Aplicações clínicas do princípio de Scheimpflug na Oftalmologia / Clinical applications of the Scheimpflug principle in Ophthalmology

RESUMO Este artigo apresenta uma revisão dos princípios e das aplicações clínicas do princípio de Scheimpflug na área da imagiologia do segmento anterior. Ao disponibilizar uma imagem tridimensional do segmento anterior, esta tecnologia permite a caraterização da elevação e curvatura das superfícies anterior e posterior da córnea, o mapeamento paquimétrico, o cálculo do poder refrativo total da córnea e a biometria do segmento anterior. Na subespecialidade de cirurgia refrativa, esta abordagem melhora a capacidade de identificação de casos com risco de desenvolver ectasia, bem como de planeamento e de avaliação dos resultados dos procedimentos cirúrgicos. Recentemente, esta tecnologia foi introduzida na avaliação biomecânica in vivo da córnea e na cirurgia de catarata assistida por laser de femtossegundo.

ABSTRACT This article presents a review of the principles and clinical applications of the Scheimpflug principle in the anterior segment imaging. By providing a three-dimensional image of the anterior segment, this technology provides elevation and curvature data of the anterior and posterior surfaces of the cornea, pachymetric mapping, the total refractive power of the cornea and the anterior segment biometry. For the refractive surgery sub-specialty, this approach improves the ability to identify cases at risk of ectasia, as well as the planning and evaluation of the results of surgical procedures. Recently, this technology was introduced in corneal biomechanical in vivo evaluations and in femtosecond laser-assisted cataract surgery.

Simulated cup/disc ratio: a tool for ophthalmologists / Razão escavação/disco simulada: uma ferramenta para oftalmologistas

PURPOSE: To evaluate and compare the observers' ability to measure simulations of cup/disc ratios (CDR) as concentric and non-concentric circles. METHODS: In a prospective, random, and masked setting, 43 images representing the CDR spectrum from 0.2 to 0.9 for vertical and horizontal CDR measurements were developed and presented on a computer screen to 171 participants. RESULTS: There were satisfactory agreements according to the kappa coefficient (0.755 and 0.730 for horizontal and vertical cup disc ratios, respectively) and Lin's concordance correlation (R=0.88 and R=0.86 for horizontal and vertical measurements, respectively). However, very poor agreement was found for intermediate CDR values. The worst agreement occurred when the CDR was between 0.4 and 0.6 for both the horizontal and vertical values. The kappa coefficient was 0.37 and 0.39 for 0.4 CDR (horizontal and vertical, respectively), 0.39 and 0.38 for 0.5 CDR (horizontal and vertical, respectively) and 0.45 and 0.41 for 0.6 CDR (horizontal and vertical, respectively). CONCLUSION: Despite a good general agreement between the gold standard and the participants' responses, the absolute agreement for intermediate CDR values was very poor for both horizontal and vertical values.

OBJETIVO: Avaliar e comparar a habilidade de observadores em medir a razão escavação/disco (CDR) por meio de figuras esquemáticas. MÉTODOS: Em um estudo prospectivo, randomizado e mascarado, 43 imagens representado CDR horizontais e verticais entre 0,2 e 0,9 foram desenvolvidas e apresentadas em uma tela de computador para 171 participantes. RESULTADOS: Para todos os intervalos de CDR a concordância foi satisfatória para análise kappa (0,755 e 0,730 para CDR horizontais e verticais, respectivamente) e para concordância de Lin (R=0,88 e R=0,86 para medidas horizontais e verticais respectivamente). No entanto, a concordância foi fraca para valores intermediários de CDR. A pior concordância ocorreu para CDR horizontais e verticais entre 0,4 e 0,6. CONCLUSÃO: Apesar da boa concordância geral entre as respostas corretas e as respostas dadas pelos participantes, a concordância absoluta para valores intermediários de CDR mostrou-se muito fraca tanto para figuras horizontais como verticais.

Valores da exoftalmometria média na população adulta da região do Grande ABC, São Paulo/Brasil / Normal exophthalmometric values in adult population of ABC Region, Sao Paulo/Brazil

OBJETIVO: Estabelecer padrões de normalidade dos valores da exoftalmometria de ambos os olhos e da distância entre os rebordos orbitários laterais (base) em adultos jovens da população do Grande ABC São Paulo/Brasil. MÉTODOS: Realizou-se a exoftalmometria com o exoftalmômetro de Hertel, em 129 pacientes do sexo feminino e 75 do sexo masculino, na faixa etária de 25 a 55 anos. Os pacientes foram separados em três grupos raciais (brancos, negros e pardos). RESULTADOS: A variação da exoftalmometria encontrada na população em estudo foi de 10 a 23mm, média de 15,57 ±2,43mm. No sexo feminino a média foi de 15,42 ±2,40mm e no masculino, 15,83 ±2,47mm. Não se encontrou uma relação estatisticamente significativa entre os sexos feminino e masculino (p=0,25). Na raça branca a média foi de 15,57 ±2,46mm, na negra foi de 16,20 ±2,70mm e na parda foi de 15,02 ±2,01mm. A diferença foi estatisticamente significativa (p=0,008) entre as raças negra e parda. A medida da base variou de 104 a 125mm (média de 113,91 ±4,37mm). A diferença entre homens e mulheres foi estatisticamente significativa (p<0,001). Na raça branca a média da base encontrada foi de 112,18 ±4,02mm, na negra foi de 115,37 ±4,71mm e na parda, 115,18 ±3,66mm. A diferença da média da base foi estatisticamente significativa (p<0,001) entre as raças branca e negra e branca e parda. Nenhum paciente apresentou assimetria entre os dois olhos maior que 2mm. CONCLUSÃO: O padrão de normalidade da exoftalmometria encontrado para a população em estudo foi de 10 a 23mm e a base variou de 104 a 125mm.

PURPOSE: To determine the normal exophthalmometry of both eyes and of the distance between lateral orbital rims (the base measurement) in young adults from ABC Region, São Paulo/Brazil. METHODS: Exophthalmometry, by Hertel's exophthalmometer, was made in 129 female and 75 male subjects, age ranging from 25 to 55 years. The subjects were divided in three groups of races (white, black and mulatto). RESULTS: The values of exophthalmometry ranged from 10 to 23mm, mean 15,57 ±2,43mm. In female the mean was 15,42 ±2,40mm and in male, 15,83 ±2,47mm. There is no statistically significant difference between female or male (p=0,25). In whites subjects the mean was 15,57 ±2,46mm, in black was 16,20 ±2,70mm and in mulatto was 15,02 ±2,01mm. There was a statistically significant difference between blaks and mulattos (p=0,008). The base measurement ranged from 104 to 125mm (mean 113,91 ±4,37mm). There was a statistically significant difference between males and females (p<0,001). In whites the base was 112,18 ±4,02mm, in blacks 115,37 ±4,71mm and in mulattos, 115,18 ±3,66mm. There was a statistically significant difference for the base measurement between white subjects and black ones, and between white subjects and mulattos (p<0,001). No individual had more than 2mm of assimetry between eyes. CONCLUSION: The normal exophthalmometric value in the studied population was 10 to 23mm and the base measurement ranged from 104 to 125mm.

Responsabilidade social em oftalmologia: interdisciplinaridade e inclusão na visão subnormal / Social responsability in ophthalmology: interdisciplinarity and inclusion in low vision

Há ainda hoje uma importante exclusão das pessoas defi cientes visuais, principalmente das de baixa visão (em especial daqueles com visão corrigida entre 0,3 e 0,05 no melhor olho). É importante que a família, a escola, a sociedade e o/a paciente participem deste processo de inclusão social para proporcionar uma vida próxima da normal para essas pessoas combaixa visão. Deve haver uma interação entre os educadores e o paciente, a família (para apoio psicológico e continuação da reabilitação em casa) e o oftalmologista para otimizar o uso dosequipamentos visuais para as atividades cotidianas do paciente na escola, trabalho, lazer ou em outras situações. É também importante uma interação entre a oftalmologia e profi ssionais de design para fornecer aparelhos de auxílio o mais ergonômicos possíveis para permitir ao paciente com baixa visão uma adaptação adequada à vida cotidiana. Na Universidade de SãoPaulo, o Departamento de Oftalmologia da Faculdade de Medicina iniciou uma colaboração com membros do Departamento de Design da Faculdade de Arquitetura e desenvolveram umequipamento óptico que torna a leitura mais fácil e confortável para os pacientes com baixa visão acima citados...

There is still today an important exclusion of the visually impaired people, mainly the low vision ones (particularly people with corrected vision between 0,3 and 0,05 in the better eye). It is important that the family, the school, the society and the patient him/herself participatein this process of social inclusion to provide a near normal life for these low vision people. There must be an interaction between the educators and the patient, the family (for psychologicalsupport and continuing the home rehabilitation) and the ophthalmologist for optimizing the use of visual devices for the patient´s daily activities at school, work, leisure or whatsoever. It is also important an interaction between the ophthalmology and design professionals for providing themost ergonomic as possible devices to permit the low vision patient an adequate adaptation to the everyday life. In the University of São Paulo/Brazil the Ophthalmology Department of the Medical School initiated a collaboration with members of the Design Department of the Architecture School and developed an optical device that can make reading easier and more comfortablefor low vision patients. The method of work was based in the integration of knowledge, in thinking across disciplines as well as in the participative observation of the patients´ needs in their life...

Alternativa quirúrgica que disminuye las recidivas en cirugía de pterigión / Surgical alternative to reduce recurrences after pterygium surgery

ANTECEDENTE: la cirugía de pterigión con autoinjerto conjuntival es una excelente técnica, pero todavía se busca la técnica ideal para disminuir o eliminar las recidivas. OBJETIVO: Determinar el porcentaje de recidivas en cirugía de pterigión en pacientes a quienes además del autoinjerto conjuntival se les aplicó el medicamento mitomicina C. MATERIAL Y MÉTODOS: estudio de casos y controles, la muestra la constituyó 168 pacientes con diagnóstico de pterigión primario, atendidos en el Hospital y Clínica de Ojos “Visión Integral Honduras” en San Pedro Sula, Cortes, en el periodo comprendido de julio del 2004 a enero del 2006, los pacientes se dividieron en 2 grupos escogidos al azar. El Grupo I incluyó 92 pacientes a quienes se les realizó escisión de pterigión y se les colocó autoinjerto conjuntival. El Grupo II incluyó 76 pacientes a quienes se les aplicó mitomicina c además del autoinjerto conjuntival. RESULTADOS: Las recidivas se presentaron en 6 (6.5) de los 92 pacientes a quienes se les realizó solo autoinjerto conjuntival (p=0.004), mientras, en los que además del autoinjerto conjuntival se les aplicó mitomicina se presentó en1 (1.3, p= 0.083). CONCLUSIÓN: Los resultados sugieren que el porcentaje de recidivas es menor en pacientes a quienes además del autoinjerto conjuntival se les aplica el medicamento mitomicina C...

clinical utility of a non-mydriatic retinal camera in a diabetes clinic

we aim to evaluate a non-mydriatic retinal camera as a safe and efficacious screening tool, for diabetic retinopathy, in diabetes centers. 221 consecutive patients attending a Diabetes Center submitted to retinal photographs using a non-mydriatic camera. Patients were included if they had not had previous laser therapy and if they had a formal ophthalmologic consultation within 6 months of the photography Four endocrinologists reviewed the retinal photographs and recommended an interval [urgent referral, early referral, non-referral] for ophthalmologic assessment. Endocrinologists' grades were compared against the gold standard of ophthalmological findings. The endocrinologists were privy only to the patient's age, type and duration of diabetes mellitus. Twenty-seven cases were deemed as requiring early referral by the ophthalmologists. The endocrinologists agreed with ophthalmologist referral times in 27, 26, 23 and 27 cases respectively. Two cases requiring urgent referral according to the ophthalmologists were also judged as requiring urgent referral by all endocrinologists. A mean sensitivity of 95.4% [95% CI 88.5%-100%] was attained. The use of a non-mydriatic camera to determine need for ophthalmologic referral was found to be safe and efficacious, with no serious delays in referral noted. On average this tool can safely defer 53.5% of routine ophthalmologic referrals without any risk to the patient's eyesight

Ophthalmic photography using a digital camera.

PURPOSE: To report the application of a digital camera for ophthalmic photography in routine clinical use. METHODS: A digital camera (Nikon Coolpix 995) was used both for external macrophotography of the eye and ocular adnexa, and slitlamp photography of the anterior segment of the eye. RESULTS: We were able to take external macrophotographs under high magnification of the eye and ocular adnexa. Slitlamp photography could be performed under diffuse, slit beam, and retroillumination. The structures of the angle, the optic disc and surrounding retina could be photographed using appropriate lenses. The attachment to the operating microscope allowed intraoperative photography. It could also be attached to the laboratory microscope to capture images of various histopathology and microbiology slides. CONCLUSIONS: A digital camera is a versatile instrument for ophthalmic photography. It is easy to use in routine clinical practice and provides good quality photographs.

Successful amblyopia therapy by using synoptophore.

BACKGROUND: Amblyopia is the most common cause of monocular visual impairment in children. Even though occlusion therapy is the treatment of choice, the success rate has not been well achieved due to poor compliance. Other alternative treatments have been tried for a better outcome. OBJECTIVE: To report successful therapy for amblyopia using synoptophore. METHOD: A retrospective study of 25 amblyopic children enrolled in the amblyopic treatment program, from September 18, 1996 to October 14, 2002. The program included patching of the good eye, stimulating the amblyopic eye with synoptophore, and recording the visual acuity of both eyes each time. All children were regularly examined every 3 months by the same ophthalmologist. The compliance of each individual was reassessed and adjusted. At the end of the training program, visual acuity of the amblyopic and the good eyes were measured, plus the binocularity of both eyes were recorded as the main outcome measurement. RESULT: Final (best) visual acuities were between 20/20 and 20/30 for 19 cases of 21 cases (90%). Final best binocularity was maintained in 15 of 25 patients (60%), including 4 anisometropic patients (100%), 2 ptosis patients (50%), 4 pseudophakic patients (80%), 2 strabismic patients (40%), and 3 combined group patients (100%) CONCLUSION: By using synoptophore to stimulate the amblyopic eye, while occluding the good eye, it improved the level of vision to a certain acceptable degree. Thus, compliance of the treatment can be well achieved. However, the understanding and good cooperation of the parents were also a must for successful amblyopia therapy.

Semiologia oftalmológica / Ophthalmologic semiology

Iniciando pela anamnese oftalmológica e seguindo com o exame externo do globo ocular, com a avaliaçäo da movimentaçäo ocular e da acuidade visual, concluímos com o exame das estruturas oculares internas do olho com auxílio de instrumentos. Trata-se dos primeiros elementos da propedêutica oftalmológica básica, necessária para o médico näo oftalmologista.

Desenho ótico e mecânico do instrumento oftálmico: lâmpada de fenda / Optical and mechanical drawing of ophthalmic tool: slit lamp

Este trabalho tem por objetivo desenvolver uma linha de pesquisa bastante interessante dentro da área de Instrumentação Ótica, a parte da Ótica Técnica denominada de Desenho Ótico integrada à área de Oftalmologia, cujo o intuito é desenvolver um instrumento oftálmico muito utilizado na área oftálmica: a Lâmpada de Fenda. A Lâmpada de Fenda é um instrumento ótico bastante utilizado pelos oftalmologistas para a realização de exames da visão.

This work has been developed in an interesting line of research within the Optical Instrumentation area named Optical Design, associated to the Ophthalmology area, with the purpose of designing a widely used ophthalmic instrument: the Slit Lamp. The Slit Lamp is an optical instrument widely used by ophthalmologists for eye examination.

An outbreak of post-operative endophthalmitis in Lampang Hospital.

An outbreak of post-operative endophthalmitis involving 48 patients from October 1991 to October 1992 in Lampang Hospital was reported. There were 3 waves of clustered cases, i.e. from October 1991 to January 1992, April-June 1992, and August-October 1992. Investigation revealed several risk factors: defects in sterilization of surgical instruments, poor operating room hygiene, contaminated tap water and the use of multiple-dose fluids and medication. Bacteria isolated from vitreous fluid showed different bacteria, indicating multiple sources of infection or failure of asepsis. Each episode of infection was brought under control by removing the risk factors and emphasis on aseptic techniques. The value of an effective survey programme for the detection of post-operative endophthatmitis was emphasized.