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Elaborar um Manual de Procedimento Operacional Padrão destinado ao Setor de Glaucoma a fim de contribuir com a redução de dúvidas referentes aos processos, perdas financeiras e de tempo associados aos erros de agendamento de exames. Métodos: O estudo foi norteado pelo ciclo do PDCA: planejamento (P), implantação e desenvolvimento (D), análise crítica do desempenho (C) e ação corretiva das disfunções ou assunção de inovações (A). O gerenciamento desse processo permite identificar oportunidades de inovação, diminui a variação nos processos e previne os erros. Foi elaborado um manual de procedimento operacional padrão com a expectativa de identificar as raízes dos problemas de agendamento dos exames do Setor de Glaucoma e eliminá-los e, desse modo, foram estabelecidos os processos de apoio identificados durante a análise para produção deste manual e implementado o fluxograma com a aplicação das novas guias para agendamento dos exames. Foram elaboradas seis guias para o agendamento dos exames como a seguir: Campo Visual Humphrey (Computadorizado), Campo Visual Goldmann (Manual), FDT-Perimetria de Dupla Frequência, OCT-Tomografia de Coerência Óptica, Retinografia (Estereofotografia) e Paquimetria Ultrassônica. As guias foram disponibilizadas no Setor de Glaucoma e seu uso foi imediatamente liberado em todos os ambulatórios e para todos os médicos do setor. Após a utilização completa das guias: a solicitação do exame pelo médico, o agendamento feito pela recepção, a execução do exame pelo tecnólogo-oftálmico ou colaborador responsável e o agendamento do retorno médico do paciente, todas foram recolhidas e separadas para uma análise do processo envolvido desde a solicitação feita pelos médicos até o retorno do paciente à consulta. Resultados: Durante o estudo foram recolhidas 501 guias, sendo 228 (45,5%) de Campo Visual Humphrey, 103 (20,6%) de Campo Visual Goldmann, 4 (0,8%) de FDT–Perimetria de Dupla Frequência, 66 (13,2%) de OCT–Tomografia de Coerência Óptica, 61 (12,2%) de Retinografia (Estereofoto) e 39 (7,8%) de Paquimetria Ultrassônica. Desse total detectaram-se três erros de agendamento, sendo duas guias de exames que foram anotadas somente na própria guia, mas não constavam no sistema e uma guia cujo exame foi agendado em outro perfil. Conclusões: Exemplificou-se por meio do fluxograma a interação entre os colaboradores do processo de agendamento dos exames e como as informações ocorrem, incluindo suas falhas. Além disso, foram elaboradas seis guias a fim de diminuir os erros e dúvidas dos processos administrativos, permitindo investigar as causas das falhas dos agendamentos dos exames e proporcionar melhores condições de assistência médica. Pode-se concluir que a proposta de um Manual de Procedimento Operacional Padrão e a implementação das novas guias para agendamento de exames são capazes de ser oferecidas e utilizadas em benefício do Setor de Glaucoma e, principalmente, do usuário., Keywords: 1. Organization and Administration. 2. Quality Management. 3. Standard Operating Procedure.

Roberto Vessani, Thalyta Frota, Gabriella Shigetomi, Priscila Correa, Eduardo B Mariottoni, Ivan Tavares Department of Ophthalmology and Visual Sciences, Paulista School of Medicine, São Paulo Hospital, Federal University of São Paulo, São Paulo, BrazilCorrespondence: Roberto VessaniFederal University of São Paulo, Rua Pará 222, Apto 92, São Paulo, 01243020, BrazilTel +55 1132370707Email rmvessani@gmail.comPurpose: To evaluate the magnitude of change in optic disc, peripapillary retinal nerve fiber layer (RNFL) and macular parameters measured by swept-source optical coherence tomography (SS-OCT) in glaucomatous eyes after filtration surgery, and to determine any possible relationship between these measurements and baseline factors.Patients and Methods: This multicenter, prospective, consecutive observational study included patients with open-angle glaucoma who required glaucoma filtering surgery (surgical group, 29 eyes) and those with stable disease (control group, 25 eyes). Patients from the surgical group underwent measurement of optic disc, peripapillary retinal nerve fiber layer (RNFL) and macular parameters before and after surgery.Results: In the surgical group, there was a significant increase in rim area and a significant decrease in the linear cup/disc ratio, vertical cup/disc ratio and cup volume 1 and 2 months postoperatively (p< 0.05). No significant change in the mean RNFL thickness and also sectorial measurements were observed from baseline to 1 and 2 months after surgery (p> 0.05). Furthermore, significant increases in macular parameters were observed until 2 months after surgery (p< 0.05). No significant changes were observed for all SS-OCT measurements in the control group. There was a significant correlation between the magnitude of the structural measurements change and the IOP reduction for two topographic parameters (rim area and linear cup-disc ratio) and macular average thickness 1 month and 2 months postoperatively.Conclusion: In open-angle glaucoma patients submitted to surgical IOP reductions, improvements in topographic and macular OCT parameters measured by SS-OCT were observed for at least 2 months.Keywords: filtering surgery, intraocular pressure, optic disc, macula, optical coherence tomography

Background and ObjectivesTo determine optic nerve and retinal damage in aquaporin-4 antibody (AQP4-IgG)-seropositive neuromyelitis optica spectrum disorders (NMOSD) in a large international cohort after previous studies have been limited by small and heterogeneous cohorts.MethodsThe cross-sectional Collaborative Retrospective Study on retinal optical coherence tomography (OCT) in neuromyelitis optica collected retrospective data from 22 centers. Of 653 screened participants, we included 283 AQP4-IgG–seropositive patients with NMOSD and 72 healthy controls (HCs). Participants underwent OCT with central reading including quality control and intraretinal segmentation. The primary outcome was thickness of combined ganglion cell and inner plexiform (GCIP) layer; secondary outcomes were thickness of peripapillary retinal nerve fiber layer (pRNFL) and visual acuity (VA).ResultsEyes with ON (NMOSD-ON, N = 260) or without ON (NMOSD-NON, N = 241) were assessed compared with HCs (N = 136). In NMOSD-ON, GCIP layer (57.4 ± 12.2 μm) was reduced compared with HC (GCIP layer: 81.4 ± 5.7 μm, p < 0.001). GCIP layer loss (−22.7 μm) after the first ON was higher than after the next (−3.5 μm) and subsequent episodes. pRNFL observations were similar. NMOSD-NON exhibited reduced GCIP layer but not pRNFL compared with HC. VA was greatly reduced in NMOSD-ON compared with HC eyes, but did not differ between NMOSD-NON and HC.DiscussionOur results emphasize that attack prevention is key to avoid severe neuroaxonal damage and vision loss caused by ON in NMOSD. Therapies ameliorating attack-related damage, especially during a first attack, are an unmet clinical need. Mild signs of neuroaxonal changes without apparent vision loss in ON-unaffected eyes might be solely due to contralateral ON attacks and do not suggest clinically relevant progression but need further investigation.

The current lack of consensus for diagnosing glaucoma makes it difficult to develop diagnostic tests derived from deep learning (DL) algorithms. In the present study, we propose an objective definition of glaucomatous optic neuropathy (GON) using clearly defined parameters from optical coherence tomography and standard automated perimetry. We then use the proposed objective definition as reference standard to develop a DL algorithm to detect GON on fundus photos. A DL algorithm was trained to detect GON on fundus photos, using the proposed objective definition as reference standard. The performance was evaluated on an independent test sample with sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and likelihood ratios (LR). The test sample had 2118 fundus photos from 585 eyes of 405 individuals. The AUC to discriminate between GON and normal was 0.92 with sensitivity of 77% at 95% specificity. LRs indicated that the DL algorithm provided large changes in the post-test probability of disease for the majority of eyes. A DL algorithm to evaluate fundus photos had high performance to discriminate GON from normal. The newly proposed objective definition of GON used as reference standard may increase the comparability of diagnostic studies of glaucoma across devices and populations.

Background: patients with anti-aquaporin-4 antibody seropositive (AQP4-IgG+) neuromyelitis optica spectrum disorders (NMOSDs) frequently suffer from optic neuritis (ON) leading to severe retinal neuroaxonal damage. Further, the relationship of this retinal damage to a primary astrocytopathy in NMOSD is uncertain. Primary astrocytopathy has been suggested to cause ON-independent retinal damage and contribute to changes particularly in the outer plexiform layer (OPL) and outer nuclear layer (ONL), as reported in some earlier studies. However, these were limited in their sample size and contradictory as to the localisation. This study assesses outer retinal layer changes using optical coherence tomography (OCT) in a multicentre cross-sectional cohort. Method: 197 patients who were AQP4-IgG+ and 32 myelin-oligodendrocyte-glycoprotein antibody seropositive (MOG-IgG+) patients were enrolled in this study along with 75 healthy controls. Participants underwent neurological examination and OCT with central postprocessing conducted at a single site. Results: no significant thinning of OPL (25.02 +/- 2.03 mu m) or ONL (61.63 +/- 7.04 mu m) were observed in patients who were AQP4-IgG+ compared with patients who were MOG-IgG+ with comparable neuroaxonal damage (OPL: 25.10 +/- 2.00 mu m; ONL: 64.71 +/- 7.87 mu m) or healthy controls (OPL: 24.58 +/- 1.64 mu m; ONL: 63.59 +/- 5.78 mu m). Eyes of patients who were AQP4-IgG+ (19.84 +/- 5.09 mu m, p=0.027) and MOG-IgG+ (19.82 +/- 4.78 mu m, p=0.004) with a history of ON showed parafoveal OPL thinning compared with healthy controls (20.99 +/- 5.14 mu m); this was not observed elsewhere. Conclusion: the results suggest that outer retinal layer loss is not a consistent component of retinal astrocytic damage in AQP4-IgG+ NMOSD. Longitudinal studies are necessary to determine if OPL and ONL are damaged in late disease due to retrograde trans-synaptic axonal degeneration and whether outer retinal dysfunction occurs despite any measurable structural correlates., Guthy Jackson Charitable Foundation (GJCF); German Research Foundation (DFG)

PurposeTo propose a reference standard for the definition of glaucomatous optic neuropathy (GON) consisting of objective parameters from spectral-domain optical coherence tomography (SDOCT) and standard automated perimetry (SAP), and to apply it to the development and evaluation of a deep learning (DL) algorithm to detect glaucomatous damage on fundus photographs.DesignRetrospective, cross-sectional study.MethodsData were extracted from the Duke Glaucoma Registry and included 2,927 eyes of 2,025 participants with fundus photos, SDOCT and SAP acquired within six months. Eyes were classified as GON versus normal based on a combination of objective SDOCT and SAP criteria. A DL convolutional neural network was trained to predict the probability of GON from fundus photos. The algorithm was tested on an independent sample with performance assessed by sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and likelihood ratios (LR).ResultsThe test sample included 585 eyes of 405 participants. The median DL probability of glaucoma in eyes with GON was 99.8% versus 0.03% for normal eyes (P < 0.001), with an AUC of 0.92 and sensitivity of 77% at 95% specificity. LRs indicated that the DL algorithm provided large changes in the post-test probability of disease for the majority of eyes.ConclusionsThe DL algorithm had high performance to discriminate eyes with GON from normal. The newly proposed objective definition of GON used as reference standard may increase the comparability of diagnostic studies of glaucoma across devices and populations, helping to improve the development and assessment of tests in clinical practice.

Julia D Rossetto, Luiz Alberto S Melo Jr, Mauro S Campos, Ivan M Tavares Department of Ophthalmology and Visual Sciences, Paulista School of Medicine, Universidade Federal de São Paulo, Sao Paulo, Brazil Objectives: To assess agreement among ophthalmology residents and a glaucoma expert in the evaluation of cross-sectional glaucomatous optic nerve head characteristics using stereoscopic photographs. Methods: Twenty stereo photographs were analyzed by ophthalmology residents just after completion of their first (First-Year Group) or third (Third-Year Group) year of residency and by a glaucoma expert. The agreement was assessed using the kappa statistic (κ) and limits of agreement. Results: Agreement among resident groups and the expert ranged from poor to moderate. Agreement between Third Years and the expert seems to be better than that between First Years and the expert, especially in the evaluation of “nasal cupping”, “barring circumlinear vessel,” “notching”, and “retinal nerve fiber layer defect” criteria. However, no improvement was seen in the agreement with the expert regarding glaucomatous optic neuropathy, which was 64% (κ=0.19) for First Years and 63% (κ=0.20) for Third Years. Conclusion: Agreement between residents and the expert was poor to moderate and similar when comparing both groups. This may suggest that the residents learn how to identify glaucoma signals during the first year of training, and the results of this study may facilitate the creation of targeted teaching tools in residency training. Keywords: optic disk, residency and internship, medical education, glaucoma&nbsp

Objective To study the automated segmentation of retinal layers using spectral domain optical coherence tomography (OCT) and the impact of manual correction over segmentation mistakes. Methods This was a retrospective, cross-sectional, comparative study that compared the automated segmentation of macular thickness using Spectralis™ OCT technology (Heidelberg Engineering, Heidelberg, Germany) versus manual segmentation in eyes with no macular changes, macular cystoid edema (CME), and choroidal neovascularization (CNV). Automated segmentation of macular thickness was manually corrected by two independent examiners and reanalyzed by them together in case of disagreement. Results In total, 306 eyes of 254 consecutive patients were evaluated. No statistically significant differences were noted between automated and manual macular thickness measurements in patients with normal maculas, while a statistically significant difference was found in central thickness in patients with CNV and with CME. Segmentation mistakes in macular OCTs were present in 5.3% (5 of 95) in the normal macula group, 16.4% (23 of 140) in the CME group, and 66.2% (47 of 71) in CNV group. The difference between automated and manual macular thickness was higher than 10% in 1.4% (2 of 140) in the CME group and in 28.17% (20 of 71) in the CNV group. Only one case in the normal group had a higher than 10% segmentation error (1 of 95). Conclusion The evaluation of automated segmented OCT images revealed appropriate delimitation of macular thickness in patients with no macular changes or with CME, since the frequency and magnitude of the segmentation mistakes had low impact over clinical evaluation of the images. Conversely, automated macular thickness segmentation in patients with CNV showed a high frequency and magnitude of mistakes, with potential impact on clinical analysis.

Objetivo: O objetivo deste estudo foi avaliar a espessura central da cornea (ECC) e a pressao intraocular (PIO) em recem-nascidos (RN) a termo, correlacionando seus valores entre as variaveis peso, sexo e idade pos-concepcao (PCA). Metodos: A pressao intraocular e a espessura central da cornea foram determi­nadas em 52 recem-nascidos a termo com idade gestacional media de 39,43 ± 1,03 semanas, peso medio de nascimento de 3.273 ± 558 g. A media de idade durante as medicoes apos o nascimento foi 1,15 ± 1,38 dias. A pressao intraocular foi determinada com Tono-pen. A espessura central da cornea foi determinada com paquimetro ultrassonico portatil. Resultados: A pressao intraocular media foi de 14,0 ± 2,91 mmHg em ambos os sexos, de 13,77 ± 2,88 mmHg nos recem-nascidos do sexo masculino e 14,32 ± 3,05 mmHg nos recem-nascidos do sexo feminino. A espessura central da cornea media foi de 605,87 ± 62,98 µm em ambos os sexos; de 626,70 ± 67,46 µm recem-nascidos do sexo masculino e de 577,45 ± 45,50 µm nos recem-nascidos do sexo feminino. A maior media da espessura da cornea foi no sexo masculino. A variavel idade pos-concepcao teve uma relacao decrescente com espessura central da cornea, pressao intraocular e peso, porem, a correlacao so foi significante com a espessura central da cornea. Na comparacao entre os sexos houve diferencas significativas para duas variaveis: peso e espessura central da cornea. Conclusoes: Nao houve relacao entre a espessura central da cornea e a pressao intraocular neste estudo, entretanto verificou-se que existe uma relacao de aumento de peso com a espessura central da cornea.

CAPES/Ministry of Education of Brazil CNPq/Ministry of Science and Technology of Brazil Our objective was to compare the diagnostic accuracies of and to determine the correlations between the disc damage likelihood scale (DDLS) and anatomical and functional tests used for glaucoma detection. A total of 54 healthy subjects (54 eyes) and 47 primary open-angle glaucoma patients (47 eyes) were included in this cross-sectional observational study. DDLS scores and cup-to-disc (C/D) ratios were evaluated. Subjects underwent standard automated perimetry (SAP), optic disc and retinal nerve fiber layer (RNFL) imaging with time and spectral-domain optical coherence tomography (TD and SD-OCT), Heidelberg Retina Tomograph (HRT II), and scanning laser polarimetry (GDx-VCC). Areas under the receiver operating characteristic curves (AROCs) for DDLS and diagnostic tests parameters were calculated. DDLS correlations (Spearman's rank) among these parameters were analyzed. Fifty-four eyes were healthy and 47 had glaucoma, including 16 preperimetric glaucoma. DDLS, vertical and horizontal C/D ratios had the largest AROCs (0.92, 0.94 and 0.91, respectively). DDLS diagnostic accuracy was better than the accuracies of HRT II parameters, TD and SD-OCT RNFL thicknesses, and SAP mean deviation (MD) index. There were no significant differences between the accuracies of the DDLS and the C/D ratios, TD-OCT vertical (0.89) and horizontal (0.86) C/D ratios, TD-OCT C/D area ratio (0.89), and GDx-VCC NFI (0.81). DDLS showed significant strong correlations with vertical (r = 0.79) and horizontal (0.74) C/D ratios, and with the parameters vertical C/D ratio and C/D area ratio from HRT II (both 0.77) and TD-OCT (0.75 and 0.72, respectively). DDLS had significant moderate correlations with most of the other structural measurements and SAP MD. The optic disc clinical evaluation with DDLS system and C/D ratio demonstrated excellent accuracy in distinguishing glaucomatous from healthy eyes. DDLS had moderate to strong correlations with most structural and functional parameters. These findings stress the importance of optic disc clinical examination to detect glaucoma in a clinical scenario. Univ Fed Sao Paulo, Escola Paulista Med, Dept Ophthalmol & Visual Sci, Glaucoma Div, Sao Paulo, SP, Brazil Univ Fed Sao Paulo, Escola Paulista Med, Dept Ophthalmol & Visual Sci, Glaucoma Div, Sao Paulo, SP, Brazil CAPES CNPq Web of Science

Purpose. To evaluate the diagnostic accuracy of retinal ganglion cell (RGC) counts as estimated by combining data from standard automated perimetry (SAP) and spectral domain optical coherence tomography (SD-OCT).Methods. Healthy individuals and glaucoma patients were included in this cross-sectional study. All eyes underwent 24-2 SITA SAP and structural imaging tests. RGC count estimates were obtained using a previously described algorithm, which combines estimates of RGC numbers from SAP sensitivity thresholds and SD-OCT retinal nerve fiber layer (RNFL) average thickness.Results. A total of 119 eyes were evaluated, including 75 eyes of 48 healthy individuals and 44 eyes of 29 glaucoma patients. RGC count estimates performed better than data derived from SD-OCT RNFL average thickness or SAP mean deviation alone (area under ROC curves: 0.98, 0.92, and 0.79;P<0.001) for discriminating healthy from glaucomatous eyes, even in a subgroup of eyes with mild disease (0.97, 0.88, and 0.75;P<0.001). There was a strong and significant correlation between estimates of RGC numbers derived from SAP and SD-OCT (R2=0.74;P<0.001).Conclusion. RGC count estimates obtained by combined structural and functional data showed excellent diagnostic accuracy for discriminating the healthy from the glaucomatous eyes and performed better than isolated structural and functional parameters.

Normal-tension glaucoma (NTG) is a progressive optic neuropathy with intraocular pressure (IOP) within the statistically normal range (≤21 mmHg). The prevalence of NTG varies widely among different population studies, being the most prevalent open-angle glaucoma subtype in some reports. The etiology of NTG possibly is multifactorial and still not well defined. Alternative treatments have been proposed based on pathogenesis details. However, in clinical practice, adequate reduction of IOP remains the keystone of managing patients with NTG. We review the pathogenesis of NTG and the available therapies for this optic neuropathy.

BackgroundPrimary congenital glaucoma (PCG), occurs due to the developmental defects in the trabecular meshwork and anterior chamber angle in children. PCG exhibits genetic heterogeneity and the CYP1B1 gene has been widely implicated worldwide. Despite the diverse mutation spectra, the clinical implications of these mutations are yet unclear. The present study attempted to delineate the clinical profile of PCG in the background of CYP1B1 mutations from a large cohort of 901 subjects from India (n=601) and Brazil (n=300).MethodsGenotype-phenotype correlations was undertaken on clinically well characterized PCG cases from India (n=301) and Brazil (n=150) to assess the contributions of CYP1B1 mutation on a set of demographic and clinical parameters. The demographic (gender, and history of consanguinity) and quantitative clinical (presenting intraocular pressure [IOP] and corneal diameter [CD]) parameters were considered as binary and continuous variables, respectively, for PCG patients in the background of the overall mutation spectra and also with respect to the prevalent mutations in India (R368H) and Brazil (4340delG). All these variables were fitted in a multivariate logistic regression model using the Akaike Information Criterion (AIC) to estimate the adjusted odds ratio (OR) using the R software (version 2.14.1).ResultsThe overall mutation spectrum were similar across the Indian and Brazilian PCG cases, despite significantly higher number of homozygous mutations in the former (p=0.024) and compound heterozygous mutations in the later (p=0.012). A wide allelic heterogeneity was observed and only 6 mutations were infrequently shared between these two populations. The adjusted ORs for the binary (demographic) and continuous (clinical) variables did not indicate any susceptibility to the observed mutations (p>0.05).ConclusionsThe present study demonstrated a lack of genotype-phenotype correlation of the demographic and clinical traits to CYP1B1 mutations in PCG at presentation. However, the susceptibility of these mutations to the long-term progression of these traits are yet to be deciphered.

Objetivo: Comparar a densidade vascular peripapilar e macular superficial (pDV e mDVsup) medida pela angiotomografia de coerência óptica (Angio-TCO) de olhos com atrofia em banda (AB) do nervo óptico e defeito de campo visual (CV) temporal por compressão quiasmática com controles e avaliar a performance diagnóstica da Angio- TCO. Verificar a relação da densidade vascular (DV) com parâmetros da tomografia de coerência óptica (TCO) e do CV. Métodos: Trinta e três olhos de 26 pacientes com AB do nervo óptico e 42 olhos de 22 controles foram avaliados. Medidas da DV média e setorial da região peripapilar e macular superficial foram obtidas com a Angio-TCO. Foram também realizados o exame de TCO com medidas da espessura da camada de fibras nervosas da retina peripapilar (pCFNR) e do complexo de células ganglionares da retina macular (mCxCG) e os exames de CV 24-2 e 10-2. Resultados: Em comparação ao grupo controle, a pDV e a mDVsup dos olhos com AB do nervo óptico mostrou-se reduzida em seus valores médios (p < 0,001, AROC=0,91 para ambos) e em medidas setoriais, especialmente na média dos setores peripapilar nasal e temporal (p < 0,001, AROC=0,96) e no quadrante nasal inferior da mácula (p < 0,001, AROC 0,93). Os valores de DV demonstraram significativa correlação (p < 0,001) com as medidas da pCFNR (r entre 0,67 e 0,78), mCxCG (r entre 0,56 e 0,76) e da perda de CV (r entre 0,45 e 0,68) nas áreas afetadas pela doença. Conclusão: A pDV e a mDVsup em olhos com AB do nervo óptico encontram-se reduzidas em comparação a controles e apresentam forte correlação com medidas de perda neural e defeitos de CV. Esses achados podem indicar que redução da DV medida pela Angio-TCO poderia ocorrer de forma secundária à perda neural em neuropatias compressivas e, no futuro, contribuir no acompanhamento dessas patologias Purpose: To compare the circumpapillary and superficial macular vessel density (cpVD and mVDsup) of eyes with temporal visual field (VF) defect and band atrophy (BA) of the optic nerve and normal controls using optical coherence tomography angiography (OCTA) and to verify the association of vessel density parameters with retinal neural loss assessed by conventional optical coherence tomography (OCT) and VF loss. Methods: Thirty-three eyes of 26 patients with BA and 42 eyes of 22 age-matched normal controls underwent OCT + OCTA scanning. cpVD and circumpapillary retinal nerve fiber layer (cpRNFL) thickness were expressed as average and sector measurements. mVDsup and macular ganglion cell complex (mGCC) thickness were calculated as averages and in quadrants and hemiretinas. VF loss was estimated using the 24-2 and the 10-2 protocols. Results: Compared with controls, BA eyes displayed smaller average cpVD and mVDsup values (p < 0.001 and AROC = 0.91 for both). Sectorial measurements were also reduced, especially the nasotemporal sector average cpVD (p < 0.001 and AROC = 0.96) and the nasal inferior retina mVDsup measurements (p < 0.001 and AROC = 0.93). cpVD and mVDsup correlated strongly (p < 0,001) with corresponding cpRNFL and mGCC thickness measurements in affected regions (r range: 0.670.78 and 0.560.76, respectively). Similarly, cpVD and mVDsup parameters correlated significantly with corresponding VF loss (r range: 0.450.68). Conclusion: cpVD and mVDsup are significantly reduced in BA eyes compared with controls and are strongly correlated with retinal neural and VF loss. cpVD and mVDsup reduction on OCTA could serve as a surrogate for retinal neural loss in compressive optic neuropathy and might be useful in its management

Introdução: O implante de lente intraocular (LIO) na cirurgia de catarata pediátrica é recente e, apesar de ser progressivamente mais realizado, há ainda controvérsias em relação à técnica cirúrgica empregada e em relação ao momento ideal para se implantar a LIO. Existem evidências na literatura de que a idade ideal para realizar o implante primário seja após os dois anos de idade e para o implante secundário após os três anos de idade. Contudo, são poucas as publicações de implante de LIO em crianças antes dessa faixa etária, o que pode enviesar as conclusões. Existem também novas plataformas de LIOs que ainda não foram avaliadas em crianças. Objetivos: Avaliar os resultados de implante de LIO em crianças submetidas a cirurgia de catarata. Métodos: Os principais desfechos avaliados foram complicações pós-operatórias, cirurgias adicionais e mudança refracional. Foram realizados três estudos retrospectivos e um estudo prospectivo. No primeiro estudo retrospectivo, comparou-se duas técnicas cirúrgicas de capsulotomia posterior (via corneal e via pars plana) com vitrectomia anterior no implante primário de LIO no saco capsular em 46 crianças (56 olhos) entre três meses e nove anos de idade. No segundo estudo retrospectivo, avaliou-se o implante primário de LIO no saco capsular em 68 crianças (93 olhos) entre cinco e 24 meses de idade. No terceiro estudo retrospectivo, foi avaliado o implante secundário de LIO no sulco ciliar em 50 crianças (75 olhos) entre 11 e 30 meses de vida. Prospectivamente, no quarto estudo, comparouse duas LIOs acrílicas, uma hidrofóbica (AcrySof SA60AT) e outra hidrofílica (Akreos Adapt AO) com bordas quadradas implantadas em 17 crianças (26 olhos) entre cinco e 12 anos. Resultados: No primeiro estudo houve mais complicações na modalidade cirúrgica via corneal (p

Introdução: Glaucoma é uma neuropatia óptica caracterizada por afinamento progressivo da rima neurorretiniana, aumento da escavação e perda da camada de fibras nervosas da retina, acompanhada ou não de perdas funcionais. Estadiar a gravidade da lesão glaucomatosa é essencial para o correto manejo médico da doença, e também para fornecer informações prognósticas. Diversos sistemas de classificação de gravidade de campos visuais (CV) foram propostos no passado, mas nenhum ainda obteve ampla aceitação devido a necessidade de cálculos matemáticos complexos; demorados procedimentos de análise do sistema; e interpretação subjetiva. Objetivos: O objetivo desta tese é avaliar o software Glaucoma Staging Application (GSA), desenvolvido para classificação automatizada da gravidade de defeitos glaucomatosos de CV quanto à: 1. Sua capacidade de classificar defeitos glaucomatosos de CV; 2. Sua reprodutibilidade; 3. Ao tempo gasto pelo software para classificação dos exames de campo visual e o tempo gasto por um oftalmologista experiente. Métodos: O GSA foi criado baseado na classificação Modified University of Sao Paulo Glaucoma Visual Field Staging System (mUSP-GVFSS). Este sistema consiste em três seções separadas por barras no seguinte formato: A/B/C. A seção \"A\" mostra a gravidade baseada no visual field index (VFI); \"B\" define a localização do defeito; \"C\" retrata a extensão topográfica da lesão. Para sua validação, foram analisados 612 CVs de 32 pacientes, sendo um olho para cada paciente. Os pacientes foram escolhidos aleatoriamente pelo software e os exames selecionados refletem apresentações comuns de defeitos de CV na prática clínica. Os CVs foram inicialmente analisados e classificados por um especialista em glaucoma e posteriormente comparados com os resultados da classificação dada pelo software. Para avaliar a reprodutibilidade, os mesmo critérios de pesquisa foram repetidos uma semana depois usando o mesmo GSA. A classificação dada pelo software foi considerada correta ou acurada se ela concordava completamente em todas variáveis (gravidade, localização e extensão topográfica da lesão) e em todos os casos com a classificação realizada manualmente pelo especialista em glaucoma. Também foi avaliado e comparado o tempo despendido para classificação de todos os exames de CV pelo GSA e pelo oftalmologista. Resultados: Cento e setenta e oito CV foram classificados como defeito inicial de campo visual, 148 como moderados e 156 como severos. Centro e trinta campos visuais foram classificados como normais. Quando repetidos uma semana depois para avaliar a reprodutibilidade a classificação automatizada dada pelo GSA mostrou concordância com a classificação feita pelo especialista em 100% dos casos. O oftalmologista precisou de cinco horas para avaliar e classificar todos os 612 exames manualmente. O GSA despendeu 16 minutos para avaliar os 612 CVs. Conclusão: O GSA permite uma classificação rápida, automática, reprodutível, objetiva e acurada do CV 24-2 realizada em campímetros Humphrey da série \"i\". Desta forma este software poderá se tornar uma ferramenta útil para analisar e estadiar CV objetivamente e de forma mais rápida que a avaliação manual Introduction: Glaucoma is an optic neuropathy characterized by progressive thinning of the neuroretinal rim, increased cupping of the optic disc head and loss of retinal nerve fiber layer, whether or not accompanied by functional loss. Staging the severity of the glaucomatous lesion is essential for the correct medical management of the disease, as well as for providing prognostic information. Several visual fields (VF) staging systems have been proposed in the past, but none has yet gained wide acceptance due to the need for complex mathematical calculations; lengthy system analysis procedures; and subjective interpretation. Objectives: The objective of this thesis is to evaluate the software Glaucoma Staging Application (GSA), developed for automated classification of the severity of glaucomatous VF defects regarding: 1. It\'s ability to classify glaucomatous VF defects; 2. Its reproducibility; 3. The time spent by the software for the classification of VF exams and the time spent by an experienced ophthalmologist. Methods: The GSA is based upon the Modified University of Sao Paulo Glaucoma Visual Field Staging System (mUSP-GVFSS) classification. It consists of 3 sections in the following format: A/B/C. Section \"A\" shows the severity based on the visual field index (VFI); \"B\" defines the defect location based on eccentricity; \"C\" portrays the extent of topographic damage by hemifields. We analyzed 612 VF of 32 patients, one eye for each patient. Patients were randomly selected by the software and their exams reflect common presentations of VF defects in clinical practice. VFs were analyzed by a glaucoma expert and then compared with the output of the GSA. To evaluate the repeatability, the same search criteria were repeated 1 week later using the same GSA. The classification given by the software was considered correct or accurate if it completely agreed in all variables (severity, location and extent of topographic damage) and in all cases with the classification performed manually by the glaucoma expert. We also evaluated and compared the time spent to classify all VF exams by the GSA and the ophthalmologist. Results: One hundred seventy-eight eyes were classified as early VF damage, 148 moderate, and 156 severe. One hundred and thirty VF were classified as normal. When repeated, 1 week later, the GSA showed excellent repeatability. The automated classification agreed with the expert\'s grading in 100% of cases. The ophthalmologist spent five hours to evaluate and classify all 612 exams manually whereas the GSA needed 16 minutes to evaluate the same 612 VF. Conclusions: The GSA allows an automated, fast, reproducible, objective and accurate classification system for multiple 24-2 VFs of Humphrey perimetry. This study is a proof-of-concept that could translate into a useful tool to analyze and stage VFs more objectively and faster than manual evaluation

OBJETIVO: avaliar a reprodutibilidade da curva tensional modificada e do teste de sobrecarga hídrica em portadores de glaucoma de ângulo aberto ou hipertensos oculares, sem uso de hipotensor ocular, em dois dias consecutivos. MÉTODOS: análise prospectiva de pacientes portadores de glaucoma de ângulo aberto ou hipertensos oculares, submetidos à curva tensional modificada (medida da pressão intraocular às 8h, 11h, 14h e 16h), seguida do teste de sobrecarga hídrica (três medidas com intervalo de 15 minutos, iniciando-se 15 minutos após a ingestão, em cinco minutos, de um litro de água em temperatura ambiente), realizados pelo mesmo examinador, em dois dias consecutivos. Foram avaliadas: a reprodutibilidade da pressão intraocular em cada horário de medida durante a curva tensional modificada; a reprodutibilidade da pressão intraocular média, flutuação e pico de pressão durante a curva tensional modificada; a reprodutibilidade da flutuação e do pico de pressão durante o teste de sobrecarga hídrica. Calculou-se o coeficiente de correlação intraclasse para cada parâmetro. RESULTADOS: oitenta e oito olhos de 88 pacientes foram estudados. Destes, 64 eram portadores de glaucoma de ângulo aberto. A média das idades dos participantes foi 68,7+10,8 (51-79) anos. 65% dos pacientes eram do sexo feminino. A curva tensional modificada apresentou coeficiente de correlação intraclasse igual a 0,80, 0,82, 0,83 e 0,86 para as medidas realizadas às 8h, 11h, 14h e 16h, respectivamente (p < 0,001). A flutuação da pressão durante a curva tensional modificada, calculada pela diferença entre as pressões máxima e mínima e pelo desvio-padrão da média das medidas diurnas de pressão, a pressão média e o pico pressórico apresentaram coeficientes 0,60, 0,62, 0,91 e 0,85, respectivamente (p < 0,001). Durante o teste de sobrecarga hídrica, a flutuação apresentou coeficiente de 0,37 e o pico pressórico, 0,79. (p < 0,001). CONCLUSÕES: neste estudo, as medidas de pressão intraocular realizadas durante a curva tensional modificada, a média e o pico apresentaram excelentes níveis de reprodutibilidade. O pico pressórico durante o teste de sobrecarga hídrica apresentou também excelente reprodutibilidade. A flutuação, tanto na curva tensional modificada, quanto no teste de sobrecarga hídrica, apresentou os menores índices de reprodutibilidade OBJECTIVE: to evaluate the reproducibility of the modified daily tension curve and the water drinking test in patients with open-angle glaucoma or ocular hypertension, not under topical treatment, during two consecutive days. METHODS: prospective analysis of open-angle glaucoma or ocular hypertensive patients, submitted to a modified daily tension curve (intraocular pressure measurements at 8AM, 11AM, 2PM and 4PM), followed by the water drinking test (three intraocular pressure measurements with 15 minutes intervals, 15 minutes after ingestion of one liter of tap water), performed by the same examiner, within two consecutive days. The following parameters were evaluated for reproducibility: intraocular pressure obtained at each time-point during the modified daily tension curve; mean, peak and pressure fluctuation during the curve and peak and fluctuation during the water drinking test. Reproducibility was assessed using the intraclass correlation coefficient. RESULTS: eighty-eight eyes from 88 patients were studied. From these, 64 presented open-angle glaucoma. Mean age was 68.7+10.8 (51-79) years. 65% patients were female. Intraclass correlation coefficients were 0.80, 0.82, 0.83 and 0.86 for intraocular pressure measurements at 8AM, 11AM, 2PM and 4PM, respectively (p

Objetivos: Analisar o potencial da oftalmoscopia confocal de varredura a laser, através do Heidelberg Retina Tomograph (HRT), para predizer o risco de progressão em pacientes com suspeita de glaucoma. Comparar os resultados obtidos com o índice de probabilidade de glaucoma (GPS) do HRT aos resultados da análise de regressão de Moorfields (ARM), dos parâmetros morfométricos e da avaliação das fotografias estereoscópicas. Métodos: Uma coorte foi selecionada com 223 pacientes com suspeita de glaucoma, que foram seguidos por um período médio de 64,9 ± 37,3 meses. A suspeita de glaucoma baseou-se na aparência do disco óptico e/ou na pressão intraocular elevada (> 21 mmHg). Todos os participantes apresentavam dois exames de campo visual normais ao entrar no estudo. Conceituou-se progressão como o desenvolvimento de um defeito confirmado de campo visual ou deterioração do disco óptico na avaliação seriada das estereofotografias. A associação entre os resultados do HRT na época do início do acompanhamento e a progressão para glaucoma foi investigada através de modelos de regressão do tipo Cox. Usou-se o C-index para a comparação entre os modelos com os diversos parâmetros do HRT, isolados ou ajustados para os outros já conhecidos fatores de risco para progressão (idade, espessura corneana, pressão intraocular e pattern standard deviation PSD). Resultados: No período do estudo, 46 pacientes (21%) apresentaram progressão. Na análise multivariada, o GPS, a ARM e diversos parâmetros morfométricos foram preditivos para progressão, assim como a avaliação subjetiva das estereofotografias. Cada GPS 0,1 maior foi associado com um aumento de 23% no risco de progressão (C-index de 0,69). Os resultados anormais nas classificações finais do GPS e da ARM foram associados a aumentos de 3 e 2 vezes no risco de progressão, respectivamente (C-indexes de 0,70 e 0,68, respectivamente). O parâmetro com o melhor C-index foi a área seccional tranversa da camada de fibras nervosas (0,72). Uma área 0,3 mm2 menor foi associada a um risco 62% maior de progressão. A comparação do valor preditivo entre os modelos com o GPS e com a avaliação subjetiva das estereofotografias foi similar (C-indexes de 0,69 e 0,68, respectivamente). Conclusão: Nesse estudo observamos que as análises objetivas do disco óptico e da região peripapilar obtidas com o HRT contribuíram na avaliação do risco de progressão em pacientes com suspeita de glaucoma. O GPS mostrou-se tão eficaz quanto os parâmetros morfométricos e a análise de regressão de Moorfields, e a comparação do desempenho dos modelos contendo a avaliação subjetiva das estereofotografias e aqueles contendo a avaliação objetiva pelo GPS não mostrou diferenças significativas Purpose: To evaluate the ability of baseline confocal scanning laser ophthalmoscopy, using the Heidelberg Retina Tomograph (HRT), in predicting the development of progression in patients suspected of having glaucoma. In addition, the study also aimed to compare the predictive abilities of the glaucoma probability score (GPS) with those of the Moorfields regression analysis (MRA) and stereometric parameters, and to compare the performance of the HRT with that of subjective evaluation of optic disc stereophotographs. Methods: This longitudinal study included a cohort of 223 eyes suspected of having glaucoma, which were followed for an average of 64.9 ± 37.3 months. Included suspects had a suspicious appearance of the optic disc and/or elevated intraocular pressure, but normal visual fields. Progression was defined as the development of either repeatable abnormal visual fields or glaucomatous structural deterioration in the appearance of the optic disc during the study period. The association between baseline HRT parameters and progression was investigated by Cox regression models. The comparison between models with HRT parameters, individually or combined with other known risk factors (age, central corneal thickness, pattern standard deviation and intraocular pressure), performed by comparing their C-indexes. Results: Forty-six (21%) eyes converted during the study period. In multivariable models, the GPS, the MRA, and the stereometric parameters were all predictive of progression. A GPS 0.1 larger was associated with an increase of 23% in the risk of progression (C-index of 0.69). Abnormal final classifications for the GPS or the MRA were associated with a three-fold and two-fold increase in the risk of progression, respectively (with C-indexes of 0.70 and 0.68, respectively). The parameter with the best C-index was the nerve fiber layer cross-sectional area (0.72). An area 0.3 mm2 smaller was associated with a 62% higher risk of an individual progress. The comparison between models with the HRT parameters and those with the subjective stereophotograph evaluation had similar results (C-indexes of 0.69 and 0.68, respectively). Conclusion: In this study, we were able to show that the objective structural assessment of the optic disc and peripapillary area obtained with the HRT was significantly predictive for progression in suspected individuals. The GPS was as predictive as the other HRT parameters, and no significant differences were observed between models with the GPS and those with the subjective assessment of the stereophotographs.

O objetivo desse estudo foi comparar a habilidade da avaliação subjetiva do disco óptico e da camada de fibras nervosas (CFN) por oftalmologistas generalistas e por um glaucomatólogo com medidas objetivas pela tomografia de coerência óptica (Stratus OCT), oftalmoscopia confocal de varredura a laser (HRTIII), e a polarimetria de varredura a laser (GDxECC) para discriminar olhos glaucomatosos de olhos normais. 61 olhos glaucomatosos e 57 olhos normais de 118 indivíduos foram incluídos nesse estudo. Três oftalmologistas generalistas independentes e um glaucomatólogo avaliaram fotografias estereoscópicas do disco óptico. Curvas ROC (Receiver Operator Characteristic) foram construídas para cada técnica de imagem e a sensibilidade a uma especificidade fixa foi determinada. Comparações das áreas sob essas curvas (AROC) e a concordância (k) foram determinadas entre a graduação das fotografias estereoscópicas e o melhor parâmetro de cada exame de imagem computadorizado. O melhor parâmetro de cada técnica de imagem computadorizada (CFN temporal inferior do Stratus OCT = 0,92; área integrada vertical da topografia do disco óptico pelo Stratus OCT = 0,86; espessura macular do setor inferior externo fornecido pelo Stratus OCT = 0,82; NFI do GDxECC = 0,91; razão área E/D do HRT3 = 0,83) mostrou AROC maior do que a graduação das fotografias estereoscópicas por oftalmologistas generalistas (0,80) para separar olhos glaucomatosos de olhos normais. A graduação por glaucomatólogo forneceu AROC igual ou maior (0,92) do que o melhor parâmetro de exame computadorizado de imagem. A avaliação das fotografias estereoscópicas por glaucomatólogo mostrou melhor concordância com o melhor parâmetro de cada técnica de imagem quantitativa na classificação de olhos como glaucomatosos ou normais comparadas à avaliação de fotografias estereoscópicas por oftalmologistas generalistas. A combinação da avaliação subjetiva do disco óptico por oftalmologistas generalistas com parâmetros objetivos da CFN melhorou a identificação de olhos com glaucoma em uma proporção maior do que a combinação desses parâmetros objetivos com a avaliação do disco óptico por um glaucomatólogo (29,5% versus 19,7%, respectivamente). Os resultados sugerem que a habilidade diagnóstica de todos os exames de imagem computadorizados estudados mostrou melhor desempenho que a avaliação subjetiva do disco óptico por oftalmologistas generalistas, mas não por um glaucomatólogo. Medidas objetivas da CFN podem permitir um aperfeiçoamento na detecção de glaucoma quando combinados com a avaliação subjetiva do disco óptico por oftalmologistas generalistas ou por um glaucomatólogo. The purpose of this study was to compare the ability of subjective assessment of optic nerve head and retinal nerve fiber layer by general ophthalmologists and by a glaucoma expert with objective measurements by optical coherence tomography (Stratus OCT, Carl Zeiss Meditec, Inc.), confocal scanning laser ophthalmoscope (HRT III; Heidelberg Engineering, Heidelberg, Germany), and scanning laser polarimetry (GDx ECC; Carl Zeiss Meditec, Inc., Dublin, CA) in discriminating glaucomatous and normal eyes. 61 glaucomatous and 57 normal eyes of 118 subjects were included in the study. Three independent general ophthalmologists and one glaucoma expert evaluated ONH stereophotographs. Receiver operating characteristic curves were constructed for each imaging technique and sensitivity at fixed specificity was estimated. Comparisons of areas under these curves (aROC) and agreement (k) were determined between stereophoto grading and best parameter from each technique. Best parameter from each technique showed larger aROC (StratusOCT RNFL = 0.92; StratusOCT ONH vertical integrated area = 0.86; StratusOCT macular thickness = 0.82; GDxECC = 0.91; HRT3 global cup-to-disc area ratio = 0.83) compared to stereophotograph grading by general ophthalmologists (0.80) in separating glaucomatous and normal eyes. Glaucoma expert stereophoto grading provided equal or larger aROC (0.92) than best parameter of each computerized imaging device. Stereophoto evaluated by a glaucoma expert showed better agreement with best parameter of each quantitative imaging technique in classifying eyes either as glaucomatous or normal compared to stereophoto grading by general ophthalmologists. The combination of subjective assessment of the optic disc by general ophthalmologists with RNFL objective parameters improved identification of glaucoma patients in a larger proportion than the combination of these objective parameters with subjective assessment of the optic disc by a glaucoma expert (29.5% versus 19.7%, respectively). The results suggests that the diagnostic ability of all imaging techniques showed better performance than subjective assessment of the ONH by general ophthalmologists, but not by a glaucoma expert. Objective RNFL measurements may provide improvement in glaucoma detection when combined with subjective assessment of the optic disc by general ophthalmologists or by a glaucoma expert.