Refractive errors in Möbius sequence Contact lenses after

Transcription

issn 0004-2749
versão impressa
Arquivos brasileiros
publicação oficial do conselho brasileiro de oftalmologia
JULHO/AGOSTO 2013
d e
76 04
Refractive errors in Möbius sequence
Contact lenses after intracorneal rings
Age and corneal deformation by
ultra-high-speed scheimpflug camera
Intracapsular dexamethasone
implant for phaco
Cataract surgery and IOL in
microphthalmia
indexada nas bases de dados
medline | embase | isi | SciELO
Ronda Propaganda
O cuidado com
os olhos
pode mudar
TUDO
Gel hipoalergênico:
• Cuida suavemente da limpeza
da área dos olhos.1
• Demaquilante.1
Apresentação:
Tubo com 40g
e 100 compressas.1
Não deixa resíduos.1
Adequado para usuários
de lentes de contato.1
BLEPHAGEL® Gel hipoalergênico. Higiene diária das pálpebras e dos cílios. Tubo de 40 g. Conteúdo: Gel para a higiene das pálpebras e dos cílios. Tubo de 40 g e 100 compressas. Composição: Aqua, poloxamer 188, PEG-90, sodium borate, carbomer,
methylparaben. Indicações: BLEPHAGEL®, gel hipoalergênico, demaquilante, cuida suavemente da limpeza da área dos olhos. Pode ser recomendado aos utilizadores de lentes de contato. Propriedades: BLEPHAGEL®, hipoalergênico (formulado para
minimizar os riscos de reação alérgica), sem perfume, não é gorduroso, limpa de forma adequada as pálpebras. A sua fórmula: • Facilita a aderência do produto; • Produz uma agradável sensação de frescor, descongestionando as pálpebras e respeitando
o pH da pele; • Não deixa resíduos. Precauções de utilização: • Produto destinado a aplicação sobre as pálpebras e cílios, não aplicar no olho; • Não utilizar em crianças. NÃO USAR EM PELE LESIONADA OU IRRITADA. Modo de usar: Em média duas
vezes por dia, de manhã e à noite, ou quantas vezes seja necessária a limpeza das pálpebras. 1) Aplicar uma pequena quantidade de BLEPHAGEL® sobre uma gaze limpa e macia. 2) Frente ao espelho, aplicar com delicadeza a
gaze sobre as pálpebras e a base dos cílios com o olho fechado. 3) Passar suavemente, várias vezes a gaze com o BLEPHAGEL® sobre as pálpebras e a base dos cílios, friccionar com pequenos movimentos circulares a
fim de retirar todos os resíduos. 4) Eliminar o BLEPHAGEL® restante com a ajuda de uma gaze limpa. 5) Repetir cada etapa para o outro olho utilizando sempre gazes limpas. Reg. M.S. nº 2.5203.0006. Importado por:
UNIÃO QUÍMICA FARMACÊUTICA NACIONAL S/A. Rua Cel. Luiz Tenório de Brito, 90 – Embu-Guaçu – SP – CEP 06900-000 – SAC 0800 11 1559 – CNPJ 60.665.981/0001-18 – Farm. Resp.: Daniela Batista Paiva –
CRF-MG nº 20617. Fabricado por: LABORATOIRES THÉA – 12, rue Louis Blériot – 63017 CLERMONT-FERRAND Cedex 2 – FRANCE / FRANÇA.
Material dirigido exclusivamente a profissionais habilitados a prescrever e/ou dispensar medicamentos.
Produzido em: Abril/2013
Referência Bibliográfica: 1) Bula do produto: Blephagel®. Registro MS nº2.5203.0006.001-4.
3448-Hyabak Anun Med BULA NOVA_Layout 1 9/20/11 1:32 PM Page 1
Olho Seco
&
Muco-adesivo 2,4
Pós-Cirurgia
Refrativa1
Alta capacidade de retenção de água 2,3
Hidratação prolongada
Conforto prolongado
Ph e osmolaridade semelhantes às do filme lacrimal normal 2
Visco-elástico 4
Mais conforto ao paciente
Impede a visão turva
Indicado para usuários de lentes de contato 1
Melhora as propriedades de adesão intercelular 3,4
Promove rápida cicatrização pós-cirurgias
Tratamento sintomático do olho seco.
Lubrificação e hidratação de lentes de contato.
Referências Bibliográficas: 1) Bula do produto: Hyabak. Registro MS nº 80424140002. 2) Snibson GR, Greaves JL, Soper ND, Tiffany JM, Wilson CG, Bron AJ. Ocular surface residence times of artificial tear solutions. Cornea. 1992 Jul;11(4):288-93. 3) Nakamura M, Hikida M. Nakano T, Ito S, Hamano T,
Kinoshita S. Characterization of water retentive properties of hyaluronan. Cornea. 1993 Sep;12(5):433-6. 4) Gomes JA, Amankwah R, Powell-Richards A, Dua HS. Sodium hyaluronate (hyaluronic acid) promotes migration of human corneal epithelial cells in vitro. Br J Ophthalmol. 2004 Jun;88(6);821-5.
SE PERSISTIREM OS SINTOMAS, O MÉDICO DEVERÁ SER CONSULTADO. Informações adicionais disponíveis à classe farmacêutica mediante solicitação.
Bula do produto: HYABAK®. Solução sem conservantes para hidratação e lubrificação dos olhos e lentes de contacto. Frasco ABAK®. COMPOSIÇÃO: Hialuronato de sódio 0,15g. Cloreto de sódio, trometamol, ácido clorídrico, água para preparações injetáveis q.b.p. 100 mL. NOME E
MORADA DO FABRICANTE: Laboratoires Théa, 12 rue Louis Blériot, 63017 CLERMONT-FERRAND CEDEX 2 - França. QUANDO SE DEVE UTILIZAR ESTE DISPOSITIVO: HYABAK® contém uma solução destinada a ser administrada nos olhos ou nas lentes de contato. Foi concebido: • Para
humedecimento e lubrificação dos olhos, em caso de sensações de secura ou de fadiga ocular induzidas por fatores exteriores, tais como, o vento, o fumo, a poluição, as poeiras, o calor seco, o ar condicionado, uma viagem de avião ou o trabalho prolongado à frente de uma tela de computador. • Nos
utilizadores de lentes de contato, permite a lubrificação e a hidratação da lente, com vista a facilitar a colocação e a retirada, e proporcionando um conforto imediato na utilização ao longo de todo o dia. Graças ao dispositivo ABAK®, HYABAK® permite fornecer gotas de solução sem conservantes. Pode,
assim, ser utilizado com qualquer tipo de lente de contato. A ausência de conservantes permite igualmente respeitar os tecidos oculares. ADVERTÊNCIAS E PRECAUÇÕES ESPECIAIS DE UTILIZAÇÃO: • Evitar tocar nos olhos com a ponta do frasco. • Não injetar, não engolir. Não utilize o produto caso
o invólucro de inviolabilidade esteja danificado. MANTER FORA DO ALCANCE DAS CRIANÇAS. INTERAÇÕES: É conveniente aguardar 10 minutos entre a administração de dois produtos oculares. COMO UTILIZAR ESTE DISPOSITIVO: POSOLOGIA: 1 gota em cada olho durante o dia, sempre que
necessário. Nos utilizadores de lentes: uma gota em cada lente ao colocar e retirar as lentes e também sempre que necessário ao longo do dia. MODO E VIA DE ADMINISTRAÇÃO: INSTILAÇÃO OCULAR. STERILE A - Para uma utilização correta do produto é necessário ter em conta determinadas
precauções: • Lavar cuidadosamente as mãos antes de proceder à aplicação. • Evitar o contato da extremidade do frasco com os olhos ou as pálpebras. Instilar 1 gota de produto no canto do saco lacrimal inferior, puxando ligeiramente a pálpebra inferior para baixo e dirigindo o olhar para cima. O tempo
de aparição de uma gota é mais longo do que com um frasco clássico. Tapar o frasco após a utilização. Ao colocar as lentes de contato: instilar uma gota de HYABAK® na concavidade da lente. FREQUÊNCIA E MOMENTO EM QUE O PRODUTO DEVE SER ADMINISTRADO: Distribuir as instilações
ao longo do dia, conforme necessário. CONSERVAÇÃO DE DISPOSITIVO: NÃO EXCEDER O PRAZO LIMITE DE UTILIZAÇÃO, INDICADO NA EMBALAGEM EXTERIOR. PRECAUÇÕES ESPECIAIS DE CONSERVAÇÃO: Conservar a uma temperatura inferior a 25ºC. Depois de aberto, o frasco não
deve ser conservado mais de 8 semanas.
UNIÃO QUÍMICA FARMACÊUTICA NACIONAL S/A
Divisão GENOM
Unidade Brasília: Trecho 01 Conjunto 11 Lote 6 a 12
Pólo de Desenvolvimento JK
Santa Maria- Brasília - DF - CEP: 72549-555
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EXTRAESCURAS
AS LENTES MAIS ESCURAS DA TRANSITIONS
Conheça o último lançamento da linha de lentes adaptáveis de uso
diário Transitions. As lentes Transitions® EXTRActive™ foram criadas
especialmente para proporcionar o maior nível de escurecimento
dentre todas as lentes Transitions. Elas têm uma ativação moderada
atrás do para-brisa do carro e, em ambientes internos, uma leve
tonalidade para proporcionar maior conforto visual.
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Transitions e o “Swirl” são marcas registradas e Transitions EXTRActive e Transitions Lentes Adaptáveis são marcas da Transitions Optical, Inc.©2013. Transitions
Optical, Inc. O desempenho fotossensível é influenciado pela temperatura, pela exposição aos raios UV e pelo material das lentes. Fotos meramente ilustrativas.
TRA-0022-13C-An Extrative 21x28.indd 1
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Registro de Especialista no CRM:
muito bom para você, e para nossa
especialidade também!
Exercer especialidade não registrada é infração ética
Desde a publicação do novo Código de Ética Médica (CEM), em abril de 2010, é considerada uma infração
ética (sujeita a um processo ético-profissional) anunciar e exercer uma especialidade médica sem registro
no Conselho Regional de Medicina de seu estado (Art. 115).
Infelizmente, um grande contingente de oftalmologistas, detentores de título de especialista, por esquecimento ou mesmo por não saberem disso, nunca fez o registro de sua titulação, se sujeitado ao constrangimento de um processo, e ao prejuízo financeiro relativo à produção de materiais de divulgação e da papelaria do consultório.
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CONSELHO BRASILEIRO
DE OFTALMOLOGIA
ISSN 0004-2749
(Versão impressa)
ISSN 1678-2925
Periodicidade: bimestral
Arq Bras Oftalmol. São Paulo, v. 76, n. 4, p. 209-264, jul./ago. 2013
Sumário | Contents
V
Editorial | Editorial
Tratamento atual da ambliopia: onde estamos?
Current treatment of amblyopia: where are we?
Galton Carvalho Vasconcelos, Marcelo Fernandes da Costa
VII
Galton Carvalho Vasconcelos, Marcelo Fernandes da Costa
Artigos Originais | Original Articles
209
One year results of anti-VEGF treatment in pigment epithelial detachment secondary to macular degeneration
Harun Yüksel, Fatih M. Türkcü, Alparslan Şahin, Muhammed Şahin, Yasin Çinar, Abdullah K. Cingü, Şeyhmus Ari, İhsan Çaça
212
The surgical management of massive intraoperative and postoperative suprachoroidal hemorrhage anatomic and functional outcomes
Resultados após um ano de tratamento anti-VEGF para o descolamento do epitélio pigmentado secundário à degeneração macular
O tratamento cirúrgico da hemorragia supracoroidea massiva intraoperatória e pós-operatória: resultados anatômicos e funcionais
Fabio Lavinsky, Joseph Moisseiev, Hani Levkovitch-Verbin
215
Contact lenses fitting after intracorneal ring segments implantation in keratoconus
Luciane Bugmann Moreira, Ricardo Augustho Canto Bardal, Leila Roberta Crisigiovanni
218
An evaluation of estimation methods for determining addition in presbyopes
Leonardo Catunda Bittencourt, Milton Ruiz Alves, Daniel Oliveira Dantas, Pablo Felipe Rodrigues, Edson dos Santos-Neto
221
The prevalence of ocular surface complaints in Brazilian patients with glaucoma or ocular hypertension
Vital Paulino Costa, Italo Mundialino Marcon, Roberto Pedrosa Galvão Filho, Roberto Freire Santiago Malta
226
Intracapsular dexamethasone implant in patients undergoing phacoemulsification and intraocular lens implantation
Lucas Monferrari Monteiro Vianna, Lincoln Leme Freitas, Walton Nosé, Liliane Andrade Almeida Kanecadan, Eduardo Sone Soriano,
Cristina Muccioli, Rubens Belfort Jr.
Adaptação de lentes de contato após implante de anel intracorneano no ceratocone
Avaliação de diferentes métodos para determinar adição em présbitas
Prevalência de sintomas da doença da superfície ocular em pacientes brasileiros com glaucoma ou hipertensão ocular
Implante intracapsular de dexametasona em pacientes submetidos a facoemulsificação e implante de lente intraocular
229
Effects of age on corneal deformation by non-contact tonometry integrated with an ultra-high-speed (UHS)
Scheimpflug camera
Efeitos da idade sobre a deformação da córnea utilizando o sistema de tonometria de não contato com a câmera de Scheimpflug
Bruno Freitas Valbon, Renato Ambrósio Jr., Bruno Machado Fontes, Milton Ruiz Alves
233
Pacientes com astigmatismo submetidos à cirurgia de catarata: LIO tórica x LIO asférica?
Emilio de Almeida Torres Netto, Marina Carvalho Gulin, Marcio Zapparoli, Hamilton Moreira
237
Prevalence of refractive errors in Möbius sequence
Monica Fialho Cronemberger, Mariza Polati, Iara Debert, Tomás Scalamandré Mendonça, Carlos Souza-Dias, Marilyn Miller,
Liana Oliveira Ventura, Célia Regina Nakanami, Mauro Goldchmit
240
Congenital cataract surgery with intraocular lens implantation in microphthalmic eyes: visual outcomes and complications
Marcelo Carvalho Ventura, Virgínia Vilar Sampaio, Bruna Vieira Ventura, Liana Oliveira Ventura, Walton Nosé
Patients with astigmatism who underwent cataract surgery by phacoemulsification: toric IOL x asferic IOL?
Prevalência de erros refrativos na sequência de Möbius
Cirurgia de catarata congênita com implante de lente intraocular em olhos microftálmicos: resultados visuais e complicações
Relatos de Casos | Case Reports
Lipossarcoma periorbital em paciente pediátrico: relato de caso
244
Periorbital liposarcoma in pediatric patient: a case report
Fernanda Marcio, José Vital Filho, Sylvia Regina Temer Cursino, Patrícia Gomes Martins de Sousa, Dino Martini Filho
247
Orbital retinoblastoma: case report
Eduardo Darahem Mabtum, Maria Teresa Brizzi Chizzotti Bonanomi, Patricia Picciarelli de Lima, Maria Tereza Assis de Almeida
250
Choroidal metastasis as the first sign of bronchioloalveolar lung cancer: case report
Ricardo Evangelista Marrocos de Aragão, Ieda Maria Alexandre Barreira, Lorena Maria Araújo Gomes, Ariane Sá Vieira Bastos, Felipe de Freitas Beserra
253
Torpedo maculopathy with an anisometropic amblyopia in a 5-year-old Caucasian girl: case report
Marco Dutra-Medeiros, Paula Leitão, Ana Magriço, Alcina Toscano
Retinoblastoma orbitário: relato de caso
Metástase coroidal como primeira manifestação de carcinoma bronquioloalveolar: relato de caso
Maculopatia torpedo numa criança caucasiana de 5 anos de idade com ambliopia anisometrópica: relato de caso
Artigos de Revisão | Review Articles
Neuroretinite unilateral subaguda difusa (DUSN): atualização continuada
256
Diffuse unilateral subacute neuroretinitis (DUSN): current update
Alexandre Antonio Marques Rosa, Taurino dos Santos Rodrigues Neto
261 Instruções para os Autores | Instructions to Authors
Editorial |
Editorial
Galton Carvalho Vasconcelos1, Marcelo Fernandes da Costa²,³
Desde os primeiros contatos com a oftalmologia aprendemos a diagnosticar a ambliopia e iniciar prontamente seu tratamento. Apesar de valiosos os conhecimentos recebidos nesse processo de aprendizado, parte
do que aprendemos de terapêuticas empregadas no tratamento da ambliopia, passado às sucessivas gerações
de oftalmologistas, carece ainda de evidência. Embora seja uma das doenças do desenvolvimento mais antigas
e tenha suas características básicas conhecidas com maior profundidade pelos trabalhos experimentais dos
prêmios Nobel Hubel e Wiesel, parte de sua fisiopatologia ainda é desconhecida, permanecendo como uma
das mais enigmáticas e interessantes doenças visuais do desenvolvimento(1). Desde os anos da década de 1960,
muitos aspectos intrigantes da ambliopia foram revelados. Hoje sabemos que a ambliopia não causa apenas
uma redução anatômica cortical das colunas de dominância ocular do olho amblíope, com redução principal
das células binoculares, estudos mostram que funções visuais como sensibilidade ao contraste estão reduzidas
não somente nas altas frequências espaciais como também nas médias e baixas. Assimetrias em processamento
temporo-nasal de estímulos visuais permanecem imaturas em adultos com ambliopia e outras capacidades
tais como realizar de forma satisfatória alinhamentos espaciais, detectar fases de, bem como a visão periférica
estão também alteradas nesses indivíduos(2). Somados aos estudos experimentais, muito se comenta sobre os
novos estudos clínicos multicêntricos conhecidos como ATS (Amblyopia Treatment Study) ou mais comumente
como PEDIG (Pediatric Eye Disease Investigator Group), que vêm influenciando de forma marcante a nossa forma
de entender e realizar o tratamento da ambliopia no mundo e também no Brasil. A presença de sua influência
já se faz sentir, seja por preconizar a redução do número de horas no tratamento das ambliopias refracionais e
estrabísmicas, seja por nos informar da descontinuição lenta ao final do tratamento, por ampliar as faixas de idade
de tratamento além de sete anos e em diversos outros itens relacionados à prescrição óptica nas anisometropias,
ao uso da atropina, etc. O valor desses estudos realizados por uma colaboração entre mais de 100 centros de pesquisa distribuídos nos Estados Unidos, Canadá e Reino Unido e envolvendo mais de 200 oftalmologistas pediá
tricos(3), dá-se não somente por seu caráter multicêntrico e grande rigor metodológico, mas principalmente por
ousar questionar paradigmas no tratamento do estrabismo que tomávamos como absolutos, tais como tempo
de oclusão por tempo integral e o início do tratamento em pacientes de 7 ou 13 anos, antes considerados sem
potencial para melhora. A oclusão de dias ou semanas para ambliopias refracionais e estrabísmicas realizadas nas
décadas anteriores perdeu espaço para oclusões de seis horas como mostrou pesquisa da Associação Americana
de Oftalmologia Pediátrica e Estrabismo (AAPOS) entre seus membros(4). Somado a estes estudos, pesquisas
feitas em laboratório sobre os efeitos da oclusão, mostram efeitos privativos secundários no olho fixador e que
o tempo de oclusão não deveria ser maior que 6 horas(5). Tal tendência também vem sendo observada no Brasil,
entre a comunidade oftalmológica, apesar de poucas evidências clínicas nacionais.
Ao lermos os estudos ATS do PEDIG observamos no entanto, que apesar do rigor científico, leitura cuidadosa
identifica inúmeras questões ainda não respondidas e viés metodológico, principalmente no que se refere a
possíveis adaptações às características epidemiológicas e clínicas de pacientes amblíopes em diversas áreas do
globo. Observou-se em estudo em uma grande cidade canadense que, as orientações feitas pelo PEDIG nem
sempre são implementadas ou traduzidas para a prática clínica da mesma forma, embora tenha sido verificada
tendência à redução do número de horas de oclusão(6). Carecem ainda de evidências clínicas aspectos relativos
ao tratamento da ambliopia por privação sensorial, para a qual, segundo a base Cochrane, não há até o momento
estudos com boas evidências(7).
Estas novas aquisições de conhecimento nos fazem colocar em questão o limite dos princípios fisiopatológicos conhecidos, nossa capacidade de lidar com as alterações apresentadas pelos pacientes e, talvez o primordial,
a necessidade de uma nova revisão sobre o conceito, diagnóstico e tratamento desta importante doença.
Submetido para publicação: 27 de agosto de 2013
Aceito para publicação: 27 de agosto de 2013
Médico, setor de Baixa Visão Infantil e setor de Estrabismo, Hospital São Geraldo, Universidade
Federal de Minas Gerais - UFMG, Belo Horizonte (MG), Brasil.
2
PhD, Setor de Psicofísica Clínica, Departamento de Psicologia Experimental, Instituto de Psicologia,
Universidade de São Paulo - USP, São Paulo (SP), Brasil.
3
Núcleo de Neurociências e Comportamento, Programa de Neurociências Aplicadas, Universidade
de São Paulo - USP, São Paulo (SP), Brasil.
Financiamento: Não houve financiamento para este trabalho.
Divulgação de potenciais conflitos de interesse: G.C.Vasconcelos, Nenhum; M.F.da Costa, Nenhum.
1
V
REFERÊNCIAS
1. Granet DB, Khayali S. Amblyopia and strabismus. Pediatric Ann. 2011;40(2):89-94.
2.Wilson GA, Welch D. Does amblyopia have a functional impact? Findings from the
Dunedin Multidisciplinary Health and Development Study. Clin Experiment Ophthalmol. 2013;41(2):127-34.
3. Pediatric Eye Disease Investigator Group (PEDIG). General Information about the Pediatric Eye Disease Investigator Group (PEDIG) [Internet]. Tampa, Florida: Jaeb Center
for Health Research; 2013. [cited 2013 Aug 21]. Available from: http://pedig.jaeb.org/
ViewPage.aspx?PageName=General_Info
4. Wygnanski-Jaffe T, Levin AV. The effect of the randomized trial of patching regimens
VI
for treatment of moderate amblyopia on pediatric ophthalmologists: 3-year outcome.
JAAPOS. 2007;11(5):469-72.
5.Li J, Thompson B, Ding ZF, Chan LY, Chen X, Yu MB, et al. Does partial occlusion
promote normal binocular function? Invest Ophthalmol Vis Sci. 2012;53(11):6818-27.
6. Jin YP, Chow AH, Colpa L, Wong AM. Clinical translation of recommendations from
randomized clinical trials on patching regimen for amblyopia. Ophthalmology. 2013;
120(4):657-62.
7. Antonio-Santos A, Vedula SS, Hatt SR, Powell C. Interventions for stimulus deprivation
amblyopia. Cochrane Database Syst Rev. 2006;19(3): CD005136. [cited Nov 2012 Nov 21].
Available from: http://www.update-software.com/pdf/CD005136.pdf
Editorial |
Editorial
Galton Carvalho Vasconcelos1, Marcelo Fernandes da Costa²,³
Early on in our training as ophthalmologists, we are taught how to diagnose amblyopia and promptly initiate
its treatment. Although such information during the learning process seems to be quite valuable, evidence is
lacking for some of the procedures used to treat amblyopia that have been taught to successive generations
of ophthalmologists. Nobel laureates Hubel and Wiesel characterized the basic features of this well-known
developmental disease, yet the complete pathophysiology is not known, and amblyopia remains one of the
most enigmatic and interesting visual developmental diseases(1). Since the early 1960s, many intriguing aspects
of amblyopia have been revealed. Today we know that amblyopia not only causes an anatomic reduction of
the cortical ocular dominance columns of the amblyopic eye and a reduction of binocular cells, but also affects
visual functions, such as contrast sensitivity, which can be reduced not only in high spatial frequencies but also
in medium and low frequencies. Asymmetries in processing nasal-temporal visual stimuli persist in adults with
amblyopia, and other capabilities, such as satisfactory alignment and spatial phase detection as well as peripheral vision, are also altered in these individuals(2). In addition to experimental studies, much has been written
about the new multicenter clinical trials known as the Amblyopia Treatment Study (ATS) or more commonly
known as the Pediatric Eye Disease Investigator Group (PEDIG), which has markedly influenced the way clinicians understand and treat amblyopia throughout the world, including Brazil. The findings from these clinical
trials have already influenced treatment, such as by reducing the number of hours in the treatment of refractive
and strabismic amblyopias, advising slow patch tapering at the end of treatment, extending the treatment age
beyond 7 years, and several other items related to the medications used to treat amblyopia (e.g., atropine).The
value of such studies, performed in collaboration among more than 100 research centers in the United States,
Canada, and the United Kingdom, and involving more than 200 pediatric ophthalmologists(3), is due not only to
its multicentric characteristic and methodologic rigor, but especially to it daring paradigms in the treatment of
strabismus that are in stark contrast with what we learned in our training, such as full-time occlusion and initiating treatment in patients prior to 7 years of age, which were previously considered necessary for improvement.
Full-time patching for days or weeks for refractive and strabismic amblyopia, recommended in previous decades,
has given way to part-time occlusions of 6 hours, as reported in a recent survey of the members of the American
Association for Pediatric Ophthalmology and Strabismus (AAPOS)(4). In addition to those studies, experimental
studies of the effects of occlusion have demonstrated secondary deprivation effects resulting from fixation of the
eye and indicate that the occlusion time should not be longer than 6 hours(5). This trend has also been observed
in the ophthalmic community in Brazil, although there is a lack of national clinical evidence.
The ATS PEDIG studies, despite their scientific rigor, require careful reading to identify numerous unanswered
questions and methodologic bias, particularly with regard to possible adaptations to the epidemiologic and
clinical characteristics of amblyopic patients in various areas around the world. A study performed in a large
Canadian city indicated that the PEDIG guidelines are not always implemented or translated into clinical practice
in the same way, although there has been a trend toward a reduction in the number of hours of occlusion(6). The
practice of partial occlusion lacks clinical evidence in some aspects of the treatment of deprivation amblyopia,
for which, according to the Cochrane Database of Systemic Reviews, there are currently no studies with good
evidence(7).
This new accrual of knowledge calls into question the limits of the known pathophysiologic principles, our
ability to cope with the changes made by patients, and, perhaps paramount, the need for a new review of the
concept, diagnosis, and treatment of this important disease.
Submitted for publication: August 27, 2013
Accepted for publication: August 27, 2013
Physician, Children’s Low-vision and Strabismus sectors, São Geraldo Hospital, Universidade
Federal de Minas Gerais - UFMG, Belo Horizonte (MG), Brazil.
2
PhD, Setor de Psicofísica Clínica, Department of Psicologia Experimental, Instituto de Psicologia,
Universidade de São Paulo - USP, São Paulo (SP), Brazil.
3
Núcleo de Neurociências e Comportamento, Programa de Neurociências Aplicadas, Universidade
de São Paulo - USP, São Paulo (SP), Brazil.
Funding: No specific financial support was available for this study.
Disclosure of potencial of interest: G.C.Vasconcelos, None; M.F.da Costa, None.
1
VII
References
1. Granet DB, Khayali S. Amblyopia and strabismus. Pediatric Ann. 2011;40(2):89-94.
2.Wilson GA, Welch D. Does amblyopia have a functional impact? Findings from the
Dunedin Multidisciplinary Health and Development Study. Clin Experiment Ophthalmol. 2013;41(2):127-34.
3. Pediatric Eye Disease Investigator Group (PEDIG). General Information about the Pediatric Eye Disease Investigator Group (PEDIG) [Internet]. Tampa, Florida: Jaeb Center
for Health Research; 2013. [cited 2013 Aug 21]. Available from: http://pedig.jaeb.org/
ViewPage.aspx?PageName=General_Info
4. Wygnanski-Jaffe T, Levin AV. The effect of the randomized trial of patching regimens
VIII
for treatment of moderate amblyopia on pediatric ophthalmologists: 3-year outcome.
JAAPOS. 2007;11(5):469-72.
5.Li J, Thompson B, Ding ZF, Chan LY, Chen X, Yu MB, et al. Does partial occlusion
promote normal binocular function? Invest Ophthalmol Vis Sci. 2012;53(11):6818-27.
6. Jin YP, Chow AH, Colpa L, Wong AM. Clinical translation of recommendations from
randomized clinical trials on patching regimen for amblyopia. Ophthalmology. 2013;
120(4):657-62.
7. Antonio-Santos A, Vedula SS, Hatt SR, Powell C. Interventions for stimulus deprivation
amblyopia. Cochrane Database Syst Rev. 2006;19(3): CD005136. [cited Nov 2012 Nov 21].
Available from: http://www.update-software.com/pdf/CD005136.pdf
Artigo Original | Original Article
One year results of anti-VEGF treatment in pigment epithelial detachment secondary
to macular degeneration
Resultados após um ano de tratamento anti-VEGF para o descolamento do epitélio pigmentado secundário
à degeneração macular
Harun Yüksel1, Fatih M. Türkcü1, Alparslan Şahin1, Muhammed Şahin1, Yasin Çinar1, Abdullah K. Cingü1, Şeyhmus Ari1, İhsan Çaça2
ABSTRACT
RESUMO
Purpose: Pigment epithelial detachment (PED) may be seen in all stages of age-
related macular degeneration (ARMD) and may lead to poor prognosis. In this
study, we retrospectively examined the effect of anti-VEGF treatments in ARMD
patients with vascularized PED.
Methods: Medical records of 15 patients with PED secondary to ARMD were
reviewed retrospectively. The diagnosis of PED was made with fundoscopy, fundus fluorescein angiography and optical coherence tomography. Patients were
treated with intravitreal ranibizumab or/and bevacizumab and followed up for
a minimum of one year. PED height and best corrected visual acuity (BCVA) was
obtained before the first intravitreal anti-VEGF injection and again at the 1st, 3rd,
6th and 12th month after the injection.
Results: The mean baseline BCVA was 0.71 ± 0.48 logarithm of the minimal angle
of resolution (logMAR) unit and the mean baseline PED height was 361 ± 153 µ.
The mean injection count per eye was 3.9 ± 2.9. There was a significant reduce
in mean PED height (247 ± 177 µ) also in 2 eyes PED completely resolved at the
end of the follow up period. The mean BCVA at 12th month (0,69 ± 0,37) were not
different from the baseline record.
Conclusions: This retrospective case series showed that intravitreal anti-VEGF
therapy preserved vision and reduced PED height in PED patients in a one-year
follow-up period.
Objetivo: O descolamento do epitélio pigmentado (DEP) pode ser observado em
todas as fases da degeneração macular relacionada com a idade (ARMD) e pode
propiciar um mau prognóstico. Neste estudo, analisamos retrospectivamente o efeito
dos tratamentos anti-VEGF em pacientes com DMRI e DEP vascularizado. Métodos: Foram revisados prontuários de 15 pacientes com DEP secundário à DMRI.
O diagnóstico do DEP foi feito por meio de fundoscopia, angiofluoresceínografia e
tomografia de coerência óptica. Os pacientes foram tratados com injeção intravítrea
de ranibizumab e/ou bevacizumab e acompanhados por um período mínimo de um
ano. A altura do DEP e a melhor acuidade visual corrigida (AVCC) foi obtida antes e
no primeiro, terceiro, sexto e 12o mês após a primeira injeção. Resultados: A média inicial da AVCC foi de 0,71 ± 0,48 (logaritmo do ângulo mínimo
de resolução unidade - logMAR) e a média inicial da altura do DEP foi 361 ± 153 μ. A
contagem média de injeções por olho foi de 3,9 ± 2,9. Houve uma significativa redução
na altura média do PED (247 ± 177 μ) e, em dois olhos, o DEP estava completamente
resolvido ao final do período de acompanhamento. A acuidade visual média aos 12
meses (0,69 ± 0,37) não foi diferente da inicial. Conclusões: Esta série de casos retrospectiva mostrou que a injeção intravítrea de
terapia anti-VEGF preservou a visão e a reduziu a altura do DEP em pacientes com DMRI
por um período de seguimento de um ano.
Keywords: Vascular endothelial growth factor A/antagonists & Inhibitors; Retinal
pigment epithelium/pathology; Retinal detachment; Macular degeneration/drug
therapy; Aged
Descritores: Fator A de crescimento do endotélio vascular/antagonistas e inibidores;
Epitélio pigmentado da retina/patologia; Descolamento retiniano; Degeneração ma
cular/quimioterapia; Idoso
INTRODUCTION
Age-related macular degeneration (ARMD) is a very common cause
of vision loss especially in elderly patients living in developed countries(1). ARMD is caused by the accumulation of drusen in the macula,
which is the most important part of the retina, and this process ends
in serious irreversible visual impairment. Pigment epithelial detachment (PED) may be seen in all stages of ARMD and may lead to
poor prognosis because of retina pigment epithelial (RPE) tears, submacular haemorrhage and, finally, disciform scars(2,3). ANCHOR and
MARINA studies showed that the vascular endothelial growth factor
inhibitor (anti-VEGF), ranibizumab, was effective in the treatment of
neovascular ARMD and repeated injections improved or preserved
visual acuity (VA)(4,5). However, these large studies did not provide
specific information about ARMD patients with PED. In this study, we
retrospectively examined the effect of anti-VEGF treatments in ARMD
patients with vascularized PED.
Submitted for publication: February 4, 2013
Accepted for publication: May 8, 2013
Study carried out at Dicle University Faculty of Medicine, Department of Ophthalmology, Diyarbakir,
Turkey.
1
2
Physician, Dicle University Faculty of Medicine, Department of Ophthalmology, Diyarbakir, Turkey.
Physician, Dicle University Faculty of Medicine, Department of Ophthalmology, Diyarbakir, Turkey.
METHODS
This retrospective study was performed in the Department of
Ophthalmology at the University of Dicle School of Medicine. The
study was approved by the local ethics committee at Dicle University. The medical records of patients with ARMD were reviewed and
abstracted between January 2008 and December 2012. The demographic and clinical characteristics of the patients were recorded.
The diagnosis of PED was made with fundoscopy, fundus fluorescein angiography (FA) and optical coherence tomography (OCT)
(Stratus, Carl Zeiss Meditec, Dublin, CA)(6,7).
Disclosure of potential conflicts of interest: H.Yüksel, None; F.M.Türcü, None; A.Şahin, None;
M.Şahin, None; Y.Çinar, None; A.K.Cingü, None; Ş.Ari, None; I.Çaça, None.
Correspondence address: Harun Yüksel. Dicle Üniversitesi Tıp Fakültesi, Sur/Diyarbakır, Turkey E-mail: harunyukselll@gmail.com
Arq Bras Oftalmol. 2013;76(4):209-11
209
One year results of anti-VEGF treatment in pigment epithelial detachment secondary to macular degeneration
In this study, the patients were treated with ranibizumab (Lucentis; Genetech Inc., South San Francisco, CA, USA) or/and bevacizumab
(Avastin, Genentech, South San Francisco, CA, USA) and followed up for
a minimum of one year. Baseline best corrected visual acuity (BCVA)
was obtained before the first intravitreal anti-VEGF injection (V0) and
again at the 1st (V1), 3rd (V3), 6th (V6) and 12th (V12) months after the
injection, using the Snellen chart. The treatment modalities used on
the patients were also recorded. BCVA was converted to a logarithm
of the minimal angle of resolution (logMAR units) for analysis. PED
heights were measured during the same visits and noted as PED0,
PED1, PED3, PED6 and PED12. PED height was measured from the
scanned image using the Proportional Process Report Software in
the OCT device (Carl Zeiss Meditec, Dublin, CA), using the method
described by Chan et al.(8) (Figure 1). The following exclusion criteria
were used: intravitreal triamcinolone (IVTA) injection, photodynamic
therapy (PDT), laser photocoagulaton, glaucoma, associated retinal
disease, cataract surgery and loss to follow-up.
Results are presented as mean ± standard deviation (Range).
Friedman and Wilcoxon tests were used for statistic analysis of changes in PED height and BCVA. A p-value less than 0.05 was considered
statistically significant.
RESULTS
The medical records of 324 patients were evaluated between January 2008 and December 2012. Fifteen patients were eligible for the
study (9 males). The mean age of the patients was 70.9 ± 5.5 (61-77)
years. Nine of 15 eyes also had intraretinal fluid and four of these nine
eyes had also RPE tears. The mean injection count per eye was 3.9 ±
2.9 (1-9). Twelve patients received only ranibizumab (n=6) or bevacizumab (n=6) and three patients received both treatments. Three of
the patients with RPE tears received ranibizumab and another three
received bevacizumab.
In the group, the mean V0 was 0.71 ± 0.48 logMAR units and the
mean PED0 was 361 ± 153 µ. In follow-up visits there was no statistically
significant decrease or increase in the mean BCVA (Figure 2). The mean
PED3 and PED12 were lower than the baseline PED height (p=0.003,
p=0.009, respectively, Table 1). At the end of the follow-up period, PED
completely resolved only in two patients. Neither systemic nor local
adverse effects, like uveitis, cataract formation, glaucoma or endoph
thalmitis, were observed throughout the follow-up period.
Figure 1. Measurement of pigment epithelial detachment height according to Chan
et al. method(8).
Figure 2. Best corrected visual acuity of patients during follow up visits.
Table 1. Mean macular thickness changes of patients during follow up
period
Mean PED
height
Prior to
treatment
1st month
3rd month
6th month
12th month
361 ± 153a,b
273 ± 223
241 ± 175
270 ± 207
247 ± 177
= there is a significant difference p=0.003 when compared with 3rd month value;
there is a significant difference p=0.009 when compared with 12th month value;
PED= pigment epithelial detachment.
a
b=
DISCUSSION
It is very difficult to treat patients with ARMD that is also accompanied by PED. The eyes of these patients often have poor prognosis.
The pathogenesis of PED in ARMD is explained by age-related changes in Bruch’s membrane. In elderly patients, Bruch’s membrane
thickens due to the accumulation of lipids and abnormal materials.
This accumulation results in reduced hydraulic conductivity of the
Bruch’s membrane-choroid complex, which leads to a decreased capacity for fluid exchange between the choroidal and retinal pigment
epithelial compartments(9-11).
Anti-VEGF drugs are thought to be effective in treating PED be
cause they reduce vascular RPE permeability. Bevacizumab and rani
bizumab have been efficacious for treating various types of retinal
vascular diseases. Intravitreal injection of those drugs was shown
to be effective in diabetic and veno-occlusive macular edema and
ARMD(5,12,13).
In our study, we investigated the BCVA and PED height of patients
with pigment epithelial detachments due to ARMD, who were treated with anti-VEGF agents over the course of one year. An average
3.9 ± 2.9 (1-9) injections were performed on patients. Repeated injections of ranibizumab and bevacizumab provided a stable BCVA and
reduced PED height, despite the fact that PED was not completely
resolved in most of patients at the end of one year.
210
Many treatments, such as laser photocoagulation and PDT have
been used to treat PED that is associated with ARMD. In PDT studies,
it has been reported that the VA of patients did not increase and that,
in some cases, the patient’s VA decreased due to the development of
RPE tears, depending on the treatment or the natural course of the
disease(14,15). Consequently, on the basis of the association between
PED and inflammation, IVTA treatment was added to the PDT. However, that treatment resulted in complications, such as glaucoma
and cataracts.
Lommatzsch et al. reported that anti-VEGF agents are the most
effective treatment for PED. In their study, they found that anti-VEGF
agents were more effective in the treatment of PED due to ARMD
than triamcinolone acetonide combined PDT therapy(16). Similar to our
study, Chen et al. reported stable or increased vision in PED patients,
secondary to ARMD, when treated with intravitreal bevacizumab in
an average follow-up period of 30 weeks, despite the continuation
of PED(17). However Ritter et al. reported that reduction of PED height
was significant at the 6th month mark, but it was not maintained for
one year in PED patients treated with anti-VEGF(18).
Yüksel H, et al.
The lack of vision increase was thought to be the result of a loss of
function in the photoreceptors due to the presence of long-term RPE
detachment and RPE tears in some of the patients. RPE tears, which
were seen in four (27%) of our cases, are one of the most important
factors affecting VA in patients with PED. RPE tears either appear at
the time of admission or occur after the applied treatment modalities.
The incidence of RPE tears in PED patients secondary to ARMD is
reported in 40% of patients treated with PDT and in 26% of patients
treated with anti-VEGF(19).
In the literature, some publications reported a worsening of VA
due to the occurrence of an RPE tear after the anti-VEGF injection.
Other studies reported no change(20). However, long-term follow-up
of these patients is required and when deciding on the course of
treatment to use, possible complications should be considered.
This study has some limitations. The number of patients included
in the study was not satisfactory because of the one year follow-up
period and the retreatment indications were not standardized because of the retrospective study design. Indocyanin angiography could
not performed to patients. Furthermore, some of the patients had
previously been treated with anti-VEGF drugs. Despite these limitations, this retrospective case series showed that intravitreal anti-VEGF
therapy preserved vision and reduced PED height in PED patients in
a one-year follow-up period. It is important to note, however, that
PED is still difficult to treat and the use of anti-VEGF drugs was not
entirely adequate in completely resolving PED in ARMD patients. We
need prospective large-scale studies on this subject.
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211
The surgical management of massive intraoperative and postoperative suprachoroidal
hemorrhage - anatomic and functional outcomes
O tratamento cirúrgico da hemorragia supracoroidea massiva intraoperatória e pós-operatória:
resultados anatômicos e funcionais
Fabio Lavinsky1,2, Joseph Moisseiev1, Hani Levkovitch-Verbin1
ABSTRACT
RESUMO
Purpose: To describe the clinical characteristics, management and treatment out
comes of patients with post-surgical suprachoroidal hemorrhage (SCH).
Methods: A retrospective cross-sectional study was conducted, in which the
medical records of 9 consecutive patients with SCH admitted to the Goldschleger
Eye Institute were reviewed.
Results: The mean age was 74 years (range 61-84) and the mean follow-up time
was 38.3 ± 0.1 months (range 4-87 months). Four cases were associated with
glaucoma surgeries (2 trabeculectomies and 2 Ahmed valve implantations), 3 cases
with cataract surgery and 2 cases with pars plana vitrectomy. The diagnosis of
SCH was ranging from intra-operative to 8 days following the primary procedure.
Most patients underwent posterior sclerotomies and drainage alone or combined
with pars plana vitrectomy in a mean timing of intervention of 11 ± 4 days. At one
month of follow-up the visual acuity improved in 7 eyes and remained stable in 2,
compared to the VA prior to the drainage operation. The mean VA improved from
2.03 to 1.285 logMAR units at 1 month following the drainage procedure (p=0.003).
Conclusions: SCH still remains a challenging complication of many ophthalmological procedures. The current surgical management may improve visual acuity
though the general prognosis is still poor.
Objetivos: Descrever as características clínicas, manejo e desfechos do tratamento
de pacientes com hemorragia supracoroidea pós-operatória.
Métodos: Um estudo transversal foi realizado. Neste foram revisados os prontuários
médicos de nove pacientes consecutivos com hemorragia supracoroidea que foram
admitidos para internação no Serviço de Oftalmologia do Goldschleger Eye Institute.
Resultados: A média de idade foi 74 anos (61-84) e o tempo médio de seguimento
foi 38,3 ± 0,1 meses (4-87 meses). Quatro casos foram associados com cirurgias de
glaucoma (2 trabeculectomias e 2 implantes de válvula de Ahmed), 3 casos com cirurgia
de catarata e 2 casos com vitrectomia. O diagnóstico de hemorragia supracoroidea foi
de intraoperatório até 8 dias após o procedimento primário. A maioria dos pacientes
se submeteu a esclerectomia posterior e drenagem com ou sem vitrectomia via pars
plana combinada. A média do tempo de intervenção foi 11 ± 4 dias. Após um mês
de seguimento a acuidade visual melhorou em 7 olhos e se manteve estável em 2,
comparando com a acuidade visual prévia a cirurgia de drenagem. A acuidade visual
media melhorou de 2,03 para 1,285 logMAR após 1 mês de seguimento depois da
drenagem por esclerectomia posterior (p=0,003).
Conclusões: Hemorragia supracoroidea ainda é uma complicação desafiadora de
muitos procedimentos oftalmológicos. O manejo cirúrgico atual pode melhorar a
acuidade visual apesar de o prognostico desta afecção ser ainda reservado.
Keywords: Choroid hemorrhage/complications; Cataract extraction; Glaucoma/
surgery; Vitrectomy; Ophthalmologic surgical procedures/complications
Descritores: Hemorragia da coroide/complicações; Extração de catarata; Glaucoma/
cirurgia; Vitrectomia; Procedimentos cirúrgicos oftalmológicos/cirurgia
INTRODUCTION
Appositional suprachoroidal hemorrhage (SCH) (“expulsive hemorrhage”) is considered as one of the most devastating complication
of intraocular surgery. Most studies report poor prognosis with low
visual acuity at follow up(1-3). SCH has been reported to occur in the
setting of all types of intraocular procedures, including cataract extraction(4-7), penetrating keratoplasty(8-10), glaucoma filtering surgery(10-12),
and vitreoretinal surgery(13-15). The incidence of expulsive SCH during
glaucoma filtering surgery has been reported to be approximately
0.15%(10) The hypotonous eye may be more susceptible to episcleral
venous pressure fluctuations induced by post-operative Valsalva ma
neuvers and therefore, be more vulnerable to rupture of cilliary arteries(1,16). Myopia was also described as a potential risk factor(1).
The systemic risk factors described to be associated with SCH
such as advanced age, systemic hypertension (HTN), and arteriosclerosis are presumably related to increased sclerosis and fragility of the
choroidal vessels(1,17,18). Other risk factors implicated in these patients
are blood dyscrasias or coagulation defects and diabetes mellitus.
There were also reports of an association between the development
of SCH in the perioperative period with a history of liver disease and
with preoperative use of digoxin(7).
If an intraoperative SCH is suspected, immediate tamponade
of the open globe is required. This can be accomplished by either
direct digital pressure or rapid suturing of all surgical incisions. The
long-term benefit of performing posterior sclerotomies immediately
is doubtful. The creation of drainage sclerotomies in an experimental
model, during the acute formation of SCH, resulted in a further increa
se in the size of the SCH with marked extension of the hemorrhage
into the retina and vitreous(19). The mean clot lysis time for an SCH
has been reported to be between 7 and 14 days. Attempts to drain
an SCH before some degree of clot lysis has occurred are usually
unsuccessful(1). Some recent reports have advocated early surgical
Submitted for publication: April 26, 2013
Study carried out at Goldschleger Eye Institute, Tel Aviv University.
1
2
Physician, The Goldschleger Eye Institute, Sheba Medical Center, Tel Aviv University, Tel Hashomer,
Israel.
Physician, Grupo de Estudos e Pesquisa em Oftalmologia; Instituto de Oftalmologia Lavinsky, GEPO Porto Alegre, RS, Brazil.
212
Disclosure of potential conflicts of interest: F.Lavinsky, None; J.Moisseiev, None; H.Levkovitch-Verbin,
None.
Corresponding author: Hani Levkovitch-Verbin. Goldschleger Eye Institute, Sheba Medical Center,
Tel-Hashomer, Israel, 52621 - E-mail: halevko@hotmail.com, hani.verbin@sheba.health.gov.il
Lavinsky F, et al.
The primary procedures associated with the SCH are presented
in table 1. There were four cases of glaucoma surgery (2 trabeculectomies and 2 Ahmed valve implantations), three cataract operations
and two pars plana vitrectomies (PPV) for retinal detachment treatment. Intraoperative SCH occurred in the three cataract operations,
and the other six cases had postoperative SCH, within 6 ± 3 days (range 1 to 8 days) of the operation. On US examination there were kissing
choroidals in 7 eyes. Retinal detachment was observed in 1 eye.
The surgical management of the SCH was performed 11 ± 4 days
following the SCH, as our policy is to wait at least 1 week prior to intervention, to allow for the liquefaction of the suprachoroidal blood.
The procedure included: insertion of an anterior chamber maintainer
(ACM) at the limbus for inducing the pressure required for the drainage and volume replacement, exposure of the sclera and bridle sutures for the extraocular muscles, and posterior drainage sclerotomies
(beginning 5-8 mm posterior to the limbus and extending 3-5 mm
posteriorly). The exact site of the sclerotomies was based on the US
findings, corresponding to the locations where the SCH was thicker.
PPV was performed in 6 of the 9 eyes at the same operation (Table 1),
with silicone oil injection in five of these eyes. Additional procedures
following the drainage procedures included removal of the silicone
oil in 4 eyes (cases 4-6, 8), removal of the Ahmed valve (case 7), and
reinsertion of the Ahmed valve tube to the anterior chamber (case 1).
At the end of the follow up the retina was attached in all 9 eyes, and
the silicone oil was retained in 2 eyes.
At one month of follow-up the visual acuity improved in 7 eyes
and remained stable in 2, compared to the VA prior to the drainage
operation (Table 2). The mean VA improved from 2.03 to 1.285 logMAR
units at 1 month following the drainage procedure. In Snellen units,
the VA improved from hand motions to 20/385. This corresponds to
more than quadrupling of the visual angle (p=0.003). In the 7 eyes
that improved, the mean change was 1 logMAR unit, which is more
than 10 lines of improvement. The VA slightly deteriorated at the end
of the follow, to 1.441 (20/552) (p=0.027).
intervention in the management of SCH(20-22). Despite all the surgical
efforts, most studies report poor visual prognosis with a low final
visual acuity at follow up(17,23,24).
The indications and timing of drainage procedures in patients
with a postoperative SCH depend on the ocular findings. These include the presence of retinal detachment, central retinal apposition
(“kissing choroidals”), vitreous incarceration into the surgical wound,
or a breakthrough vitreous hemorrhage; increased IOP; retained lens
material during cataract surgery; and intractable eye pain. The surgical approach includes drainage through posterior sclerotomies, often
in association with vitrectomy for removal of vitreous hemorrhage
and/or retained lens material, and for reattaching detached retina(1).
The present study describes the anatomic and functional results
of drainage surgery in a consecutive series of cases with suprachoroidal hemorrhage.
METHODS
This is a cross-sectional retrospective study based on chart data
from 9 eyes of 9 consecutive patients diagnosed with intraoperative
or postoperative suprachoroidal hemorrhage (“expulsive hemorrhage”) in our Institute between March 2002 and December 2007. The
review of the charts was authorized by the hospital IRB. All patients
had at least 4 month of follow up.
The data retrieved included demographic, ocular and systemic
details of the patients prior to the procedure complicated by SCH
(the primary procedure), following the SCH and prior to the second
procedure (the drainage procedure), and throughout the follow up.
Visual acuity (VA) was measured with Snellen chart, and the values
were converted to logMAR for statistical analysis.
RESULTS
There were 3 females and 6 males, and the mean age was 74 years
(range 61-84). The average follow-up time was 38.3 ± 30.1 months
(range 4-87 months). Table 1 describes the demographic, systemic
and ocular data of these patients. Three patients were taking aspirin
when the SCH occurred, 6 patients had documented glaucoma and
3 patients had high myopia.
DISCUSSION
In this study we present the results of a retrospective study that
includes nine consecutive cases of intraoperative and postopera-
Table 1. Demographic and clinical characteristics
Patient. gender,
age, eye
Systemic
conditions
Ocular
pathology
Primary
procedure
Extent of
SCH by US
SCH
procedure
Additional
procedures
1. F, 77, LE
HTN, Hyperlipidemia
Glaucoma
Ahmed valve
implant
Kissing
SCD & removal of
tube
Reinsertion of tube
(8 mo later)
2. M, 84, LE
None
BE glaucoma
Trabeculectomy
Kissing
SCD
None
3. M, 74, LE
HTN, Aspirin
BE glaucoma, BE uveitis
Trabeculectomy
Non-kissing & RD
SCD & PPV & SO
None
4. M, 65, RE
HTN, IHD, Aspirin
None
PPV due to RD
Non-kissing
SCD & PPV & SO
SO removal
(7 mo)
5. F, 79, RE
CLL
BE glaucoma, BE myopia,
BE advanced cataract
ICCE
Kissing
SCD & PPV & SO
SO removal
(6 months)
6. M, 81, RE
IHD, sp CVA,
HTN, aspirin
None
PHACO + PCIOL
Kissing
SCD & PPV & SO
SO Removal
(9 months)
7. M, 77, RE
HTN, IHD, DM,
BE glaucoma
Ahmed valve
Implant
Kissing
SCD & PPV
Removal of the
Ahmed valve (4 months)
8. M, 68, RE
None
BE glaucoma
ECCE + ACIOL
with vitreous loss
Kissing
SCD & ACIOL
removal
SO removal
(2 months)
9. F, 61, RE
None
High myopia, aphakia,
retinal detachment
PPV due to
RD recurrent
Kissing
SCD & PPV & SO
None
F= female; M= male; LE= left eye; RE= right eye; HTN= hypertension; IHD= ischemic heart disease; DM= diabetes mellitus; SCH= suprachoroidal haemorrhage; SCD= suprachoroidal
haemorrhage drainage; SO= silicone oil; PPV= pars plana vitrectomy.
213
The surgical management of massive intraoperative and postoperative suprachoroidal hemorrhage anatomic and functional outcomes
Table 2. Visual acuity - in logMAR
Patient
Prior to SCD
1 month follow-up
1
2.2
0.8
Last follow-up (months)
2.0 (87)
2
1.9
0.5
0.5 (52)
3
2.2
1.3
1.6 (04)
4
1.9
0.5
0.2 (39)
5
2.2
1.7
1.7 (22)
6
1.9
1.0
1.6 (09)
7
1.9
2.0
1.4 (66)
8
1.6
1.7
1.9 (61)
9
2.5
2.0
2.2 (05)
Average
2.0
1.3
1.4 (38.3)
SCD= suprachoroidal hemorrhage drainage.
tive SCH in our department between 2002 and 2007. All patient
included in this study had at least one systemic or ocular risk factor
for developing SCH. The more prevalent systemic risk factors were
HTN and aspirin treatment, a finding that is in agreement with other
studies(17,18,25). Two well established ocular risk factors, glaucoma and
myopia, were also common among our patients(17,26).
Moshfeghi et al. published a case control study with 37 cases
with SCH. Twenty-six cases (71%) of SCH were related to a glaucoma
operations. In a multivariate analysis they found that age, prior history of PPVx, and a history of glaucoma were each associated with
a significantly greater risk of SCH(2). In a British case-control study by
Ling et al. the risk factors for developing SCH after cataract surgery
included: older age (p<0.001), taking at least one cardiovascular
medication (p<0.001), peripheral vascular disease (p=0.014), hyperlipidemia (p=0.005), glaucoma (p<0.001), elevated preoperative in
traocular pressure (p<0.001), sub-Tenon’s local anaesthesia (p<0.001),
topical local anesthesia (p<0.001), the lack of orbital compression
following local anesthesia (p<0.001), posterior capsule rupture before SCH (p<0.001), elective extracapsular cataract extraction (ECCE)
(p=0.038), and phacoemulsification conversion (p<0.001)(4). In our
study SCH occurred intraoperatively in the cataract cases, and postoperatively in the glaucoma and vitrectomy cases, most likely due
to severe postoperative hypotony.
The best timing for the surgical drainage of the SCH is still undetermined. In our series the mean time from the occurrence of SCH
to the drainage procedure was 11 days, similar to the report of Meier
and Wiedermann - 11.3 days (range 6-20 days)(3).
In our cases vitrectomy and silicone oil injection were performed
in the majority of the cases, in order to prevent rebleeding or redetachment, and to maintain the vitreous space until the eye stabilizes.
Preservation of the globe and attached retina were achieved in all
nine eyes. The VA improved significantly in seven eyes, but overall the
final VA remained poor, except in one case (case 4) that improved dramatically. Wang et al.(17) reported that after follow-up of 6 months, 12
eyes (30.77%) had a final VA >4 ⁄ 200, and 12 eyes (30.77%) measured
no light perception (NLP), but they included cases of hemorrhagic
AMD, that usually have very bad prognosis. Scott et al.(27) also reported poor visual prognosis after appositional SCH - only 15 (29.4%)
patients achieved either their prehemorrhage VA or 20/200 or better,
and 14 (27.5%) patients had no light perception. Feretis et al. published a case series of five patients with SCH. All cases received medical
therapy and underwent secondary surgical intervention with radial
sclerotomies combined with vitrectomy, use of perfluorocarbon, and
silicone oil. In all cases, anatomic restoration of ocular structures was
achieved. The distance visual acuity improved in all cases(28).
214
CONCLUSION
Suprachoroidal hemorrhage is a severe operative complication,
and if left untreated is likely to result in phthysis and complete loss
of all vision. Timely surgical management with drainage of the blood
and often vitrectomy with silicone oil injection is indicated for restoring some vision and preserving the globe.
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12. Ruderman JM, Harbin TS Jr, Campbell DG. Postoperative suprachoroidal hemorrhage
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13. Ghoraba HH, Zayed AI. Suprachoroidal hemorrhage as a complication of vitrectomy.
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14. Lakhanpal V, Schocket SS, Elman MJ, Dogra MR. Intraoperative massive suprachoroidal hemorrhage during pars plana vitrectomy. Ophthalmology. 1990;97(9):1114-9.
15. Piper JG, Han DP, Abrams GW, Mieler WF. Perioperative choroidal hemorrhage at pars
plana vitrectomy. A case-control study. Ophthalmology. 1993;100(5):699-704.
16. Beyer CF, Peyman GA, Hill JM. Expulsive choroidal hemorrhage in rabbits. A histopathologic study. Arch Ophthalmol. 1989;107(11):1648-53.
17.Wang LC, Yang CM, Yang CH, Huang JS, Ho TC, Lin CP, et al. Clinical characteristics
and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan. Acta
Ophthalmol. 2008;86(8):908-12.
18. Cantor LB, Katz LJ, Spaeth GL. Complications of surgery in glaucoma. Suprachoroidal
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19. Lakhanpal V. Experimental and clinical observations on massive suprachoroidal he
morrhage. Trans Am Ophthalmol Soc. 1993;91:545-652.
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1986;104(10):1455-8.
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Adaptação de lentes de contato após implante de anel intracorneano no ceratocone
Luciane Bugmann Moreira1, Ricardo Augustho Canto Bardal2, Leila Roberta Crisigiovanni3
ABSTRACT
RESUMO
Purpose: Evaluate contact lenses fitting after intracorneal ring implantation for
keratoconus, its visual acuity and comfort.
Methods: Retrospective study of patients undergoing contact lenses fitting,
after intracorneal ring for keratoconus. The criterion for contact lens fitting was
unsatisfactory visual acuity with spectacle correction as referred by the patients.
All patients were intolerants to contact lenses prior to intracorneal implantation.
Visual acuity analysis was done by conversion of Snellen to logMAR scales. The
comfort was evaluated according subjective questioning of good, medium or
poor comfort.
Results: Nineteen patients were included in the study. Two patients (10.5%)
did not achieved good comfort with contact lenses and underwent penetrating
keratoplasties. All the others 17 patients showed good or medium comfort. Four
rigid gas-permeable contact lenses were fitted, one piggyback approach, 3 toric soft
contact lenses, 2 soft lenses specially design for keratoconus and 7 disposable soft
lenses. The average visual acuity improved from 0.77 ± 0.37 to 0.19 ± 0.13 logMAR
units after contact lenses fitting.
Conclusion: Contact lens fitting after intracorneal ring is possible, provides good
comfort, improves visual acuity, and therefore, may postpone the need for penetrating keratoplasty.
Objetivos: Avaliar a adaptação de lentes de contato após implante de anel intracorneano para ceratocone perante a acuidade visual e o conforto. Local: Hospital de
Olhos do Paraná, Curitiba, Paraná.
Métodos: Estudo retrospectivo de pacientes submetidos à adaptação de lentes de
contato após implante de anel intracorneano em pacientes com ceratocone. A impossibilidade do uso de lentes de contato foi usada como critério para indicação de
implante de anel intracorneano, sendo a adaptação de lentes de contato reservada
aos pacientes com acuidade visual menor que o desejado após o implante. A acuidade
visual foi considerada segundo a correlação entre a tabela de Snellen e a tabela de
logMAR. O conforto foi avaliado segundo o questionamento subjetivo entre lentes
confortáveis, conforto moderado e lentes desconfortáveis.
Resultados: Foram incluídos 19 pacientes no estudo. Apenas 2 pacientes (10,5%) não
alcançaram um conforto adequado com as lentes de contato, sendo encaminhados
para transplante de córnea. Nos outros 17 pacientes foram adaptadas: 4 lentes de
contato rígidas gás-permeáveis, 1 sistema à cavaleiro, 3 lentes de contato gelatinosas
tóricas, 2 lentes para ceratocone e 7 lentes gelatinosas descartáveis. A acuidade visual
média melhorou de 0,7 ± 0,3 para 0,2 ± 0,1 unidades logMAR após a adaptação das
lentes de contato.
Conclusão: Adaptação de lentes de contato após anel intracorneano é possível, resulta
em bom conforto e melhora da acuidade visual. Todas lentes de contato gelatinosas
adaptadas demonstraram-se confortáveis. Esta adaptação pode ser útil aos pacientes
que desejem adiar o transplante de córnea.
Keywords: Contact lenses; Corneal stroma; Prostheses and implants; Keratoconus
Visual acuity; Adaptation, ocular
Descritores: Lentes de contato; Substância própria; Próteses e implantes; Ceratocone;
Acuidade visual; Adaptação ocular
INTRODUCTION
Keratoconus is an eye condition where the cornea becomes thinner
and starts to protrude, forming an irregular cone-like shape(1). This ectasia normally begins at puberty and progressively leads to different
degrees of visual impairment varying according to the stage of the
disease(2). At the beginning may be asymptomatic, however, with the
evolution it induces a low visual acuity or image distortion and may
be associated with photophobia, glare and ocular itching(3).
The treatment of keratoconus is customized and depends on the
severity of the disease, ocular sensitivity and psychosocial aspects of
the patient(4,5). For visual improvement can be used: glasses, soft contact lenses, rigid gas permeable (RGP) contact lenses, intracorneal rings
segments (ICRS) implantation, lamellar keratoplasty, penetrating
keratoplasty and the photorefractive keratectomy (PRK) associated
with crosslinking(2,6-8).
Spectacles provide good visual acuity (VA) only in the early stages of the disease, in more regular corneas(2). With the progression
of the astigmatism, RGP contact lenses become more effective to
improve vision(9). Many lens designs and methods can be used for
this purpose. Multicurve sets with specific parameters designed for
keratoconic corneas have many curves progressively flatter to align
with the cornea as best as possible are the most used. However, there
are other options as aspheric contact lens that vault the apex of the
cone and align the more normal peripheral cornea, hybrid contact
lenses manufactured by combining a highly oxygen-permeable rigid
center with a soft peripheral skirt, scleral and semi-scleral lenses with
a large diameter. Custom soft contact lenses specially designed can
correct mild-to-moderate keratoconus also can be used. Piggyback
fit is a method fitting a RGP lens over a soft lens and has been used
successfully in patients with difficulties in adapting RGP lenses(10,11).
Surgical treatment is reserved for cases when contact lenses can
no longer be fitted, become intolerable or do not provide good visual
acuity(12). Alternative surgical techniques, such as the implantation of
ICRS have been developed to try to avoid or postpone penetrating
keratoplasties(13).
Submitted for publication: December 21, 2012
Study carried out at Hospital Universitário Evangélico de Curitiba - Curitiba (PR), Brasil.
1
2
3
Physician, Faculdade Evangélica de Medicina do Paraná - Curitiba (PR), Brasil.
Physician, Hospital Universitário Evangélico de Curitiba - Curitiba (PR), Brasil.
Physician, Curitiba (PR), Brasil.
Disclosure of potential conflicts of interest: L.B.Moreira, None; R.A.C.Bardal, None; L.R.Crisgiovanni,
None.
Correspondence address: Ricardo Augustho Canto Bardal. Hospital Universitário Evangélico de
Curitiba. Rua Brigadeiro Franco, 125 - Apto. 42 - Curitiba (PR) - 80430-210 - Brazil
E-mail: ricardobardal@hotmail.com
215
Intracorneal ring segments are intended to change the corneal
curvature, improving visual acuity with absence of endothelial rejection; however, some patients may remain with residual ammetropias,
requiring optical correction(14). In this context, the adaptation of contact lenses after implantation of ICRS becomes an option to improve
visual acuity of patients who are not satisfied(9).The same lens designs
and methods used for keratoconus can be used for this purpose.
The prevalence of the disease in the population, the technical
diffi culty to fit contact lenses after ICRS(15), and the lack of scientific
articles in the literature about the subject stimulated this research.
The purpose of this work is to evaluate visual acuity and comfort
of contact lenses fitting after ICRS implantation for keratoconus.
METHODS
Retrospective study with analysis of medical records of patients
who underwent contact lenses fitting after ICRS for keratoconus held
at Hospital de Olhos do Paraná, located in Curitiba, Paraná, Brazil.
The study was reviewed and approved by the Ethics and Research
Committee of the Positivo University.
The inclusion criterion for contact lens fitting was unsatisfactory
visual acuity with spectacle correction as referred by the patients.
Complete eye exam was performed, followed by corneal topography by (EyeSys Technologies®, Dallas, USA).
Visual acuity analysis was done by conversion of Snellen to logMAR
scales(16). Student t-test was used to compare visual acuity. Spectaclecorrected visual acuity was considered prior to ICRS implantation,
considering that all patients were intolerant to contact lenses prior
to surgery. Uncorrected visual acuity was considered after ICRS
implantation and before contact lens fitting, as well as after contact
lens fitting.
Analysis of comfort was done by a subjective parameter, being
judged by the patient and classified in: good, moderate or poor
comfort.
RESULTS
A total of 19 patients were included in the study, being 9 men and
10 women, age ranged from 18 to 41 years old (mean of 27 years old).
The analysis of visual acuity from each patient can be found in
table 1. Average visual acuity before ICRS implantation was 1.26 ±
0.63 logMAR and improved to 0.77 ± 0.37 logMAR after ICRS implantation and before the adaptation of contact lenses (p<0.001). Further
improvement was observed after contact lens fitting over the ICRS
up to 0.19 ± 0.13 logMAR (p<0.001).
Table 2 shows the 19 contact lenses adapted, 12 (63%) were soft
and 7 (37%) were rigid gas-permeable lenses. Analyzing the comfort
reported by patients, 13 of them refered good comfort (68.5%),
being 12 soft lenses and one RGP lens users; 4 (21%) patients had
moderate comfort with the lenses tested, 3 lenses of these were RGP
and one with a piggyback fit; and 2 (10.5%) patients, who needed
piggyback fit, judged poor comfort and were referred to undergo
corneal transplant.
DISCUSSION
The present study analyzes a series of 19 cases, being able to show
percentages, different from the literature that shows only isolated
case reports(17-20).
The visual acuity improvement observed in this series is compatible with already published studies. This clearly demonstrates the role
of contact lens in the improvement of visual acuity of these patients,
however the data found in the literature do not allow to estimate by
which time interval this accuracy is maintained.
Evaluating the comfort performance through a subjective range, it was observed that most of the patients (68.5%) obtained a
216
Table 1. Visual acuities of each patient before intracorneal ring segment
(ICRS) implantation (spectacle-corrected), after ICRS implantation and
before contact lens fitting (uncorrected) and after contact lens fitting
(uncorrected)
Before ICRS
Before CL
After CL
01
Patient
1.9
0.6
0.1
02
0.5
0.3
0.3
03
1.0
0.7
0.5
04
0.5
0.5
0.3
05
1.9
1.0
0.3
06
1.9
0.5
0.2
07
0.6
0.5
0.2
08
1.9
1.0
0.2
09
1.3
1.0
0.2
10
1.9
0.6
0.3
11
1.9
1.9
0.0
12
1.9
1.0
0.1
13
0.5
1.0
0.3
14
1.0
1.0
0.0
15
0.5
0.5
0.2
16
1.3
0.7
0.0
17
0.3
0.3
0.0
18
1.3
0.5
0.2
19
1.9
1.0
0.2
Average
1.26
0.77
0.19
Standard deviation
0.63
0.37
0.13
ICRS= Intracorneal ring segment; CL= contact lens.
Table 2. Subjective comfort score of each patient separately
Patient
Contact lens fitted
Comfort
01
Soft lens specially designed for keratoconus
Good
02
Toric soft lens
Good
03
Disposable soft lens
Good
04
Toric soft lens
Good
05
Good
06
Good
07
Good
08
Rigid gas-permeable lens
Moderate
09
Moderate
10
Toric soft lens
Good
11
“Piggyback” system
Poor
12
Good
13
Good
14
Moderate
15
Good
16
Good
17
Moderate
18
Soft lens specially designed for keratoconus
Good
19
Poor
Moreira LB, et al.
good comfortable with proposals lenses, showing that contact lens
fitting after intracorneal ring is feasible and with good acceptance
by patients.
Making an analogy of this information with others studies on
quality of life in patients with keratoconus, we can assume that the
patient using lenses associated with corneal ring improves not only
your vision but also your quality of life(5).
Analyzing the lenses data, it was found that all soft lenses reached
a good comfort and only one RGP lens adapted reached the same. It
goes in accordance with data found in the literature that refer higher
comfort for soft lenses(21).
For 7 cases soft contacts did not reach good visual acuity and
needed a rigid gas permeable lens fitting, however the RGP lens
demonstrated a worse comfort. In an attempt to give more comfort,
we tried the piggyback fitting in 3 patients. Despite the attempt, 2
patients continued their poor comfort and were referred to undergo
corneal transplant. Piggyback fitting was well tolerated in a prior
published case report(18).
CONCLUSION
Contact lenses fitting after intracorneal rings segments implantation is possible and provides good comfort with improvement of
visual acuity. For those patients studied, soft lenses had better acceptance in comparison with the other lenses tested.
REFERENCES
1. Krachmer JH, Feder RS, Belin MW. Keratoconus and related noninflammatory corneal
thinning disorders. Surv Ophtalmol. 1984;28(4):293-322.
2. Kanski JJ, Menon J. Oftalmologia clínica: uma abordagem sistemática. Rio de Janeiro:
Elsevier; 2004.
3. Kara-José N, Bechara SJ. Ceratocone. In: Newton KJ, Belfort Jr R. organizadores. Córnea
clínica - cirúrgica. São Paulo: Roca; 1996. p.359-66.
4.Buxton JN, Keatles RH, Hoefle FB. The contact lens correction of keratoconus. In:
Dabezies OH Jr. The CLAO guide to basic science and clinical practice. Orlando: Grune
& Statton; 1984. p.55.1-14.
5.Moreira LB, Alchieri JC, Belfort R Jr., Moreira H. Aspectos psicossociais do paciente
com ceratocone. Arq Bras Oftalmol. 2007;70(2):317-22.
6.Keating A, Pineda R 2nd, Colby K. Corneal cross linking for keratoconus. Semin
Ophthalmol. 2010;25(5-6):249-55.
7.Renesto AC, Sartori M, Campos M. [Cross-linking and intrastomal corneal ring segment]. Arq Bras Oftalmol. 2011;74(1):67-74. Portuguese.
8. Espandar L, Meyer J. Keratoconus: overview and update on treatment. Middle East
Afr J Ophthalmol. 2010;17(1):15-20.
9. Coral-Ghanem C, Alves MR. [Fitting Monocurve and Bicurve (Soper-McGuire design)
rigid gas-permeable contact lenses in keratoconus patients: a prospective randomized comparative clinical trial]. Arq Bras Oftalmol. 2008;71(3):328-36. Portuguese.
10.Yamazaki ES, da Silva VC, Morimtsu V, Sobrinho M, Fukushima N, Lipener C. [Kera
toconus special soft contact lens fitting]. Arq Bras Oftalmol. 2006;69(4):557-60.
Portuguese.
11.Gomes JP, Lani LA, Juliano YG, Pedro EA, Anbar R. Uso da topografia de córnea na
adaptação de lente de contato rígida gás-permeável em pacientes portadores de
ceratocone: descrição de técnica e resultados preliminares. Arq Bras Oftalmol. 2002;
65(5):519-23.
12. Mascaro VL, Scarpi MJ, Hofling-Lima AL, Sousa LB. Transplante de córnea em ceratocone: avaliação dos resultados e complicações obtidos por cirurgiões experientes e
em treinamento. Arq Bras Oftalmol. 2007;70(3):395-405.
13. Moreira H, Oliveira CS, Godoy G, Wahab SA. Anel intracorneano de Ferrara em ceratocone. Arq Bras Oftalmol. 2002;65(1):59-63.
14. Colin J, Cochener B, Savary G, Malet F. Correcting keratoconus with intracorneal rings.
J Cataract Refract Surg. 2000;26(8):1117-22. Comment in: J Cataract Refract Surg. 2000;
26(8):1099-100. J Cataract Refract Surg. 2001;27(3):341.
15. Cunha PF, Alves EA, Silva FB, Cunha GH. Estudo das modificações oculares induzidas
pelo implante estromal do anel de Ferrara em portadores de ceratocone. Arq Bras
Oftalmol. 2003;66(4):417-22.
16.Johnson GJ, Minassian DC, Weale RA, editors. The epidemiology of eye diseases.
London: Chapman & Hall; 2003.
17. Hladun L, Harris M. Contact lens fitting over intrastromal corneal rings in a keratoconic patient. Optometry. 2004;75(1):48-54. 18. Smith K, Carrell J. High-Dk. piggyback contact lenses over intacs for keratoconus: a
case report. Eye Contact Lens. 2008;34(4):238-41.
19. Uçakhan OO, Kanpolat A, Ozdemir O. Contact lens fitting for keratoconus after Intacs
placement. Eye Contact Lens. 2006;32(2):75-7.
20. Dalton K, Sorbara L. Fitting an MSD (mini scleral design) rigid contact lens in advanced keratoconus with INTACS. Cont Lens Anterior Eye. 2011;34(6):274-81.
21. Leal F, Lipener C, Chalita MR, Uras R, Campos M, Hofling-Lima AL. Lente de contato de
material híbrido em pacientes com ceratocone e astigmatismo miópico composto.
Arq Bras Oftalmol. 2007;70(2):247-54.
217
Avaliação de diferentes métodos para determinar adição em présbitas
Leonardo Catunda Bittencourt1, Milton Ruiz Alves2, Daniel Oliveira Dantas3, Pablo Felipe Rodrigues4, Edson dos Santos-Neto5
ABSTRACT
RESUMO
Purpose: The optical correction of presbyopia must be handled individually. Our
aim was to compare the methods used in addition to the refractive near vision,
with the final addition used in presbyopic patients.
Methods: Eighty healthy subjects with a mean age of 49.7 years (range 40 to 60
years) were studied. Tentative near additions were determined using four different techniques: one-half amplitude accommodation with minus lenses (AAL);
one-third accommodative demand with positive lens (ADL); balanced range of
accommodation with minus and positive lenses (BRA) and crossed cylinder test
with initial myopisation (CCT). The power of the addition was then refined to
arrive at the final addition.
Results: The mean tentative near additions were lower than the final addition
for ADL and BRA addition methods. The mean differences between tentative and
final additions were low for all the tests examined (less than 0.25 D). The intervals
between the 95% limits of agreement differed substantially and were always higher
than ±0.50 D.
Conclusion: All the methods used displayed similar behavior and provided a
tentative addition close to the final addition. The coefficient of agreements (COA)
detected suggests that every tentative addition should be adjusted according to
the particular needs of the patient.
Objetivo: A correção óptica da presbiopia deve ser manejada individualmente. Nosso
intuito é de comparar os métodos usados para calcular a adição na elaboração do
grau para perto em pacientes présbitas.
Métodos: Oitenta pacientes com média de idade de 49,7 anos (intervalo de 40 a
60 anos) foram estudados. Adições provisórias foram determinadas usando quatro
diferentes técnicas: metade da amplitude de acomodação com lentes negativas
(AAL); um terço da demanda acomodativa com lentes positivas (ADL); média arit
mética da acomodação usando lentes positivas e negativas (BRA); teste com o
cilindro cruzado com miopização (CCT ). O grau final foi refinado até chegar a
grad uação final da adição.
Resultados: A média das adições nos testes foram menores que as adições finais nos
métodos ADL e BRA. As diferenças médias entre os testes e o grau final foram baixas
em todos os métodos (menores que +0,25 D). Os intervalos entre os 95% dos limites
da concordância diferenciaram substancialmente e foram todos maiores que ±0.50 D.
Conclusão: Todos os métodos usados demonstraram comportamentos similares e
forneceram resultados bem próximos da adição final. O coeficiente de concordância
(COA) detectado, sugere que todos os métodos utilizados devem ser ajustados de
acordo com as necessidades do paciente.
Keywords: Accommodation, ocular; Eyeglasses; Presbyopia/therapy; Depth per
ception; Lenses
Descritores: Acomodação ocular; Óculos; Presbiopia/terapia; Percepcão de profun
didade; Lentes
INTRODUCTION
Presbyopia (from the Greek presbys, elder or old, and, -ops, eye)
is a progressive condition where the ability to focus on near objects
is gradually lost as part of the natural aging process(1). Presbyopia
tends to manifest itself around the age of 40 to 45 years, at an extremely productive stage in life and its inadequate correction will
compromise a person’s work performance with the economic loses
that this entails(2).
The optical correction of presbyopia must be handled indivi
dually. The amount of accommodation varies not only from person to
person, but also from eye to eye. Therefore it is necessary to prescribe
the weakest lenses which are tolerable for good and comfortable
near vision in order to find harmony between the processes of accommodation and convergence(3). Normally, a tentative addition is
established first and this is then adjusted to obtain the final addition(4).
In the case of correction it is necessary to respect working distance to
which a person has to adapt their vision and which is very important
in various professions. An error in reading addition is one of the most
common causes of patients’ unhappiness with their new spectacles(5).
For example, when the range of clear vision is not well determined,
patients may complain that the new spectacles are fine for reading,
but that they are now unable to see a computer screen(6). A classic
clinical rule, used by most ophthalmologists, is that the patient
should be able to support up to half of its full range of amplitude of
accommodation (AA)(7).
Many variables affecting accommodative testing are difficult to
control, including illumination, depth of focus, target size, contrast,
visual angle, lens affectiveness, monocular and binocular cues, kines-
Submitted for publication: August 21, 2012
Study carried out at Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo USP - São Paulo (SP), Brazil.
Physician, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo - USP - São
Paulo (SP), Brazil.
2
Physician, Setor de Córnea e Doenças Externas do Hospital das Clínicas da Faculdade de Medicina,
Universidade de São Paulo - USP - São Paulo (SP), Brazil.
3
Statistician, São Paulo (SP), Brazil.
4
Physician, Setor de Córnea e Doenças Externas no Hospital das Clínicas da Faculdade de Medicina,
Universidade de São Paulo - USP - São Paulo (SP), Brazil.
5
Physician, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo - USP - São
Paulo (SP), Brazil.
1
218
Disclosure of potential conflicts of interest: L.C.Bittencourt, None; M.R.Alves, None; D.O.Dantas,
None; P.F.Rodrigues, None; E.Santos-Neto, None.
Correspondence address: Leonardo Catunda Bittencourt. Rua Loefgren, 441 - Apto. 153 - São
Paulo (SP) - 04040-030 – Brazil - E-mail: leocatunda@gmail.com
Número do projeto no comitê de ética: 0821/10 HCFMUSP.
Bittencourt LC, et al.
thetic feedback, and the rate at which accommodative demand is
changed during testing(8). We feel it would be more reasonable to use
the method that provides the tentative addition closest to the final
addition. It is felt that it would accelerate the entire evaluation process. This study was designed to compare final addition values with
the tentative additions obtained using the tests: one-half amplitude
accommodation with minus lenses (AAL); one-third accommodative
demand with positive lens (ADL); balanced range of accommodation
with minus and positive lenses (BRA) and crossed cylinder test with
initial myopisation (CCT).
METHODS
An observational, cross-section study was carried out. The re
search followed the tenets of the Declaration of Helsinki, and Insti
tutional Review Board approval was obtained. All patients were
informed about the purpose of the study and gave informed consent
before inclusion. Patients were sequentially evaluated from February
to November 2011. The age range of the subjects was 40 to 60 years
(mean: 49.7, standard deviation: ± 5.0 years). Fifty (62.5%) patients
were women and thirty (37.5%) were men. The spherical refractive
error ranged from -5.75 to +5.00 D with up to -1.50 D of astigmatism.
All patients required addition; and presented corrected monocular visual acuity (VA) greater than or equal to 6/7.5 at distance and
near; anisometropy less than 1.50 D; no binocular problems; no history
of refractive surgery, strabismus or amblyopia; no ocular pathology;
no systemic disease that could affect accommodation, fusional
vergences and/or ocular motility; and no medication likely to have
side effects on accommodation and/or on fusional vergences. All the
patients were submitted to the four different methods.
Demographic and clinical data were obtained, including data
of birth and gender. Each subject underwent a comprehensive oph
thalmologic examination including review of medical history, sub
jective refraction followed by binocular balancing, with Snellen
optotypes presented at 6 meters, best correct visual acuity, slit-lamp
biomicroscopy, ocular tonometry and fundoscopic examination.
The subjective refractions were conducted to maximize the amount
of positive sphere and minimize the amount of negative sphere
without compromising distance visual acuity. Astigmatism was adjusted using the Jackson cross-cylinder. All the procedures used to
determine tentative addition were performed in random order. The
final addition for a 40 cm working distance was established for each
patient by adjusting the tentative addition (AdT) obtained using one
to the four methods selected at random:
AAL Method - one-half amplitude accommodation (AA)
with minus lenses
This procedure assumes that the prescription of addition should
not use more than one-half of the total amplitude, the working
distance in this study was 40 cm, so the tentative addition value was
calculated as 2.50 D -1/2(AA), where AA is the mean amplitude of
accommodation between both eyes. To measure the AA, the subject was instructed to read the fine print on the nearpoint test card,
placed at 40 cm, while the accommodative demand was increased
using minus lens in 0.25 D steps by making a conscious accommodative effort.
ADL Method - one-third accommodative demand (AD)
with positive lens
To measure the AD, with distance refraction in the phoropter
and the nearpoint test card at 40 cm, the subject was instructed to
read the fine print on the test card. Then, plus lenses in 0.25 steps
were added until the fine print on test card become clear (L), so the
AD was calculated as 2.50 D - L, and the tentative addition value was
calculated as 1/3AD + L.
BRA Method - balanced range of accommodation
with minus and positive lenses
This procedure assumes that the prescription of addition is to
place the dioptric midpoint of the range of clear vision at the patient’s
customary near working distance. The dioptric midpoint was determined, with the patient’s distance refraction in the phoropter and the
near point test card at 40 cm, by adding plus power lenses binocularly
until the subject was no longer able to read the fine print on the test
card, and by adding minus power lenses until the patient was no
longer able to read the fine print, so the tentative addition value was
calculated as the arithmetical media of these values.
CCT Method - crossed cylinder test with initial myopisation
A cross-grid target was placed on the near point rod of the phoropter at the patient’s working distance, in this study at a 40 cm, and
the crossed cylinder (with the minus axis vertical) was positioned
before both eyes. With the distance correction in place, were added
plus lenses until the vertical lines on the target become as clear and
dark as the horizontal lines, this was the tentative addition value.
The data were analyzed using the Analyze-it program for Microsoft
Excel (Leeds, UK. See http://www.analyse-it.com statistics program)(6).
The level of agreement between the different tentative addition tests
and the prescribed addition, or reference addition, was estimated using
the Bland-Altman method(9,10). Correlation is normally used to evaluate
the agreement between two methods. The problem of correlation is that
it is high when the points of the scatter plot fall on any straight line with
positive derivative(6). The factors determined were the mean difference
(Bias), the standard deviation (SD), the coeffi cient of agreement (COA=
1.96 x SD) and the limits of agreement at the 95% level (Bias ± COA). The
t-test for paired samples was also used to establish the significance of the
differences. The level of significance was set at p<0.05.
RESULTS
Table 1 provides data on the level of agreement between each
of the tests used to determine tentative addition in presbyopes and
the final addition. The mean differences between tentative and final
additions were low (less than 0.25 D) and the coefficients of agreement
are moderately high in clinical terms, as they always exceeded 0.50 D.
Figure 1 shows plots for each subject of the difference between
the tentative addition (AdT) and the final addition (AdF) versus the
mean of the two additions. The lines at U and L, respectively, show
the upper and the lower 95% limits of agreement. The same scales
are used in all figures to aid the visual comparison of biases and
agreement intervals.
DISCUSSION
The evaluation and management of presbyopia are important
because significant functional deficits can occur when the condition is left untreated. Undercorrected or uncorrected presbyopia
can cause significant visual disability and have a negative impact
on the patient’s quality of life(3). Careful distance refraction provides
the foundation for determining the management of presbyopia(3).
The optical correction for presbyopia is the sum of the refractive
correction for distance plus the power of the near addition(3). The
nature of the distance correction itself influences the near addition(11).
Determining the addition in the presbyope is an essential clinical
test for evaluating patients over the age of 40 years(7). The results of
these tests are usually refined according to the subject’s preference
in terms of image clarity and a comfortable near task distance(12). The
refinement stage will be shorter and easier if the tentative addition is
determined as precisely as possible(6).
In this study, the aim was to establish the level of agreement bet
ween tentative additions determined by four methods and the final
addition. The results indicate that the mean differences between tenArq Bras Oftalmol. 2013;76(4):218-20
219
Table 1. Agreement between tentative and final addition
Mean
BIAS
p value
COA
AAL
1.925
-0.003 (AAL>Adf)
0.9400
± 0.725
ADL
1.803
-0.100 (ADL<Adf)
0.0003
± 0.700
BRA
1.784
-0.100 (BRA<Adf)
0.0008
± 0.550
CCT
1.941
-0.019 (CCT>Adf)
0.5705
± 0.577
AdF= final addition; COA= coefficient of agreement (1.96 x standard deviation); Tentative
add: AAL= one-half amplitude accommodation (AA) with minus lenses; ADL= one-third
accommodative demand with positive lens; BRA= balanced range of accommodation
with minus and positive lenses; CCT= crossed cylinder test with initial myopisation.
tative and final additions were low for all the tests examined (less than
0.25 D). The agreement intervals ranged from about ± 0.50 D to ± 0.75 D
(Table 1 and Figure 1). This means that the tentative addition provided
by the AAL and ADL methods could be up to 0.75 D higher or lower
than the final addition prescribed to the patient. Likewise the tentative
addition provided by BRA and CCT methods could be up to 0.50 D
higher or lower than the final addition prescribed for the patient. The
ADL based addition underestimated the addition (p=0.0003). Likewise,
the BRA based addition underestimated the addition (p=0.008).
The different methods used to determine tentative addition
based on objective or subjective tests are not very reliable. Besides
that, characteristics of the patient, such as visual needs, work habits,
previous prescriptions may contribute to the different results, and
consequently the wide COA obtained.
Antona et al.(6) compared final addition values with the tentative
additions obtained using dynamic retinoscopy, amplitude of accom
modation, age expected addition, fused cross cylinder without initial
myopisation, fused cross cylinder with initial myopisation, near duochrome and the negative relative accommodation/positive relative
accommodation (NRA/PRA) balance. For these authors the method
that provided the result closest to the final addition power was the
age-expected AA procedure. For them this test showed the narrowest agreement interval and the least bias.
As a result of this study the choice of method will be affected
because all tests were similar in accuracy for the tentative addition,
in other aspects, such as ease of application and time taken, the
age expected addition method for assessing the tentative addition
is an easy and effective test and it takes no time. A table of age-ex
pected accommodative amplitudes can serve as a starting point for
determining a near addition(13-15). However, the values in the tables
represent population averages, and the measured amplitude of accommodation for the individual patient may differ significantly from
the age-group average. Measuring the amplitude of accommodation
provides a more appropriate indication of the patient’s accommodative ability and range of clear vision(3).
These findings suggest that all the studied techniques displayed
similar behavior and provided a tentative addition close to the final
addition. Finally, the wide agreements detected here suggest that
every tentative addition should be adjusted according to the particular needs of the patient.
REFERENCES
Figure 1. Plots for each subject of the difference between the tentative addition and
the final addition (AdF- AdT) against the mean of both. The lines at U and L, respectively,
indicate the upper and lower 95% limits of agreement.
220
1.Koretz JK. Presbyopia. In: Levin LA, Albert DM, editors. Ocular disease: mechanism
and management. China: Saunders Elsevier; 2010. p.258-66.
2. Bito LZ. Presbyopia. Arch Ophthalmol. 1988;106(11):1526-7.
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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
Vital Paulino Costa1, Italo Mundialino Marcon2, Roberto Pedrosa Galvão Filho3, Roberto Freire Santiago Malta4
Abstract
RESUMO
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 me
dicação para redução da PIO apresenta sintomas decorrentes de doença da superfície
ocular (DSO).
Keywords: Glaucoma; Ocular hypertension/therapy; Dry eye syndromes/drug the
rapy; Preservatives, pharmaceutical/therapeutic use; Brazil
Descritores: Glaucoma; Hipertensão ocular/quimioterapia; Síndrome do olho seco/
quimioterapia; Conservantes farmacêuticos/uso terapêutico
Submitted for publication: November 9, 2012
Accepted for publication: March 12, 2013
Funding: Alcon Research, Ltd. sponsored this study and provided the services of medical writers
and editors for assistance with preparing this manuscript.
Study carried out Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo - São
Paulo (SP), Brazil.
Disclosure of potential conflicts of interest: V.P.Costa, has received a grant from Alcon and he
is a consultant and a board member for Alcon and Merck, has received a grant and provision of
writing assistance, medicines, equipment, or administrative support from the Instituto de Olhos
do Recife; I.M.Marcon, None; R.P.Galvão Filho, has received a grant and provision of writing assistance, medicines, equipment, or administrative support from the Instituto de Olhos do Recife;
R.F.S.Malta, has received a grant from Faculdade de Medicina da Universidade de São Paulo.
Physician, Glaucoma Service, Universidade Estadual de Campinas - Campinas (SP), Brazil.
Physician, Glaucoma Service, Santa Casa de Porto Alegre - Porto Alegre (RS), Brazil.
Physician, Research Center, Instituto de Olhos do Recife - Recife (PE), Brazil.
4
Physician, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo - São Paulo
(SP), Brazil.
1
2
3
Corresponding author: Vital Paulino Costa. Universidade Estadual de Campinas - UNICAMP. Rua
Mato Grosso, 306 - São Paulo (SP) - 01239-040 - Brazil - E-mail: vp.costa@uol.com.br
The study protocol and the participating investigators were approved as number 22/01/2011 by
the Comitê de Ética em Pesquisa do Hospital Samaritano affiliated with the Comitê Nacional de
Ética em Pesquisa (CONEP). Because this was a noninterventional study, it was not registered on
a public clinical trials registry.
221
Introduction
Ocular surface disease (OSD) is a multifactorial ocular condition
associated with inadequate tear film volume, tear film instability, and
damage to the ocular surface(1). Clinically meaningful signs such as
rapid tear film breakup, high tear osmolarity, and increased ocular
surface staining also may be observed in patients with OSD(2). Individuals with OSD may experience the symptoms of ocular dryness,
burning/stinging, itching, irritation, tearing, foreign body sensation,
redness, and blurred vision, at varying levels of severity(2). Because of
the overlap of the signs and symptoms of OSD versus dry eye disease,
the literature to date has often treated these diseases interchangeably. Studies suggest that OSD or dry eye disease can negatively affect
overall quality of life(3), functional visual acuity(4), and the ability to
carry out daily tasks (eg, driving and participating in sports and other
leisure activities, such as reading and cooking)(4).
Approximately 15% of the general elderly population in the Uni
ted States experiences some level of symptomatic OSD(5). Studies in
the United States(6), Australia(7), and Brazil(8) have indicated that the
prevalence of OSD or dry eye is higher in glaucoma patients than in
the nonglaucomatous population. The etiology of OSD in patients
with glaucoma is thought to be multifactorial. Anterior segment
ocular disorders such as allergy, blepharitis, dry eye, or eyelid anatomical abnormalities may contribute to the onset or exacerbation of
OSD(2). The use of preservative-containing topical ocular medications
to lower intraocular pressure (IOP) may be another key factor. Topical
ocular IOP-lowering drugs that contain the preservative benzalkonium chloride (BAK) may trigger or exacerbate OSD by inducing
ocular surface damage(9). The effects of BAK on the ocular surface may
increase over time due to chronic exposure, since IOP-lowering me
dications are generally administered daily for many years, and since
multiple medications are sometimes required to achieve and maintain desired IOP-lowering effects(9).
A recent global study noted that patients who were enrolled
at clinics in Latin America (Argentina, Colombia, and Mexico), had
OSD that was significantly worse than the OSD of Asian patients or
Caucasian patients globally(10). Since race and geography may be
important to OSD prevalence, this study was designed to determine
the prevalence of ocular surface complaints in a Brazilian population
of patients with glaucoma or ocular hypertension who were on an
IOP-lowering regimen.
Methods
This multicenter, noninterventional, single-visit study at four
study centers in Brazil evaluated the ocular surface complaints of patients with glaucoma or ocular hypertension. Upon entry, all patients
provided their written informed consent. An independent Ethics
Committee approved the protocol and the qualifications of all of the
participating investigators. The study was conducted in accordance
with Good Clinical Practices and the ethical principles described
within the Declaration of Helsinki.
During a regularly scheduled clinic visit, eligible patients completed
the Ocular Surface Disease Index (OSDI) questionnaire. Demographic
information, medical histories, and use of concomitant medications,
including artificial tears, were recorded. Eligible patients were men
and women of any race or ethnicity, at least 18 years of age, who had a
best-corrected visual acuity of at least 20/60 Snellen in each eye, who
were diagnosed with ocular hypertension or glaucoma (closed-angle,
open-angle, pseudoexfoliation, or pigment dispersion), and who were
receiving any topical ocular regimen to lower IOP.
The OSDI is a 12 item, disease specific quality-of-life questionnaire used to quantify the effect of dry eye on vision-related quality
of life. The OSDI questionnaire has been validated for its test-retest
reliability and its usefulness to clinically differentiate among absence
of OSD, mild to moderate OSD, and severe OSD(11). The questionnaire
includes three subscales: ocular discomfort (OSDI symptoms), func222
tioning (OSDI-function), and environmental triggers (OSDI-triggers).
The individual items within the subscales refer to a 1-week recall
period; possible responses to each item are based on the frequency
of the associated disturbance. Each response was scored based on
a scale that ranged from 0 (none of the time) to 4 (all of the time).
The average score for each of the 12 items rated by each patient
was transformed to a scale ranging from 0 to 100, with higher scores
representing worse disability. Ocular surface disease index 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), as previously described(11,12).
Descriptive statistics (including number, percentage, mean,
standard deviation, and range) were calculated for demographics,
baseline characteristics, and OSDI scores. Mean OSDI scores also were
summarized by the categorical time since diagnosis of glaucoma or
ocular hypertension (ie, 1 category for patients with a diagnosis shorter than the mean number of years since diagnosis and 1 category for
patients with a diagnosis longer than or equal to the mean number
of years since diagnosis); the comparison of the mean values of those
2 subgroups was performed using a 2-sample t-test, with inferences
drawn at an alpha level of 0.05. Comparisons between groups of the
distribution of patients with normal OSDI scores vs. all other patients
and of the distribution of patients with severe OSD scores vs. all other
patients were performed using a Chi-square test. The interaction
between OSDI scores and duration of current glaucoma therapy was
analyzed using a Pearson correlation. Statistics were analyzed using
Statistica version 5.1/97.
Results
A total of 173 patients were enrolled at 4 investigational centers
in Brazil (Table 1). The 173 patients were 13 to 88 years of age, with
a mean (± standard deviation, SD) age of 61.2 (± 14.3) years. The
majority of patients (68.8%) were Caucasian and 65.3% were women.
Most patients (89.0%) had a diagnosis of glaucoma (primary openangle glaucoma, 74.0%; closed-angle glaucoma, 13.3%; open-angle
glaucoma with pseudoexfoliation, 1.7%) and the remainder (11.0%)
had ocular hypertension. Fourteen patients were excluded from
the analysis for protocol deviations (8 patients who were using an
“unknown” number of IOP-lowering medications, and 6 patients who
were using more than 1 medication), leaving 159 patients eligible for
analysis.
One patient did not answer all of the OSDI questions, yielding
evaluable OSDI data for 158 patients. Of those, 37.3% (59 of 158) had
OSDI scores indicating absence of OSD. The remainder of the population - approximately two thirds of the patients (62.7%, 99 of 158;
95% confidence interval 55.2% to 70.2%) - had OSDI scores indicating
some degree of OSD. Scores indicated mild OSD in 33 of 158 patients
(20.9%), moderate OSD in 27 of 158 patients (17.1%), and severe OSD
in 39 of 172 patients (24.7%); (Figure 1).
In the overall population of 173 patients, 40 had an unknown
duration of diagnosis of glaucoma or ocular hypertension. Of those
with a known duration (n=133), the mean (± SD) time since diagnosis
of glaucoma or ocular hypertension was 6.0 (± 6.9) years. That mean
value was used as the basis for dividing patients into categories of
duration since glaucoma diagnosis (ie, < 6 years and ≥ 6 years). After
excluding for protocol deviations related to number of IOP-lowering
medications and for incomplete responses to the OSDI questionnaire, 120 patients were evaluable for duration of diagnosis versus
OSDI score. Mean OSDI scores were higher (worse) for patients in the
longer-duration diagnosis category than for those in the shorter-du
ration diagnosis category. Specifically, evaluable patients who had a
diagnosis of <6 years (n=81) had a mean (± SD) OSDI score of 22
(± 20) units, indicating mild severity OSD, while patients with a
diagnosis of 6 years or longer (n=39) had a mean (± SD) OSDI score
of 25 (± 20) units, indicating moderate severity OSD. However, diffe-
Costa VP, et al.
Table 1. Demographic and baseline characteristics
Total
(N=173)
Characteristics
Age, years
Mean (standard deviation)
Range (minimum, maximum)
061.2 (14.3)
(13, 88)a
Sex, n (%)
Men
060 (34.7)
Women
113 (65.3)
Race, n (%)
Caucasian
119 (68.8)
Black
028 (16.2)
Asian
003 (01.7)
Other
023 (13.3)
Diagnosis type, n (%)
Ocular hypertension
019 (11.0)
Primary open-angle glaucoma
128 (74.0)
Open-angle glaucoma with pseudoexfoliation
003 (01.7)
Open-angle glaucoma with pigment dispersion
000 (00.0)
Closed-angle glaucoma
023 (13.3)
Time since diagnosis, years
006 (06.9)
< 6 years, n (%)
086 (49.7)
≥ 6 years, n (%)
047 (27.2)
Unknown duration, n (%)
040 (23.1)
Number of glaucoma medications
001.0 (00.2)
1, n (%)b
159 (91.9)
2 or 3, n (%)
006 (03.5)
Unknown, n (%)
008 (04.6)
= one patient younger than 18 years of age was enrolled and included in the study
endpoint analyses. b= Included monotherapies and fixed-combination therapies.
a
OSD = ocular surface disease.
Figure 1. Ocular surface disease index (OSDI) score category results for patients with
glaucoma or ocular hypertension at four study centers in Brazil.
rences in OSDI scores in terms of duration of diagnosis were not statistically significant by t-test of means (P=0.49) or when investigated
by Pearson correlation (P=0.77). The poorer mean OSDI score in the
longer-duration group (with respect to the shorter-duration group)
appeared to be due to a smaller proportion of patients without OSD
and a larger proportion of patients with severe OSD, as shown in
figure 2A. These proportions were not significantly different by Chisquare tests between shorter-duration and longer-duration groups
(P=0.43 for severe OSD and P=0.26 for absence of OSD) as shown in
figure 2B.
Discussion
In individuals with glaucoma or ocular hypertension, ocular surface complaints are common. Scores on OSDI questionnaires in this
study indicated that 62.7% of patients who had glaucoma or ocular
hypertension and who were using 1 IOP-lowering medication had
mild, moderate, or severe OSD. That overall prevalence of OSD was
slightly higher than the reported prevalence of dry eye among glaucoma patients in Germany (53%)(13) or the OSDI-based prevalence of
OSD among glaucoma patients in the United States (48%-59%)(1,14) or
globally (59.2%)(10). When compared to other OSDI-based studies, the
prevalence of severe OSD in patients with glaucoma or ocular hypertension observed in this study (24.7%) was slightly higher than its
prevalence in one previous study in the United States (13.8%)(14), was
approximately similar to its prevalence in a global study (20.3%)(10),
and was slightly lower than its prevalence (27%) reported in another
study in the United States(1). However, results from the current study
of patients using 1 IOP-lowering medication cannot easily be compared with other studies of patients using 1 or more IOP-lowering medications, since many of those studies have reported that relationships
may exist between higher numbers of IOP-lowering medications and
worse signs or symptoms of OSD or dry eye disease(1,11,13,14).
The high prevalence of mild, moderate, or severe OSD as classified in this study may be multifactorial, with factors including anterior
segment ocular disorders such as allergy, blepharitis, dry eye, or eyelid
anatomical abnormalities(2). Moreover, environmental issues in Brazil
may influence ocular surface integrity(15). In addition, results may be
partially attributed to frequent use of BAK-preserved medications(9).
Due to its broad spectrum of antimicrobial efficacy and its effects on
the tight junctions between corneal epithelial cells (which facilitates
ocular penetration of active compounds), BAK is the most widely
used preservative in ophthalmic preparations(9,16). When compared
with preservative-free medication, long-term topical ocular use of
BAK-preserved medications in patients with glaucoma has been
associated with ocular surface alterations. One such alteration is a
decrease in goblet cell density associated with BAK-preserved therapy that was significantly larger than the decrease with unpreserved
therapy(17). Another such alteration is lower tear production volume
and greater tear film instability in patients using BAK-preserved therapies versus those using unpreserved therapy(18). These BAK-induced
effects may be reversible or partially reversible in some cases; switching patients with mild OSD from a BAK-preserved IOP-lowering
therapy to an alternatively preserved IOP-lowering therapy resulted
in a mean OSDI score that indicated absence of clinically significant
OSD and that was significantly better than the mean OSDI score for
patients who continued on a BAK-preserved IOP-lowering therapy(19).
Alternatives to BAK-preserved therapies include preservative-free
therapies and alternatively preserved therapies. Various advantages
of preservative-free therapies for ocular health have been demonstrated(17,18,20). Alternative preservatives (eg, Purite® from Allergan; SofZia®
buffer system and Polyquad® preservative from Alcon) are intended
to be gentler to the ocular surface than BAK(21) and have been used
in reformulating BAK-preserved IOP-lowering medications, which
may offer patients with glaucoma or ocular hypertension alternate
therapies and may reduce their exposure to BAK. Preservative-free
223
A
B
Figure 2. A) Proportions of ocular surface disease (OSD) Index categories, sorted by duration of diagnosis. B) P-values show chi-square results for severe OSD versus any other OSD
category (left panel) or no OSD versus any other OSD category (right panel).
or alternatively preserved therapies may be important to potentially
help preserve the ocular surface health of patients who use ophthalmic product(s) over many years.
Some studies have reported associations between worse OSD
or dry eye and longer-term use of IOP-lowering medications (in
terms of a surrogate for that variable - longer duration of diagnosis).
These associations have been observed as trends over time(13) and
as significant differences between duration categories(10). In the
current study, patients who had glaucoma or ocular hypertension
for <6 years had mean OSDI scores of 22 ± 20, indicative of mild
OSD, while patients with longer histories of glaucoma or ocular
hypertension had worse mean OSDI scores (25 ± 20), indicating
moderate OSD; however, the difference in scores was not statistically significant.
Some study limitations were related to the multitude of variables.
This was evident in the wide variation (ie, large SDs) in the mean
OSDI scores for the population, which made data interpretation
complicated. The pathogenesis of OSD in patients with glaucoma is
multifactorial. While the role of preserved topical ocular drops in OSD
has been well-studied, other anterior segment ocular conditions (eg,
blepharitis, allergies, or anatomic abnormalities of the eyelid[s]) are
known to exacerbate OSD(2). Collecting data about comorbid conditions and determining the impact of all these factors on the OSD
prevalence was beyond the scope of this study.
An additional study limitation was the nature of the OSDI trans
lation. While a recent translation to Portuguese of the OSDI has been
reported to have good inter-observer and intra-observer agree224
ment(22), that version was not available to us at the time of our study.
Supplementing the subjective OSDI with objective assessments of
the ocular surface would have made it possible to determine the
prevalence of OSD rather than simply presenting the prevalence
of its symptoms. However, the purpose of the study was solely to
examine the prevalence of ocular surface complaints in Brazilian
patients on IOP-lowering therapy, and this aim was accomplished.
Although it would have been interesting to determine the prevalence of OSD, the correlation between the signs and symptoms of
OSD has been poor(23).
Despite study limitations, findings for these patients in Brazil were
generally in agreement with studies in other countries that observed
a high prevalence of ocular surface complaints among patients with
glaucoma or ocular hypertension. A recent report examining factors
related to glaucoma treatment compliance among Brazilian patients
revealed that side effects of eye drops were the most frequently cited reason for noncompliance(24). This suggests that patients scoring
high on the OSDI, half of whose 12 items deal directly with ocular
discomfort, may be at risk for noncompliance.
COnCLUSION
Thus, Brazilian clinicians should be aware of the high prevalence
of abnormal OSDI scores among patients with glaucoma or ocular
hypertension and should address any ocular surface complaints in
these patients so that they can maintain compliance with their IOPlowering medications.
Costa VP, et al.
Acknowledgements
Alcon Research, Ltd. sponsored this study and provided the
services of medical writers and editors for assistance with preparing
this manuscript.
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índice da doença da superfície ocular para a língua portuguesa. Arq Bras Oftalmol.
2012;75(1):24-8.
23. Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with dry eye disease. Cornea. 2004;23(8):762-70.
24. Silva LR, Paula JS, Rocha EM, Rodrigues ML. Fatores relacionados à fidelidade ao tra
tamento do glaucoma: opiniões de pacientes de um hospital universitário. Arq Bras
Oftalmol. 2010;73(2):116-9.
Simpósio Internacional de Córnea
do Hospital de Olhos de Sorocaba
24 a 26 de outubro de 2013
Sorocaba (SP)
Organização:
Hospital de Olhos de Sorocaba
Informações:
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225
Intracapsular dexamethasone implant in patients undergoing phacoemulsification
and intraocular lens implantation
Implante intracapsular de dexametasona em pacientes submetidos a facoemulsificação
e implante de lente intraocular
Lucas Monferrari Monteiro Vianna1, Lincoln Leme Freitas1, Walton Nosé 1, Liliane Andrade Almeida Kanecadan1, Eduardo Sone Soriano1,
Cristina Muccioli1, Rubens Belfort Jr.1
ABSTRACT
RESUMO
Purpose: To relate the outcomes of 7 eyes of 7 patients in which a dexamethasone
0.7 mg implant (Ozurdex®) was placed inside the capsule bag after phacoemulsification and intraocular lens (IOL) implantation and compare with the fellow
eyes, that were operated by the same technique and received dexamethasone
eyedrops in the post-operatory.
Methods: Report review of 7 eyes of 7 patients who received dexamethasone
0.7 mg implant after phacoemulsification and IOL, comparing them to the fellow
eyes. All the patients underwent bilateral cataract surgery, with one month interval,
by the same technique and by experienced surgeons, without complications. Post
operatory medication consisted of moxifloxacin eye drops for all the 14 eyes and
topic dexamethasone for the 7 eyes that did not received the implant.
Results: Nuclear cataract classification (according to LOCS III) was 3.28 ± 0.69 in
the implant eye group and 3.14 ± 0.83 in the fellow eye group. Postoperative best
spectacle correct visual acuity (BSCVA) was 0.85 ± 0.12 and 0.87 ± 0.13, respectively
in the implant and fellow eye groups. The intraocular pressure remained stable
and similar to the pre-operative measurements. Anterior chamber reaction and
cornea edema were similar in both groups in the follow-up. Two of the four no
sutured pellet migrated to the anterior chamber during the first post-operative
week and had to be repositioned. Another no sutured pellet dislocated and
remained partially inside the capsule bag. The 3 patients with IOL haptic-sutured
pellet had no complications.
Conclusions: In the present study, dexamethasone 0.7mg implant were effective
in controlling the inflammation after phacoemulsification and IOL implantation,
with no significant side effects.
Objetivos: Relatar os resultados de 7 olhos de 7 pacientes em que foi realizado o
implante de dexametasona 0,7 mg (Ozurdex ®) no saco capsular após facoemulsificação e implante de lente intraocular (LIO) e comparar com os olhos contralaterais,
que foram operados pela mesma técnica e receberam colírio de dexametasona no
pós-operatório.
Métodos: Relato de casos de 7 olhos de 7 pacientes que receberam o implante de
dexametasona 0,7 mg após facoemulsificação e implante de LIO, comparando-os
com os olhos contralaterais. Todos os pacientes foram submetidos a cirurgia de
catarata bilateral, com intervalo de um mês entre as cirurgias, pela mesma técnica,
por cirurgiões experientes e sem complicações. No pós-operatório foi utilizado colírio
de moxifloxacino em todos os 14 olhos e dexametasona tópica nos olhos que não
receberam o implante.
Resultados: A classificação da catarata de acordo com o LOCS III foi de 3,28 ± 0,69 no
grupo que recebeu o implante e 3,14 ± 0,83 no grupo de olhos contralateral. A acuidade
visual com melhor correção foi de 0,85 ± 0,12 e 0,87 ± 0,13 respectivamente nos grupos
com e sem implante. A pressão intraocular permaneceu estável e similar aos valores
pré-operatórios. A reação de câmara anterior e o edema de córnea foram similares
nos dois grupos. Dois dos 4 implantes sem sutura migraram para a câmara anterior
durante a primeira semana de pós-operatório e necessitaram de reposicionamento.
Outro implante sem sutura teve deslocamento e permaneceu parcialmente dentro
do saco capsular. Os 3 pacientes com implante suturado não tiveram complicações.
Conclusão: No presente estudo, o implante de dexametasona 0,7 mg foi efetivo no
controle da inflamação intraocular após cirurgia de facoemulsificação e implante de
LIO, sem efeitos colaterais significativos.
Keywords: Cataract/classification; Dexamethasone/administration & dosage; Ad
ministration, topical; Phacoemulsification
Descritores: Catarata/classificação; Dexametasona/administração & dosagem; Ad
ministração tópica; Facoemulsificação
INTRODUCTION
Topical anti-inflammatory drugs usually associated to antibiotics
continues to be the standard practice to reduce the inflammation
resulting from intraocular surgery in spite disadvantages related to
poor corneal penetration, difficulties with patient’s compliance and
ocular toxicity(1-3).
Ozurdex® 0.7 mg (dexamethasone 0.7 mg implant) is a 0.46 mm
in diameter and 6 mm in length FDA approved biodegradable implant to be injected into the eye (vitreous) to treat different retinal
and uveal pathologies. Several studies have shown that it’s a safety
and efficient dispositive(4). It has also been used off label to treat non
necrotizing non infectious scleritis(5).
Study carried out at Vision Institute and Ophthalmology Department, Universidade Federal de São
Paulo - UNIFESP - São Paulo (SP), Brazil.
1
Physician, Vision Institute and Ophthalmology Department, Universidade Federal de São Paulo UNIFESP - São Paulo (SP), Brazil.
226
METHODS
Report review of 7 eyes of 7 patients who received a fragment
of dexamethasone 0.7 mg implant after phacoemulsification and
hydrophilic foldable IOL (Type 7B, Alcon®) implantation at the São
Paulo Hospital, Federal University of São Paulo, comparing them to
the fellow eyes. All the patients underwent bilateral cataract surgery,
Disclosure of potential conflicts of interest: L.M.M.Vianna, None; L.L.Freitas, None; W.Nosé,
None; L.A.A.Kanecadan, None; E.S.Soriano, None; C.Muccioli, None; R.Belfort Jr, None.
Correspondence address: Lucas Monferrari Monteiro Vianna. Rua Botucatu, 821 - São Paulo (SP),
04023-900 - Brazil - E-mail: lucasmmvianna@yahoo.com.br
Aprovado pelo Comitê de Ética Médica da UNIFESP através da Plataforma Brasil sob número 15199.
Vianna LMM, et al.
with one month interval, by the same technique and by experienced
surgeons, without complications. Cataracts were graded according
to the “Lens Opacities Classification System” III (LOCS III)(6). Patients
were aged 58 to 71 years old. None of them had glaucoma or others
ophthalmologic diseases.
Four eyes received a half pellet of the implant (3 mm) inside the
bag, positioned between one of the IOL’s haptic and the equator of
the capsular bag, without suturing. Three eyes received one-third
pellet of the implant (2 mm), sutured to one of the IOL haptic with
nylon 10.0. Postoperatory medication consisted of moxifloxacin
eye drops, four times a day, during one week for all the 14 eyes
and topic dexamethasone for the 7 eyes that did not received the
implant. Patients were followed with biomicroscopy, tonometry and
ophthalmoscopy on days 1, 3, 7, 30, 60 and 90 after surgery. Wide
scanning angle Ultrasound Bio Microscopy (UBM) (50-MHz transducer, immersion technique, Vumax II, Sonomed) was used to evaluate
the operated eyes on day 2. Anterior chamber reaction was graded
according to SUN Working Group(7). None of them had glaucoma or
others ophthalmologic diseases.
The study was approved by the Institutional Review Board and
followed the tenets of the Declaration of Helsinki. None of the patients had any expenses with the treatment and none of the authors
received any type of compensation, including financial for the study.
RESULTS
Nuclear cataract classification (according to LOCS III) was 3.28
± 0.69 in the implant eye group and 3.14 ± 0.83 in the fellow eye
group, varying from 2 to 4 in both groups. In the first day, the cornea
edema was 1.0 ± 0.53 in average in both groups and no detectable
corneal edema in none of groups from the seventh day on. Preoperative best spectacle correct visual acuity (BSCVA) using Snellen
chart was 0.25 ± 0.11 in the implant group and 0.27 ± 0.13 in the
fellow eye group. On the third month postoperative, BSCVA was
0.85 ± 0.12 and 0.87 ± 0.13, respectively. The intraocular pressure
(IOP) remained stable and similar to the preoperative measurements
during the postoperative visits. Anterior chamber reaction (ACR) is
shown in figure 1.
The UBM performed on day 2 showed the positioning of the im
plant and its relations with the iris, IOL haptic and the capsular bag
(Figure 2).
Two of the four no sutured pellet migrated to the anterior chamber during the first post-operative week and had to be repositioned
(Figure 3). Another no sutured pellet dislocated and remained partially inside the capsule bag (Figure 4). The 3 patients with IOL hap
tic-sutured pellet had no complications.
DISCUSSION
Reducing or eliminating the responsibility of administering postoperative anti-inflammatory drops would be a significant benefit to
patients since lack of drug compliance is frequent.
The ideal postoperative drug delivery system for cataract surgery should have high and prolonged drug level only at the desired
site, with safety and short-acting enough to diminish the risks from
side effects or allergy(8). Topical anti-inflammatory medication after
cataract surgery continues to be the standard practice, but it does
not have some of this related attributes. The intraocular absorption
of the topical preparation is low, with fluctuations in the anterior
chamber concentration and may be absorbed systemically by the
nasal and gastric mucosa(9). Options like subconjunctival injection,
collagen shield and intracameral injection fail to provide a therapeutic drug level of more than several hours(1). Drugs like Surodex (Oculex
Pharmaceuticals, Inc., Sunnyvale, CA) containing dexamethasone 60
micrograms was used after phacoemulsification and its safety and
efficacy has been related in the literature(8,10).
Figure 1. Average clinical assessment of anterior chamber reaction in the group with
dexamethasone implant and in the fellow eye (control). Anterior chamber reaction was
graded according to SUN Working Group(7).
Figure 2. Dexamethasone 0.7 mg implant and its relations with the iris, IOL haptic and
the capsular bag.
Figure 3. Dexamethasone 0.7 mg implant migration to the anterior chamber before
and after repositioning.
Figure 4. Non-sutured pellet on days 7 (left) and 90 (right) postoperative.
227
Intracapsular dexamethasone implant in patients undergoing phacoemulsification and intraocular lens implantation
In our study we have reported the outcomes of 7 patients who
received a dexamethasone 0.7 mg implant inside the bag after phacoemulsification and IOL implantation.
Clinical slit-lamp assessment of anterior chamber flare and cells
showed normal follow-up for the postoperative comparing with eye
drops corticosteroids in the fellow eye. Chang et al.(11) report that
rescue medication was required for intraocular inflammation in 12%
of patients with a Surodex® implant by the end of a 2-month study.
We found no rebound inflammation in the seven patients and there
were no need of corticosteroids eye drops complementation in any
of them.
The IOP remained stable during all the follow-up visits and were
similar to the fellow eye. There were no needs of antihypertensive
medications in any of the patients.
No significant edema was detected in any of the follow-up visits.
BSCVA was better than preoperative in all the seven patients and
were similar to the fellow eye.
An ultrasound biomicroscopy (UBM) was performed on day 2
to evaluate the positioning of the implant in the non-dilated eye
(Figure 3). Since there are reports of Surodex migration and remnants
in the anterior chamber in the literature(8,10). In our study, the dexamethasone 0.7 mg implant was placed sutureless in the first four patients
and there was a migration to the anterior chamber in two of them
and a migration from the original intraoperative position in another
one, almost reaching the visual axis (Figure 4). Because of this, the
other 3 implants were sutured on the IOL haptic and remained stable
throughout the follow-up.
Larger series would be necessary to compare the potential benefits of reduced systemic side effects and toxicity of dexamethasone
implant after phacoemulsification.
ACKNOWLEDGEMENTS
Flávio Hirai, MD, PhD.
REFERENCES
1.Kamal S. Steroid depot injection versus postoperative steroid eyedrops to prevent
inflammation and macular edema after cataract surgery. J Cataract Refract Surg.
2012;38(1):186; author reply 187. Comment on Dieleman M, Wubbels RJ, van KootenNoordzij M, de Waard PW. J Cataract Refract Surg. 2011;37(9):1589-97.
2.Negi AK, Browning AC, Vernon SA. Single perioperative triamcinolone injection
versus standard postoperative steroid drops after uneventful phacoemulsification
surgery: Randomized controlled trial. J Cataract Refract Surg. 2006;32(3):468-74.
3. Braich PS, Almeida DR, Hollands S, Coleman MT. Effects of pictograms in educating
3 distinct low-literacy populations on the use of postoperative cataract medication.
Can J Ophthalmol. 2011;46(3):276-81.
4. London NJ, Chiang A, Haller JA. The dexamethasone drug delivery system: indications
and evidence. Adv Ther. 2011;28(5):351-66.
5. Nascimento H, França M, García LG, Muccioli C, Belfort R Jr. Subconjunctival dexamethasone implant for non-necrotizing scleritis. J Ophthalmic Inflamm Infect. 2013;3(1):7.
6. Chylack LT Jr, Wolfe JK, Singer DM, Leske MC, Bullimore MA, Bailey IL, et al. The Lens
Opacities Classification System III. The Longitudinal Study of Cataract Study Group.
Arch Ophthalmol. 1993;111(6):831-6.
7. Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN)
Working Group. Standardization of uveitis nomenclature for reporting clinical data.
Results of the First International Workshop. Am J Ophthalmol. 2005;140(3):509-16.
8.Chang D, Wong V V. Two clinical trials of an intraocular steroid delivery system for
cataract surgery. Am J Ophthalmol. 2000;129(5):703-4.
9. Bodor N. Designing safer ophthalmic drugs by soft drug approaches. J Ocul Pharmacol. 1994;10(1):3-15.
10. Wadood AC, Armbrecht AM, Aspinall PA, Dhillon B. Safety and efficacy of a dexamethasone anterior segment drug delivery system in patients after phacoemulsification.
J Cataract Refract Surg. 2004;30(4):761-8. Comment in J Cataract Refract Surg. 2005
Aug; 31(8):1479-80.
11.Chang DF, Garcia IH, Hunkeler JD, Minas T. Phase II results of an intraocular steroid
delivery system for cataract surgery. Ophthalmology. 1999;106(6):1172-7.
XXXIII Congresso do
Hospital São Geraldo
30 de outubro a 2 de novembro 2013
Dayrell Hotel & Centro de Convenções
Belo Horizonte (MG)
Informações:
Tel.: (31) 3342-3888
E-mail: lyriumk@lyrium.com.br
Site: www.hospitalsaogeraldo.com.br
228
Effects of age on corneal deformation by non-contact tonometry integrated
with an ultra-high-speed (UHS) Scheimpflug camera
Efeitos da idade sobre a deformação da córnea utilizando o sistema de tonometria
de não contato com a câmera de Scheimpflug
Bruno Freitas Valbon1,2, Renato Ambrósio Jr.2, Bruno Machado Fontes2, Milton Ruiz Alves1
RESUMO
ABSTRACT
Purpose: To correlate parameters derived from corneal deformation resulting
from non-contact tonometry integrated with an ultra-high-speed (UHS) Scheimpflug
camera (Oculus Corvis ST, Scheimpflug Technology; Wetzlar, Germany) with age
in normal eyes from young patients.
Methods: Observational, retrospective study involving one eye randomly selected
from study participants, totaling 89 healthy eyes. The Scheimpflug images were
taken with an ultra-high-speed camera during each measurement by the corvis
ST. The deformation amplitude (DA) and other parameters (e.g., pachy apex, intraocular pressure, 1st A time, highest concavity-time, 2nd A time, 1st A Length, 2nd
A Length, Wing-Dist, curvature radius highest concavity, curvature radius normal,
Vin, Vout) measured by the corvis ST were correlated with age. The KolmogorovSmirnov test was applied, and Spearman’s correlation test was utilized to evaluate
the parameters measured by the Corvis ST and age.
Results: Mean patient age was 27.50 ± 6.30 years. The highest concavity-time was
the only studied parameter statistically significantly correlated to age (i.e., p=0.04,
rs=0.18). All other corvis parameters were not correlated to age. This included
DA (p=0.319), intraocular pressure (p=0.854), pachy apex (p=0.066), 1st A time
(p=0.959), 2nd A time (p=0.561), 1st Length (0.552), 2nd Length (p=0.697), Wing-Dist
(p=0.769), curvature radius HC (p=0.145), curvature radius normal (p=0.513), Vin
(p=0.980) and Vout (p=0.592).
Conclusions: In healthy eyes, age and pressure or biomechanics as derived
from the Corvis ST parameters were not associated with exception to highest
concavity-time, i.e., the time from starting until the highest concavity is reached.
Objetivo: Correlacionar os parâmetros derivados da deformação da córnea pelo
sistema de tonometria de não-contato integrado com a câmera ultra-rápida de
Scheimpflug (Oculus Corvis ST, Scheimpflug Technology; Wetzlar, Germany) com a
idade de pacientes jovens saudáveis.
Métodos: Estudo observacional, retrospectivo envolvendo 89 olhos de 89 pacientes. As imagens de Scheimpflug foram feitas pela câmera acoplada ao sistema de
tonometria de não-contato (Corvis ST) em cada paciente e os parâmetros utilizados
foram: Deformidade de amplitude (DA), paquimetria, pressão intraocular, 1st A time,
tempo de concavidade máxima, 2nd A time, 1st A Length, 2nd A Length, Wing-Dist, raio
de curvatura de maior alcance, raio de curvatura normal, Velocidade de entrada (Vin)
e de saída (Vout). Estes parâmetros foram correlacionados com a idade.
Resultados: A média de idade dos pacientes foi de 27,50 ± 6,30 anos. O tempo de
concavidade máxima alcançada da córnea (HC-time) foi o único parâmetro estudado
estatisticamente significante correlacionado com a idade (p=0,04, rs=0,18). O valor p
das correlações dos parâmetros derivados do Corvis ST e idade foram: DA (p=0,319),
pressão intraocular (p=0,854), paquimetria (p=0,066), 1st A time (p=0,959), 2nd A time
(p=0,561), 1st Length (0,552), 2nd Length (p=0,697), Wing-Dist (p=0,769), raio de curvatura de maior alcance (p=0,145), curvature radius normal (p=0,513), Vin (p=0,980)
e Vout (p=0,592).
Conclusão: Em olhos saudáveis de pacientes jovens, a idade e os parâmetros pressóricos e biomecânicos da deformação da córnea não foram associados, exceto o tempo
de concavidade máxima, que é o tempo do início de aplanação até a concavidade
máxima alcançada da córnea.
Keywords: Tonometry, ocular; Cornea; Biomechanics; Age factors
Descritores: Tonometria ocular; Córnea; Biomecânica; Fatores etários
INTRODUCTION
The biologic variability of healthy corneas probably results from
differing amounts of collagen fibrils, glycosaminoglycans, and proteoglycans found in the stroma of various individuals(1,2). Corneal
stiffening may result from collagen fibril diameters increasing(3) and
interfibrillar spacings decreasing(4,5). Age-related changes in corneal
biomechanical properties have been studied and were associated
with corneal stiffening and decreasing viscoelasticity(6). Experimental
ex vivo studies have demonstrated age-related changes in corneal
collagen fibril properties that may contribute to an increased stiffness
of the cornea with age(7,8). In vivo endothelial specular microscopic
studies by Sherrard et al.,(9) have demonstrated corneal signs that
indicate an increased corneal stiffness with age.
Knowledge of corneal biomechanics is essential to the under
standing of the behavior of the cornea in certain corneal diseases,
surgical procedures, and intraocular pressure (IOP) measurements.
In 1973, some authores(10), asserted that the viscoelastic response
of an intact human cornea subjected to physiological IOP could be
determined by the local deformation as measured by a flying spot
micrometer. In 2004, The Ocular Response Analyzer (ORA, Reichert
Inc., Depew, NY), a modified non-contact tonometer (NCT) designed
to provide a more accurate measurement of IOP through the understanding of compensation for corneal properties, was the first clinical
tool developed to assess the in vivo biomechanical properties of the
cornea(11). The Corvis ST (Scheimpflug Technology) is a new NCT system integrated with an ultra-high-speed (UHS) Scheimpflug camera
Study carried out at Instituto de Olhos Renato Ambrósio.
1
2
Physician, Department of Ophthalmology, University of São Paulo - São Paulo (SP), Brazil.
Physician, Rio de Janeiro Corneal Tomography and Biomechanics Study Group - Rio de Janeiro
(RJ), Brazil.
Disclosure of potential conflicts of interest: B.F.Valbon, None; R.Ambrósio Jr. is consultant for
Oculus; B.M.Fontes, None; M.R.Alves, None.
Correspondence address: Bruno Freitas Valbon. Av. Marechal Mascarenhas de Moraes, 2767/102 Vitória (ES) - 29052-121 - Brazil - E-mail: brunovalbon@usp.br
229
Effects of age on corneal deformation by non-contact tonometry integrated with an ultra-high-speed (UHS) Scheimpflug camera
that was recently introduced by Oculus (Wetzlar, Germany); it also
provides corneal biomechanical and IOP information.
This study was designed to evaluate and correlate corneal response to NCT integrated with an UHS Scheimpflug camera with age
in healthy corneas from young patients.
METHODS
This retrospective study population included 89 eyes from 89
healthy patients at the Instituto de Olhos Renato Ambrósio in Rio de
Janeiro, Brazil, between March of 2011 and June of 2012. The research
followed the tenets of the Declaration of Helsinki, and institutional
review board approval (protocol 2012/10) from the Federal University
of Sao Paulo, Brazil, was obtained.
Each clinical examination involved tests for visual acuity, slit-lamp
microscopy of the anterior and posterior segment, Goldmann appla
nation tonometry (Haag-Streit, Koeniz, Switzerland), and Corvis ST
measurements. Exclusion criteria included previous corneal surgery,
diseases (e.g., glaucoma, uveitis, corneal ectatic disease, Fuchs’ dystrophy, diabetic retinopathy, systemic collagen diseases), chronic
use of topical medications, corneal scars and/or opacities, irregular
astigmatisms, and refusal to sign informed consent.
The central corneal thickness (CCT) was determined by rotating
Scheimpflug imaging (Pentacam, Oculus, Wetzlar, Germany).
The instrument (i.e., the Corvis ST from Oculus in Wetzlar, Germany) has an ergonomic design with an adjustable head console
and chin rest. The patient can be comfortably positioned due to the
proper placement of the chin and forehead. The patient is asked to
focus at the central red light emitting diode (LED). A frontal view
camera is mounted with a keratometer-type projection system for
focusing and aligning the corneal apex. The exam is programmed for
automatic release when alignment is achieved with the first Purkinje
reflex of the cornea. Manual release is also possible.
The UHS Scheimpflug camera takes over 4,300 frames per second
in order to monitor corneal response to a metered, collimated air pulse with symmetrical fixed profile and a fixed maximal internal pump
pressure of 25 kPa. The UHS Scheimpflug camera has a blue light LED
(455 nm, UV free) and horizontally covers 8.5 mm of a single slit. Recording measurement time is 30 ms, which allows for the acquisition
of 140 digital frames. Each image has 576 measuring points.
This imaging system permits the dynamic inspection of the actual deformation process during NCT. Advanced algorithms for edge
detection of the corneal contours are applied for every frame. The
recording starts with the cornea at the natural convex shape. The air
pulse forces the cornea inwards (i.e., the ingoing phase) through applanation (i.e., the first or ingoing applanation) into a concavity phase
until it achieves the highest concavity (HC). An oscillation period
precedes the outgoing or returning phase. The cornea undergoes a
second applanation before achieving its natural shape with possible
oscillation.
The timing and corresponding pressure of the air pulse at the
first and second applanations and at the HC moments are identified.
IOP is calculated based on the timing of the first applanation event.
The deformation amplitude (DA) is measured as the highest displacement of the apex in the HC moment image. The radius of curvature
at the HC is recorded. Applanation lengths (AL) and corneal velocities
(CVel) are recorded during ingoing and outgoing phases. Corneal thickness is also calculated through the horizontal Scheimpflug image.
The lowest value is displayed.
The parameters measured by the Corvis ST (Table 1) under investigation were as follows: IOP, DA, pachy apex, 1st A time, HC-time, 2nd A
time, 1st A length (max), 2nd A length (max), Wing-Dist, curvature radius
highest curvature, curvature radius normal, Maximum Velocity-Vin
and Maximum Velocity-Vout.
Statistical analysis were performed using the Bioestat version 5.0
software (Belém, PA, Brazil). Variables that were not normally distributed in all data samples were confirmed by the Kolmogorov-Smirnov
test. Spearman’s correlation coefficient was utilized, and p values less
than 0.05 were considered statistically significant (Table 2).
RESULTS
The study investigated 89 healthy eyes from 89 patients (i.e.,
51 females and 38 males) with normal cornea. The single eye from
each patient was randomly chosen, and the study investigated 43
right eyes and 46 left eyes (i.e., 48.31% and 51.68%, respectively). The
mean patient age was 27.50 ± 6.30 (i.e., range: 12.54 to 39.70 years).
The Spearman’s correlation test between CCT and IOP Corvis was
statiscally significant (Figure 1).
The mean IOP as measured by the Corvis ST was 17.73 mmHg ±
3.81 (i.e., range: 7.00 to 32.20). Spearman’s correlation test was not
statistically significant (i.e., p=0.854, rs -0.01).
The mean deformation amplitude was 1.02 mm ± 0.09 (i.e., range:
0.78 to 1.26). Spearman’s correlation test was not statistically significant (i.e., p=0.319, rs 0.09) (Figure 2).
The mean pachy apex was 522.99 µm ± 24.15 (i.e., range: 463 to
605). Spearman’s correlation test was not statistically significant (i.e.,
p=0.06, rs 0.16) (Figure 3).
Table 1. All parameters derived from Corvis ST and their meanings
Corvis ST - clinical parameters
Is the nct measurement based on the 1st applanation
1st A-time
Is the time from starting until the first applanation
Highest Concavity-time
Time from starting until highest concavity is reached
2 A-time
Time from starting until the second applanation
1st A length
Cord length of the first applanation
2nd A length
Cord length of the second applanation
Deformation amplitude
Maximum amplitude at the apex (highest concavity)
Wing-Dist
Distance of the two “knee’s” at highest concavity (hc)
Curvature radius HC
Central concave curvature at hc
Curvature radius normal
Initial central convex curvature
Maximun velocity (in) - Vin
Corneal speed during the first applanation moment
Maximum velocity (out) - Vout
Corneal speed during the second applanation moment
nd
230
Means
Intraocular pressure
Valbon BF, et al.
Table 2. Age versus all parameters from Corvis ST. Spearman correlation test was utilized; value p and Spearman correlation coefficient (rs)
Age
versus
IOP
Deformation
Amplitude
Pachy
apex
Highest
concavity - time
1st
A time
2nd
A time
1st
Length
2nd
Length
WingDistance
Curvature
radius HC
Curvature
radius normal
Vin
Vout
Value p
0.854
0.319
0.066
0.048
0.959
0.561
0.552
0.697
0.769
0.145
0.513
0.980
0.592
Rs
-0.01
0.09
0.16
0.18
0.004
-0.06
-0.05
0.03
-0.02
0.13
-0.06
-0.002
0.04
Figure 1. Correlations between CCT x IOP Corvis.
Figure 3. Correlations between Age x Pachy apex.
Figure 2. Correlations between Age x Deformation Amplitude.
Figure 4. Correlations between Age x Highest Concavity time.
The mean HC-time was 18.83 ms ± 0.93 (i.e., range: 16.72 to 21.07).
Spearman’s correlation test was statistically significant (p=0.04, rs 0.18)
(Figure 4).
The mean 1st A time was 8.47 ms ± 0.51 (i.e., range: 6.60 to 10.40).
Spearman’s correlation test was not statistically significant (p=0.95;
rs 0.004). The mean 2nd A time was 23.68 ms ± 0.55 (i.e., range: 22.06
to 24.95). Spearman’s correlation test was not statistically significant
(p=0.56, rs -0.05).
The mean 1st A length (max) was 2.09 mm ± 0.38 (i.e., range: 1.20
to 3.10). Spearman’s correlation test was not statistically significant
(i.e., p=0.55, rs -0.05). The mean 2nd A length (max) was 2.37 mm ±
statistically significant (p=0.69, rs 0.03).
The mean Wing-Dist was 4.77 mm ± 0.28 (i.e., range: 3.98 to 5.24).
Spearman’s correlation test was not statistically significant (i.e.,
p=0.76, rs -0.02).
The mean curvature radius highest concavity was 11.59 mm ±
statistically significant (p=0.14, rs 0.13) (Figure 5).
The mean curvature radius normal was 7.63 mm ± 0.91 (i.e., range:
6.82 to 13.77). Spearman’s correlation test was not statistically significant (i.e., p=0.51, rs - 0.06).
The mean Vin was 0.21 m/s ± 0.05 (i.e., range: 0.15 to 0.72). Spearman’s
correlation test was not statistically significant (i.e., p=0.98; rs - 0.002). The
mean Vout was -0.32 m/s ± 0.07 (i.e., range: -0.75 to -0.19). Spearman’s
correlation test was not statistically significant (i.e., p=0.59, rs 0.04).
231
Effects of age on corneal deformation by non-contact tonometry integrated with an ultra-high-speed (UHS) Scheimpflug camera
CONCLUSION
We believe that the positive association between age and HC-time
can be explained as an increase in the cross-linkage of collagen fibrils
within the cornea, which results in a less viscoelastic structure in
young patients. Further studies with this new technology are needed
to corroborate our findings and to expand the knowledge base of
corneal biomechanical properties.
REFERENCES
Figure 5. Correlations between Age x Curvature Radius highest concavity.
DISCUSSION
The cornea is a complex viscoelastic tissue with both viscous
and elastic properties(12).Corneal biomechanics involve thickness,
hydration, elasticity, viscosity, and other unrevealed factors(13), and
its behavior is mostly controlled by the stroma(14), which composes
90% of the total corneal thickness and presents higher mechanical
stiffness than the other corneal layers(15). This stromal microstructure
is known to change with aging(16).
Several studies showed the relationship between corneal biomechanics as measured by ORA (i.e., corneal hysteresis [CH] and corneal
resistance factor [CRF]) and age. Other authors(17) demonstrated the
inverse association between age and corneal biomechanics metrics,
and the mean CH and the mean patient age were 10.17 and 46.5
years, respectively. Kirwan et al.(18), showed that in healthy children
the mean CH was 12.5, which was not correlated to age. Other studies(19,20), did not identify a strong association between CH and age or
CRF and age and observed a negative association between corneal
viscoelastic properties with advancing age, which may be further
evidence of an increase in the cross-linkage of collagen fibrils within
the cornea, thereby making the cornea a stiffer and less viscoelastic
structure. This indicates that the biomechanical viscoelasticity of the
cornea decreases with age.
In our study, we utilized an innovative imaging system that provides in vivo biomechanical information and avoids the limitations
of previous in vivo and in vitro techniques. The retrieved data and
deformations obtained by the Corvis ST provide information related
to the biomechanical properties of the tissue, including elasticity
and viscoelasticity. Consequently, this technique shows enormous
potential as a research and clinical tool used to retrieve in vivo biomechanical properties of the cornea(21).
The only parameter measured by the Corvis ST that was statistically significantly associated with age was HC-time, i.e., the time from
starting until HC is reached, and this association was presented as a
positive linear correlation (rs 0.18). The pachy apex (i.e., the corneal
thickness) and other parameters, such as the DA and the curvature
radius highest concavity, were not statistically significantly associated
with age, by they also demonstrated a positive linear correlation with
age in young patients (Figures 3, 2, and 4, respectively).
232
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Rev Bras Oftalmol. 2013;72(2):99-102.
Pacientes com astigmatismo submetidos à cirurgia de catarata:
LIO tórica x LIO asférica?
Patients with astigmatism who underwent cataract surgery by phacoemulsification:
toric IOL x asferic IOL?
Emilio de Almeida Torres Netto1, Marina Carvalho Gulin1, Marcio Zapparoli1, Hamilton Moreira2
RESUMO
ABSTRACT
Objetivos: Comparar a acuidade visual dos pacientes que foram submetidos à
facoemulsificação com implante de LIO AcrySof® tórica versus LIO AcrySof® IQ e
avaliar a redução da dioptria cilíndrica (DC) pós-operatória.
Métodos: Estudo analítico retrospectivo de 149 olhos submetidos à cirurgia de
catarata por facoemulsificação, com astigmatismo ceratométrico regular, simétrico,
com 1 dioptria ou mais. Foram divididos em dois grupos. O grupo tórica com 85
olhos e o grupo não tórica com 64 olhos. No pré-operatório foram avaliados dados
topográficos do olho a ser operado e refração. No período pós-operatório foram
revisados dados da refração e acuidades visuais com e sem correção.
Resultados: O astigmatismo corneano pré-operatório variou de 1,00 a 5,6 DC
em ambos os grupos, sendo que no grupo tórica houve redução média de 1,37
DC (p<0,001), quando comparado ao refracional. O grupo não tórica apresentou
redução média de 0,16 DC (p=0,057). Com relação a acuidade visual sem correção (AVSC), o grupo tórica apresentou 44 olhos (51,7%) com AVSC de 0 logMAR
(20/20) ou 0,1 logMAR (20/25), e o grupo não tórica apenas 7 olhos (10,93%) com
estas mesmas AVSC.
Discussão: Ficou bem evidenciado que os pacientes com astigmatismo ceratométrico significativo apresentam benefício visual com o implante de LIO tórica. A
diminuição do uso de auxílios ópticos para distância pode ser possível a partir do
momento que conseguimos corrigir com melhor precisão as aberrações do olho
humano. Na atualidade, a facoemulsificação passou a ser além de uma cirurgia
para restabelecimento funcional, um procedimento refracional.
Purposes: Compare the visual acuity of patients who underwent cataract surgery
by phacoemulsification with IOL AcrySof® toric implantation versus AcrySof® IQ and
evaluate the reduction of cylindrical diopters (CD) in the postoperative period.
Methods: Analytical and retrospective study of 149 eyes with 1 or more diopters of
regular symmetrical keratometric astigmatism, which underwent cataract surgery by
phacoemulsification. The eyes were divided into two groups: the toric group with 85
eyes and the non-toric group with 64 eyes. In the pre-operative phase, topographic data
and refraction of each eye to be operated were assessed. In the postoperative phase,
refraction and visual acuity with and without correction were measured.
Results: The preoperative topographic astigmatism ranged from 1.00 to 5.6 DC
in both groups. Average reduction of 1.37 CD (p<0.001) and 0.16 CD (p=0.057)
was obtained for the toric and non-toric group when compared to the refractive
astigmatism, respectively. Considering visual acuity without correction (NCVA), the
toric group presented 44 eyes (51.7%) with NCVA of 0 logMAR (20/20) or 0.1 logMAR
(20/25) and the toric group presented 7 eyes (10.93%) with these same NCVA values.
Discussion: The results show that patients with a significant keratometric astigma
tism presented visual benefits with the toric IOL implantation. The reduction of the use
of optical aids may be obtained provided aberrations of the human eye are corrected
more accurately. Currently, phacoemulsification surgery has been used not only for
functional improvement, but also as a refraction procedure.
Descritores: Astigmatismo/cirurgia; Implante de lente intraocular/métodos; Fa
coemulsificação; Extração de catarata; Acuidade visual
Keywords: Astigmatism/surgery; Intraocular lens implantation/methods; Phacoemul
sification; Cataract extraction; Visual acuity
INTRODUÇÃO
O termo astigmatismo vem de “a” que significa “falta de” e “stigma”
que significa “um ponto”. O astigmatismo ocorre quando os meridianos principais do olho têm poderes refrativos diferentes. Assim, no
astigmatismo a imagem não atinge a retina em um único ponto focal,
mas sim, sempre, em duas linhas focais. A medida do intervalo focal
entre eles corresponde ao grau do astigmatismo(1,2).
O astigmatismo regular tem os dois meridianos principais a ângulos retos um do outro, ou seja, a 90º. No astigmatismo irregular, os
dois meridianos principais não se encontram perpendicularmente e,
geralmente, é secundário (doença corneana, trauma, pterígio, subluxação do cristalino, cirurgia de catarata)(3,4).
Sabe-se que o astigmatismo é mais comumente produzido pela
toricidade da superfície anterior da córnea, embora sua etiologia, na
maior parte das vezes, seja desconhecida. Se o meridiano de menor
curvatura estiver em um ângulo entre 160º e 20º com o plano horizontal, chamamos de astigmatismo a favor da regra; entre 70º e 110º,
astigmatismo contra a regra; e entre 21º e 69º e entre 111º e 159º,
astigmatismo oblíquo(3).
No passado havia certa satisfação por parte do médico e paciente
de realizar cirurgias sem intercorrências. Porém, o avanço tecnológico
e as exigências impostas pelos pacientes, cada vez mais informados,
conduziu-nos a aprimorar nossos resultados e fornecer além de boa
acuidade visual, a correção refracional, com uma possível indepen-
Submetido para publicação: 18 de julho de 2012
Aceito para publicação: 27 de maio de 2013
Trabalho realizado no Hospital de Olhos do Paraná - Curitiba (PR), Brasil.
1
2
Médico, Hospital de Olhos do Paraná - Curitiba (PR) - Brasil.
Médico, Universidade Federal do Paraná; Faculdade Evangélica do Paraná; Hospital de Olhos do
Paraná - Curitiba (PR) - Brasil.
Divulgação de potenciais conflitos de interesse: E.A.T.Netto, Nenhum; M.C.Gulin, Nenhum;
M.Zapparoli, Nenhum; H.Moreira, Nenhum.
Endereço para correspondência: Hamilton Moreira. Rua Coronel Dulcidio,199 - 4o andar - Curitiba
(PR) - 80420-170 - Brasil - E-mail: hamiltonmoreira@mac.com
Comitê de Ética em Pesquisa da Sociedade Evangélica Beneficente de Curitiba, protocolado sob
número 4977/10.
233
dência de óculos(5-12). Neste sentido, a lente intraocular tórica vem a
contribuir muito no manejo de pacientes com astigmatismo.
O objetivo deste estudo é comparar a acuidade visual e a redução
do componente cilíndrico nos pacientes que foram submetidos à cirurgia de extração do cristalino por facoemulsificação com implante
de lente intraocular (LIO) AcrySof® tórica versus LIO AcrySof® IQ.
MÉTODOS
Estudo analítico e retrospectivo baseado em análise de prontuá
rios de pacientes submetidos à cirurgia de catarata por facoemulsificação no Hospital de Olhos do Paraná, no período de fevereiro de
2010 a setembro de 2011. Foi revisado um total de 1.453 cirurgias,
sendo que 1.256 olhos foram submetidos a implante de lente LIO
AcrySof® IQ (Alcon®), e 196 submetidos a implante de LIO AcrySof®
tórica (Alcon®). Os pacientes foram incluídos em dois grupos: Grupo
tórica (olhos com implante de LIO AcrySof® tórica) e Grupo não tórica
(olhos com implante de LIO AcrySof® IQ).
O comprimento axial foi determinado com ultrassonografia de
imersão AScan (Ocuscan XP, Alcon®). O cálculo do poder esférico da
LIO foi determinado considerando o comprimento axial dos olhos estudados, sendo usada a formula Holladay para comprimentos axiais
variando entre 22 a 24 mm, a regra SRK-T foi utilizada nos olhos com
mais de 24 mm e Hoffer Q usada nos olhos que apresentaram comprimento menor que 22 mm, objetivando a emetropia. O cálculo do
poder cilíndrico da lente e seu posicionamento foram determinados
pelo seu fabricante levando em consideração a topografia computadorizada, poder esférico da LIO, posição da incisão e astigmatismo
induzido pelo cirurgião. Este cálculo foi realizado pelo fabricante da
LIO (Alcon®) através do site www.acrysoftoriccalculator.com.
O critério de inclusão foi olhos que apresentavam, além de cata
rata, astigmatismo corneano maior ou igual a 1,00 D comprovado
ao exame de topografia corneana computadorizada (Eye Sys Vista®.
Texas, USA) e que foram submetidos ao implante de alguma das LIO´s
citadas (AcrySof® tórica ou AcrySof® IQ).
Foram excluídos todos os olhos que apresentaram qualquer comorbidade que comprometesse a acuidade visual final (retinopatia
diabética, glaucoma com perda de campo visual além dos 30 graus
centrais, sequelas de uveítes e conjuntivites, degeneração macular,
ceratocone e astigmatismo irregular) e aqueles que não apresentaram dados da topografia pré-operatória no prontuário. Excluímos
também olhos que implantaram outro tipo de LIO.
Analisando as 1.256 cirurgias pertencentes ao grupo LIO não
tórica 61,30% (770 olhos) foram excluídas por apresentarem astigmatismo menor que 1,00D, 24,6% (309 olhos) por apresentarem dados
insuficientes no prontuário (entre eles, falta de dados topográficos,
refracionais e de acuidade visual) e 8,99% (113 olhos) devido comorbidades que prejudicassem a avaliação da acuidade visual final.
Dentre os 196 olhos do grupo LIO tórica, 36,73% (72 olhos) foram
excluídos por dados insuficientes no prontuário e 19,89% (39 olhos)
devido patologias que interfiram na performance visual. Curioso salientar que um dos olhos foi excluído devido insatisfação do paciente
após o implante de LIO tórica, e foi submetido à remoção cirúrgica da
LIO, em tempo subsequente.
O projeto do estudo foi submetido à apreciação e aprovado pelo
Comitê de Ética em Pesquisa da Sociedade Evangélica Beneficente de
Curitiba, protocolado sob o número 4977/10, em 31 de maio de 2010.
No pré-operatório foram avaliados idade, sexo, dados topográficos do olho operado, e refração por método automatizado (Autorefrator Topcon RM8800, Japão). No período pós-operatório (um mês
após a cirurgia), foram revisados dados da refração dinâmica e acuidades visuais com e sem correção. Realizou-se comparação do astigmatismo corneano pré-operatório (delta K pré) com o astigmatismo
refracional pós-operatório (cilindro pós). Em pacientes com diagnóstico de rotação de LIO no pós-operatório (apenas 2 pacientes), os
dados considerados foram aqueles após o reposicionamento da LIO.
234
Para calcular a média da acuidade visual e seu desvio padrão, uti
lizamos o equivalente em logMAR(13).
Para análise da correlação entre as variáveis e idade utilizamos teste
de Spearman. Para a comparação dos resultados em dois diferentes
momentos em relação a variáveis quantitativas foi considerado o teste
não-paramétrico de Wilcoxon. Para a comparação dos dois grupos
definidos pelo tipo de lente (AcrySof® tórica e AcrySof® IQ), em relação a variáveis quantitativas, foi considerado o teste não-paramétrico
de Mann-Whitney. A homogeneidade dos dois grupos em relação às
distribuições de acuidade visual sem correção foi avaliada pelo teste de
Qui-quadrado. Valores de p<0,05 indicaram significância estatística. Os
dados foram analisados com o programa computacional Statistica v.8.
RESULTADOS
A média da idade dos pacientes do grupo tórica foi de 65,6 anos
e a do grupo não tórica foi de 72,1 anos. A distribuição do gênero foi
semelhante em ambos os grupos. Não houve correlação entre idade
e gênero (p=0,309), nem entre idade e Delta K pré (p=0,117).
Ao compararmos o astigmatismo corneano pré-operatório (Delta
K pré) com o astigmatismo refracional pós-operatório residual (cilindro pós) observamos no grupo tórica uma redução estatisticamente
significante (p<0,001) (Tabela 1 e Gráfico 1). No grupo não tórica
também houve uma tendência a redução, porém este número não
foi significativo (Tabela 2 e Gráfico 1). Observamos que a redução
média no grupo tórica foi igual a 1,37 dioptrias cilíndricas (DC) e no
grupo não tórica foi igual a 0,16 DC.
Comparamos, também, a acuidade visual não corrigida (Tabela 3
e Gráfico 2) e corrigida (Tabela 4 e Gráfico 3) em ambos os grupos no
período pós-operatório. Nas duas situações o grupo tórica apresentou melhor acuidade visual, com significância estatística. Acuidade
visual expressa em logMAR.
Tabela 1. Grupo tórica
n
Delta K (pré)
Desvio
Média Mediana Mínimo Máximo padrão
85
2,10
1,79
-1,0
5,60
1,05
Cilindro (pós) 85
0,73
0,75
-0,0
4,00
0,68
Redução
1,37
1,26
-1,8
5,32
1,07
85
Valor
de p*
<0,001
*= teste não-paramétrico de Wilcoxon, p<0,05; **= números expressos em dioptrias
cilíndricas (DC).
*p<0,001
Gráfico 1. Dioptrias cilíndricas em ambos os grupos.
Netto EAT, et al.
Tabela 2. Grupo não tórica
n
Delta K (pré)
Tabela 4. Acuidade visual com correção
Desvio
64
1,65
1,34
-1,00
5,57
0,85
Cilindro (pós) 64
1,49
1,25
-0,00
7,00
1,08
Redução
0,16
0,22
-3,31
2,50
0,93
64
Valor
de p*
0,057
Desvio
Grupo
N
Tórica
85
0,05
0,00
0,00
0,50
0,09
Não tórica
64
0,12
0,10
0,00
0,50
0,12
Valor
de p*
0,003
*= teste não-paramétrico de Mann-Whitney, p<0,05; **= números expressos em logMAR.
*= teste não-paramétrico de Wilcoxon, p<0,05; **= números expressos em dioptrias
cilíndricas (DC).
Tabela 3. Acuidade visual sem correção
Desvio
Grupo
N
Tórica
85
0,18
0,15
0,00
1,30
0,20
Não tórica
64
0,49
0,50
0,00
2,00
0,33
Valor
de p*
<0,001
*= teste não-paramétrico de Mann-Whitney, p<0,05; **= números expressos em logMAR.
Gráfico 3. Acuidade visual com correção.
Gráfico 2. Acuidade visual sem correção.
DISCUSSÃO
Sabemos através dos resultados apontados por diversas pesquisas que a prevalência de astigmatismo na população geral gira em
torno de 35 a 50% na maioria dos estudos(3,14-16). Isto resulta em uma
grande quantidade de pessoas que permanecem dependentes de
óculos após a cirurgia de catarata quando ela corrige somente o componente esférico. Por isso, cada vez mais surgem novas tecnologias
para a correção total das ametropias(5,7,8,10-12,17), melhorando assim a
qualidade de vida dos pacientes(7,8).
Na atualidade, a cirurgia de facoemulsificação para a extração da
catarata também é considerada para o paciente e para o cirurgião
uma cirurgia refracional(6,7,8,10-12). Por este motivo decidimos comparar
os resultados cirúrgicos dos pacientes com astigmatismo maior ou
igual a 1 D que implantaram lente AcrySof® tórica e os que implantaram lente AcrySof® IQ.
Erros refrativos residuais após a cirurgia de catarata geralmente
decorrem do cálculo biométrico imperfeito, inadequação da fórmula
usada, posicionamento inadequado da lente e da presença de astigmatismo pré-operatório(1).
Observamos neste estudo que os pacientes do grupo tórica
obtiveram uma redução do astigmatismo médio (Delta K pré versus
cilindro pós) de 1,37 D em comparação a 0,16 D no grupo não tórica
(p<0,001). Esta diferença leva a uma melhora importante na performance visual final dos pacientes com este tipo de implante. Na prática, podemos observar a significância destes valores quando comparamos a acuidade visual sem correção (AVSC) destes dois grupos.
Sabemos que no paciente pseudofácico a origem principal do
astigmatismo refracional é a córnea. O Delta K pré foi maior no grupo
tórica (2,10 DC) do que no grupo não tórica (1,65 DC). Ainda assim,
o astigmatismo refracional pós-operatório foi menor nos pacientes
do grupo tórica. Demonstra-se, desta forma, que esta redução não
ocorreu simplesmente ao acaso. O implante de LIO tórica foi determinante para que se obtivesse uma diminuição do astigmatismo
refracional no período pós-operatório.
Vale lembrar que as incisões confeccionadas para a realização
da facoemulsificação e implante da LIO alteram pouco a curvatura
corneana(17,18). Assumimos, teoricamente, que a cirurgia alterou a cur
vatura corneana de ambos os grupos de forma similar.
Ao considerarmos a AVSC, o grupo tórica apresentou em 44 olhos
(51,7%) AVSC de 0 logMAR (20/20) ou 0,1 logMAR (20/25), enquanto
apenas 7 olhos (10,93%) do grupo não tórica apresentaram este mes
mo resultado.
Sanders et al. também já demonstraram que o implante de LIO
tórica é eficaz e previsível, inclusive nos casos de moderados e altos
astigmatismos(7). O estudo Europeu Multicêntrico corrobora com
nossos resultados, pois apresentou ganho de linhas na tabela de
Snellen com implantes intraoculares tóricos, já em 2003(9). Análises
vetoriais recentes também demonstraram uma correção efetiva do
astigmatismo com LIO’s tóricas(19).
Devemos lembrar que a rotação da LIO é uma das intercorrências
que teremos de lidar com alguns pacientes. A técnica cirúrgica para
implante de LIO’s tóricas exige planejamento pré e intraoperatórios
adequados, visto que estas LIO’s devem ser colocadas no eixo correto para correção do astigmatismo, e permanecer assim no período
pós-cirúrgico. Uma biometria de precisão é fundamental neste
cenário. Mesmo com todos estes cuidados, a rotação das LIO’s pode
235
ocorrer. Nestes casos, o reposicionamento precoce traz melhores
resultados(20,21). Roturas zonulares ou quaisquer outras alterações
que comprometam a centralização precisa da LIO no saco capsular
podem contraindicar seu implante.
Com a evolução das técnicas cirúrgicas e variedade de lentes in
traoculares disponíveis, a independência do uso de óculos passou a
se tornar uma expectativa dos pacientes. Com as técnicas cirúrgicas
atuais ainda não podemos assegurar tal independência. Porém, cada
avanço tecnológico neste sentido é uma conquista.
Em conclusão, pudemos observar diminuição estatisticamente
significativa do astigmatismo refracional pós-cirúrgico nos pacientes submetidos a facoemulsificação com implante de LIO tórica.
Mostrou-se, também, uma técnica efetiva, previsível e relativamente
simples. Esperamos que com o advento das lentes multifocais tóricas possamos ofertar uma excelente performance visual, tanto para
longe, quanto para perto de forma satisfatória.
REFERÊNCIAS
1. Ventura LO, Barros EA, Arruda Junior JR. Sinais e sintomas das ametropias. In: Schor P,
Uras R, Veitzman S. Óptica, refração e visão subnormal. Rio de Janeiro: Cultura Médica;
2008. p.205-17. Série Oftalmologia Brasileira.
2. Alves MR, Polati M, Faria e Sousa SJ. Refratometria ocular e a arte da prescrição mé
dica. Rio de Janeiro: Cultura Médica; 2009.
3. Rayes TR, Rayes GR, Eing F, Gumarães Neto HP, Marquardt FA, Rayes A. Prevalência do
astigmatismo e distribuição de seu eixo em pacientes de um serviço oftalmológico
privado. Rev Bras Oftalmol. 2007;66(6):396-75.
4. Gills JP. Treating astigmatism at the time of cataract surgery. Curr Opin Ophthalmol.
2002;13(1):2-6.
5. Rocha RC, Oechsler RA, Carvalho RG, Moreira H. Influência do astigmatismo corneano
na acuidade visual final após implante de AcrySof® ReSTOR®: relato de caso. Arq Bras
Oftalmol. 2007;70(6):1040-2.
6.Silva EF, Trindade FC. Correção do astigmatismo na cirurgia da catarata. Arq Bras
Oftalmol. 2007;70(4):609-14.
7.Sanders DR, Schneider D, Martin R, Brown D, Dulaney D, Vukich J, et al. Toric Im-
plantable Collamer Lens for moderate to high myopic astigmatism. Ophthalmology.
2007;114(1):54-61.
8.Correia RJ, Moreira H, Netto SU, Pantaleão GR. Visual performance after toric IOL
implantation in patients with corneal astigmatism. Arq Bras Oftalmol. 2009;72(5):
636-40.
9. Dick HB, Alió J, Bianchetti M, Budo C, Christiaans BJ, El-Danasoury MA, et al. Toric phakic
intraocular lens: European multicenter study. Ophthalmology. 2003;110(1):150-62.
10. Nichamin LD. Astigmatism management for modern phaco surgery. Int Ophthalmol
Clin. 2003;43(3):43-63.
11. Nichamin LD. Treating astigmatism at the time of cataract surgery. Curr Opin Oph
thalmol. 2003;14(1)35-8. Review.
12.Hida WT, Motta AF, Inomata DL, Jales MQ, Facio Júnior AC, José Júnior NK, et al.
Incisões relaxantes limbares ou incisões no meridiano mais curvo associadas a fa
coemulsificação com implante de lente intra-ocular multifocal: relato de três casos.
13. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg. 1997;
13(4):388-91.
14. Attebo K, Ivers RQ, Mitchell P. Refractive errors in an older population: the Blue Moun
tains Eye Study. Ophthalmology. 1999;106(6):1066-72.
15. Bourne RR, Dineen BP, Ali SM, Noorul Huq DM, Johnson GJ. Prevalence of refractive
error in Bangladeshi adults: results of the National Blindness and Low Vision Survey
of Bangladesh. Ophthalmology. 2004;111(6):1150-60.
16. Fledelius HC. Prevalences of astigmatism and anisometropia in adult danes. With reference to presbyopes’ possible use of supermarket standard glasses. Acta Ophthalmol
(Copenh). 1984;62(3):391-400.
17.Tejedor J, Pérez-Rodríguez JA. Astigmatic change induced by 2.8-mm corneal incisions for cataract surgery. Invest Ophthalmol Vis Sci. 2009;50(3):989-94.
18. Giansanti F, Rapizzi E, Virgili G, Mencucci R, Bini A, Vannozzi L, et al. Clear corneal in
cision of 2.75 mm for cataract surgery induces little change of astigmatism in eyes
with low preoperative corneal cylinder. Eur J Ophthalmol. 2006;16(3):385-93.
19. Visser N, Berendschot TT, Bauer NJ, Nuijts RM. Vector analysis of corneal and refractive
astigmatism changes following toric pseudophakic and toric phakic IOL implantation. Invest Ophthalmol Vis Sci. 2012;53(4):1865-73.
20. Amesbury EC, Miller KM. Correction of astigmatism at the time of cataract surgery.
Curr Opin Ophthalmol. 2009;20(1):19-24. Review.
21. Kersey JP, O’Donnell A, Illingworth CD. Cataract surgery with toric intraocular lenses
can optimize uncorrected postoperative visual acuity in patients with marked corneal
astigmatism. Cornea. 2007;26(2):133-5.
16o Congresso de Oftalmologia USP e
15o Congresso de Auxiliar de Oftalmologia
29 e 30 de novembro de 2013
Centro de Convenções Rebouças
São Paulo (SP)
Informações:
Secretaria Executiva
Organização de Eventos JDE
Tels.: (11) 5082-3030 / 5084-9174
Site: www.jdeeventos.com.br / www.oftalmologiausp.com.br
236
Prevalência de erros refrativos na sequência de Möbius
Monica Fialho Cronemberger1, Mariza Polati2, Iara Debert2, Tomás Scalamandré Mendonça3, Carlos Souza-Dias4, Marilyn Miller5,
Liana Oliveira Ventura6, Célia Regina Nakanami3, Mauro Goldchmit4,7
ABSTRACT
RESUMO
Purpose: To assess the prevalence of refractive errors in Möbius sequence.
Methods: This study was carried out during the Annual Meeting of the Brazilian
Möbius Society in November 2008. Forty-four patients diagnosed with the Möbius
sequence were submitted to a comprehensive assessment, on the following
specialties: ophthalmology, neurology, genetics, psychiatry, psychology and
dentistry. Forty-three patients were cooperative and able to undertake the oph
thalmological examination. Twenty-two (51.2 %) were male and 21 (48.8%) were
female. The average age was 8.3 years (from 2 to 17 years). The visual acuity was
evaluated using a retro-illuminated logMAR chart in cooperative patients. All
children were submitted to exams on ocular motility, cyclopegic refraction, and
fundus examination.
Results: From the total of 85 eyes, using the spherical equivalent, the major of
the eyes (57.6%) were emmetropics (>-0.50 D and <+2.00 D). The prevalence of
astigmatism greater than or equal to 0.75 D was 40%.
Conclusion: The prevalence of refractive errors, by the spherical equivalent, was
42.4% in this studied group.
Objetivo: Avaliar a prevalência de erros refrativos em crianças portadoras da se
quência de Möbius.
Métodos: Trabalho realizado durante o encontro anual da Associação Möbius do
Brasil (AMoB) em novembro de 2008. Quarenta e quatro pacientes com diagnóstico
de sequência de Möbius foram submetidos a avaliação multidisciplinar: oftalmoló
gica, neurológica, genética, psiquiátrica, psicológica e odontológica. Quarenta e três
pacientes colaboraram com exame oftalmológico. Vinte e dois (51,2 %) eram do sexo
masculino e 21 (48,8 %) do sexo feminino. A idade média foi de 8,3 anos (2 a 17 anos).
A medida da acuidade visual foi realizada com tabela logMAR retro-iluminada, nos
pacientes que colaboravam. Todas as crianças foram submetidas a exame da motili
dade ocular, refração sob cicloplegia e fundo de olho.
Resultados: Do total de 85 olhos estudados, usando o equivalente esférico, a maioria
dos olhos (57,6%) são emétropes (>-0,50 D e <+2,00 D). A prevalência de astigmatismo
maior que 0,75D foi 40%.
Conclusão: A prevalência de erros refrativos, pelo equivalente esférico, no grupo es
tudado foi de 42,4%.
Keywords: Möbius syndrome; Refractive errors/epidemiology; Strabismus; Ani
sometropia; Astigmatism
Descritores: Síndrome de Möbius; Erros de refração/epidemiologia; Estrabismo; Ani
sometropia; Astigmatismo
INTRODUCTION
The Möbius syndrome was first reported in 1881(1), when Von
Graefe described one of his patients as having congenital facial di
plegia(2).
In 1888, Möbius traced a relationship between congenital facial
diplegia and other malformations. He also described the classical
signs of this syndrome: absence of abduction in both eyes, along
with the deficiency of other cranial nerves (V, IX and XII especially)(3).
The Möbius syndrome designation has recently been replaced
by Möbius sequence. A sequence is thought to represent a pattern
of multiple anomalies derived from a single structural defect or me
chanical factor, usually due to multiple etiologies compared with the
designation “syndrome” which implies a single cause(4,5).
In a recent publication, Souza-Dias and Goldchmit have stated
that the variation in ocular motility in Möbius sequence patients is,
in reality, horizontal conjugate eye movement paralysis(6). Its patho
genesis is unclear, but it seems to be related to an embryonic insult
from heterogeneous causes, which affects the developing cranial
nerve nuclei(7,8).
Many ophthalmic disorders in Möbius sequence patients have
been described, but we only found two studies in the literature re
garding refractive errors in such patients(9,10). Uncorrected refractive
errors can interfere in school performance, reduce employability and
economic productivity, and generally impair quality of life(11). There
fore, the main purpose of this study was to assess the prevalence of
refractive errors in a group of patients with Möbius sequence.
Submitted for publication: July 18, 2012
Study carried out at Department of Ophthalmology of the Santa Casa Medical School of São Paulo.
Physician, Department of Ophthalmology, Universidade Federal de São Paulo - UNIFESP - São
Paulo (SP), Brazil; Disable Children Care Association - São Paulo (SP), Brazil.
Physician, Department of Ophthalmology, São Paulo University - USP, São Paulo (SP), Brazil.
3
Paulo (SP), Brazil.
4
Physician, Department of Ophthalmology, Santa Casa Medical School - São Paulo (SP), Brazil.
5
Physician, Department of Ophthalmology & Visual Sciences, University of Illinois, Chicago, USA.
6
Physician, Altino Ventura Foundation - Recife (PE), Brazil.
7
Physician, Cema Institute.
1
2
METHODS
This is a multidisciplinary and collaborative study, approved by
the Ethics Committee of the Human Research of the Santa Casa de
Misericórdia de São Paulo Hospital (400/08).
Disclosure of potential conflicts of interest: M.F.Cronemberger, None; M.Polati, None; I.Debert, None;
T.F.S.Mendonça, None; C.R.Souza-Dias, None; M.Miller, None; L.O.Ventura, None; C.R.Nakanami,
None; M.Goldchmit, None.
Correspondence address: Monica Fialho Cronemberger. Rua Mirassol, 227 - Apto. 101 - São
Paulo (SP) - 04044-010 - Brasil - E-mail: mfcronemberger@uol.com.br
Patients were referred from the following institutions: Department of Ophthalmology, Federal
University of São Paulo - UNIFESP; Department of Ophthalmology, São Paulo University - USP;
Department of Ophthalmology, Santa Casa Medical School; Disable Children Care Association and
from Brazilian Möbiius Society.
This is a multidisciplinary study, approved by the Ethics Committee of the Human Research of the
Santa Casa de Misericórdia de São Paulo Hospital (400/08).
237
Table 1. Visual acuity (VA), cycloplegic refraction, type of ocular deviation (D), presence of anisometropia (Anis.) in patients with the Möbius
sequence
VA
P
#
Cycloplegic refraction
OD
OS
OD
OS
01
Nc
0.80
0.63
+2.50 -0.75 x 180
02
Wc
0.20
LP
+6.50 -2.50 x 180o
o
D
+3.00 -2.50 180
Ortho
RD
Ortho
ET
o
03
Nc
0.80
0.80
+0.75
+0.75
04
Wc
1.00
1.00
+2.50 -1.50 x 15o
+2.75 -0.25 x 165o
ET
05
Nc
Ni
Ni
+2.50 -1.50 x 180
+3.00 -2.00 x 180
Ortho
06
Nc
0.40
0.40
-1.00
-1.00
ET
07
Nc
Ni
Ni
+0.50
+0.75
Ortho
08
Wc
0.80
0.63
+2.50
+6.00 -1.00 C x 90o
ET
09
Wc
0.80
0.80
+3.00 -1.00 x 180o
+2.75 -1.00 x 180o
Ortho
10
Wc
0.25
0.40
+4.00
+6.00 -1.50 x 180o
XT
11
Nc
0.50
0.50
+1.50
+1.50
Ortho
12
Nc
0.50
0.63
-2.00 x 90o
13
Wc
0.50
0.50
-2.25 -1.50 x 180
14
Wc
Ni
Ni
15
Nc
0.32
16
Nc
0.63
o
o
Anis.
x
x
-2.00 x 90o
XT
-5.25 -5.25 x 180o
Ortho
x
-10.00 -2.00 x 30o
-7.00
ET
x
0.32
+4.00 -2.25 x 180o
+4.50 -2.50 x 180o
ET
0.50
+1.00
-1.50
ET
Ortho
o
17
Nc
Ni
Ni
+0.50
+0.50
18
Nc
0.50
0.32
+1.00
+1.00
19
Nc
0.20
0.25
+4.00 -2.50 x 160
20
Nc
0.50
0.50
+0.50
21
Nc
0.40
0.50
+2.75 -0.50 x 90o
+1.25
22
Wc
0.32
0.50
-7.50 -2.75 x 180
23
Wc
0.80
0.63
+2.50 -2.00 x 120o
24
Nc
Ni
Ni
+0.75 -1.00 x 180o
+1.50
ET
25
Nc
0.40
0.32
+1.00
+1.00
ET
26
Wc
0.50
0.80
+1.50 -1.50 x 30o
+0.75 -1.00 x 100o
Ortho
27
Wc
0.63
0.80
+1.50 -0.50 x 180
+2.00 -0.75 x 180o
ET
28
Nc
0.63
0.63
+0.75
+1.00
Ortho
29
Nc
0.90
0.90
Plano
-0.50 x 180 o
XT
30
Nc
0.50
0.32
+1.50 -0.50 x 180o
+1.50
Ortho
31
Wc
cf
0.63
+4.50 -5.25 x 175o
+4.75 -3.25 x 10o
Ortho
32
Wc
0.50
0.60
+3.00
+3.00
Ortho
o
o
o
ET
+3.75 -3.25 x 20
ET
+0.50
Ortho
o
Ortho
x
o
-6.00 -0.75 x 180
ET
x
+2.50 -2.00 x 20o
ET
33
Nc
Ni
Ni
+4.50
+4.50
ET
34
Nc
Ni
Ni
+1.75
+1.50
ET
35
Nc
Ni
Ni
+0.75
+0.75 -0.50 x 90 o
Ortho
36
Nc
0.32
0.32
-2.00
-2.25
ET
37
Wc
0.32
0.50
+4.00
+4.00
Ortho
38
Nc
0.32
0.32
+1.50
+0.50
ET
39
Nc
1.00
1.00
+1.75 -1.00 x 180o
+1.75 -1.00 x 180o
Ortho
40
Nc
0.40
0.40
-0.50
+0.25 -0.75 x 90o
ET
41
Nc
0.80
0.80
Plano
Plano
Ortho
42
Nc
Ni
Ni
+1.50
43
Wc
0.30
0.50
+1.50 -2.75 x 10
+1.50
o
x
+1.50 -1.50 x 170
x
x
Ortho
o
Ortho
OD= right eye; OS= left eye; Nc= no correction; Wc= with correction; Ni= not informed; Cf= counting fingers; LP= light perception; RD= retinal detachment; Ortho= orthotropia; ET=
esotropia; XT= exotropia.
238
Cronemberger MF, et al.
This study was carried out during the Annual Meeting of the
Brazilian Möbius Society on November 2008, in the Department of
Ophthalmology of Santa Casa de Misericórdia de São Paulo Hospital.
Forty-four patients diagnosed with Möbius sequence were examined
by a multidisciplinary group: ophthalmology, neurology, genetics,
psychiatry, psychology and dentistry
A cross-sectional transversal study was performed on 43 coo
perative patients to undertake the ophthalmic exam. Of these 43
patients, 22 (51.2 %) were male and 21 (48.8 %) were female. The
average age was 8.3 years (2 to 17 years).
The visual acuity was measured each eye separately. The patients
were tested with the retro-illuminated logMAR chart.
Measurement of ocular deviation was determined by cover test
or a Krimsky test for uncooperative patients.
Retinoscopy was performed with loose trial lenses and cyclople
gia was obtained using 1 drop of tropicamide 1% (Alcon), 1 drop of
cyclopentolate 1% (Allergan), after anesthesia induced by proxime
tacaine chloride 0.5% (Alcon). The refractometric examination was
performed 40 minutes after the instillation of the last eye drops.
Prevalence of myopia spherical equivalent of -0.50 diopters or
less and of hyperopia spherical equivalent of +2.00 diopters or grea
ter were calculated. Emmetropia was considered greater than -0.50
spherical equivalent diopters or less than +2.00 spherical equivalent
diopters. The prevalence of astigmatism was assessed at two levels:
≥0.75 to <2.0 cylinder diopters, and ≥2.0 cylinder diopters(12,13).
The fundus exam was performed by an indirect ophthalmoscopy,
soon after the refraction exam.
RESULTS
Table 1 shows the data of the 43 patients who participated in the
exam, with their respective results of visual acuity, cycloplegic reti
noscopy of both eyes, and type of ocular deviation. The last column
in table 1 shows the patients who had anisometropia. Out of the 43
patients, 9 (20.9%) were anisometropic.
Myopia was defined as spherical equivalent (SE) refractive error
of at least -0.50 D in 13 (15.3%) eyes. The average myopia was -3.69 D
(from -0.50 D to -11.0 D). Hyperopia as +2.00 D or more in 23 (27.1%)
eyes. The average hyperopia was +3.47 D (from +2.00 D to +6.37 D).
Forty-nine (57.6%) eyes were emmetropics (>-0.50 D and <+2.00 D),
average +0.95 D (from -0.25 D to +1.87 D). The prevalence of astig
matism greater than or equal to 0.75 to less than 2 cylinder diopters
was 17 (20%) and greater than or equal to 2 diopters was 17 (20%).
The fundus exam showed that 3 patients had an increased cupto-disc ratio in both eyes (OU).
DISCUSSION
Refractive error can place a substantial burden on the individual.
School-age children constitute a particularly vulnerable group, be
cause uncorrected refractive error may have a dramatic impact on
learning capability and education potential(13). Refractive error as a
cause of blindness has been recognized only recently with the increa
sing use of presenting visual acuity for defining blindness(14).
Reviewing the literature it was found only two studies on refrac
tive errors related to Möbius sequence. Some authors(10), in a group
of 28 patients, the most frequent refractive error was astigmatism,
considering hyperopic astigmatism, myopic astigmatism and mixed
astigmatism, diagnosed in 33 eyes (58.9%) out of a total of 56, follo
wed by hyperopia in 33.9% eyes. Other authors(9) found compound
hyperopic astigmatism to be the main refractive error (40.6%) in a
series of 16 patients. Mean spherical equivalent was +1.90 ± 2.49
(median=+2.00). In our study, using spherical equivalent, most of the
patitents (57.6%) were emmetropic (>-0.50 D and <+2.00 D). The pre
valence of myopia (at least -0.50 D) was 15.3% eyes and hyperopia as
+2.00 D or more in 27.1% eyes. The prevalence of astigmatism greater
than or equal to 0.75 D was 40%.
Uncorrected refractive error is recognized as the major cause of
avoidable visual impairment in worldwide population, regardless
age, sex or ethnicity. For children, there may be severe consequences
such as delayed neuropsychomotor development, learning disabili
ties and special needs education in more severe cases. In o long term,
it may result in a burden for the country and society(11).
Furthermore, optical correction for refractive error is the most
cost-effective intervention in eye health care(11), due to easy detec
tion, diagnosis and the correction with spectacles.
Especially for those patients in this study and considering their
many individual limitations, detection and appropriated optical cor
rection could improve their visual acuity and their daily activities and
school performance, improving their quality of life.
CONCLUSION
We conclude that the prevalence of refractive errors, by the sphe
rical equivalent, was 42.4% in this studied group.
ACKNOWLEDGEMENTS
Special thanks to Dr Flavio Hirai who kindly reviewed and made
suggestions and the cooperation of Dra Nilce Tiemi Shiwaku Kamida.
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49(10):4308-13.Available from: http://www.iovs.org/content/49/10/4308.long
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sampling and measurement methods for a multi-country survey. Am J Ophthalmol.
2000:129(4):421-6. Comment in: Am J Ophthalmol. 2000;129(4):525-7.
14.Dandona R, Dandona L. Refractive error blindness. Bull World Health Organ. 2001:
79(3):237-43.
239
Congenital cataract surgery with intraocular lens implantation in microphthalmic eyes:
visual outcomes and complications
Cirurgia de catarata congênita com implante de lente intraocular em olhos microftálmicos:
resultados visuais e complicações
Marcelo Carvalho Ventura1,2, Virgínia Vilar Sampaio1, Bruna Vieira Ventura1, Liana Oliveira Ventura1,2, Walton Nosé3
ABSTRACT
RESUMO
Purpose: To report the visual outcomes and complications of congenital cataract
surgery with primary intraocular lens implantation in microphthalmic eyes of
children younger than 4 years of age.
Methods: This retrospective interventional case series included 14 microphthalmic
eyes from 10 children who underwent congenital cataract surgery with primary
intraocular lens implantation younger than 4 years of age. Seven patients had
bilateral cataracts (11 eyes met the study’s inclusion criteria) and 3 patients had
unilateral cataract. Patients’ medical charts were reviewed to obtain information
regarding the preoperative and postoperative ophthalmological examination.
Main outcome measures were intraocular pressure (IOP), best-corrected visual
acuity, and intraoperative and postoperative complications.
Results: Mean age at the time of surgery was 21.7 ± 2.9 months. Mean ocular
axial length was 19.2 ± 0.9 mm. Mean preoperative IOP was 9.7 ± 1.7 mmHg and
10.3 ± 3.1 mmHg on final follow-up (P=0.18). There were no intraoperative com
plications. Two (15.4%) eyes developed secondary visual axis opacification, of
which only one needed to be reoperated due to significantly decreased vision
(0.5 logMAR). Preoperative and postoperative best-corrected visual acuity was 2.09
± 0.97 logMAR and 0.38 ± 0.08 logMAR in bilateral cases and 1.83 ± 1.04 logMAR
and 0.42 ± 0.13 logMAR in unilateral cases, respectively.
Conclusion: Primary intraocular lens implantation in congenital cataract sur
gery in microphthalmic eyes resulted in a significant best-corrected visual acuity
improvement with no intraoperative complications and minimal postoperative
complications.
Objetivos: Relatar os resultados visuais e as complicações da cirurgia de catarata
congênita com implante primário de lente intraocular em olhos microftálmicos de
crianças menores de 4 anos.
Métodos: Esta série de casos retrospectiva incluiu 14 olhos microftálmicos de 10
crianças menores de 4 anos que foram submetidas à cirurgia de catarata congênita
com implante primário de lente intraocular. Sete pacientes tinham catarata bilateral
(11 foram incluídos no estudo) e 3 tinham catarata unilateral. Os prontuários dos pacientes foram revisados para se obter informação sobre o exame oftalmológico pré- e
pós-operatório. As principais variáveis analisadas foram pressão intraocular, acuidade
visual com melhor correção e complicações intra- e pós-operatórias.
Resultados: A média da idade dos pacientes na época da cirurgia foi de 21,7 ± 2,9
meses. O diâmetro antero-posterior médio foi de 19,2 ± 0,9 mm. A pressão intraocular
média pré-operatória foi 9,7 ± 1,7 mmHg e 10,3 ± 3,1 mmHg no último exame de acompanhamento pós-operatório (P=0,18). Não houve complicações intraoperatórias. Dois
(15,4%) olhos desenvolveram opacificação secundária do eixo visual, dos quais um foi
reoperado devido à baixa visual significativa (0,5 logMAR). AV pré- e pós-operatórias
foram 2,09 ± 0,97 logMAR e 0,38 ± 0,08 logMAR em casos de catarata congênita bilateral e 1,83 ± 1,04 logMAR e 0,42 ± 0,13 logMAR em casos unilaterais, respectivamente.
Conclusão: O implante primário de lente intraocular em cirurgia de catarata congênita
em olhos microftálmicos resultou em uma melhora significativa da acuidade visual com
nenhuma complicação intraoperatória e com pouca complicação no pós-operatório.
Keywords: Cataract/congenital; Cataract extraction/adverse effects; Microphthal
mos; Visual Acuity/physiology; Intraocular lenses; Postoperative complications
Descritores: Catarata/congênito; Extração de catarata/efeitos adversos; Microftalmia;
Acuidade visual/fisiologia; Lente intraocular; Complicações pós-operatórias
INTRODUCTION
Congenital cataract is the cause of 24.8% to 29.3% of the avoidable
blindness in children(1), with a prevalence varying from 1.2 to 6.0 cases
per 10,000 children(2). Microphthalmos has been identified in 7.2% to
16.9% of these patients(3,4). The visual prognosis of a child with infan
tile cataract is related to ocular characteristics, early diagnosis and
surgical treatment, associated with visual rehabilitation(5).
Advances in surgical techniques have resulted in a decrease in
the incidence of complications(5). Many authors support early pri
mary intraocular lens (IOL) implantation in the first year of life for
aphakia correction in children(5,6). The goal is to decrease amblyopia
and strabismus(7). Although IOL implantation is possible even in very
young children, in microphthalmic eyes there are more technical dif
ficulties(8). However, the visual prognosis of microphthalmic eyes with
congenital cataract that are left aphakic is generally poor(8,9).
The purpose of the present study is to describe the visual outco
mes and complications in microphthalmic eyes of children operated
for unilateral or bilateral congenital cataracts with primary IOL im
plantation younger than 4 years of age.
Study carried out at Fundação Altino Ventura - FAV.
Physician, Department of Congenital Cataract, Fundação Altino Ventura - FAV - Recife, Brazil.
Physician, Department of Congenital Cataract, Hospital de Olhos de Pernambuco - HOPE - Recife,
Brazil.
3
Paulo, Brazil.
1
2
240
METHODS
This retrospective interventional case series was approved by the
Ethics Committee of the Fundação Altino Ventura (Protocol 071/09)
Disclosure of potential conflicts of interest: M.C.Ventura, None; V.V.Sampaio, None; B.V.Ventura,
None; L.O.Ventura, None; W.Nosé, None.
Correspondence address: Marcelo C. Ventura. Fundação Altino Ventura - FAV. Rua da Soledade,
170 - Recife (PE) - 50070-040 - Brazil - E-mail: marcelovhope@gmail.com
This study was approved by the Ethics Committee of the Fundação Altino Ventura (Protocol 071/09).
Ventura MC, et al.
and followed the tenets of the Declaration of Helsinki. Patients’ guar
dians received an explanation concerning the surgical treatment and
gave oral informed consent for the surgery before the procedure.
The study comprised of eyes from children younger than 4 years
of age with microphthalmos, who underwent congenital cataract
surgery with IOL implantation at the Altino Ventura Foundation, in
Recife, Brazil, between 2005 and 2010. Microphthalmos was defined
as an eye with an axial length more than 2 standard deviations smaller
than the normal for that age group(10). Infants with other associated
ocular abnormalities that could compromise vision, such as ocular
trauma, corneal leucoma, congenital glaucoma, aniridia, persistent
hyperplastic primary vitreous, chorioretinal coloboma, and chorio
retinal scars, were not included. Minimum follow-up time was 6
months. Ten patients met the criteria and were included in this study.
The patients’ medical charts were reviewed to obtain information
regarding the preoperative ophthalmological examination, which
included the measurement of the best-corrected visual acuity (BCVA),
ocular extrinsic motility assessment, biomicroscopy (in cooperative
patients) or inspection (in non-cooperative patients), retinoscopy
under cycloplegia, and fundoscopy. Teller Acuity Cards and Lea Hy
varinen Chart were used to measure BCVA. Ocular alignment was
measured using alternate cover testing. When this exam was not
feasible, Krimsky test was performed.
Preoperative intraocular pressure (IOP) measured with a calibra
ted Perkins applanation tonometer and central corneal thickness
(CCT) were attained from the medical charts. These measurements
had been taken before surgery, under general anesthesia. All surge
ries were performed by one surgeon (M.C.V.) with a vast experience
in congenital cataract surgery. A standardized surgical technique
was implemented, which included phacoaspiration, posterior cap
sulorhexis, endocapsular tension ring implantation (endocapsular
tension ring of 10/12 mm; Visiontech Medical Optics Ltda, Belo
Horizonte, Brazil), anterior vitrectomy and primary IOL implantation.
In all patients, a foldable, hydrophobic acrylic Type 7B IOL (Alcon,
Fort Worth, USA) was placed in the capsular bag. This lens has an
optical diameter of 5.5 mm and a total diameter of 12.5 mm. The
IOL power was calculated based on a protocol created by one of the
authors (M.C.V.)(5). The goal of this protocol is emmetropia at 4 years
of age. Briefly, the IOL power is first calculated using an A-scan (DGH
4000B, DGH Technology, Inc., Exton, USA) and the Holliday II formula.
Depending on the age of the child at surgery, a specific amount of
undercorrection determines the final power of the IOL that will be
placed (Table 1). If the child is pseudophakic in the fellow eye or has
unilateral cataract, the refraction of the fellow eye is also taken into
consideration to avoid anisometropias.
All patients used postoperative topical moxifloxacin 0.5% (Viga
mox; Alcon Laboratories, São Paulo, São Paulo, Brazil) 4 times a day
for 10 days; tropicamide 1% (Mydriacyl; Alcon Laboratories, São Paulo,
São Paulo, Brazil) diluted 1:1 with artificial tears twice daily for 10 days;
Table 1. Amount of undercorrection based on the patient’s age at
surgery to determine the final intraocular lens power to be used
Age at surgery (months)
Undercorrection (D)
≤3
9.00
6
7.00
9
5.00
12
4.00
18
3.00
24
2.00
36
1.00
≥48
0.00
betaxolol 0.5% (Presmin; Latinofarma Indústrias Farmacêuticas Ltda.,
Cotia, São Paulo, Brazil) twice a day for 15 days; prednisolone acetate
1% (Oftpred; Latinofarma Indústrias Farmacêuticas Ltda) every 6 hours
daily for a week, tapered over the next 4 weeks; and 1 mg/kg/day of
prednisolone syrup (Prelone; Achè Laboratórios Farmacêuticos S.A.,
Guarulhos, São Paulo, Brazil) for 15 days, half the dose on the third
week, and one fourth of the dose on the fourth week.
Patients returned for follow-up examinations on the 1st, 15th, 30th,
90th and 180th postoperative day, and every 6 months thereafter,
unless amblyopia treatment required more frequent visits. On the 1st
day, patients were examined by inspection. On the 15th day, patients
were submitted to cycloplegic refraction. On the other visits, evalua
tion consisted of BCVA, ocular extrinsic motility, and slit lamp and
fundus examination. BCVA and ocular extrinsic motility were tested
as previously described. In addition, during these other visits, the
children were examined under anesthesia to measure IOP, using a
calibrated Perkins applanation tonometer.
Treatment for amblyopia was prescribed, which consisted of re
fractive error correction, patching of the dominant eye, and visual sti
mulation. The spectacles had an overcorrection of +2.00 D in babies
to provide near point correction. When the patient started walking, a
Kriptok bifocal lens with a +3.00 D for near was prescribed(5). A visual
success in the congenital cataract treatment was defined as a BCVA
on last follow-up equal or better than 0.5 logarithm of the minimum
angle of resolution (logMAR)(11).
Statistical analysis was performed using SPSS for windows (ver
sion 12.0, SPSS, Inc.). For statistical analysis, BCVA was converted to
logMAR. The results of the qualitative variables were expressed by
their absolute and relative frequencies. The results of the quantitative
variables were expressed by their minimum and maximum value,
means, and standard deviation (SD). Normality was checked using
the Kolmogorov-Smirnov test. The Spearman correlation test was
used to verify the correlation between preoperative and postopera
tive IOP. P values <0.05 were used to reject the null hypothesis.
RESULTS
Fourteen microphthalmic eyes from 10 patients submitted to
congenital cataract surgery with primary IOL implantation were
included in this study. Five (50.0%) patients were male and 5 (50.0%)
were female. Seven (70.0%) patients had bilateral cataracts. Of these
14 eyes, 11 met the criteria to be included in the study. The other 3
eyes were excluded because 1 had a normal axial length for their age,
1 was operated at age 6, and the third eye had a small posterior polar
cataract that was not compromising the red reflex and, thus, was not
operated. Three patients had unilateral cataract. The mean age at
surgery was 21.7 ± 2.9 months (range, 9 to 44 months). At the time
of surgery, the mean ocular axial length was 19.2 ± 0.9 mm (range,
17.5 to 20.6 mm). The mean follow-up was 38.5 ± 3.1 months (range,
23 to 48 months).
There were no surgical complications. Two eyes (15.4%) had se
condary opacification of the visual axis at 6 and 8 months after the
surgery (eyes #10 and #14 on tables 2 and 3, respectively). One of
these eyes maintained good BCVA (0.1 logMAR) despite opacifica
tion. The other underwent further pars plana anterior vitrectomy due
to significantly decreased vision (0.5 logMAR).
The central corneal thickness prior to surgery was 568.1 ± 51.5 µm
(range, 493 to 644 μm). The preoperative and final postoperative
mean IOP were 9.7 ± 1.7 mmHg (range, 8 to 12 mmHg) and 10.3 ±
3.1 mmHg (range, 7 to 18 mmHg), respectively. There was no signi
ficant difference in IOP before and after surgery (rho=0.06; P=0.87).
Fundoscopy was normal in all patients during follow-up. There were
no cases of postoperative glaucoma.
None of the patients had strabismus. Two patients (3 eyes) with
bilateral congenital cataracts had preoperative nystagmus. Their
mean age at surgery was 14.3 ± 3.1 months (range, 11 to 17 months).
241
Congenital cataract surgery with intraocular lens implantation in microphthalmic eyes: visual outcomes and complications
Table 2. Preoperative and final postoperative best-corrected visual
acuity (BCVA) in microphthalmic eyes with and without nystagmus
operated for bilateral congenital cataract with intraocular lens implantation
Eye
#
Preoperative
BCVA (logMAR)
Final postoperative
BCVA (logMAR)
Nystagmus
01
1.5
0.4
No
02
3.0
0.6
No
03
3.0
0.2
No
04
3.0
0.7
Yes
05
3.0
0.8
Yes
06
3.0
0.6
Yes
07
1.3
0.1
No
08
1.3
0.2
No
09
1.0
0.1
No
10
0.8
0.1
No
11
1.5
0.4
No
Table 3. Preoperative and final postoperative best-corrected visual
acuity (BCVA) in microphthalmic eyes operated for unilateral congenital
cataract with primary intraocular lens implantation
Eye
#
Preoperative
BCVA (logMAR)
Final postoperative
BCVA (logMAR)
12
3.0
0.6
13
1.5
0.2
14
1.0
0.5
Mean preoperative BCVA was 2.09 ± 0.97 logMAR and 1.83 ± 1.04
logMAR in bilateral and unilateral cases, respectively. The mean final
BCVA in patients with bilateral congenital cataracts was 0.38 ± 0.08
logMAR, including the patients with nystagmus. When evaluated se
parately, patients without nystagmus had a mean final BCVA of 0.23 ±
0.07 logMAR versus 0.7 ± 0.05 logMAR in the patients with nystagmus
(Table 2). The mean final BCVA in patients with unilateral congenital
cataracts was 0.42 ± 0.13 logMAR (Table 3).
DISCUSSION
The studied sample comprised of 14 eyes with congenital cata
racts and simple microphthalmos, meaning that their axial length
was small, but otherwise normal(12). They were submitted to conge
nital cataract surgery with primary IOL implantation younger than
4 years of age. Two eyes (15.4%) had secondary opacification of the
visual axis, of which 1 required reoperation due to low vision. Pre
vious studies in microphthalmic(1) and non-microphthalmic(13) eyes
operated for congenital cataract with IOL implantation had similar
rates of secondary opacification. However, others report higher inci
dences(14-16): Astle et al.(14), reported reopacification in 37.3% of nonmicrophthalmic eyes in children operated younger than 4 years of
age. Many factors determine the occurrence of secondary visual axis
opacification and it is known that younger children develop seconda
ry opacifications more often(14). Acrylic IOLs are more biocompatible
than poly(methyl methacrylate) (PMMA) and reduce the formation of
secondary membranes(17). In addition, it has been previously reported
that anterior limbic incision has a 1.66 lower risk for secondary visual
axis opacification when compared to pars plicata incision(8). As we
previously described(5), we use an endocapsular tension ring in infan
tile cataract surgery to expand the capsular bag in all its circumferen
242
ce to provide a stable capsular bag in despite of the implantation of
a three-piece IOL with 12.5 mm of total diameter in a child’s eye. This
expansion and stability maintains a circular and central capsulorhexis,
with the IOL functioning as a physical barrier between the posterior
chamber and the vitreous cavity. We postulate that this may contri
bute to decrease secondary visual axis opacification(5).
Our patients’ mean CCT before surgery was 568.1 ± 51.5 µm, which
is slightly thicker than what has been previously described for normal
children younger than 2 years of age(18). Some authros(19) reported
that the Perkins tonometer is more accurate when CCT is approxima
tely 560 to 580 μm. In the present study, no significant IOP elevation
or cup-to-disc ratio alteration was verified during the follow-up pe
riod, although glaucoma is a common complication after congenital
cataract surgery(14) and microphthalmos is an additional risk factor
for its development.
Our patients with nystagmus had a mean age at surgery of 14.3 ±
3.1 months. Children with dense bilateral congenital cataract should
ideally be operated before the development of nystagmus, which
occurs in many cases after 10 weeks of age(20). Nystagmus is a predic
tive factor for poor visual acuity(5,9); however, the visual acuity of our
patients with nystagmus improved after surgery, supporting the
findings of previous papers(21,22). Yet, as expected, the improvement
was not as great as in bilateral cases without nystagmus or unilateral
cases. In addition, the improvement was less than what was descri
bed by Rabiah et al.(23), who reported visual results after surgery better
than 0.33 in 46% of 95 patients with bilateral congenital cataract
and nystagmus. These authors postulated that their better results
could be due to a selection bias: the possibility of mild, non-deepamblyogenic cataract, or the presence of developmental instead of
congenital cataract(23).
In the present study, preoperative BCVA and BCVA on final fol
low-up visit were measured in all bilateral cases (10 eyes). Visual
success was accomplished in 6 eyes (60%), which is within the
range described in bilateral congenital cataract cases with primary
IOL implantation in eyes without microphthalmos (33 to 85% of
success)(11,24,25). Visual results in unilateral cases are generally worse
than in bilateral cases(24,26,27). Our 3 cases of unilateral cataracts had
a mean final BCVA of 0.42 ± 0.13, in contrast to 0.38 ± 0.08 achieved
in the bilateral cases when including the eyes with nystagmus, and
0.23 ± 0.07 when excluding these eyes. Our results in unilateral ca
taracts are similar to a previous study, in which patients without
microphthalmos achieved a mean visual acuity on last follow-up
visit of 0.43(28), and better than another in which the BCVA achieved
in non-microphthalmic eyes was of 0.91(29).
The results of the present study should be viewed in light of the
study’s limitation. This study was limited by its small sample, a result
of the uncommon incidence of children with congenital cataract and
microphthalmos. In addition, a longer follow-up period may reveal
the development of glaucoma in some of these eyes(30).
CONCLUSION
The present study suggests that primary IOL implantation in con
genital cataract surgery in microphthalmic eyes of children younger
than 4 years of age can be a safe and successful treatment option for
aphakia, improving visual function in unilateral and bilateral cases.
However, patients have to be selected carefully and the surgery
should be performed by an anterior segment surgeon familiar with
the posterior segment and with broad experience in congenital ca
taract surgery.
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243
Relato de Caso |
Case Report
Periorbital liposarcoma in pediatric patient: a case report
Fernanda Marcio1, José Vital Filho1, Sylvia Regina Temer Cursino1, Patrícia Gomes Martins de Sousa1, Dino Martini Filho2
RESUMO
ABSTRACT
O objetivo desse estudo é descrever uma criança com lipossarcoma periorbital,
caracterizando seus aspectos clínico-epidemiológicos e terapêuticos. Menina
de 6 meses de idade com tumoração crescente há dois meses em região fronto-zigomática direita, a qual foi submetida à exérese e cujas análises anatomopatológica (AP) e imuno-histoquímica (IH) observaram achados típicos de lipoblastoma.
Após isso, apresentou mais três recidivas tumorais com diagnósticos similares.
Um ano depois da última cirurgia, houve nova recorrência, porém, dessa vez, o
resultado dos exames análises anatomopatológica e imuno-histoquímica foi de
lipossarcoma, sendo, então, encaminhada para complementar o tratamento com
radio e quimioterapia, sem novas lesões até o momento. Devido a sua raridade,
geralmente o lipossarcoma não entra no diagnóstico diferencial em pacientes
com massas orbitais, porém, por ser localmente agressivo, torna-se vital a pronta
identificação e tratamento de forma a oferecer melhores resultados terapêuticos
e influência sobre a qualidade de vida do paciente.
The purpose of this study is report a child with periorbital liposarcoma describing
the clinical, epidemiological and therapeutic aspects. Six-months-old female baby
with increasing tumor in the right fronto-zigomatic region wich was submitted to
excision and the patologic and immunohistochemistry analisys observed typical
findings of lipoblastoma. After that, there were three tumors relapse with the same
diagnosis. One year after the last surgery there was a recurrence of the tumor but at
this time the diagnosis was lipossarcoma and the patient was referred for additional
treatment wilth radiotherapy and chemotherapy no new injuries so far Due to its
rarity, liposarcoma usually does not enter the differencial diagnosis in the patients
with orbital masses, however because of its local aggressiveess, it’s vital the early
identification and treatment to provide better therapeutic results and quality of life.
Descritores: Lipossarcoma/radioterapia; Lipossarcoma/quimioterapia; Neoplasias or
bitárias/cirurgia; Lipoblastoma; Marcadores biológicos de tumor; Humanos; Feminino;
Lactente; Relato de caso
Keywords: Liposarcoma/radiotherapy; Liposarcoma/drug therapy; Orbital neo
plasms/surgery; Lipoblastoma; Tumor markers, biological; Humans; Female; Infant;
Case report
INTRODUÇÃO
Em relação a outros tipos de câncer, os sarcomas de tecidos moles
são relativamente raros. O lipossarcoma constitui cerca de 9,8% a 18%
dos sarcomas e é derivado de células primitivas que se diferenciam em tecido adiposo. A maioria dos casos de lipossarcoma orbital são
primários e raramente metastáticos (1-5).
O objetivo desse estudo é relatar uma criança com lipossarcoma
periorbital, descrevendo seus aspectos clínico-epidemiológicos e
terapêuticos.
A tomografia computadorizada da órbita evidenciou lesão hipodensa, arredondada, bem delimitada, na região fronto-zigomática
direita, sem erosão óssea. A paciente foi submetida à exérese da
lesão (Figuras 1B e 1C) e o exame anatomopatológico (AP) mostrou
neoplasia coincidente com margens cirúrgicas e a análise imuno-his
toquímica (IH) demonstrou achados típicos de lipoblastoma, como
proteína S100 focalmente positiva, vimentina positivo, além de desmina, AE1/AE3, CDE 34 negativos.
Após cinco meses, houve recidiva da lesão e feita nova ressecção.
Nesse caso, o AP evidenciou aspecto agressivo com polimorfismo,
presença de mitoses, os quais não existiam na lesão inicial e, adicionalmente, não se observava arquitetura lobulada que era presente
anteriormente, e a IH apresentava vimentina difusamente positivo,
S100 focalmente positivo, desmina e CD99 negativos, o que não
contribuiu para concluir quanto à linha de diferenciação da proliferação. Diante da alteração desses aspectos, o caso foi enviado para
Royal National Orthopedic Hospital em Londres (serviço de patologia
especializado em lesões mesenquimais), onde foi realizado o teste
de translocação FUS-CHOP, o qual foi negativo, corroborando com
diagnóstico de lipoblastoma. Como desde a primeira cirurgia, as
margens cirúrgicas eram comprometidas, houve recorrência tumoral
mais duas vezes sempre com o mesmo diagnóstico.
RELATO DO CASO
Paciente de 6 meses de idade, do sexo feminino, foi encaminhada ao serviço com história de tumoração periorbital crescente
há dois meses. Os antecedentes revelavam apenas polidactilia em
mãos e pés.
À ectoscopia observava-se tumoração arroxeada, medindo 4,5
x 5 cm, sem sinais flogísticos, na região fronto-zigomática direita. À
palpação o tumor tinha consistência firme e era aderido a planos
profundos. Ao exame oftalmológico, a paciente seguia objetos, não
reagia à oclusão e apresentava ortotropia ao teste de Hirschberg. Os
exames de motilidade ocular extrínseca, das reações pupilares e fundoscopia não revelaram alterações em ambos os olhos (Figura 1A).
Submetido para publicação: 26 de julho de 2012
Aceito para publicação: 30 de julho de 2013
Trabalho realizado na Santa Casa de Misericórdia de São Paulo.
1
2
Médico, Departamento de Oftalmologia, Santa Casa de Misericórdia de São Paulo, São Paulo (SP) Brasil.
Médico, Departamento de Patologia, Santa Casa de Misericórdia de São Paulo, São Paulo (SP) - Brasil.
244
Divulgação de potenciais conflitos de interesse: F.Marcio, None; J.Vital Filho, None; S.R.T.Cursino,
None; P.G.M.Sousa, None; D.Martini Filho, None.
Endereço para correspondência: Fernanda Marcio. Rua Inhambu, 973 - Apartamento 21ª - São
Paulo (SP) - 04520-013 - Brasil - E-mail: fernandamarcio@hotmail.com
Marcio F, et al.
Um ano após, com novo aparecimento da lesão, foi necessária
outra intervenção cirúrgica (Figura 2A), sendo, desta vez, diagnosticado lipossarcoma mixoide devido à presença de focos de necrose,
alto índice de proliferação, áreas mixoides, proteína S100 negativa
e fenótipos epitelioide e fusocelular (Figura 2B e 2C), diferente das
características dos tumores prévios que tinham fenótipo adipocítico,
baixo grau histológico e imunoexpressão focal pela proteína S100.
Com avaliação junto à Oncopediatria, foram instituídos tratamentos radioterápico e quimioterápico, além de acompanhamento periódico semestral com avaliações clínicas e exames de imagem, sem
recorrência tumoral ao longo dos quatro anos seguintes (Figura 2D).
A
B
C
Figura 1. A) Tumoração arroxeada, de consistência firme e aderida, medindo 4,5 x 5 cm
de diâmetro, sem sinais flogísticos, em região fronto-zigomática direita. B) TC órbita:
lesão hipodensa, arredondada, bem delimitada, localizada em região fronto-zigomática
direita, sem erosão óssea. C) Exérese do tumor.
A
B
C
D
Figura 2. A) Segunda recidiva tumoral. B) HE: fenótipos epitelioide e fusocelular, focos
de necrose alto índice proliferativo e áreas mixoides. C) Imuno-histoquímica: Vimentina
positivo. D) Pós-operatório tardio da quinta cirurgia, sem indícios de recidiva tumoral
até o momento.
DISCUSSÃO
Lipossarcoma é o sarcoma de tecidos moles mais comum em
adultos e em geral afeta o retroperitôneo, coxa e região inguinal,
mas é raro na órbita(1,4,5). Apesar de raros, os sarcomas são tumores
que também podem acometer a região da face e devem ser conside
rados como diagnóstico diferencial em lesões orbitais e periorbitais.
Acredita-se que se desenvolva a partir de células mesenquimais em
vez de um lipoma preexistente(6).
É mais frequente no sexo masculino do que no feminino e na faixa
etária entre 30-60 anos com idade média de aparecimento aos 53
anos de idade, sendo extremamente incomuns na infância(4,7). Produz
um quadro clínico que se assemelha a outros tumores orbitais, tais
como proptose, distopia, diplopia, compressão do nervo óptico, dor
e alteração da visão caso o tumor esteja no ápice orbital(1,4).
Pode ser classificado nos seguintes cinco subtipos: bem diferenciado, mixoide, células redondas, indiferenciado e pleomórfico(1-3,7). A
maioria dos casos são tipo mixoide (30-50% dos casos) ou bem diferenciado (20-30%) e ambos têm um curso indolente(1,7). A recorrência
é comum, principalmente nos tipos pleomórfico e células redondas,
entretanto, metástases locais ou à distância são raras(1,4,5).
Histologicamente, o mixoide é caracterizado por matrix mixoide
com lipoblastos e uma rede capilar delicada. Já o tipo bem diferenciado mostra predominância de linfócitos maduros e variedade de
células fusiformes com núcleo hipercromático e lipoblastos com mul
tiplos vacúolos(4,7). Na imuno-histoquímica, apresenta S100 e vimentina
positivos e actina, miogenina e desmina negativos(7).
Um diagnóstico diferencial é o lipoblastoma que é um raro tumor
benigno dos tecidos moles. Este ocorre preferencialmente na infância,
sendo 90% dos casos em menores de 3 anos de idade, e, como o lipossarcoma, é mais frequente no sexo masculino(4). Histologicamente, o
lipoblastoma apresenta tecido adiposo lobulado com septos fibrosos e
estroma mixoide e lipoblastos imaturos, bastante semelhante com o lipossarcoma mixoide(6). Na criança, o lipossarcoma e o lipoblastoma podem mimetizar hemangioma, diferenciando-se por meio da biópsia(8).
O tratamento de escolha do lipossarcoma é a exérese completa
evitando, assim, a recidiva, que é comum. Além disso, os tipos mixoide são radiossensíveis, podendo, assim, ser utilizado como tratamento adjuvante, mas os bem diferenciados são menos responsivos
à radioterapia(4,7).
O uso da quimioterapia em lipossarcoma orbital não é bem descrito porém esquema de doxorrubicina e dacarbazina mostrou-se
efetivo para o tipo mixoide(5).
Apesar de mais frequente em adulto e sexo masculino, nosso
caso era uma criança no primeiro ano de vida e do sexo feminino,
com tumor que recidivou cinco vezes e cujos primeiros diagnósticos
foram de lipoblastoma, sendo que somente na quinta recorrência
observaram-se características de lipossarcoma. Além das cirurgias,
foi submetida à radioterapia e quimioterapia com doxorrubicina e
isofosfamida com desaparecimento da lesão até o momento.
O caso atual evidencia que, embora o lipossarcoma seja um
tumor raro na órbita e na criança, deve ser incluído no diagnóstico
diferencial das massas orbitais, e, por ser localmente agressivo, tor
245
na-se vital a pronta identificação e tratamento de forma a oferecer
melhores resultados terapêuticos e influência sobre a qualidade de
vida do paciente. O caso serve ainda para mostrar que o diagnóstico
anátomo-patológico pode ser difícil, podendo simular um lipoblastoma mesmo após várias recidivas.
REFERÊNCIAS
1. Al-Qahtani AA, Al-Hussain H, Chaudhry I, El-Khamary S, Alkatan HM. Primary orbital
liposarcoma: histopathologic report of two cases. Middle East Afr J Ophthalmol. 2011;
18(4):314-6.
2. MacNab A, Moseley I. Primary orbital liposarcoma: clinical and computed tomographic features. Br J Ophthalmol [Internet]. 1990[cited 2012 Jul 21];74(7):437-9. Available
from: http://bjo.bmj.com/content/74/7/437.long
3. Naeser P, Moström U. Liposarcoma of the orbit: a clinicopathological case report. Br
J Ophthalmol[Internet]. 1982[cited 2012 Mar 19];66(3):190-3. Available from: http://
bjo.bmj.com/content/66/3/190.long
4. Mridha AR, Sharma MC, Sarkar C, Suri V. Primary liposarcoma of the orbit: a report of
two cases. Can J Ophthalmol. 2007;42(3):481-3.
5. Madge SN, Tumuluri K, Strianese D, Bonavolonta P, Wilcsek G, Dodd TJ, et al. Primary
orbital liposarcoma. Ophthalmology. 2010;117(3): 606-14.
6. Anantharajan N, Ravindranathan N. Parotid lipoblastoma in a child: Rare presentation
as huge infratemporal mass with cervical extension. Indian J Plast Surg. 2010;43(1):
84-7.
7.Torrado CS, Zaldibar NM, Velasco-Benito V, Fernández-Hermida R. Primary orbital li
posarcoma. J Craniofac Surg. 2011;22(3):1139-41.
8. Cai YC, McMenamim ME, Rose G, Sandy CJ, Cree IA, Fletcher CD. Primary liposarcoma of the orbit: a clinicopathologic study of seven cases. Ann Diagn Pathol. 2001;
5(5):255-66.
39o Congresso da
Sociedade Brasileira de Retina e Vítreo
10 a 12 de abril de 2014
Royal Palm Plaza
Campinas (SP)
Informações:
Site: www.retina2014.com.br
246
Relato de Caso |
Case Report
Retinoblastoma orbitário: relato de caso
Eduardo Darahem Mabtum¹, Maria Teresa Brizzi Chizzotti Bonanomi1, Patricia Picciarelli de Lima1, Maria Tereza Assis de Almeida1
ABSTRACT
RESUMO
We describe the case of a 9-month old boy with unilateral retinoblastoma and
bulftalmo. Primary enucleation was the treatment of choice due to the lack of
visual prognosis. The histology of the enucleated eye showed massive choroidal
invasion by the tumor and the optic nerve free of neoplastic tissue. Therefore,
no adjuvant chemotherapy or radiotherapy was indicated. Three months after
the enucleation, the patient returned with massive orbital retinoblastoma with
exposure of the conjunctiva. Treated with chemotherapy, the patient has been
in remission for 12 months. The risk factors for orbital recurrence are discussed.
Relatamos paciente de 9 meses de idade com buftalmo e retinoblastoma unilateral.
O paciente foi tratado com enucleação primária devido à falta de prognóstico vi
sual. O exame do olho enucleado mostrou invasão maciça de coroide e ausência de
comprometimento do nervo óptico não sendo, portanto, submetido a tratamento
adjuvante de quimioterapia ou de radioterapia. Três meses após a enucleação, o
paciente apresentou-se com retinoblastoma orbitário volumoso com exposição da
conjuntiva. Tratado com quimioterapia permanece em remissão após 12 meses. São
discutidos os fatores de risco para a ocorrência da recidiva orbitária.
Keywords: Orbital retinoblastoma; Risk factors; Recurrence/drug therapy; Che
motherapy, adjuvant; Case report
Descritores: Retinoblastoma orbitário; Fatores de risco; Recorrência/quimioterapia
Quimioterapia adjuvante; Relato de caso
INTRODUCTION
Retinoblastoma is an intraocular neuroectodermal neoplasia. Uni
lateral disease is the most common form, occurring in 60 to 70% of the
cases(1). Between 4.2% and 9.5% of patients who undergo enucleation
present orbital recurrence(2), and the main risk factors are compro
mised surgical margins and extrascleral invasion(3,4). The infiltration
of the retrolaminar optic nerve, regardless of its association with
choroidal invasion, is also associated with tumor recurrence, and an
adjuvant treatment may be indicated. Conversely, isolated choroidal
invasion as a risk factor is controversial. While some authors suggest
adjuvant treatment(5), others argue that choroidal involvement does
not justify additional therapy(6). We report a case of retinoblastoma
with isolated choroidal invasion and orbital recurrence.
biopsy. The patient was then subjected to 6 cycles of chemotherapy
with vincristine sulfate, etoposide phosphate and carboplatin (VEC)
and 45 Gy of external radiotherapy, with complete tumor reduction
and no recurrence after 24 months.
CASE REPORT
A 9-month-old boy was admitted to the Hospital das Clínicas
da Faculdade de Medicina da Universidade de São Paulo on August
3, 2010 with leukocoria in the right eye (RE). On examination, he
presented no vision and buphthalmia in the RE and normal fixation
and no changes in the left eye. Ultrasonography and magnetic
resonance imaging (MRI) of the RE showed an intraocular tumor
presenting calcification compatible with retinoblastoma (Figure 1).
The anatomopathological examination of the enucleated RE sho
wed moderately differentiated retinoblastoma occupying the entire
vitreous cavity with massive choroidal invasion and without optic
nerve invasion (Figure 2). The patient returned after 3 months with
massive proptosis and conjunctival exposure. The MRI finding was
consistent with tumor recurrence (Figure 3), which was confirmed by
Submitted for publication: October 9, 2012
Accepted for publication: July 27, 2013
Study carried out at Ophthalmology Department, Hospital das Clínicas, Universidade de São
Paulo - USP, São Paulo (SP), Brazil.
1
Physician, Ophthalmology Department, Hospital das Clínicas, Universidade de São Paulo - USP,
São Paulo (SP), Brazil.
DISCUSSION
Currently, retinoblastoma has been conservatively treated using
various methods with excellent results. If the disease is at a very
advanced stage and no vision recovery is expected, enucleation is
indicated and is considered curative for the intraocular tumor. After
the enucleation of an eye with many anatomical changes, such as
those our patient presented, orbital recurrence is unpredictable,
and knowledge of the risk factors is essential. Orbital tumor and re
trolaminar nerve invasion are predictive of metastatic disease(2,4,5,7,8),
and retrolaminar optic nerve invasion, especially with compromised
surgical margins and scleral invasion, are major risk factors for orbital
recurrence(5,8). In a study of 1,674 enucleated eyes, 71 (4.2%) develo
ped orbital recurrence; only 2 presented scleral erosion, 32 presented
choroidal invasion, 35 presented postlaminar optic nerve invasion
(7 with positive surgical margins), and 11 had no histological risk
factor(2).
Neovascular glaucoma could be a relative risk factor for the orbi
tal extension of the tumor because the increase in IOP would cause
thinning of the sclera and cornea, which would facilitate the tumor’s
extension(7); meanwhile, the massive choroidal invasion would give
the tumor access to the emissary veins and the sclera, especially in
patients with glaucoma, and facilitate tumor metastasis(4,7). Evidently,
it is impossible to histologically detect all of the tumor cells that have
Disclosure of potential conflicts of interest: E.D.Mabtum, None; M.T.B.C.Bonanomi, None; P.P.Lima,
None. M.T.A.de Almeida, None.
Correspondence address: Eduardo Darahem Mabtum. Hospital das Clínicas da Faculdade de Me
dicina da USP - Departamento de Oftalmologia. Av. Dr. Enéas de Carvalho Aguiar, 255 - 6o andar São Paulo - SP - 05403-000 - Brazil - E-mail: emabtum@hotmail.com
247
A
B
C
Figure 1. A) Clinical aspect of buphthalmia in the right eye. B) Ultrasonography demonstrated calcium within the tumor. 206x127 mm (96 x 96 dpi). C) Magnetic resonance image
showing an intraocular tumor occupying the entire vitreous cavity without changing
the posterior contour of the sclera in T1 (without extrascleral invasion suspicion).
Figure 3. Magnetic resonance image three months after the enucleation, with a tumor
mass occupying the entire orbit and moving the polymethylmethacrylate orbital implant
out of the orbit. 203x130 mm (96 x 96 dpi).
A
B
C
D
Figure 2. A) General view of the optic nerve, partially showing the lamina cribrosa (arrow)
without tumor cell invasion. B) Massive choroidal invasion with tumor cells that infiltrate
the entire thickness of this layer. C) Microscopy of the tumor tissue showing poorly
differentiated neuroblastic cells, minimal cytoplasm, basophilic nuclei (several of them
pyknotic), mitotic figures and Flexner-Wintersteiner (arrow) and Homer-Wright rosettes
(arrowhead). D) Viable tumor cells invading the choroid, with a necrotic area and the
presence of pseudorosettes with a central blood vessel (arrow). 203x130 mm (96 x 96 dpi).
left the intraocular area and lodged in the orbit. A retrospective study
of 182 consecutive cases of enucleated unilateral retinoblastoma
shows an association of glaucoma and buphthalmia with high-risk
anatomopathological findings(9). Our patient presented with neovas
cular glaucoma and buphthalmia, with massive choroidal invasion
as the only risk factor identified upon anatomopathological analysis,
which did not justify adjuvant treatment according to our protocol.
Adjuvant therapy with chemotherapy in the postoperative period,
regardless of whether it is associated with radiotherapy, is indicated
when retrolaminar nerve invasion is present with or without choroi
dal invasion or in the presence of scleral invasion(3,10). However, the
importance of even massive isolated choroidal invasion is controver
sial. An analysis of 361 cases in the literature showed that only nerve
and orbit invasions are predictive of death, and isolated choroidal
invasion is not lethal(5). A retrospective analysis of 224 eyes enuclea
ted by unilateral retinoblastoma showed that among 108 eyes with
high-risk features, 55 had isolated choroidal invasion, and 16 of these
248
had prelaminar nerve invasion. None of the patients underwent adju
vant treatment, and 3 had orbit recurrence, 2 of them with associated
systemic involvement. Because all of the patients survived intensive
chemotherapy, the authors concluded that the risk of the adjuvant
treatment is unnecessary and may be avoided; they do not indicate
adjuvant treatment for cases with isolated choroidal invasion(6).
In contrast, we should remember that orbital retinoblastoma is
associated with a 10 to 27 times greater risk of metastasis(3,5,8), which
can be devastating(11). A prospective study of 80 enucleated eyes
with unilateral retinoblastoma and high-risk histological features (an
terior chamber, iris, ciliary body and massive choroidal, retrolaminar
nerve and extrascleral invasions) divided the patients to groups of
46 patients with and 34 patients without adjuvant therapy after the
enucleation. The study found a significant difference in the incidence
of metastasis between the treated (4%) and untreated group (23%)
among patients with massive choroidal invasion or retrolaminar optic
nerve invasion without any important complications. The authors
concluded that adjuvant chemotherapy is safe and effective and
significantly reduces the occurrence of metastases in patients with
high-risk histological features(12).
The fact that our patient presented with a substantial orbital re
currence only 3 months after enucleation demonstrates that some
tumor cells were already present in the extraocular areas when the
enucleation was performed. In fact, orbital recurrence can occur 1 to
24 months after the enucleation. The majority (97%) of recurrences
occur in the first 12 months(2) and can be treated successfully, as was
the case for this patient, who remained disease-free 24 months after
treatment.
If chemotherapy had been administered p
rior to the enucleation,
could the recurrence have been avoided? A controversial retrospec
tive study of 100 patients treated in Beijing stated that prior chemo
therapy may increase deaths from metastasis because histological
features of risk may be masked, which results in reduced monitoring
and delayed treatment(13). This concern was allayed by a multicenter
consensus recommending that current protocols include preopera
tive chemotherapy followed by planned enucleation and continuing
cycles after surgery. This preoperative treatment is helpful for patients
with MRIs that suggest extraocular disease or patients with clinically
suspicious conditions, such as proptosis and buphthalmia(14).
Unilateral retinoblastoma associated with glaucoma and buph
thalmia must be subjected to chemotherapy with therapeutic doses
Mabtum ED, et al.
of VEC and should never receive subtherapeutic doses. Enucleation
can be safely planned between the second and the fourth cycle, and
the treatment should occur until the sixth cycle, as for intraocular reti
noblastoma treatment(14). Alternatively, the same systemic treatment
can be used after the detection of massive isolated choroidal invasion
because the VEC multidrug protocol proved to be more effective at
preventing metastases(15).
REFERENCES
1.Bonanomi MT, Almeida MT, Cristofani LM, Odone Filho V. Retinoblastoma: a three-
year-study at a Brazilian medical school hospital. Clinics. 2009;64(5):427-34.
2. Kim JW, Kathpalia V, Dunkel IJ, Wong RK, Riedel E, Abramson DH. Orbital recurrence
of retinoblastoma following enucleation. Br J Ophthalmol. 2009;93(4):463-67.
3. Khelfaoui F, Validire P, Auperin A, Quintana E, Michon J, Pacquement H, et al. Histopa
thologic risk factors in retinoblastoma: a retrospective study of 172 patients treated
in a single institution. Cancer. 1996;77(6):1206-13.
4. Messmer EP, Heinrich T, Höpping W, Sutter E, Havers W, Sauerwein W. Risk factors for
metastases in patients with retinoblastoma. Ophthalmology. 1991;98(2):136-41.
5.Kopelman JE, McLean IW, Rosenberg SH. Multivariate analysis of risk factors for
metastasis in retinoblastoma treated by enucleation. Ophthalmology. 1987;94(4):
371-77.
6. Chantada GL, Dunkel IJ, de Dávila MT, Abramson DH. Retinoblastoma patients with
high risk ocular pathological features: who needs adjuvant therapy? Br J Ophthalmol.
2004;88(8):1069-73.
7. Shields CL, Shields JA, Baez KA, Cater J, Potter PV. Choroidal invasion of retinoblasto
ma: metastatic potential and clinical risk factors. Br J Ophthalmol. 1993;77(9):544-8.
8. Singh AD, Shields CL, Shields JA. Prognostic factors in retinoblastoma. J Pediatr Oph
thalmol Strabismus. 2000;37(3):134-41.
9.Chantada GL, Gonzalez A, Fandino A, de Davila MT, Demirdjian G, Scopinaro M, et
al. Some clinical findings at presentation can predict high-risk pathology features in
unilateral retinoblastoma. J Pediatr Hematol Oncol. 2009;31(5):325-9.
10. Gündüz K, Müftüoglu O, Günalp I, Unal E, Taçyildiz N. Metastatic retinoblastoma cli
nical features, treatment, and prognosis. Ophthalmology. 2006;113(9):1558-66.
11. Antoneli CB, Steinhorst F, de Cássia Braga Ribeiro K, Novaes PE, Chojniak MM, Arias V,
et al. Extraocular retinoblastoma: a 13-year experience. Cancer. 2003;98(6):1292-8.
12. Honavar SG, Singh AD. Management of advanced retinoblastoma. Ophthalmol Clin
North Am. 2005;18(1):65-73.
13. Zhao J, Dimaras H, Massey C, Xu X, Huang D, Li B, et al. Pre-enucleation chemothe
rapy for eyes severely affected by retinoblastoma masks risk of tumor extension and
increases death from metastasis. J Clin Oncol. 2011;29(7):845-51.
14. Chantada G, Leal-Leal C, Brisse H, de Graaf P, Sitorus RS, Qaddoumi I, et al. Is it preenucleation chemotherapy or delayed enucleation of severely involved eyes with
intraocular retinoblastoma that risks extraocular dissemination and death? J Clin
Oncol. 2011;29(24):3333-4.
15.Kaliki S, Shields CL, Rojanaporn D, Al-Dahmash S, McLaughlin JP, Shields JA, et al.
High-risk retinoblastoma based on international classification of retinoblastoma:
analysis of 519 enucleated eyes. Ophthalmology. 2013;120(5):997-1003.
Encontro Anual da
Academia Americana de Oftalmologia
16 a 19 de novembro de 2013
Nova Orleans, Louisiana (EUA)
Informações:
Site: www.aao.org
249
Relato de Caso |
Case Report
Metástase coroidal como primeira manifestação de carcinoma bronquioloalveolar: relato de caso
Ricardo Evangelista Marrocos de Aragão1, Ieda Maria Alexandre Barreira1, Lorena Maria Araújo Gomes1, Ariane Sá Vieira Bastos1,
Felipe de Freitas Beserra1
ABSTRACT
RESUMO
Metastatic tumors are the most common intraocular malignances and choroid is by
far the most common site. Breast and lung cancer are the first cause in women and
men respectively. We report the case of a 71-year old woman who had choroidal
tumor in her left eye. Further image body scans demonstrated several lesions in
both sides of the lungs with dissemination to other organs. Diagnosis of a brochioloalveolar carcinoma established after a biopsy carried out. The patient died
before initiating a proper treatment.
Tumor metastático é a neoplasia ocular mais frequente, e a coroide é o local mais comum desta. Tumor de mama seguido de tumor pulmonar são as causas mais comuns
de metástases oculares em mulheres e homens, respectivamente. Relatamos o caso de
uma paciente de 71 anos com tumor coroidal no olho esquerdo. Posteriormente, estudos
de imagem mostraram lesões pulmonares em ambos os pulmões e disseminação a
outros órgãos. O diagnóstico de carcinoma bronquioloalveolar foi feito por biópsia.
A paciente foi a óbito antes de se iniciar tratamento adequado.
Keywords: Choroid; Neoplasm metastasis; Eye neoplasms; Lung neoplasm; Eye/
pathology; Case report
Descritores: Coróide; Metástase neoplásica; Neoplasia ocular; Neoplasias pulmonares;
Olho/patologia; Relato de caso
INTRODUCTION
The incidence of ocular metastasis from lung cancer is reported
to be 2-7% according to the international literature. The majority of
cases involves end-stage patients(1). Metastatic tumors are the most
common intraocular malignancies, and choroid is by far the most
common site for intraocular malignancies. Multiple foci are usually involved and bilateral involvement is frequently seen(2). The lung cancer
is the first cause of choroidal metastasis in men, as the breast cancer
is in women. Estimates of the incidence of intraocular metastases in
patients dying from disseminated cancer range from 22,000 to 66,000
affected individuals per year in the United States(3).
investigation including complete blood cell count, platelet count,
bleeding time, urine analysis, serum electrolytes, blood biochemical
studies for hepatic and renal function was carried out A chest x-ray
showed a homogenous opaque mass in patient’s left hilar area. A
computer tomography scan of the thorax revealed a several small
nodules in both superior lobe of the lung and pleural effusions. (Figure 2). Transbronchial biopsy revealed bronchioloalveolar carcinoma
(Figure 3). At this time the patient also showed bone metastasis. The
chemotherapy was not initiated because our patient died after few
weeks.
CASE PRESENTATION
A 71 year-old woman noticed, progressive vision reduction in
both eyes. Ocular examination revealed her best visual acuity to be
20/40 RE (right eye) and 20/100 LE (left eye). Results of her slit lamp
revealed nuclear cataract in both eyes. Her pupil size and reaction
was normal. Her ocular movements were normal in all gazes. Her
intraocular pressure was also normal. Fundus examination of the left
eye showed an ill-defined, yellow-white elevated lesion in choroid
about five times the disc diameter in size (Figure 1). A fundus picture
of the right eye was normal. An ultrasonographic evaluation of the
eye demonstrated that the tumor had a height 4,1 mm, anterior-posterior length 13 mm and lateral length 12,9 mm. The tumor revealed
a dome-surfaced, elevated choroidal lesion with moderated internal
reflectivity. Fluorescein angiography showed hiperfluorescence from
the surface of her choroidal tumor. The lesion was on its late phase
and it had already accumulated subretinal fluid. Routine systemic
Submitted for publication: October 4, 2012
Accepted for publication: June 20, 2013
Study carried out at Universidade Federal do Ceará - UFC, Fortaleza (CE), Brazil.
1
Physician, Ophthalmology Service, Hospital Universitáro Walter Cantídio, Universidade Federal do
Ceará - UFC, Fortaleza (CE), Brazil.
250
DISCUSSION
The highly vascular uveal tract is the most common part of the
eye involved by metastasis. Within the uvea, the choroid (88%) is the
most commonly affected site followed by the iris (9%) and ciliary
body (2%). Breast cancer seems to be the most frequent type of cancer
giving intraocular metastasis(4).
The incidence for breast cancer is reported to be 37 - 41%, while
lung cancer is considered to be responsible for no more than 7% of
choroidal metastasis. Approximately 50% of suspect choroidal metastasis and no history of cancer, has no primary site detected despite
systemic evaluation by oncologists. It is generally considered that
this kind of metastatic lesion occur at the final stages of the disease,
where the mean survival is not expected to be more than 6 months
and the majority of the patients already suffer from the typical lung
cancer symptoms. The reason for this unusual site to be target for
secondary metastasis from lung cancer is generally unknown. It is,
however speculated that is high vascularity may consist a reasonable
Disclosure of potential conflicts of interest: R.E.M.de Aragão, None; I.M.A.Barreira, None;
L.M.A.Gomes, None; A.S.V.Bastos, None; F.F.Beserra, None.
Endereço para correspondência: Ricardo Evangelista Marrocos de Aragão. Rua Osvaldo Cruz,
2335 - Fortaleza (CE) - 60125-151 - Brazil - E-mail: ricardomarrocos@yahoo.com
Aragão REM, et al.
Figure 1. Fundus photography of the left eye showing the choroidal metastasis.
Figure 3. Histopathology images demonstrating brochioloalveolar carcinoma. Showing
microscopically the bronchiocarcinoma, composed of columnar cells that proliferated
along the framework of alveolar septae. The cells are well-differentiated. All images
stained with hematoxylin-eosin.
Figure 2. Computer tomography features of the lesions in the lung showing small
nodules and pleural effusion.
explanation(1). The other frequent sites of choroidal metastasis are
alimentary tract cancers, prostate, skin melanoma, kidneys, contralateral choroidal melanoma, thyroid and testis(5).
To date, only 2 series describing 13 and 90 patients, respectively,
with predominantly choroidal metastasis from lung cancer, have been
published. Shields and et al. reported that in 56% of patients with
intraocular lung cancer metastasis, the primary tumor was detected
after the diagnosis of intraocular metastasis(6).
Choroidal metastasis commonly complain of loss of vision, pain
and photopsia. Ophthalmic examination may reveal multiple or bi
lateral lesions sometimes associated with exudative retinal detach
ment. The typical lesion is flat and ill defined, most of the cases
grey-yellow or yellow-white, with alterations of the retinal pigment
epithelium. In rare cases the breaking of the Bruch membrane can
lead to mushroom configuration.
The diagnosis of ocular metastasis is based primarily on clinical
findings supplemented by imaging studies. The diagnostic procedures include ultrasonography, fluorescein angiography, computed
tomography/MRI, fine needle aspiration, or wedge biopsy. Brain imaging is useful before initiation of radiotherapy to assist in treatment
planning. It is reported that 22% of patients diagnosed with CM had a
concurrent diagnosis of central nervous system metastasis. Differential diagnosis includes primary choroidal melanomas, benign lesions
such as hemangioma, and inflammatory granulomas(1).
Systemic chemotherapy can lead to total involution of the CM with
improvement of the visual acuity(7). Despite systemic chemotherapy or
hormone therapy the growing of the choroidal metastasis with symptomatic subretinal fluid, external beam radiation therapy or plaque
raditoin therapy is recommended. A systematic search for lung cancer
is required in patients presenting as CM. If compatible with the patient
general status, histologically adapted chemotherapy must be instituted. This approach can avoid the use of radiotherapy and therefore
deterioration of the visual acuity after radiation. However, the diagnosis
of CM is associated with a poor prognosis. The initial sign of lung cancer
may rarely be visual symptoms due to choroidal metastasis. In such a
condition, the lung cancer is already at an advanced stage(8).
The ophthalmologist ought to be aware of the choroidal metastasis sings to its prompt recognition and appropriated treatment.
ACKNOWLEDMENT
The authors thank Dr. Patty Saldanha (pathologist) and Dr. Diana
Bezerra (radiologist) for their assistance and appropriate counseling.
251
The authors also thank the ICC (Instituto do Cancer do Ceará) for te
chnical assistance.
REFERENCES
1. Asteriou C, Konstantinou D, Kleontas A, Paliouras D, Samanidis G, Papadopoulou F, et
al. Blurred vision due to choroidal metastasis as the first manifestation of lung cancer:
a case report. World J Surg Oncol. 2010;8:2.
2. Singh A, Singh P, Sahni K, Shukla V, Pant NK. Non-small cell lung cancer presenting
with choroidal metastasis as first sign and showing good response to chemotherapy
alone: case report. J Med Case Rep. 2010;4:185.
3.Kreusel KM, Wiegel T, Stange M, Bornfeld N, Hinkelbein W, Foerster MH. Choroidal
metastasis in disseminated lung cancer: frequency and risk factors. Am J Ophthalmol.
2002;134(3):445-7.
4. Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal
metastases. Ophthalmology. 1997;104(8):1265-76.
5. Tazi N, Le Thi Huong D, Bodaghi B, Rixe O, Lehoang P, Piette JC. Choroidal metastasis
revealing pulmonary adenocarcinoma. Rev Med Interne. 2006;27(9):699-701.
6. Kreusel KM, Bechrakis NE, Wiegel T, Krause L, Foerster MH. Incidence and clinical characteristics of symptomatic choroidal metastasis from lung cancer. Acta Ophtalmolol.
2008;86(5):515-9.
7. Fernandes BF, Fernandes LH, Burnier MN Jr. Choroidal mass as the presenting sign of
small cell lung carcinoma. Can J Ophthalmol. 2006;41(5):605-8.
8.Herrag M, Lahmiti S, Yazidi AA, Le Lez ML, Diot P. Choroidal metastasis revealing a
lung adenocarcinoma. Ann Thorac Surg. 2010;89(3):1013-4.
XXI Congresso Brasileiro de
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252
Relato de Caso |
Case Report
Torpedo maculopathy with an anisometropic amblyopia in a 5-year-old
Caucasian girl: case report
Maculopatia torpedo numa criança caucasiana de 5 anos de idade com ambliopia anisometrópica:
relato de caso
Marco Dutra-Medeiros1, Paula Leitão1, Ana Magriço1, Alcina Toscano1
ABSTRACT
Resumo
The aim of this study is to report a clinical case of asymptomatic female Caucasian
children with torpedo maculopathy. A 5-year-old girl was referred to our clinic for
routine evaluation. The ophthalmic examination revealed best-corrected visual
acuity of 20/20 in both eyes, without any changes in the biomicroscopy. Fundus
examination showed normal findings in one eye, whereas in the contralateral
eye it disclosed, in the temporal sector of the macular region, a whitish, atrophic,
oval chorioretinal lesion with clearly defined margins. Posterior evaluations
documented the stability of the lesion. Torpedo maculopathy diagnosis is based
on its characteristic shape and peculiar location. The differential diagnosis has
to be estabilished versus choroidal lesions (melanoma and nevus), congenital or
iatrogenic hyperplasia of the retinal pigment epithelium (RPE) and particularly
versus the congenital pigmented lesions associated with Gardner’s syndrome.
Os autores descrevem um caso clínico de uma criança caucasiana, 5 anos do sexo
feminino, com maculopatia torpedo. Ao exame oftalmológico apresentava uma
acuidade visual corrigida de 10/10 e sem alterações à biomicroscopia. À fundoscopia
apresentava uma lesão oval isolada, esbranquiçada, atrófica, unilateral, de margens
bem definidas no setor temporal da região macular. Avaliações posteriores documentaram a estabilidade da lesão. O diagnóstico da maculopatia torpedo baseia-se na sua forma característica e localização peculiar. É importante o diagnóstico
diferencial com lesões da coroideia (melanoma e nevo), hiperplasias congênitas
ou iatrogênicas do epitélio pigmentado da retina (EPR) e com lesões congênitas
associadas à síndrome de Gardner.
Keywords: Pigment epithelium of eye/pathology; Retinal diseases/congenital;
Macula lutea; Visual acuity; Eye neoplasms/pathology; Humans; Female; Child;
Case report
Descritores: Epitélio pigmentado ocular/patologia; Doenças retinianas/congênito;
Macula lutea; Acuidade visual; Neoplasias oculares/patologia; Humanos; Feminino;
Criança; Relato de caso
INTRODUCTION
Torpedo maculopathy is a single hypopigmented congenital nevi
of the retinal pigment epithelium (RPE), first described by Roseman,
Gass(1), in 1992. Gass described it as a focal congenital abnormality
of the RPE consisting in an asymptomatic oval lesion located along
the horizontal raphe, in the temporal portion of the macular region.
Subsequently, Daily(2) described an oval albinotic lesion in the
temporal macula that was asymptomatic and consistent with one of
the solitary focal developmental anomalies of the REP described by
Roseman, Gass. While the lesions described by Daily were albinotic
in appearance (paramacular albinotic spot syndrome), other authors
have observed lesions with varying degrees of pigmentation.
It would therefore seem that torpedo maculopathy is the appropriate name for this condition, since it specifically describes the lesion
shape wich include variations in pigment.
croscopy revealed no abnormalities of the anterior segment. Under
cycloplegia, her best corrected visual acuity was: OD 20/80 with +2.75
+2.00 x 100 and OS 20/20 with +1.00 +0.75 x 100.
Dilated fundus examination revealed a sharply demarcated oval
chorioretinal lesion OD, located <1 DD (disc diameter) temporal to
the macula, with a characteristic torpedo-like shape with the tip
pointig towards the macula. The lesion was whitish, atrophic and
approximately 1 DD in width and 0.5 DD in height. On binocular stereo fundoscopy, both retinal and choroidal vessels were unobscured
except in a small pigment clump located within the temporal border
of the lesion (Figure 1). The peripheral retina was normal and devoid
of any chorioretinal lesions bilaterally. The retinal examination of the
left eye was unremarkable (Figure 2).
The refractive error was corrected and the patient begun an oc
clusion therapy of the right eye.
Because the lesion had remained stable over the past 4 years
and clinically was consistent with a torpedo maculopathy lesion, no
fluorescein was ordered. Currently, she has a BVCA of 20/20 in both
eyes for near and distance vision. Retina assessments were performed
on a regular basis, every six months, by performing fundoscopy and
proceeding to its documentation by retinography. The absence of
symptoms and the normal findings obtained in the various investigations performed suggest the benign nature of the lesion.
CASE REPORT
A 5 -year-old Caucasian girl was referred for routine examination.
Medical history was unremarkable.
On examination, the uncorrected visual acuity was 20/200 in
the right eye and 20/80 in the left eye. Pupils were equal, round, and
reactive to light with no afferent pupillary defect. Slit-lamp biomi-
Submitted for publication: July 18, 2012
Accepted for publication: June 20, 2013
Study carried out at Department of Ophthalmology, Central Hospital of Lisbon Center, Lisbon,
Portugal.
1
Physician, Department of Ophthalmology, Central Hospital of Lisbon Center, Lisbon, Portugal.
Disclosure of potential conflicts of interest: M.Dutra-Medeiros, None; P.Leitão, None; A.Magriço,
None; A.Toscano, None.
Correspondence address: Marco Dutra Medeiros. Centro Hospitalar de Lisboa Central. Rua António
José Serrano, 1150-199 - Lisboa - Portugal - E-mail: marcodutramedeiros@gmail.com
253
Torpedo maculopathy with an anisometropic amblyopia in a 5-year-old Caucasian girl: case report
DISCUSSION
Torpedo maculopathy is a congenital lesion of the RPE characterized by a very unique shape and location. There are few cases
described in the literature, making it difficult to assess the prevalence.
Classification with various nomenclatures may add to the scarcity of
reports (Table 1), further complicating the issue of prevalence.
Roseman, Gass described a case of a 12-year-old male with normal
visual acuity and no abnormalities on Amsler grid or Goldmann visual
field testing(1). The authors observed a solitary oval lesion, located
temporal to the macula in the left eye, with a wedge shaped tail that
obscured choroidal layers. They hypothesized that this “hypopigmented nevus of the RPE” was composed of intact RPE cells containing
a milky white material of abnormal melanin or its precursor. Daily(2)
described a collection of oval albinotic lesions located temporal to
the macula centered on the horizontal raphe with a tail pointing to
ward the macula. He referred to this as “paramacular albinotic spot
syndrome”. Some authors(3) observed the same type of lesion and
called it “torpedo maculopathy” based on its pathognomonic shape.
Other authors(4) observed three cases of asymptomatic unilateral
lesions in a child and two adults. A- and B-scan ultrasonography did
not detect any retinochoroidal defects or calcifications in the macular
area. Shields et al.(5), reported two cases of torpedo maculopathy.
Based on observations from Streeten(6), they speculate that torpedo
maculopathy could represent a persistent defect in the development
of the RPE in the fetal temporal bulge. Accordingly, the uniform location and size of this lesion points toward a congenital defect during
RPE embryogenesis as well as its fetal development. So far, the largest
case series has been published by Golchet et al.(7), in 2009, and inclu-
ded the medical records of 13 patients sharing similar features after
evaluation by fluorescein angiography, autofluorescence and optical
coherence tomography (OCT).
The differential diagnosis must include choroidal lesions (melanoma and nevus), congenital anomalies of the RPE and focal retinal
pigmentation due external agents (traumatic or drug-induced toxic
effects)(4-8).
Beyond torpedo maculopathy, there are several other congenital
lesions of the RPE, including combined hamartoma of the retina
and RPE, congenital simple hamartoma of the RPE and particularly
the congenital hypertrophy of the RPE (CHRPE) linked to Gardner´s
syndrome, a dominantly inherited familial cancer syndrome that
includes familial adenomatous polyposis and various soft tissue tumours. Those lesions associated with Gardner´s syndrome tend to be
bilateral, with multiple solitary lesions that are located away from the
macula, much smaller and more irregular in shape(8).
Acquired focal retinal pigmentation (due trauma, drugs, inflammation) presents a highly irregular shape, with erratic distribution of
pigment and is often accompanied by signs suggesting the nature
of the lesion.
In our clinical case the characteristic shape and the location in
the temporal macula suggested the diagnosis. Of note is the fact that
our patient had a hyperopic astigmatism. Despite being interesting,
it cannot be concluded that refractive error is related to torpedo maculopathy. To the best of our knowledge this association has already
been described in the literature by Pian et al.(9). Beyond this, no studies
link refractive error to this lesion.
Performing retinography is a good means of monitoring the
nev us. Fluorescein angiography, ultrasonography, and macular
Figure 1. Fundus photo OD - Torpedo-like shape lesion, in the temporal sector of ma
cular region.
Figure 2. Fundus photo OS - normal.
Table 1. Literature review of torpedo maculopathy
Author
Name used in publication
Hypopigmented nevus of the RPE
Abnormal melanin deposition in intact RPE cells
Daily(2)
Paramacular albinotic spot syndrome
None given
Teitelbaum et al.(3)
Torpedo maculopathy
Prenatal disturbance in choroidal vasculature to macular area
Rigotti et al.
Torpedo maculopathy
Congenital hypertrophy of the RPE
Shields et al.(5)
Torpedo maculopathy
Persistent defect in the development of the RPE in the fetal temporal bulge
Golchet et al.
Torpedo maculopathy
Disfunction or absence of RPE
Mahieu, Mathis(10)
Maculopathie en torpille
None given
Sharma et al.(11)
Macular coloboma
Maldevelopment of the retina
Townsed et al.
Paramacular coloboma
Embryological lesions occurring along the horizontal raphe
(4)
(7)
(12)
RPE= retinal pigment apithelium.
254
Hypothesis of origin
Roseman, Gass
(1)
Dutra-Medeiros M, et al.
threshold perimetry should be considered if there is a change in the
size or shape of the lesion or if a change in vision is documented by
the patient or examiner(7-10). Due benign nature, this pathology has a
good prognosis. In the absence of ocular symptoms, annual evaluations of the nevus are sufficient.
REFERENCES
1. Roseman RL, Gass JD. Hypopigmented nevus of the retinal pigment epithelium in the
macula. Arch Ophthalmol. 1992;110(10):1358-9. Erratum in: Arch Ophthalmol. 1992;
110(12):1762.
2. Daily MJ. Torpedo maculopathy or paramacular spot syndrome. In: New Dimensions
in Retina Symposium. 1993; Nov. 10-13.Chicago.
3. Teitelbaum BA, Hachey DL, Messner LV. Torpedo maculopathy. J Am Optom Assoc.
1997;68(6): 373-6.
4. Rigotti M, Babighian S, Carcereri de Prati, Marchini G. Three cases of a rare congenital
abnormality of the retinal pigment epithelium: torpedo maculopathy. Ophthalmologica. 2002;216(3):226-7.
5.Shields CL, Guzman JM, Shapiro MJ, Fogel LE, Shields JA. Torpedo maculopathy at
the site of the fetal “bulge”. Arch Ophthalmol. 2010;128(4):499-501.
6. Streeten BW. Development of the human retinal pigment epithelium and the posterior segment. Arch Ophthalmol. 1969;81(3):383-94.
7. Golchet PR, Jampol LM, Mathura JR Jr, Daily MJ. Torpedo maculopathy. Br J Ophthalmol. 2010;94(3):302-6.
8.Shields JA, Shields CL. Tumours and related lesions of the pigment epithelium. In:
Shields JA, Shields CL., eds. Intraocular tumours: an atlas and textbook. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. p.431-80.
9.Pian D, Ferruci S, Anderson SF, Wu C. Paramacular coloboma. Optom Vis Sci. 2003;
80(8):556-63.
10. Mahieu L, Mathis A. [« Torpedo » maculopathy]. J Fr Ophtalmol 2003;26(5):533. French.
11. Sharma S, Naqvi A, Cruess AF. Bilateral macular colobomata. Can J Ophthalmol. 1996;
31(1):27-8.
12. Townsed J, Selvin G, Grifin J, Comer G. Visual fields: clinical case presentations. Stoneham: Butterworth-Heinmann, 1991.
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255
Artigo de Revisão |
Review Article
Diffuse unilateral subacute neuroretinitis (DUSN): current update
Alexandre Antonio Marques Rosa1, Taurino dos Santos Rodrigues Neto2
RESUMO
ABSTRACT
A neurorretinite subaguda difusa unilateral (DUSN) é uma forma de uveíte que
pode potencialmente levar à cegueira. No Brasil e em outras partes da América do
Sul, a neurorretinite subaguda difusa unilateral cada vez mais é considerada uma
causa importante de uveíte posterior em crianças e em adultos jovens e saudáveis. Se diagnosticada e tratada ainda em fase inicial, permite uma resolução dos
sintomas com melhora da acuidade visual. Caso progrida para a fase tardia, poderá
acarretar uma perda visual significativa. Nesse estudo, por meio de uma revisão
da literatura, descreve-se as principais características desta doença, incluindo os
seguintes aspectos: histórico, etiologia, fisiopatologia, quadro clínico, diagnóstico,
diagnóstico diferencial e tratamento.
Diffuse unilateral subacute neuroretinitis (DUSN) is a form of uveitis that can potentially lead to blindness. In Brazil and other parts of South America, diffuse unilateral
subacute neuroretinitis is an important cause of posterior uveitis in children and
healthy young adults. If diagnosed and treated in early stage, allows a resolution of
symptoms with improvement of visual acuity. If the disease progresses to the late
stage, can result in significant visual loss. In this study, through a literature review,
we describe the main characteristics of this disease, including the following aspects:
history, etiology, physiopathology, clinical features, diagnosis, differential diagnosis
and treatment.
Descritores: Retinite/fisiopatologia; Retina/lesões; Retinite/epidemiologia; Retinite/
diagnóstico; Infecções oculares parasitárias/etiologia; Neurite optica/patologia
Keywords: Retina/physiopathology; Retina/injuries; Retina/diagnosis; Retina/parasitology; Eye Infections, Parasitic/etiology; Optic neuritis/pathology
INTRODUÇÃO
A uveíte é uma doença inflamatória intraocular que depende
de diversos fatores socioeconômicos, geográficos e culturais(1). Sua
ocorrência varia de acordo com os agentes causais mais prevalentes
em cada região. Em muitos países, as infecções parasitárias são uma
causa importante de uveíte(2). A neurorretinite subaguda unilateral
difusa (DUSN) pode, de forma secundária, levar a uma inflamação na
úvea e potencialmente levar à cegueira(3).
sil causado por um nematódeo medindo entre 1.500 a 2.000 µm,
o qual foi identificado como provável Baylisascaris procyonis, que
parasita o intestino de pequenos carnívoros, incluindo guaxinins
e gambás(12). Embora sua etiologia seja atribuída principalmente a
espécies do filo Nematoda, existem relatos de DUSN ocasionada por
uma larva com tamanho aproximado de 555 x 190 µm, cuja origem
seja provavelmente a Alaria mesocercaria, um trematódeo, cuja provável fonte de infecção foi a ingestão de patas de rãs contaminadas
e mal cozidas(13).
A maioria dos estudos defendem que diferentes agentes possam
ser consideradas como prováveis causadores da DUSN(8,14). Os nematóides menores seriam provavelmente: Ancylostoma caninum, enquanto que as larvas maiores seriam do Baylisascaris procyonis(3,8,15,16).
HISTÓRICO
DUSN é uma doença infecciosa que foi descrita primeiramente
por Gass e Scelfo, em 1978(4). Uma larva, cuja etiologia ainda não
foi bem estabelecida, é responsável por promover um processo
inflamatório e degenerativo na retina posterior. No Brasil, a doença
foi descrita inicialmente em 1991(5). Em 1992, foi realizado a primeira
identificação da larva na retina(6). Apesar de ser primariamente unilateral, Souza et al., (1999)(7) descreveu a primeira evidência de DUSN
afetando os dois olhos.
ETIOLOGIA
Está associada com a infecção por nematódeos de diferentes
tamanhos e espécies, no geral são descritos dois tamanhos de larvas,
a menor medindo de 400 a 1.000 μm, predominando na América
Latina e sul dos Estados Unidos(8) (Figura 1), e a maior medindo de
1.500 a 2.000 μm, que prevalece no norte e meio-oeste dos Estados
Unidos(9-11). Em 1999, foi descrito o primeiro caso de DUSN no Bra-
FISIOPATOLOGIA
A etiopatogenia da DUSN está relacionada à presença de uma larva no espaço sub-retiniano, a qual promoveria um processo degenerativo extenso na retina, com infiltração de células inflamatórias, com
agregado de macrófagos e gliose podendo afetar todas as camadas,
com perda parcial de células ganglionares, também ocorreria uma
agressão tóxica às células bipolares, o que se justifica nas alterações
observadas no eletrorretinograma(17).
Na infecção ativa ou aguda, pode haver infiltração de eosinófilos
associado a retinocoroidite, vitreíte e vasculite retiniana. A migração
do verme pela retina, associado ao processo inflamatório levaria a
uma degeneração do epitélio pigmentado, com descontinuidade na
transmissão da informação entre as células retinianas(18).
Submetido para publicação: 1 de março de 2012
Aceito para publicação: 2 de abril de 2013
Trabalho realizado na Universidade Federal do Pará - UFPA, Belém (PA) - Brasil.
Endereço para correspondência: Alexandre Antônio Marques Rosa. Av. Conselheiro Furtado, 2865 Sobreloja - Sala 4 - Belém (PA) - 66060-000 - Brasil - E-mail: alexandre_ros@hotmail.com
1
2
Médico, Departamento de Oftalmologia, Universidade Federal do Pará - UFPA, Belém (PA) - Brasil.
Estudante de Medicina, Universidade do Estado do Pará - UFPA, Belém (PA) - Brasil.
256
Divulgação de potenciais conflitos de interesse: A.A.M.Rosa, Nenhum; T.S.Rodrigues Neto, Nenhum.
Rosa AAM, Rodrigues Neto TS
A
B
Figura 1. Retinografia demonstrando a larva sub-retiniana de menor tamanho que
predomina na América Latina e sul dos Estados Unidos. (Cortesia Prof. Dr. Vitor Cortizo,
Terezina - PI).
C
QUADRO CLÍNICO
Normalmente, a doença cursa sem manifestações clínicas ou
laboratoriais que possam sugerir uma infecção parasitária sistêmica
ao iniciar os sintomas oculares(19). Atinge principalmente a faixa etária
infantil e adultos jovens. O curso clínico da doença é caracterizado
por uma inflamação intraocular que tende a ser unilateral e difusa(20),
muitas vezes com caráter progressivo, culminando com uma atrofia
óptica irreversível(18).
Na fase aguda da doença, geralmente há diminuição da acuidade visual, que pode estar relacionado a vitreíte, retinite e edema de
disco óptico. Pode haver também a presença de escotomas central
ou paracentral no campo visual(21). Observam-se lesões brancoacinzentadas na retina, que podem ser transitórias, difusas ou focais,
e podem estar relacionadas a possível localização do nematódeo no
espaço sub-retiniano (Figura 2A e 2B). Após uma semana, em geral,
devido ao movimento da larva para outra área do olho, as lesões
branco-acinzentadas ativas somem e podem reaparecer distante
ou adjacente a área inicial da lesão(22). Achados menos frequentes
incluem hemorragias retinianas, cisto macular - no qual se acredita
que seja consequente a coalescência dos espaços císticos do edema
macular cistoide(23), exsudatos perivenosos, descolamento localizado da retina neurosensorial e iridociclite com hipópio, que pode
estar relacionado com a morte do nematódeo durante o curso da
doença(4,24).
A identificação do verme sub-retiniano móvel é um achado patognomônico na DUSN. Apesar de poder acometer todas as camadas,
sua localização é mais frequentemente encontrada nas camadas
externas da retina. A larva apresenta coloração esbranquiçada, e ao
exame de fundo de olho é identificada como uma linha tênue, afilada
em ambas as extremidades e geralmente assume um formato de “S”.
Na fase tardia, pode se observar estreitamento arteriolar difuso na
retina, palidez do disco óptico e degeneração do epitélio pigmentado(4,18,21) (Figura 3).
A identificação da larva pode ser realizada tanto nas fases aguda
quanto na crônica. A presença da larva define o diagnóstico, entretanto a sua ausência não o exclui, uma vez o diagnóstico pode ser
estabelecido com base nos achados clínico-oftalmológicos, configurando o quadro de DUSN presumida. Em um estudo com 121
pacientes, 7,43% encontrava-se em fase aguda, os achados clínicos
mais frequentes foram túneis retinianos (91,7%), alterações focais
do epitélio pigmentado da retina (89,3%), pontos esbranquiçados
(80,2%) e atrofia do nervo óptico (76,9%).(25)
Figura 2. Retinografia de um paciente com diagnóstico de DUSN presumível em fase
aguda, tratado com albendazol. A) Olho afetado na fase aguda com as lesões brancoacinzentadas circuladas. B) Detalhe ampliado das lesões branco-acinzentadas na fase
aguda - antes do tratamento.
Figura 3. Retinografia de um paciente com diagnóstico de DUSN presumível em fase
crônica, onde se observa palidez do disco óptico e estreitamento arteriolar.
DIAGNÓSTICO
O estabelecimento de um diagnóstico precoce na DUSN é de
extrema importância, por ser uma das poucas causas preveníveis
de cegueira na infância, a erradicação do verme nos estágios iniciais
poderá evitar a progressão para perda visual(19).
O diagnóstico de certeza da DUSN se baseia no encontro e
identificação do nematoide móvel sub-retiniano. Pacientes que
apresentam apenas os sinais do estágio agudo, na ausência da larva,
podem ter um diagnóstico de DUSN presumível. Além dos achados
fundoscópicos, outros exames complementares podem auxiliar no
diagnóstico e no acompanhamento da evolução da doença(26).
A realização de teste sorológico nos pacientes portadores de
DUSN é extremamente controversa. Em um estudo, em 1983, não
257
foi encontrado sorologia positiva para T. canis(8). Em 2000, foram
confirmados 5 casos de neurorretinite por toxocaríase utilizando a
sorologia(27). Entretanto, Casella (2001)(28) em 8 casos estudados, observou sorologia positiva em apenas 3. Gass, Braunstein (1983) não
identificaram testes sorológicos positivos.
Os testes sorológicos apresentam um valor limitado no estabele
cimento diagnóstico de DUSN, sendo mais indicados quando se quer
excluir outras doenças como diagnóstico diferencial(22). Além disso,
devido a possibilidade do compartilhamento de antígenos por diferentes nematódeos, a interpretação dos testes sorológicos, a fim de
confirmar o agente etiológico, está sujeita a erros(18).
Em 2002, foi realizado um estudo utilizando o eletrorretinograma
multifocal como um teste sensível para localizar disfunções retinianas
decorrentes da toxicidade local causadas pelos produtos metabólicos
do verme, além de auxiliar na evolução após o tratamento do DUSN(29).
O eletrorretinograma de campo total geralmente apresenta uma
onda negativa como resposta aos estímulos em condições escotópicas, havendo uma redução seletiva na onda b, responsável pelo
componente positivo, e um domínio da onda a negativa. Em geral, a
onda b é mais atingida que a onda a, com a relação b/a<1. A presença
constante de ERGs negativos pode indicar também que a doença,
através de mecanismos que são discutidos, atinge sistematicamente
as células bipolares(30-33). Apesar da redução das respostas, Audo et
al., (2006)(33) defende que, no olho afetado, nenhum ERG apresenta
resposta nula, além disso, o olho saudável sempre possui um ERG
normal. O comprometimento das respostas no exame acompanha
a progressão da doença, em que cada vez mais fotorreceptores são
afetados, podendo ocorrer também uma disfunção do nervo óptico,
provavelmente anterior ao envolvimento da retina, o que contribui
para a redução da acuidade visual.
A angiofluoresceinografia, nos estágios iniciais, permite mostrar
uma hipofluorescência na área em que se encontra as lesões brancoacinzentadas. Além disso, extravasamento de corante a partir dos
capilares do disco óptico também pode ser observado. Em estágios
mais avançados, a angiografia pode evidenciar a perda do epitélio
pigmentado da retina, que se manifesta ao exame como hiperfluorescência transmitida(34).
A tomografia de coerência óptica (OCT) é um método não invasivo que auxilia no diagnostico e no acompanhamento da doença,
uma vez que permite a mensuração da espessura da camada de fibras
nervosas da retina (CFNR)(35). Em uma pesquisa utilizando OCT em 38
pacientes, 53% apresentaram a larva viva localizada, o autor não observou diferença significante da espessura da CFNR entre os pacientes
com diagnóstico de DUSN presumida e aqueles em que o verme foi
identificado, porém encontrou-se uma relação entre a piora da acuidade visual e a diminuição da espessura(29). Quando comparado ao
olho saudável, foi demonstrado uma diferença significante entre as
espessuras da CFNR(32). O principal achado observado na OCT consiste
na atrofia da camada de fibras nervosas retinianas, outros achados
menos usuais observados neste exame são: (1) edema localizado nas
áreas afetadas pela larva, podendo ocorrer a formação de uma membrana epirretiniana foveal, presente na fase aguda e que pode regredir
com o tratamento(35), e (2) presença de cistos maculares(36). Milan Shah
et al., (2011)(37) reportou 3 casos de DUSN com achados no OCT de
domínio espectral (SD-OCT) de neovascularização retiniana, que foi
precedida por uma atrofia progressiva do epitélio pigmentado.
Os achados de OCT são importantes para diferenciar de maneira
significativa a DUSN da retinite punteada externa, causada pelo Toxoplasma gondii, a qual não apresenta atrofia de camadas de fibras
nervosas(38). Este tipo de atrofia está presente mesmo em casos em
que a acuidade visual ficou relativamente preservada(35).
DIAGNÓSTICO DIFERENCIAL
A DUSN é uma doença que pode simular várias outras desordens.
O diagnóstico diferencial pode ser feito de acordo com o estágio em
que ela se apresenta.
258
Na fase aguda, há a presença de lesões branco-acinzentadas e o
diagnóstico diferencial pode ser feito com as outras doenças que
compõem a síndrome dos pontos brancos (white dot syndrome) um grupo de condições inflamatórias idiopáticas que pode envolver
tanto a retina quanto a coroide - nela inclui-se a epiteliopatia pigmentar placoide multifocal aguda posterior, coroidite serpenginosa,
coroidite multifocal, panuveíte, retinocoroidopatia de Birdshot, retinite punteada externa e histoplasmose. Outras doenças que também
podem fazer diagnóstico diferencial nesta fase são toxoplasmose,
retinite herpética multifocal, citomegalovírus, abscessos bacterianos
ou fúngicos e doença de Behçet. Quando presente a perivasculite,
a sarcoidose pode entrar como diferencial. Em estágio precoce, na
vigência de edema do disco óptico, a neurite retrobulbar idiopática,
neuroretinite pós-vírus e o papiledema podem ser um possível diagnóstico(7,18,35,39).
Na fase crônica, na vigência da atrofia do epitélio pigmentado da
retina, deve-se considerar também a retinite pigmentosa unilateral,
a corioretinopatia secundária ao trauma e a atrofia coriorretiniana
por oclusão da artéria oftálmica. Nos casos de atrofia óptica, deve-se
investigar também neurite óptica, lesões compressivas e neuropatia
óptica isquêmica(7,18,19,26).
TRATAMENTO
Classicamente, a fotocoagulação a laser é o único tratamento re
comendado para DUSN, uma vez que a larva seja localizada, porém
a sua identificação ao exame oftalmológico é extremamente difícil,
por ser uma tarefa desgastante e que demanda um pouco de tempo,
porém com um exame minucioso seria possível a sua identificação
em alguns pacientes(40).
Caso o diagnóstico seja feito em fase inicial, seguido pela rápida localização e destruição da larva pela fotocoagulação a laser, é possível
promover uma melhora na acuidade visual dos pacientes(8).
A destruição da larva por fotocoagulação em olhos na fase crôni
ca, não melhora a acuidade visual. Garcia et al., (2004)(41) estudou 22
olhos com DUSN na fase tardia, com a identificação da larva, após o
tratamento com laser apenas dois olhos apresentaram melhora na
acuidade visual. Apesar do tratamento na fase tardia não melhorar
significativamente a acuidade visual, com ele é possível impedir a
progressão da doença e promover uma melhora do campo visual(40).
A fotocoagulação tem mostrado bons resultados quando realizada nas fases iniciais da doença e pode ser indicada quando o nematódeo encontra-se afastado da mácula. Quando a larva estiver sobre
a região macular, o uso do laser poderia promover lesão adicional no
local(42). Neste caso ou quando o diagnóstico é feito na ausência da
visualização do verme, o tratamento farmacológico pode ser uma
alternativa segura e eficaz(43).
Em 1992, foi publicado o primeiro caso de tratamento oral para
DUSN presumível, utilizando o tiabendazol, o qual se mostrou eficaz,
principalmente em pacientes com inflamação vítrea moderada a
severa(44). O tiabendazol e ivermectina tem sido utilizados em casos
de DUSN presumida, sendo a última, uma alternativa nos casos de
ineficácia ou intolerância ao tiabendazol(44,45).
Em casos de DUSN confirmada, a uso do tiabendazol e ivermectina não mostrou efeito, necessitando de fotocoagulação para
destruição da larva(46). A terapia farmacológica com tiabendazol e
ivermectina parece não ser eficaz na destruição do organismo em
todos os pacientes, especialmente naqueles com inflamação vítrea
mínima, onde há baixa penetração ocular do medicamento(22,26).
Além disso, o sucesso do tratamento com estas drogas ocorreu em
casos de diagnóstico presumível, onde a comprovação do efeito
terapêutico é difícil, o que também poderia explicar o insucesso no
tratamento registrado por alguns autores(46,47). Independente da droga ou esquema utilizado, a terapia farmacológica tem revelado bons
resultados. Recentemente, o uso de albendazol tem assumido um
papel de importância no tratamento de DUSN presumida, mostrando
Rosa AAM, Rodrigues Neto TS
ser uma alternativa segura e eficaz, além de possuir uma capacidade
maior de cruzar a barreira hematorretiniana(40,46,48). A dose e a duração
do tratamento para a DUSN ainda não são bem esclarecidas. Muitos
trabalhos têm utilizado com sucesso 400 mg diários, por 30 dias, com
base no tratamento da neurocisticercose com albendazol, uma vez
que as duas doenças apresentam alguns aspectos na patogênese e
na clínica em comum(49). Naqueles casos confirmados, vários estudos
demonstraram eficácia deste esquema terapêutico(40,46,48) .
Outro esquema de tratamento utilizado na Venezuela foi de 200 mg,
três vezes ao dia, por dez dias(50), baseado em um estudo experimental que visava manter constante a concentração plasmática da droga,
sem que ultrapassasse seu limiar de toxicidade(51).
Em outra pesquisa(52), foi utilizado 400 mg de albendazol, duas
vezes ao dia, por dez dias, baseando-se no tratamento utilizado em
infecções por Toxocara(53), o qual é um possível agente etiológico de
prevalência importante no Brasil. Observaram melhora significativa
da visão em cinco dos seis pacientes com diagnóstico de DUSN presumida, além de melhora em alguns parâmetros do ERG multifocal.
Alguns autores optaram por um esquema combinado de tratamento com corticoides orais, associado a fotocoagulação e anti-helmíntico, porém não existe consenso para esta terapia combinada(54).
Além disso, o uso de corticoide apesar de ter demonstrado melhora
nos casos que apresentam grande inflamação (vitreíte intensa ou
reação de câmara anterior), seu uso em longo prazo não tem sido
favorável, sendo contraindicado na grande maioria dos casos(55).
CONCLUSÃO
A DUSN é uma importante causa de uveíte que, se diagnosticada
e tratada ainda em fase inicial, permite uma resolução dos sintomas
com melhora da acuidade visual. Caso progrida para a fase tardia,
poderá acarretar em uma perda visual significativa.
A identificação da larva é um achado patognomônico, porém na
ausência do nematódeo o diagnóstico pode ser presumido com base
nos achados dos exames de fundo de olho.
O tratamento de escolha é a fotocoagulação, entretanto o seu
uso é indicado apenas nos casos em que a larva for identificada. Em
casos de diagnóstico presumível, o tratamento farmacológico pode
ser uma alternativa segura e eficaz.
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the rationale for treatment of DUSN in south India. Br J Ophthalmol. 2006;90(9):
1125-7.
55. Reynalds JD, Olitsky SE. Pediatric uveitis. In: Hood C, Lowder CY. Pediatric retina. Berlin:
Springer; 2011. p.452.
XX Congresso Norte-Nordeste
de Oftalmologia
27 a 29 de março de 2014
Fortaleza (CE)
Informações:
E-mail: secretaria@snno.com.br
Site: http://www.snno.com.br/
260
Instruções para Autores |
O ARQUIVOS BRASILEIROS DE OFTALMOLOGIA (ABO, ISSN 00042749 - versão impressa e ISSN 1678-2925 - versão eletrônica), publi
cação bimestral oficial do Conselho Brasileiro de Oftalmologia, objetiva divulgar estudos científicos em Oftalmologia, Ciências Visuais e
Saúde Pública, fomentando a pesquisa, o aperfeiçoamento e a atua
lização dos profissionais relacionados à área.
Metodologia
São aceitos manuscritos originais, em português, inglês ou
espanhol que, de acordo com a metodologia empregada, deverão
ser caracterizados em uma das seguintes modalidades:
Estudos Clínicos
Estudos descritivos ou analíticos que envolvam análises em
seres humanos ou avaliem a literatura pertinente a seres humanos.
Estudos Epidemiológicos
Estudos analíticos que envolvam resultados populacionais.
Estudos de Experimentação Laboratorial
Estudos descritivos ou analíticos que envolvam modelos ani
mais ou outras técnicas biológicas, físicas ou químicas.
Estudos Teóricos
Estudos descritivos que se refiram à descrição e análise teórica
de novas hipóteses propostas com base no conhecimento existente
na literatura.
Tipos de Manuscritos
A forma do manuscrito enviado deve enquadrar-se em uma das
categorias a seguir. Os limites para cada tipo de manuscrito estão
entre parênteses ao final das descrições das categorias. A contagem
de palavras do manuscrito refere-se do início da introdução ao final
da discussão, portanto, não participam da contagem a página de
rosto, abstract, resumo, referências, agradecimentos, tabelas e figuras incluindo legendas.
Editoriais
Os editoriais são feitos a convite e devem ser referentes a
assuntos de interesse atual, preferencialmente relacionados a arti
gos publicados no mesmo fascículo do ABO (limites máximos: 1.000
palavras, título, 2 figuras ou tabelas no total e 10 referências).
Artigos Originais
Artigos originais apresentam experimentos completos com
resultados nunca publicados (limites máximos: 3.000 palavras, título, resumo estruturado, 7 figuras ou tabelas no total e 30 referên
cias). A avaliação dos manuscritos enviados seguirá as prioridades
abaixo:
1.Informação nova e relevante comprovada em estudo com
metodologia adequada.
2.Repetição de informação existente na literatura ainda não
comprovada regionalmente baseada em estudo com metodologia adequada.
3.Repetição de informação existente na literatura e já comprovada
regionalmente, desde que baseada em estudo com metodologia
adequada.
* Não serão aceitos manuscritos com conclusões especulativas, não
comprovadas pelos resultados ou baseadas em estudo com metodologia inadequada.
Instructions to Authors
Relatos de Casos ou Série de Casos
Relatos de casos ou série de casos serão considerados para
publicação se descreverem achados com raridade e originalidade
ainda não comprovadas internacionalmente, ou quando o relato
apresentar respostas clínicas ou cirúrgicas que auxiliem na elu
cidação fisiopatológica de alguma doença (limites máximos: 1.000
palavras, título, resumo não estruturado, 4 figuras ou tabelas no
total e 10 referências).
Cartas ao Editor
As cartas ao editor serão consideradas para publicação se incluí
rem comentários pertinentes a manuscritos publicados anterior
mente no ABO ou, excepcionalmente, resultados de estudos originais com conteúdo insuficiente para serem enviados como Artigo
Original. Elas devem introduzir nova informação ou nova interpre
tação de informação já existente. Quando seu conteúdo fizer referência a algum artigo publicado no ABO, este deve estar citado no
primeiro parágrafo e constar das referências. Nestes casos, as cartas
estarão associadas ao artigo em questão, e o direito de réplica dos
autores será garantido na mesma edição. Não serão publicadas cartas
de congratulações (limites máximos: 700 palavras, título, 2 figuras
ou tabelas no total e 5 referências).
Manuscritos de Revisão
Manuscritos de revisão seguem a linha editorial da revista e são
aceitos apenas por convite do editor. Sugestões de assuntos para
artigos de revisão podem ser feitas diretamente ao editor, mas os
manuscritos não podem ser enviados sem um convite prévio (limi
tes máximos: 4.000 palavras, título, resumo não estruturado, 8 figuras
ou tabelas no total e 100 referências).
Processo Editorial
Para que o manuscrito ingresse no processo editorial, é fundamental que todas as regras tenham sido cumpridas. A secretaria
editorial comunicará inadequações no envio do manuscrito. Após
a notificação, o autor correspondente terá o prazo de 30 dias para
adequação do seu manuscrito. Se o prazo não for cumprido, o ma
nuscrito será excluído.
Os manuscritos enviados ao ABO são avaliados inicialmente
pelos editores quanto à adequação do seu conteúdo à linha edito
rial do periódico. Após essa avaliação, todos os manuscritos são
encaminhados para análise e avaliação por pares, sendo o anonima
to dos avaliadores garantido em todo o processo de julgamento. O
anonimato dos autores não é implementado.
Após a avaliação editorial inicial, os comentários dos avaliado
res podem ser encaminhados aos autores como orientação para as
mod ificações que devam ser realizadas no texto. Após a imple
mentação das modificações sugeridas pelos avaliadores, o manuscrito revisado deverá ser encaminhado, acompanhado de carta
(enviada como documento suplementar) indicando pont ualm en
te todas as modificações realizadas no manuscrito ou os motivos
pelos quais as modificações sugeridas não foram efetuadas. Manuscritos que não vierem acompanhados da carta indicando as
modificações ficarão retidos aguardando o recebimento da mes
ma. O prazo para envio da nova versão do manuscrito é de 90 dias
após a comunicação da necessidade de modificações, sendo
excluído após esse prazo. A publicação dependerá da aprovação
final dos editores.
Os trabalhos devem destinar-se exclusivamente ao Arquivos
Brasileiros de Oftalmologia, não sendo permitido envio simultâneo a outro periódico, nem sua reprodução total ou parcial, ou
tradução para publicação em outro idioma, sem autorização dos
editores.
261
Autoria
Os critérios para autoria de manuscritos em periódicos médi
cos está bem estabelecido. O crédito de autoria deve ser baseado
em indivíduos que tenham contribuído de maneira concreta nas
seguintes três fases do manuscrito:
I. Concepção e delineamento do estudo, coleta dos dados ou
análise e interpretação dos dados.
II. Redação do manuscrito ou revisão crítica do manuscrito com
relação ao seu conteúdo intelectual.
III. Aprovação final da versão do manuscrito a ser publicada.
O ABO requer que os autores garantam que todos os autores
preenchem os critérios acima e que nenhuma pessoa que preencha
esses critérios seja preterida da autoria. Apenas a posição de chefia
de qualquer indivíduo não atribui a este o papel de autor, o ABO não
aceita a participação de autores honorários.
É necessário que o autor correspondente preencha e envie o
formulário de Declaração de Contribuição dos Autores como docu
mento suplementar.
Preparação do Artigo
Os artigos devem ser enviados exclusivamente de forma eletrô
nica, pela Internet, na interface apropriada do ABO. As normas que se
seguem foram baseadas no formato proposto pelo International
Committee of Medical Journal Editors (ICMJE) e publicadas no artigo:
Uniform Requirements for Manuscripts Submitted to Biomedical Journals.
O respeito às instruções é condição obrigatória para que o tra
balho seja considerado para análise.
O texto deve ser enviado em formato digital, sendo aceitos
apenas os formatos .doc. ou .rtf. O corpo do texto deve ser digitado
em espaço duplo, fonte tamanho 12, com páginas numeradas em
algarismos arábicos, iniciando-se cada seção em uma nova página.
As seções devem se apresentar na sequência: Página de Rosto,
Abstract e Keywords, Resumo e Descritores, Introdução, Métodos,
Resultados, Discussão Agradecimentos (eventuais), Referências, Tabelas (opcionais) e Figuras (opcionais) com legenda.
1. Página de Rosto. Deve conter: a) título em inglês (máximo
de 135 caracteres, incluindo espaços); b) título em português ou
espanhol (máximo de 135 caracteres, incluindo espaços); c) título
resumido para cabeçalho (máximo 60 caracteres, incluindo os
esp aços); d) nome científico de cada autor; e) titulação de cada
autor (área de atuação profissional*, cidade, estado, país e, quando houver, departamento, escola, Universidade); f ) nome, endereço, telefone e e-mail do autor correspondente; g) fontes de auxilio
à pesquisa (se houver); h) número do projeto e instituição responsável pelo parecer do Comitê de Ética em Pesquisa; i) declaração dos
conflitos de interesses de todos os autores; j) número do registro
dos ensaios clínicos em uma base de acesso público.
*Médico, estatístico, enfermeiro, ortoptista, fisioterapeuta, estudante etc.
Aprovação do Comitê de Ética em Pesquisa. Todos os estudos
que envolvam coleta de dados primários ou relatos clínico-ci
rúrgicos, sejam retrospectivos, transversais ou prospectivos, devem
indicar, na página de rosto, o número do projeto e nome da Ins
tituição que forneceu o parecer do Comitê de Ética em Pesquisa.
As pesquisas em seres humanos devem seguir a Declaração de
Helsinque, enquanto as pesquisas envolvendo animais devem
seguir os princípios propostos pela Association for Research in Vision
and Ophthalmology (ARVO).
É necessário que o autor correspondente envie, como documento
suplementar, a aprovação do Comitê de Ética em Pesquisa ou seu
parecer dispensando da avaliação do projeto pelo Comitê. Não cabe
ao autor a decisão sobre a necessidade de avaliação pelo Comitê de
Ética em Pesquisa.
262
Declaração de Conflito de Interesses. A página de rosto deve
conter a declaração de conflitos de interesse de todos os autores
(mesmo que esta seja inexistente). Para maiores informações sobre
os potenciais conflitos de interesse acesse: Chamon W, Melo LA Jr,
Paranhos A Jr. Declaração de conflito de interesse em apresenta
ções e publicações científicas. Arq Bras Oftalmol. 2010;73(2):107-9.
É necessário que todos os autores enviem os Formulários para Decla
ração de Conflitos de Interesse como documentos suplementares.
Ensaios Clínicos. Todos os Ensaios Clínicos devem indicar, na página
de rosto, número de registro em uma base internacional de regis
tro que permita o acesso livre a consulta (exemplos: U.S. National
Inst it utes of Health, Australian and New Zealand Clinical Trials
Registry, International Standard Randomised Controlled Trial Number
- ISRCTN, University Hospital Medical Information Network Clinical Trials
Registry - UMIN CTR, Nederlands Trial Register).
2. Abstract e Keywords. Resumo estruturado (Purpose, Methods,
Results, Conclusions) com, no máximo, 300 palavras. Resumo não
estruturado com, no máximo, 150 palavras. Citar cinco descritores
em inglês, listados pela National Library of Medicine (MeSH - Medical Subject Headings).
3. Resumo e Descritores. Resumo estruturado (Objetivos, Métodos, Resultados, Conclusões) com, no máximo 300 palavras. Resumo não estruturado com, no máximo, 150 palavras. Citar cinco des
critores, em português listados pela BIREME (DeCS - Descritores
em Ciências da Saúde).
4. Introdução, Métodos, Resultados e Discussão. As citações no
texto devem ser numeradas sequencialmente, em números arábicos sobrescritos e entre parênteses. É desaconselhada a citação
nominal dos autores.
5. Agradecimentos. Colaborações de pessoas que mereçam
reconhecimento, mas que não justificam suas inclusões como
autores, devem ser citadas nessa seção. Estatísticos e editores médicos podem preencher os critérios de autoria e, neste caso, dev em
ser reconhecidos como tal. Quando não preencherem os critérios de autoria, eles deverão, obrigatoriamente, ser citados nesta seção. Não são aceitos escritores não identificados no manuscrito, portanto, escritores profissionais devem ser reconhecidos
nesta seção.
6. Referências. A citação (referência) dos autores no texto deve
ser numérica e sequencial, na mesma ordem que foram citadas
e identificadas por algarismos arábicos sobrescritos. A apresenta
ção deve estar baseada no formato proposto pelo International
Committee of Medical Journal Editors (ICMJE), conforme os exemplos que se seguem.
Os títulos de periódicos devem ser abreviados de acordo com o
estilo apresentado pela List of Journal Indexed in Index Medicus, da
National Library of Medicine.
Para todas as referências, cite todos os autores, até seis. Nos traba
lhos com sete ou mais autores, cite apenas os seis primeiros,
seguidos da expressão et al.
Exemplos de referências:
Artigos de Periódicos
Costa VP, Vasconcellos JP, Comegno PEC, José NK. O uso da mitomicina C em cirurgia combinada. Arq Bras Oftalmol. 1999; 62(5):577-80.
Livros
Bicas HEA. Oftalmologia: fundamentos. São Paulo: Contexto; 1991.
Capítulos de livros
Gómez de Liaño F, Gómez de Liaño P, Gómez de Liaño R. Exploración
del niño estrábico. In: Horta-Barbosa P, editor. Estrabismo. Rio de
Janeiro: Cultura Médica; 1997. p. 47-72.
Anais
Höfling-Lima AL, Belfort R Jr. Infecção herpética do recém-nascido.
In: IV Congresso Brasileiro de Prevenção da Cegueira; 1980 Jul 28-30,
Belo Horizonte, Brasil. Anais. Belo Horizonte; 1980. v.2. p. 205-12.
Teses
Schor P. Idealização, desenho, construção e teste de um ceratômetro cirúrgico quantitativo [tese]. São Paulo: Universidade Federal
de São Paulo; 1997.
Documentos Eletrônicos
Monteiro MLR, Scapolan HB. Constrição campimétrica causada por
vigabatrin. Arq Bras Oftalmol. [periódico na Internet]. 2000 [citado
2005 Jan 31]; 63(5): [cerca de 4 p.]. Disponível em:http://www.scielo.
br/scielo.php?script=sci_arttext&pid=S0004-274920000005000
12&lng=pt&nrm=iso
7. Tabelas. A numeração das tabelas deve ser sequencial, em alga
rismos arábicos, na ordem em que foram citadas no texto. Todas
as tabelas devem ter título e cabeçalho para todas as colunas
e serem apresentadas em formatação simples, sem linhas verticais
ou preenchimentos de fundo. No rodapé da tabela deve constar
legenda para todas as abreviaturas (mesmo que definidas previa
mente no texto) e testes estatísticos utilizados, além da fonte
bibliográfica quando extraída de outro trabalho. Todas as tabelas
devem estar contidas no documento principal do manuscrito após
as referências bibliográficas, além de serem enviadas como documento suplementar.
8. Figuras (gráficos, fotografias, ilustrações, quadros). A nu
meração das figuras deve ser sequencial, em algarismos arábi
cos, na ordem em que foram citadas no texto. O ABO publicará as
figuras em preto e branco sem custos para os autores. Os manus
critos com figuras coloridas apenas serão publicados após o
pagamento da respectiva taxa de publicação de R$ 500,00 por
manuscrito.
Os gráficos devem ser, preferencialmente, em tons de cinza, com
fundo branco e sem recursos que simulem 3 dimensões ou profundidade. Gráficos do tipo torta são dispensáveis e devem ser substi
tuídos por tabelas ou as informações serem descritas no texto.
Fotografias e ilustrações devem ter resolução mínima de 300 DPI
para o tamanho final da publicação (cerca de 2.500 x 3.300 pixels,
para página inteira). A qualidade das imagens é considerada na
avaliação do manuscrito.
Todas as figuras devem estar contidas no documento principal do
manuscrito após as tabelas (se houver) ou após as referências bibliográficas, além de serem enviadas como documento suplementar.
No documento principal, cada figura deve vir acompanhada de sua
respectiva legenda em espaço duplo e numerada em algarismo
arábico.
Os arquivos suplementares enviados podem ter as seguintes extensões: JPG, BMP, TIF, GIF, EPS, PSD, WMF, EMF ou PDF, e devem
ser nomeados conforme a identificação das figuras, por exemplo:
“grafico_1.jpg” ou “figura_1A.bmp”.
9. Abreviaturas e Siglas. Quando presentes, devem ser precedidas
do nome correspondente completo ao qual se referem, quando
citadas pela primeira vez, e nas legendas das tabelas e figuras
(mesmo que tenham citadas abreviadas anteriormente no texto).
Não devem ser usadas no título e no resumo.
10. Unidades: Valores de grandezas físicas devem ser referidos de
acordo com os padrões do Sistema Internacional de Unidades.
11. Linguagem. A clareza do texto deve ser adequada a uma
publicação científica. Opte por sentenças curtas na forma direta e
ativa. Quando o uso de uma palavra estrangeira for absolutamente
necessário, ela deve aparecer com formatação itálica. Agentes
terapêuticos devem ser indicados pelos seus nomes genéricos
seguidos, entre parênteses, pelo nome comercial, fabricante, ci
dade, estado e país de origem. Todos os instrumentos ou apare
lhos de fabricação utilizados devem ser citados com o seu nome
comercial, fabricante, cidade, estado e país de origem. É necessária
a colocação do símbolo (sobrescrito) de marca registrada ® ou ™
em todos os nomes de instrumentos ou apresentações comerciais
de drogas. Em situações de dúvidas em relação a estilo, terminologia, medidas e assuntos correlatos, o AMA Manual of Style 10th
edition deverá ser consultado.
12. Documentos Originais. Os autores correspondentes devem ter
sob sua guarda os documentos originais como a carta de aprovação
do comitê de ética institucional para estudos com humanos ou
animais; o termo de consentimento informado assinado por todos
os pacientes envolvidos, a declaração de concordância com o con
teúdo completo do trabalho assinada por todos os autores e declaração de conflito de interesse de todos os autores, além dos registros
dos dados colhidos para os resultados do trabalho.
13. Correções e Retratações. Erros podem ser percebidos após a
publicação de um manuscrito que requeiram a publicação de
uma correção. No entanto, alguns erros, apontados por qualquer
leitor, podem invalidar os resultados ou a autoria do manuscrito.
Se alguma dúvida concreta a respeito da honestidade ou fidedignidade de um manuscrito enviado para publicação for levantada,
é obrigação do editor excluir a possibilidade de fraude. Nestas
situações o editor comunicará as instituições envolvidas e as agências financiadoras a respeito da suspeita e aguardará a decisão
final desses órgãos. Se houver a confirmação de uma publicação
fraudulenta no ABO, o editor seguirá os protocolos sugeridos pela
International Committee of Medical Journal Editors (ICMJE) e pelo
Committee on Publication Ethics (COPE).
Lista de Pendências
Antes de iniciar o envio do seu manuscrito o autor deve confir
mar que todos os itens abaixo estão disponíveis:
□Manuscrito formatado de acordo com as instruções aos autores.
□Limites de palavras, tabelas, figuras e referências adequados
□Todas as figuras e tabelas inseridas no documento principal
□Todas as figuras e tabelas na sua forma digital para serem
□Formulário
para o tipo de manuscrito.
do manuscrito.
enviadas separadamente como documentos suplementares.
de Declaração da Participação dos Autores
preenchido e salvo digitalmente, para ser enviado como
documento suplementar.
□Formulários de Declarações de Conflitos de Interesses de
todos os autores preenchidos e salvos digitalmente, para
serem enviados como documentos suplementares.
□Número do registro na base de dados que contem o protocolo do ensaio clínico constando na folha de rosto.
□Versão digital do parecer do Comitê de Ética em Pesquisa
com a aprovação do projeto, para ser enviado como documento suplementar.
263
Lista de Sítios da Internet
Interface de envio de artigos do ABO
http://www.scielo.br/ABO
Formulário de Declaração de Contribuição dos Autores
http://www.cbo.com.br/site/files/Formulario Contribuicao dos Autores.pdf
International Committee of Medical Journal Editors (ICMJE)
http://www.icmje.org/
Uniform requirements for manuscripts submitted
to biomedical journals
http://www.icmje.org/urm_full.pdf
Declaração de Helsinque
http://www.wma.net/en/30publications/10policies/b3/index.html
Princípios da Association for Research in
Vision and Ophthalmology (ARVO)
http://www.ar vo.org/eweb/dynamicpage.aspx?site=ar vo2&
webcode=AnimalsResearch
Chamon W, Melo LA Jr, Paranhos A Jr. Declaração de conflito de
interesse em apresentações e publicações científicas.
http://www.scielo.br/pdf/abo/v73n2/v73n2a01.pdf
Princípios de Autoria segundo ICMJE
http://www.icmje.org/ethical_1author.html
Australian and New Zealand Clinical Trials Registry
http://www.anzctr.org.au
International Standard Randomised Controlled
Trial Number - ISRCTN
http://isrctn.org/
University Hospital Medical Information Network
Clinical Trials Registry - UMIN CTR
http://www.umin.ac.jp/ctr/index/htm
Nederlands Trial Register
http://www.trialregister.nl/trialreg/index.asp
MeSH - Medical Subject Headings
http://www.ncbi.nlm.nih.gov/sites/entrez?db=mesh&term=
DeCS - Descritores em Ciências da Saúde
http://decs.bvs.br/
Formatação proposta pela International Committee
of Medical Journal Editors (ICMJE)
http://www.nlm.nih.gov/bsd/uniform_requirements.html
List of Journal Indexed in Index Medicus
http://www.ncbi.nlm.nih.gov/journals
AMA Manual of Style 10th edition
http://www.amamanualofstyle.com/
Formulários para Declaração de Conflitos de Interesse
http://www.icmje.org/coi_disclosure.pdf
Protocolos da International Committee of
Medical Journal Editors (ICMJE)
http://www.icmje.org/publishing_2corrections.html
U.S. National Institutes of Health
http://www.clinicaltrials.gov
Protocolos da Committee on Publication Ethics (COPE)
http://publicationethics.org/flowcharts
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PARA MAIS INFORMAÇÕES, LIGUE PARA 0800 7288281 OU ENVIE E-MAIL PARA OFTALMOLOGISTA@CONBR.JNJ.COM
Senofilcon A - 1ACUVUE® OASYS® com HYDRACLEAR® PLUS: Reg.ANVISA 80148620045, 2ACUVUE® OASYS® para ASTIGMATISMO com HYDRACLEAR® PLUS: Reg.ANVISA 80148620054, 3ACUVUE®
OASYS® com HYDRACLEAR® PLUS (Bandage): Reg.ANVISA 80148620058, Galyfilcon A - 4ACUVUE® ADVANCE® com HYDRACLEAR®: Reg.ANVISA 80148620026, Etafilcon A - 5ACUVUE® 2: Reg.ANVISA
80148620019, 61-DAY ACUVUE® MOIST®: Reg.ANVISA 80148620052, 71-DAY ACUVUE® MOIST para ASTIGMATISMO: Reg.ANVISA 80148620064, 8ACUVUE® 2 COLOURS: Reg.ANVISA 80148620013,
9
ACUVUE® CLEAR: Reg.ANVISA 80148620021 e 10ACUVUE® BIFOCAL: Reg.ANVISA 80148620016, Narafilcon A - 111-DAY ACUVUE® TRUEYE® com HYDRACLEAR® 1: Reg.ANVISA 80148620065. Caixas
com 306,7, 61,2,3,4,5,8,9,10 ou 28 lentes de contato (LC). Indicações: LC Esféricas1,4,5,6,9,11: Miopia, hipermetropia (presbiopia em regime de monovisão) afácica ou não afácica. LC Esféricas Coloridas8: Miopia,
hipermetropia (presbiopia em regime de monovisão) afácica ou não afácica. LC Bifocais10: Presbiopia afácica ou não afácica associada ou não a miopia ou hipermetropia. LC Tóricas2,7: Astigmatismo afácico
ou não afácico associado ou não a miopia ou hipermetropia. LC Terapêuticas3: As lentes de contato podem ser prescritas, em determinadas condições ou doenças oculares, como lentes de proteção para
a córnea, a fim de aliviar o desconforto e servir como uma cobertura de proteção. O médico Oftalmologista informará se o usuário apresenta essa condição, podendo prescrever medicações adicionais
ou programação de substituição para a condição específica. O usuário nunca deve tratar qualquer condição, usando lentes de contato ou medicação para os olhos, sem primeiro consultar o médico
Oftalmologista. Contra-Indicações: Qualquer inflamação, infecção, doença ocular, lesão ou anormalidade que afete a córnea, conjuntiva ou pálpebras. Qualquer doença sistêmica que venha a afetar
os olhos ou ser agravada pelo uso de LC; reações alérgicas das superfícies oculares ou anexas. Qualquer infecção ativa da córnea; olhos vermelhos ou irritados. Precauções e Advertências: Problemas
oculares, incluindo úlceras de córnea, podem se desenvolver rapidamente e causar perda da visão. Em caso de desconforto visual, lacrimejamento excessivo, visão alterada, vermelhidão nos olhos ou
outros problemas, retirar imediatamente as LC e contatar o Oftalmologista. Usuários de LC devem consultar seu Oftalmologista regularmente. Não usar o produto se a embalagem estéril de plástico
estiver aberta ou danificada. Reações Adversas: Ardor, coceira ou sensação de pontada nos olhos. Desconforto quando a LC for colocada pela primeira vez. Sensação de que há algo no olho (corpo
estranho, área raspada). Lacrimejamento excessivo, secreções oculares incomuns ou vermelhidão dos
olhos. Acuidade visual deficiente, visão embaçada, arco-íris ou halos ao redor de objetos, fotofobia,
ou olho seco, podem ocorrer caso as LC sejam usadas continuamente ou por tempo excessivamente
longo. Se o usuário relatar algum problema, deve RETIRAR IMEDIATAMENTE AS LENTES e contatar
o Oftalmologista. Posologia: Uso prolongado1,2,3,5,8,10– Um a 7 dias/6 noites de uso contínuo, inclusive
durante o sono. Uso diário1,2,3,4,5,8,9,10 – Períodos inferiores a um dia de uso enquanto acordado. Descartáveis
diárias6,7,11 – uso único. VENDA SOB PRESCRIÇÃO MÉDICA REFRACIONAL (LC com grau), VENDA
SOB PRESCRIÇÃO MÉDICA (LC terapêutica plana), UTILIZAÇÃO SUJEITA À PRESCRIÇÃO MÉDICA
(LC colorida plana). Johnson & Johnson Industrial Ltda. Rod. Pres. Dutra, Km 154 - S. J. dos Campos,
SP. CNPJ: 59.748.988/0001-14. Resp. Téc.: Evelise S. Godoy – CRQ No. 04345341. Mais informações
sobre uso e cuidados de manutenção e segurança, fale com seu Oftalmologista, ligue para Central de
Relacionamento com o Consumidor: 0800-7274040, acesse www.acuvue.com.br ou consulte o Guia
de Instruções ao Usuário. A PERSISTIREM OS SINTOMAS, O MÉDICO DEVERÁ SER CONSULTADO.
1. OS BORN, K.; VEYS, J. A new silicone hydrogel lens for contact lens-related dryeness. Part 1 - Material Properties. Optician, 2005; 6004(229):
39-41.
© Johnson & Johnson do Brasil Indústria E Comércio de Produtos Para Saúde Ltda. JULHO/2013
NOVAS LENTES DE CONTATO

Refractive errors in Möbius sequence Contact lenses after

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