Suspeitos de glaucoma encaminhados do oftalmologista geral para um centro terciário no Brasil : resultados da avaliação do especialista em glaucoma

Purpose: To characterize patients with suspected glaucoma who were referred to the clinic for suspected glaucoma in a tertiary public hospital in southern Brazil and to evaluate differences in functional and structural damages between patients diagnosed with different types of glaucoma, those with normal eye examination results, and those who remained as glaucoma suspects. Methods: This is a cohort study of patients referred by general ophthalmologists to the clinic for suspected glaucoma at Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil, between March 2016 and December 2018. The patients were followed up until they had undergone reliable examinations (eye examination, visual field screening, and optic coherence tomography for classification as normal and having a suspected glaucoma, glaucoma with an elevated intraocular pressure, normotensive glaucoma, or ocular hypertension. Results: A total of 135 patients were included in this study. Of the patients, 117 subjects completed all examinations and met the inclusion criteria. Most patients were normal (36.8%), followed by those with suspected glaucoma (25.64%), normal tension glaucoma (18.8%), glaucoma with elevated intraocular pressure (12%), and ocular hypertensive (6%). The main reason for referral was increased optic nerve head cupping. The patients with normal tension glaucoma were older than the other subjects on average (p=0.03). In addition, the normal tension glaucoma group had a significantly worse baseline visual field index and mean deviation of the visual field than the normal, glaucoma suspect, and ocular hypertensive groups. The circumpapillary retinal nerve fiber layer on OCT was thinner on average in the normal tension glaucoma group than in the normal and glaucoma suspect groups (p<0.002) but did not significantly differ between the glaucoma group with elevated intraocular pressure and the other groups. Conclusions: Patients with normal tension glaucoma tend to be diagnosed later because of their normal intraocular pressures; thus, the optic nerve cupping must be greater to raise the suspicion of glaucoma. In this study, we found that the patients with normal tension glaucoma had worse disease at the time of diagnosis.Objetivo: Caracterizar a população com suspeita de glaucoma encaminhada a um centro público terciário no sul do Brasil e avaliar diferenças no dano dos parâmetros funcionais e estruturais entre os pacientes diagnosticados com diferentes tipos de glaucoma e aqueles classificados como normais e aqueles mantidos como suspeitos de glaucoma. Métodos: Esta é uma coorte dos pacientes encaminhados para o setor de glaucoma suspeito do Hospital Nossa Senhora da Conceição, Porto Alegre - BR, no período de março de 2016 a dezembro de 2018. Os pacientes foram acompanhados até obterem exames confiáveis (exame oftalmológico completo, campimetria visual, tomografia de coerência óptica) para serem classificados como: normal, glaucoma suspeito, glaucoma com pressão intraocular elevada, glaucoma de pressão normal ou hipertenso ocular. Resultados: Um total de 135 pacientes foram incluídos neste estudo, sendo que destes, 117 pacientes completaram todos os exames e foram incluídos neste estudo. A maioria dos pacientes foi considerada normal (36,8%), seguido por glaucoma suspeito (25,64%), glaucoma de pressão normal (18,8%), glaucoma com pressão intraocular elevada (12%) e hipertensão ocular (6%). A principal razão para encaminhamento foi escavação do nervo óptico aumentada. Pacientes com glaucoma de pressão normal eram em média mais velhos que os demais (p=0,03). Esses também apresentavam índice de campo visual e desvio médio da campimetria visual piores que sujeitos normal, com suspeita de glaucoma e hipertensos oculares, e tinham a camada de fibra nervosa medida pela tomografia de coerência óptica mais fina que normais e suspeitos de glaucoma (p<0,002). Os pacientes com glaucoma de pressão elevada não diferiram significativamente dos outros grupos. Conclusão: Pacientes com glaucoma de pressão normal tendem a ser diagnosticados mais tardiamente devido ao fato da pressão intraocular não estar elevada, logo a escavação do disco óptico deve ser maior para gerar a suspeita de glaucoma. Neste estudo, paciente com glaucoma de pressão normal apresentaram doença mais avançada no momento do diagnóstico em comparação com os outros grupos

Individual macular layer evaluation with spectral domain optical coherence tomography in normal and glaucoma eyes

The neuromuscular junction (NMJ) is a specialized synapse with a complex structural and functional organization. It is a target for a variety of immunological disorders and these diseases usually respond well to immunotherapies. The understanding of the immunological basis of myasthenia gravis, the most common neuromuscular junction disorder, has improved in the recent years. Most patients have antibodies to the acetylcholine receptor (AChR), but around 10% have AChR antibodies that are only identified by novel methods, and up to 5% have muscle-specific kinase antibodies which define a different subgroup of myasthenia. The spectrum of antibodies and their pathophysiological aspects are being elucidated. Even though less common, Lambert Eaton myasthenic syndrome (LEMS) is important to recognize. The abnormality in LEMS is a presynaptic failure to release enough packets of ACh, caused by antibodies to the presynaptic voltage-gated calcium channels. More than half these patients have a small cell carcinoma of lung. Acquired neuromyotonia (NMT) is a condition associated with muscle hyperactivity. Clinical features include muscle stiffness, cramps, myokymia, pseudomyotonia and weakness. The immune mechanisms of acquired NMT relate to loss of voltage-gated potassium channel function. This review will focus on the important recent developments in the immune-mediated disorders of the NMJ

Individual macular layer evaluation with spectral domain optical coherence tomography in normal and glaucomatous eyes

Purpose: To evaluate differences in the thickness of the individual macular layers between early, moderate, and severe glaucomatous eyes and compare them with healthy controls. Patients and Methods: Subjects with glaucoma presenting typical optic nerve head findings, high intraocular pressure with or without visual field (VF) damage and normal controls were included. All participants underwent 24–2 perimetry and spectral-domain OCT. Patients were divided into three groups (early, moderate, and severe) based on the mean deviation of the VF and a healthy control group. The device segmented the layers automatically, and their measurements were plotted using the means of the sectors of the inner (3mm) and outer (6mm) circles of the ETDRS grid. Results: A total of 109 eyes qualified for the study: 14 in the control group and 52, 18 and 25 in the early, moderate and severe groups, respectively. Mean age was 66.13 (SD=12.38). The mean thickness of the circumpapillary retinal nerve fiber layer (RNFL), total macular thickness (TMT), macular RNFL, ganglion cell layer (GCL) and inner plexiform layer (IPL) were significantly different between the 4 groups, with progressive decrease in thickness. Significant overall difference was found for the inner nuclear layer (INL), and the severe glaucoma group presented thicker measurements than controls and early glaucoma. Outer nuclear layer (ONL) was thinner in severe glaucoma group compared with early glaucoma group. Conclusion: Individual macular layer measurement using the inner and outer circles of the ETDRS grid is useful to evaluate different stages of glaucoma. The INL thickening and ONL thinning in advanced glaucoma should be explored in the future studies

Pressão intra-ocular em pré-termos de muito baixo peso de nascimento e sua relação com a idade pós-concepção

Objetivo: medir a pressão intra-ocular (PIO) em pré-termos de muito baixo peso (PMBP) e correlacionar com a idade pós-concepção (IPC). Métodos: Estudo longitudinal incluindo 50 pré-termos. Local: Hospital de Clínicas de Porto Alegre. Período: entre novembro de 2008 e junho de 2010. Pacientes: PMBP definido como idade nascimento ≤ 1.500 g e idade gestacional ≤ 32 semanas. Intervenção: medidas semanais da PIO. Principais desfechos: variação da PIO de acordo com a idade pós-concepção (IPC definida como a idade gestacional ao nascimento mais a idade no momento do exame) nas semanas seguintes ao nascimento pré-termo. Análise estatística: modelos de efeitos mistos foram utilizados para determinar a variação da PIO em relação a IPC. Foram calculados as médias e os percentis 10 e 90 (P10 e P90) para os valores da PIO. Resultados: Cinqüenta PMBP com idade gestacional média de 29,7 ± 1,6 semanas e peso de nascimento de 1.127,7 ± 222,7 gramas foram avaliados. Não houve diferença significativa entre a PIO do olho direito e do olho esquerdo (p=0.177). A média da PIO em toda a coorte, considerando ambos os olhos, foi de 14,9 ± 4,5 mmHg, sendo que 13,5% das medidas isoladas da PIO foram superiores a 20 mmHg. A PIO reduziu em média 0,29 mmHg para cada aumento de uma semana da IPC (p=0.047 IC95%: -0,58 a -0,0035). A PIO média (P10-P90) reduziu de 16,3 mmHg (10,52-22,16) com 26,3 semanas de IPC para 13,1 mmHg (7,28-18,92) com 37,6 semanas de IPC. Conclusões: A PIO média em PMBP foi 14,9 ± 4,5 mmHg e apresentou correlação negativa em relação a idade pós-concepção.Purpose: To measure intraocular pressure (IOP) in very low birth weight preterm infants and correlate it with the postconceptional age (PCA). Methods: Longitudinal study including 50 premature infants. Setting: Hospital de Clinicas de Porto Alegre, Brazil. Patients: Very low birth weight premature infants (defined as birth weight ≤1,500 g and gestational age ≤32 weeks). Intervention: Weekly measurements of the IOP. Main outcomes: The variation of IOP according to the postconceptional age (PCA defined as the gestational age at birth plus the age in weeks at the time of examination) in the weeks following preterm birth. Statistics: Mixed-effects models were used for the statistical analysis to determine IOP variation according to PCA. Means, 10th and 90th percentiles were calculated for IOP values. Results: Fifty preterm infants with a mean gestational age of 29.7 ± 1.6 weeks and mean birth weight of 1,127.7 ± 222.7 grams were evaluated. Mean IOP in the whole cohort considering both eyes was 14.9 ± 4.5 mmHg, and 13.5% of the IOP measurement values were greater than 20 mmHg. The analysis revealed a mean IOP reduction of 0.29 mmHg for each increase of PCA (p=0.047; 95% CI, -0.58 to -0.0035). Mean IOP (P10- P90) decreased from 16.3 mmHg (10.52-22.16) at 26.3 weeks PCA to 13.1 mmHg (7.28- 18.92) at 37.6 weeks PCA. Conclusions: Mean IOP in very low birth weight preterm infants was 14.9 ± 4.5 mmHg and was negatively correlated with PCA