismas son las lesiones comúnmente más identificadas como causa de neuropatía óptica compresiva sin edema del disco. Presentamos una paciente femenina de 50 años de edad, quien se sometió a la cirugía de catarata congénita del ojo izquierdo, sin mejoría de la función visual, a lo que se sumó el empeoramiento inespecífico de la calidad visual. La psicofísica visual, la campimetría automatizada y la tomografía de coherencia óptica aportaron hallazgos sugestivos de compresión de la vía visual intracraneal. Se indicó imagen por resonancia magnética de cráneo y órbitas para confirmar la sospecha diagnóstica. La angiografía cerebral demostró la presencia de un aneurisma de la arteria carótida interna, que se trató por vía endovascular con resultados satisfactorios(AU)

The importance of early diagnosis of compressive lesions of the optic nerve is on the increase. Timely decompression of the optic nerve or the optic chiasm may bring about significant visual function improvement, whereas erroneous diagnosis may result in irreversible visual loss, neurological dysfunction or death. The causes of compression of the anterior visual pathway are incredibly varied. Meningiomas, pituitary tumors and aneurysms are the lesions most commonly identified as causes of compressive optic neuropathy without disc edema. A case is presented of a female 50-year-old patient undergoing congenital cataract surgery of her left eye without visual function improvement, alongside unspecific visual quality worsening. Visual psychophysical testing, automated campimetry and optical coherence tomography contributed findings suggestive of intracranial visual pathway compression. Magnetic resonance imaging of the brain and orbits was indicated to confirm the diagnostic suspicion. Cerebral angiography revealed the presence of an internal carotid artery aneurysm which was treated by endovascular procedure with satisfactory results(AU)

Human Versus Machine: Comparing a Deep Learning Algorithm to Human Gradings for Detecting Glaucoma on Fundus Photographs.

PURPOSE: To compare the diagnostic performance of human gradings vs predictions provided by a machine-to-machine (M2M) deep learning (DL) algorithm trained to quantify retinal nerve fiber layer (RNFL) damage on fundus photographs. DESIGN: Evaluation of a machine learning algorithm. METHODS: An M2M DL algorithm trained with RNFL thickness parameters from spectral-domain optical coherence tomography was applied to a subset of 490 fundus photos of 490 eyes of 370 subjects graded by 2 glaucoma specialists for the probability of glaucomatous optical neuropathy (GON), and estimates of cup-to-disc (C/D) ratios. Spearman correlations with standard automated perimetry (SAP) global indices were compared between the human gradings vs the M2M DL-predicted RNFL thickness values. The area under the receiver operating characteristic curves (AUC) and partial AUC for the region of clinically meaningful specificity (85%-100%) were used to compare the ability of each output to discriminate eyes with repeatable glaucomatous SAP defects vs eyes with normal fields. RESULTS: The M2M DL-predicted RNFL thickness had a significantly stronger absolute correlation with SAP mean deviation (rho=0.54) than the probability of GON given by human graders (rho=0.48; P < .001). The partial AUC for the M2M DL algorithm was significantly higher than that for the probability of GON by human graders (partial AUC = 0.529 vs 0.411, respectively; P = .016). CONCLUSION: An M2M DL algorithm performed as well as, if not better than, human graders at detecting eyes with repeatable glaucomatous visual field loss. This DL algorithm could potentially replace human graders in population screening efforts for glaucoma.

Using sellar region tumor's size as a predictor of psychophysical and electrophysiological perimetric visual losses: a logistic regression approach.

BACKGROUND: Sellar region tumor growth represents an important cause of visual loss due to mechanical compression of the optic nerve apparatus. Many investigations have used non-invasive tools to evaluate the visual field consequences of this damage, and good associations have been reported between psychophysical and electrophysiological perimetries. Few reports have considered the tumor size as a predictor of visual field loss. AIMS: In the present study, we evaluated the association between the visual perimetry measured by Humphrey visual field analyzer and multifocal visual evoked cortical potential (mfVECP) and the tumor size. METHODS: Our sample was composed of 14 patients diagnosed with sellar tumors by magnetic resonance imaging. We accounted the number of sectors with negative visual responses for both methods. A simple logistic regression analysis was used to evaluate the association between the tumor dimensions and the visual field features RESULTS: Three patients had preserved visual fields, three patients showed hemianopic defects, and eight patients had generalized visual field losses at both evaluations. We observed that the three maximum diameters of the tumor and total tumor volume had different predictive abilities regarding the extent of visual field loss when using psychophysical and mfVECP data. The maximum craniocaudal diameter of the tumor was the better predictor of the psychophysical measurements, whereas for the mfVECP results, all tumor dimensions and volumes had similar values that predict visual field losses. CONCLUSION: Tumor size as a predictor of visual loss has potential to assist in the clinical intervention and to prevent the irreversible visual impairment caused by tumors of the sellar region.

Qualidade de vida de pessoas com glaucoma: análise conforme o defeito no campo visual / Quality of life among people with glaucoma: analysis according to the defect in the visual field

Resumo Objetivo: Analisar a qualidade de vida de pessoas com glaucoma conforme o defeito no campo visual. Métodos: Trata-se de estudo transversal, analítico, conduzido em unidade de atenção especializada em oftalmologia, Projeto Glaucoma, em Montes Claros, Minas Gerais, Brasil. A qualidade de vida dos pacientes foi avaliada por meio do National Eye Institute 25-Item Visual Function Questionnaire (NEI-VFQ-25). Utilizou- se o parâmetro Mean Deviation (MD) do melhor olho para classificar os defeitos de campo visual em leve, moderado e severo. Resultados: Participaram 400 pacientes, 60,5% do sexo feminino. A idade dos participantes variou de 19 a 80 anos, sendo a maioria acima de 60 anos (55,8%). A maioria dos pacientes apresentou defeito leve no campo visual, independente de ter sido referenciado pelo setor público ou privado (p=0,840). O escore médio de qualidade de vida foi 77,62(±18,007) pontos. O subdomínio com pior média foi 'dor ocular' (53,06±26,088) e com melhor média foi 'visão de cores' (94,13±19,207). Destacou-se uma correlação linear negativa entre os escores de qualidade de vida e o MD do campo visual, tanto do olho direito (MD-OD) como do esquerdo (MD-OE). Entre os subdomínios de qualidade de vida, 'dependência' foi a que melhor explica a variação do defeito de campo visual e vice-versa, com fator de determinação igual a 7,2% para o MD-OD e 8,4% para o MD-OE. Conclusão: A perda de campo visual foi relacionada à pior qualidade de vida entre pessoas com glaucoma. Recomenda-se propiciar o diagnóstico precoce para favorecer o tratamento e o retardo na progressão da doença.

Abstract Objective: To analyze the quality of life among people with glaucoma according to the visual field defect. Methods: This is a cross-sectional, analytical study carried out in an ophthalmology unit, Glaucoma Project, in Montes Claros, Minas Gerais, Brazil. Patients' quality of life was assessed using the National Eye Institute 25-Item Visual Function Questionnaire (NEI-VFQ-25). The Mean Deviation (MD) parameter of the best eye was used to classify the visual field defects in mild, moderate and severe. Results: Four-hundred patients participated, 60.5% female. The participants' ages ranged from 19 to 80 years, the majority being over 60 (55.8%). The majority of patients presented a visual defect, regardless of whether they were referred by the public or private sector (p = 0.840). The mean quality of life score was 77.62 (± 18.007) points. The subdomain with worse mean was 'ocular pain' (53.06 ± 26.088) and with better mean was 'color vision' (94.13 ± 19.207). A negative linear correlation was observed between the quality of life scores and the visual field MD, both of the right (MD-OD) and left eye (MD-OE). Among the subdomains of quality of life, 'dependency' was the one that best explains the variation of the visual field defect and vice versa, with a determination factor equal to 7.2% for MD-OD and 8.4% for MD-OE. Conclusion: Visual field loss was related to poor quality of life among people with glaucoma. It is recommended to provide early diagnosis to favor treatment and delay in disease progression.

Psicofísica visual em caso de toxoplasmose ocular congênita / Visual psychophysics of congenital ocular toxoplasmosis case

Resumo A toxoplasmose ocular congênita é uma manifestação da infecção pelo parasita Toxoplasma gondii que ocorrer por meio placentário. Essa doença pode provocar importantes sequelas visuais. Este trabalho descreve um estudo de caso que utilizou avaliação psicofísica visual para descrever alterações funcionais decorrentes da toxoplasmose ocular congênita. A avaliação foi realizada em paciente de 30 anos, sexo masculino, residente em São Luís (MA), hígido com histórico da mãe ter apresentado infecção por toxoplasmose no período gestacional. Somente aos 26 anos foi feita uma avaliação médica detalhada que descreveu lesão na fóvea do olho direito. Na avaliação clínica clássica e na avaliação psicofísica visual, o paciente apresentou visão normal para o olho esquerdo. O olho direito apresentou baixa acuidade visual (valor decimal: 0,028), campo visual com escotomas localizados até 20º de ângulo visual e alteração da visão de cor. O estudo fornece informações médicas seguras e relevantes para o diagnóstico de toxoplasmose ocular congênita utilizando testes eficazes, de baixo custo e boa portabilidade, possibilitando uma alternativa de diagnóstico funcional para ser aplicada em locais de difícil acesso pelo interior do Brasil.

Abstract Congenital ocular toxoplasmosis is a manifestation of infection by the parasite Toxoplasma gondii that occurs through the placenta. This disease can lead to important visual sequelae. This paper describes a case report that uses visual psychophysics for the alterations of congenital ocular toxoplasmosis. The evaluation was performed in a 30-year-old man, a resident of São Luís (MA), with a history of his mother have had toxoplasmosis in the gestational period. Only at 26 years-old he did the detailed medical evaluation that described a lesion the fovea of the right eye. In the classic clinical examination and in visual psychophysical evaluation, the patient presented normal vision for the left eye. The right eye had low visual acuity (decimal value: 0.028), visual field with scotomas up to 20º of visual angle and alteration of color vision. The study offers safe and relevant medical information for the diagnosis of congenital ocular toxoplasmosis using a low-cost evaluation and with good portability, allowing a functional diagnostic alternative to be applied in places difficult to access in the interior of Brazil.

Diabetes mellitus tipo 2 en pacientes con diagnóstico de glaucoma primario de ángulo abierto durante el período 2010-2014 / Type 2 diabetes mellitus in patients diagnosed with primary open angle glaucoma during the period 2010-2014

RESUMEN Objetivo La asociación entre diabetes mellitus tipo 2 y glaucoma primario de ángulo abierto aún no está claramente establecida. Este estudio tiene como objetivo identificar la frecuencia entre ambas patologías en pacientes del Hospital Teodoro Maldonado Carbo durante el período 2010-2014 Métodos Se realizó un estudio retrospectivo, de corte transversal, de proporción, en una muestra de 283 pacientes mayores de 30 años cuyo diagnóstico fue de GPAA (Glaucoma primario de ángulo abierto) confirmado mediante estudio de tonometría, gonioscopia, campimetría y ausencia de causas secundarias de aumento de PIO. Se utilizaron criterios de la ADA/OMS para establecer el diagnóstico de DM2. Resultados La frecuencia de pacientes con diabetes en pacientes con diagnóstico de GPAA, que fueron atendidos en consultorios de Emergencia, Endocrinología y Oftalmología del Hospital Regional Teodoro Maldonado Carbo, durante el período 2010-2014, fue de 26,15% (74 de 283 pacientes), con importantes diferencias entre sexo y lugar de residencia. Conclusiones: Se demostró la existencia de una alta proporción entre DM2 y GPAA mediante razón de proporción.

ABSTRACT Objective The association between diabetes mellitus type 2 (DM2) and Primary Open- Angle Glaucoma (POAG) is not clearly established yet. This study has the objective to identify the frequency of both diseases in patients of Teodoro Maldonado Carbo Hospital during the period 2010-2014. Methods A retrospective, cross-sectional frequency was conducted on a sample of 283 patients over age 30 whose diagnosis was confirmed by examination of POAG tonometry, gonioscopy, perimetry and absence of secondary causes of increased intraocular pressure. ADA/OMS criteria were used to establish the diagnosis of DM2. Results The frequency of patients with diabetes diagnosed with POAG patients who were treated at the services of Emergency, Endocrinology and Ophthalmology of the Regional Hospital Teodoro Maldonado Carbo, during the period 2010-2014, was 26.15% (74 of 283 patients) with significant differences between sex and place of residence. Conclusions The existence of a high proportion between DM2 and POAG was demonstrated by prevalence ratio.

Neurorehabilitation of saccadic ocular movement in a patient with a homonymous hemianopia postgeniculate caused by an arteriovenous malformation: A Case Report.

RATIONALE: Visual therapy, which includes a restorative and compensatory approach, seems to be a viable treatment option for homonymous defects of the visual field in patients with postgeniculate injury of the visual pathway, due to occipital arteriovenous malformation (AVM). Until now, the Mexican population suffering from homonymous hemianopia did not have health services that provided any type of visual therapy for their condition. PATIENT CONCERNS: A 31-year-old patient, who underwent a surgical procedure for resection of the AVM, was referred with posterior low vision on the left side. DIAGNOSES: The patient was diagnosed with left homonymous hemianopia. INTERVENTIONS: Visual neurorehabilitation therapy (NRT), which integrated restorative and compensatory approaches, was administered for 3 hours each week. NRT included fixation, follow-up, search, peripheral vision, and reading. OUTCOMES: The NRT did not change visual field defects and, retinotopocally, the same campimetric defects remained. However, after training the tracking ocular movements improved to standard values on the ENG, further, the visual search became more organized. The reading reached a level without mistakes, with rhythm and goog intonation. The Beck test demostrated an improvement in depression symptoms. Regarding the daily life activities, the patient reported significant improvements. LESSONS: Visual NRT can significantly improve eye movements, as well as the quality of life and independence of the patient. This integral approach could be an effective therapeutic option for homonymous defects of the visual field.

Structural and functional analyses of the optic nerve and lateral geniculate nucleus in glaucoma.

PURPOSE: To analyze the correlation between structural characteristics of intraorbital optic nerve (ION) and lateral geniculate nucleus (LGN) measured by 3-Tesla magnetic resonance imaging (3T MRI), and the severity of glaucomatous damage. METHODS: In this cross-sectional study, 41 glaucoma patients and 12 age- and sex-matched controls underwent standard automated perimetry (SAP) and frequency doubling technology (FDT) as functional evaluation; optic disc stereophotograph, spectral-domain optical coherence tomography (OCT) and confocal scanning laser tomography as ocular structural evaluation; and 3T MRI. Structure-structure and structure-function correlation were performed using bootstrap resampling method for clustered data. RESULTS: The ION mean diameter and cross-sectional area were different between glaucoma and control groups at 5mm and 10mm (all, p≤0.011) from the globe, but not at 15mm (both, p≥0.067). LGN height was significantly lower in glaucoma group (p = 0.005). OCT rim area and functional parameters (SAP and FDT) correlated significantly with all ION segments, showing stronger correlations at 10 and 15 mm. ION parameters at 10 and 15 mm presented mild-to-moderate correlation with OCT peripapillary nerve fiber layer thickness, and ION at 15mm had mild association with the neuroretinal rim area on stereophotographs. Although LGN height was significantly smaller in glaucoma group (p = 0.005), LGN parameters were not associated with any ocular structural or functional parameter. CONCLUSION: Assessment of central and peripheral nervous systems using 3T MRI confirmed that glaucoma patients had smaller ION dimensions and LGN height compared to the control group. In general, ION dimensions presented mild to moderate correlations with functional and ocular structural parameters. Although ION had significant correlations at any distance from the eye, the ION distal locations correlated better with OCT results and functional parameters. However, LGN parameters were not associated with functional or ocular structural parameters.

Predicting Vision-Related Disability in Glaucoma.

PURPOSE: To present a new methodology for investigating predictive factors associated with development of vision-related disability in glaucoma. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Two hundred thirty-six patients with glaucoma followed up for an average of 4.3±1.5 years. METHODS: Vision-related disability was assessed by the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) at baseline and at the end of follow-up. A latent transition analysis model was used to categorize NEI VFQ-25 results and to estimate the probability of developing vision-related disability during follow-up. Patients were tested with standard automated perimetry (SAP) at 6-month intervals, and evaluation of rates of visual field change was performed using mean sensitivity (MS) of the integrated binocular visual field. Baseline disease severity, rate of visual field loss, and duration of follow-up were investigated as predictive factors for development of disability during follow-up. MAIN OUTCOME MEASURES: The relationship between baseline and rates of visual field deterioration and the probability of vision-related disability developing during follow-up. RESULTS: At baseline, 67 of 236 (28%) glaucoma patients were classified as disabled based on NEI VFQ-25 results, whereas 169 (72%) were classified as nondisabled. Patients classified as nondisabled at baseline had 14.2% probability of disability developing during follow-up. Rates of visual field loss as estimated by integrated binocular MS were almost 4 times faster for those in whom disability developed versus those in whom it did not (-0.78±1.00 dB/year vs. -0.20±0.47 dB/year, respectively; P < 0.001). In the multivariate model, each 1-dB lower baseline binocular MS was associated with 34% higher odds of disability developing over time (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.06-1.70; P = 0.013). In addition, each 0.5-dB/year faster rate of loss of binocular MS during follow-up was associated with a more than 3.5 times increase in the risk of disability developing (OR, 3.58; 95% CI, 1.56-8.23; P = 0.003). CONCLUSIONS: A new methodology for classification and analysis of change in patient-reported quality-of-life outcomes allowed construction of models for predicting vision-related disability in glaucoma.

Influência do posicionamento vertical e horizontal do objeto nos valores de cinza dentro do FOV de um aparelho de TCFC / Influence of vertical and horizontal positioning of the object on the gray values within the FOV of a TCFC

O objetivo deste estudo foi avaliar a influência do posicionamento vertical e horizontal do objeto dentro da área do campo de visão nos valores de cinza de imagens obtidas no aparelho de Tomografia computadorizada de feixe cônico Kodak 9500. Foi utilizado um simulador com 17 corpos de prova padronizados e de densidade homogênea. Foram realizadas aquisições tomográficas ao longo de todo o campo de visão do aparelho com variação da altura do posicionamento do simulador a cada 5mm, para avaliação de variações verticais e horizontais dos tons de cinza obtidos a cada exame. Ao final das aquisições, os valores de cinza foram medidos no software Image J e os dados foram analisados estatisticamente pelo teste de ANOVA-1 way e o teste posthoc utilizado foi teste de Tukey, com nível de significância de 5%. Em relação ao posicionamento vertical dentro do campo de visão, as médias das medidas nas diferentes alturas apresentaram diferença estatística (p<0,001). As alturas (cm) 10 e 10,5, que correspondem à região externa ao campo de visão, não diferem apenas das médias das alturas 5,5 e 6, enquanto estas alturas diferem das alturas de 3,5 cm a 6,5cm e de 7,0 a 8,5. Já na análise do posicionamento horizontal dos corpos de prova no FOV, foi significativo o valor de p (p<0,001) e notam-se que os valores de cinza das regiões externas do simulador não diferem entre si, porém, essas áreas diferem das médias dos valores de cinza da região central e intermediária do simulador. Podemos concluir que variações na posição do objeto vertical e horizontalmente, dentro dos limites da área do FOV, influenciam nos valores de cinza obtidos por meio de exames de tomografia computadorizada de feixe cônico. (AU)

The aim of this study was to evaluate the influence of vertical and horizontal positioning of the object within the field of view in gray values of images obtained in the Kodak 9500 Cone beam computed tomography device. It was used a phantom with 17 standard samples with homogeneous density. Tomographic acquisitions were made throughout the FOV of the device diversifying the height of the phantom positioning every 5 mm. At the end of the acquisitions, gray values were measured by Image J software, the statistical analysis was done by ANOVA-1 way test and the post-hoc test used was a Tukey test, with 5% significance level. Regarding the vertical positioning within the FOV, the means of measurements at different heights presented statistical difference (p <0.001). The heights (cm) 10 and 10.5 only do not differ from the means of the heights 5, 5 and 6, while these areas differ from the areas 3,5 cm to 6,5cm and from 7,0 to 8,5cm. In relation to horizontal positioning of the test specimens in the FOV, the p value was significant (p <0.001), it is observed that gray values of the external regions do not differ among them, however, these areas differ from the mean values of gray of the central and intermediate regions of the object. We conclude that vertical and horizontal variations in the position of the object, within the limits of the FOV area, influence the values of gray obtained from cone beam computed tomography exams. (AU)

Structure-functional correlation using adaptive optics, OCT, and microperimetry in a case of occult macular dystrophy.

We report retinal functional and structural changes of a 40-year-old man diagnosed with occult macular dystrophy. Comprehensive ophthalmological evaluation was performed, followed by spectral-domain optical coherence tomography (SD-OC - Heidelberg) and image acquisition using an adaptive optics (AO) camera (RTX1, Imagine Eyes) for photoreceptor density analysis. Functional tests included full-field ERG (ERG) and multifocal electroretinography (mfERG) (Diagnosys, LLC) and microperimetry with scanning laser ophthalmoscope (SLO) fixation controlled (MAIA, CenterVUE). OCT revealed a line of discontinuity corresponding to cone outer-segment photoreceptors associated with a loss of cone density, highlighted by a dark blue spot on the AO co ne-density map on the fovea in both eyes. Loss of central sensitivity was revealed using microperimetry; ERG was within the normal range, although the mfERG showed a reduced central response amplitude.

Structure-functional correlation using adaptive optics, OCT, and microperimetry in a case of occult macular dystrophy / Correlação de estrutura e função da retina utilizando óptica adaptativa, OCT e microperimetria em um caso de distrofia macular oculta

ABSTRACT We report retinal functional and structural changes of a 40-year-old man diagnosed with occult macular dystrophy. Comprehensive ophthalmological evaluation was performed, followed by spectral-domain optical coherence tomography (SD-OC - Heidelberg) and image acquisition using an adaptive optics (AO) camera (RTX1, Imagine Eyes) for photoreceptor density analysis. Functional tests included full-field ERG (ERG) and multifocal electroretinography (mfERG) (Diagnosys, LLC) and microperimetry with scanning laser ophthalmoscope (SLO) fixation controlled (MAIA, CenterVUE). OCT revealed a line of discontinuity corresponding to cone outer-segment photoreceptors associated with a loss of cone density, highlighted by a dark blue spot on the AO co ne-density map on the fovea in both eyes. Loss of central sensitivity was revealed using microperimetry; ERG was within the normal range, although the mfERG showed a reduced central response amplitude.

RESUMO Relatamos exames de função e estrutura retiniana de paciente masculino, de 40 anos, com diagnóstico clínico de Distrofia Macular Oculta (DMO). Avaliação oftalmológica completa foi seguida por tomografia de Coerência Óptica (SD-OCT - Heidelberg) e exame com câmara de fundo de olho com tecnologia "Adaptive Optics" (AO - RTX1, Imagine Eyes) para análise da densidade de fotorreceptores. Os exames funcionais incluíram: Eletroretinografia de campo total (ERG) e multifocal (mfERG) (Diagnosys - LLC) e microperimetria com controle de fixação (MAIA - CenterVUE). Os exames revelam descontinuidade da camada de fotorreceptores na região central da fóvea em ambos os olhos pelo SD-OCT em associação com perda de densidade no mosaico cones, representado por mancha azulada no mapa do AO. Os exames de função apresentam diminuição da acuidade visual (20/80; 20/50), redução de sensibilidade central na microperimetria. Como esperado, o ERG está dentro da normalidade, mas há redução da amplitude das respostas centrais do mfERG em ambos os olhos.

Structure-function correlations in glaucoma using matrix and standard automated perimetry versus time-domain and spectral-domain OCT devices.

PURPOSE: We examined the structure-function relationship between two perimetric tests, the frequency doubling technology (FDT) matrix and standard automated perimetry (SAP), and two optical coherence tomography (OCT) devices (time-domain and spectral-domain). METHODS: This cross-sectional study included 97 eyes from 29 healthy individuals, and 68 individuals with early, moderate, or advanced primary open-angle glaucoma. The correlations between overall and sectorial parameters of retinal nerve fiber layer thickness (RNFL) measured with Stratus and Spectralis OCT, and the visual field sensitivity obtained with FDT matrix and SAP were assessed. The relationship also was evaluated using a previously described linear model. RESULTS: The correlation coefficients for the threshold sensitivity measured with SAP and Stratus OCT ranged from 0.44 to 0.79, and those for Spectralis OCT ranged from 0.30 to 0.75. Regarding FDT matrix, the correlation ranged from 0.40 to 0.79 with Stratus OCT and from 0.39 to 0.79 with Spectralis OCT. Stronger correlations were found in the overall measurements and the arcuate sectors for both visual fields and OCT devices. A linear relationship was observed between FDT matrix sensitivity and the OCT devices. The previously described linear model fit the data from SAP and the OCT devices well, particularly in the inferotemporal sector. CONCLUSIONS: The FDT matrix and SAP visual sensitivities were related strongly to the RNFL thickness measured with the Stratus and Spectralis OCT devices, particularly in the overall and arcuate sectors.

Does microperimetry have a prognostic value in central serous chorioretinopathy?

PURPOSE: To investigate the relationship between retinal sensitivity and persistence of subretinal fluid and then to analyze microperimetry as a prognostic predictor of acute central serous chorioretinopathy. METHODS: A prospective observational study. Fourteen eyes of 14 patients presenting with first episode acute central serous chorioretinopathy were enrolled and underwent ocular examination, spectral domain optical coherence tomography, and MAIA microperimetry were performed. After three months of follow-up, without any treatment, visual acuity and spectral domain optical coherence tomography macular thickness assessments and microperimetry were repeated. The main outcome was to find a relation between initial macular sensitivity and persistence of subretinal fluid. A receiver operating characteristic curve was plotted to indicate the best macular sensitivity cutoff point that would be able to predict whether a patient with acute central serous chorioretinopathy would progress to the chronic form. According to the cutoff, we calculated the sensitivity, specificity, and positive and negative predictive values for macular sensitivity as a method to predict persistence of subretinal fluid. RESULTS: On the basis of the receiver operating characteristic curve, a cutoff of 20 dB macular sensitivity was obtained, as the best balance between sensitivity and specificity to predict chronicity. Using this cutoff, the method had a sensitivity of 71% and specificity of 100% with a positive predictive value of 100% and negative predictive value of 78%. Furthermore, it was found that eyes with acute central serous chorioretinopathy and microperimetry of less than 20 dB had a relative risk of 4.5 to develop subretinal fluid persistence. CONCLUSION: Microperimetry with a cutoff of 20 dB may be a useful test to predict the persistence of subretinal fluid, allowing the ophthalmologist to use treatment tools earlier, preventing extracellular damage and visual impairment.

Predicting progression of glaucoma from rates of frequency doubling technology perimetry change.

PURPOSE: To evaluate the ability of longitudinal frequency doubling technology (FDT) to predict the development of glaucomatous visual field loss on standard automated perimetry (SAP) in glaucoma suspects. DESIGN: Prospective, observational cohort study. PARTICIPANTS: The study included 587 eyes of 367 patients with suspected glaucoma at baseline selected from the Diagnostic Innovations in Glaucoma Study (DIGS) and the African Descent and Glaucoma Evaluation Study (ADAGES). These eyes had an average of 6.7 ± 1.9 FDT tests during a mean follow-up time of 73.1 ± 28.0 months. METHODS: Glaucoma suspects had intraocular pressure (IOP) >21 mmHg or an optic disc appearance suspicious of glaucoma. All patients had normal or nonrepeatable abnormal SAP at baseline. Humphrey Matrix FDT (Carl Zeiss Meditec, Inc, Dublin, CA) testing was performed within 6 months of SAP testing. The study end point was the development of 3 consecutive abnormal SAP test results. Joint longitudinal survival models were used to evaluate the ability of rates of FDT pattern standard deviation (PSD) change to predict the development of visual field loss on SAP, adjusting for confounding variables (baseline age, mean IOP, corneal thickness, and follow-up measurements of SAP PSD). MAIN OUTCOME MEASURES: The R(2) index was used to evaluate and compare the predictive abilities of the model containing longitudinal FDT PSD data with the model containing only baseline data. RESULTS: Sixty-three of 587 eyes (11%) developed SAP visual field loss during follow-up. The mean rate of FDT PSD change in eyes that developed SAP visual field loss was 0.07 dB/year versus 0.02 dB/year in those that did not (P < 0.001). Baseline FDT PSD and slopes of FDT PSD change were significantly predictive of progression, with hazard ratios of 1.11 per 0.1 dB higher (95% confidence interval [CI], 1.04-1.18; P = 0.002) and 4.40 per 0.1 dB/year faster (95% CI, 1.08-17.96; P = 0.04), respectively. The longitudinal model performed significantly better than the baseline model with an R(2) of 82% (95% CI, 74-89) versus 11% (95% CI, 2-24), respectively. CONCLUSIONS: Rates of FDT PSD change were highly predictive of the development of SAP visual field loss in glaucoma suspects. This finding suggests that longitudinal FDT evaluation may be useful for risk stratification of patients with suspected glaucoma.

Análise de regressão logística na combinação de métodos propedêuticos no diagnóstico do glaucoma / Logistic regression analysis in the combination of diagnostic methods in glaucoma

OBJETIVOS: Estudar a habilidade diagnóstica do tomógrafo retiniano de Heidelberg (HRT II), GDx analisador de fibras nervosas (GDx), perimetria azul-amarelo (SWAP), tecnologia de frequência duplicada (FDT) isoladamente e em conjunto no diagnóstico do glaucoma. MÉTODOS: Sessenta glaucomatosos e 60 pacientes normais foram submetidos a exames de HRT II, GDx, SWAP e FDT. HRT foi considerado alterado quando pelo menos uma região do anel neurorretiniano esteve fora dos limites da normalidade, conforme a análise de regressão de Moorfields. GDx alterado foi definido quando pelo menos um índice foi considerado pelo programa do equipamento como fora dos limites normais, excluindo-se o índice simetria, ou ainda quando no gráfico "the deviation from normal graph" apareceu um quadrante com significância abaixo de 5%. O FDT foi considerado anormal quando pelo menos uma região testada apresentou-se com defeito severo ou com a presença de dois defeitos moderados contíguos. Para o SWAP foram adotados os critérios de anormalidade propostos por Anderson. Análise de regressão logística foi realizada. RESULTADOS: Quando foram estudadas as tecnologias isoladamente, a análise de regressão logística apresentou melhores índices de razão das chances para glaucoma com exames positivos para o HRT (22,49), seguido pelo SWAP (21,71). FDT (3,97) e GDx (2,73). Quando se associaram exames positivos de diferentes tecnologias, as razões das chances aumentaram. Nos casos com exames de HRT, FDT e SWAP fora dos limites normais, a razão das chances foi de 252,6 e com HRT, SWAP e GDx alterados, 173,1. Quando associamos exames positivos de diferentes tecnologias, a razão das chances dos pacientes serem glaucomatosos aumentou consideravelmente, chegando a 689,7 com todos os exames fora dos limites normais, o que ocorreu em 26 pacientes deste estudo. CONCLUSÕES: A análise de regressão logística confirmou que a presença de exames alterados de HRT ou SWAP apresentam as maiores razões das chances de glaucoma. A associação de exames alterados aumentou a razão das chances, principalmente, quando o HRT e o SWAP estavam fora dos limites normais.

PURPOSES: In this research was studied the diagnostic ability of the Heidelberg Retinal Tomograph (HRT II), GDx nerve fiber analyzer (GDx), Short-wavelenght Automated Perimetry (SWAP) and Frequency-doubling technology (FDT), all of them together and also separately in the diagnosis of glaucoma. METHODS: Sixty glaucomatous patients and 60 normal ones were submitted to examination with the technology of HRT II, GDx, FDT and SWAP. In the interpretation of HRT, based on the Moorfields regression analysis, were considered abnormal when at least one area of the neuroretinal ring was outside the bounds of normality. GDx was defined as altered, when it was observed that at least one index was considered by equipment program as outside of normal limits, excluding the index symmetry, or when "the deviation from normal graph" appeared a quadrant with significance below 5%. The FDT was considered abnormal when at least one region tested presented with severe defects, or two contiguous moderate defects in at least two reliable tests. For SWAP was adopted the abnormality criteria proposed by Anderson. Logistic regression analysis was performed. RESULTS: When the technologies were studied separately, the Logistic regression analysis showed better odds ratio rates to test positive for glaucoma with HRT (22.49), followed by EAP (21.71), FDT (3.97) and GDx (2.73). When positive tests were associated with different technologies, the odds ratios increased. In cases with HRT, FDT and PAA tests, outside normal bounds, the odds ratio was 252.6. Concerning the HRT, GDx and PAA the result have changed to 173.1. When we associate positive tests from different technologies, the odds ratio of glaucomatous patients have increased considerably, reaching 689.7 with all the tests outside normal bounds, which have happened with 26 patients of this study. CONCLUSIONS: The Logistic Regression analysis confirmed that the abnormal tests of HRT and PAA have shown to be the highest reasons for glaucoma occurrence. The association of abnormal tests increased the odds ratio, especially when the HRT and PAA were out of normal bounds.