Tumor de hipófise em paciente com hidrocefalia: um desafio diagnóstico / Pituitary tumor in a patient with hydrocephalus: a diagnostic challenge

RESUMO A hidrocefalia é definida como a dilatação ventricular pelo aumento da pressão intraventricular e intracraniana quando não tratada ou por insucesso do tratamento. Muitas vezes, leva ao dano das vias ópticas, podendo causar atrofia óptica, devido à proximidade dessas vias com o ventrículo lateral quando ocorre a dilatação. Assim como a hidrocefalia pode levar à atrofia óptica, outras patologias também podem. Tumores hipofisários compartilham desse mesmo sinal, além de causar hemianospsia bitemporal quando o tumor comprime quiasma óptico. Ademais, a hemianopsia bitemporal é o distúrbio visual mais comum encontrado em pacientes com tumor de hipófise. Os tumores de hipófise, por exemplo, geram manifestações clínicas que podem estar relacionadas à disfunção da glândula ou aos efeitos mecânicos da expansão tumoral. Sinais e sintomas visuais estão mais ligados ao efeito mecânico do tumor. Assim, muitas vezes, o paciente procura o oftalmologista antes do endocrinologista. Neste caso, analisaremos uma paciente portadora de hidrocefalia que apresentava, concomitantemente, um tumor hipofisário, e a investigação oftalmológica fez toda a diferença no tratamento da paciente.

ABSTRACT Hydrocephalus is defined as ventricular dilation caused by increased intraventricular and intracranial pressure when untreated or due to treatment failure. Optical pathways can often cause optic atrophy due to the proximity to the lateral hazard when dilation occurs. Hydrocephalus can lead to optic atrophy, as well as other pathologies. Pituitary tumors share this same sign, in addition to causing bitemporal hemianopia when it compresses the optic chiasm. In addition, bitemporal hemianopia is the visual disturbance most commonly found in patients with pituitary tumors. Pituitary tumors, for example, have clinical manifestations that may be related to gland dysfunction, or to mechanisms of tumor expansion. Visual signs and symptoms are more linked to the mechanical effect of the tumor. Therefore, the patient usually seeks the ophthalmologist before the endocrinologist. In this case, we analyzed a patient with hydrocephalus who presented, at the same time, a pituitary tumor, and the ophthalmological investigation made all the difference in the treatment of the patient.

Evaluation of choroidal thickness and retinal nerve fiber layer thickness in patients with unilateral amblyopia: a prospective study / Avaliação da espessura da coroide e da camada de fibras nervosas da retina em pacientes com ambliopia unilateral: um estudo prospectivo

ABSTRACT Purpose: to compare the Subfoveal choroidal thickness (SFCT) and Retinal Nerve Fiber Layer Thickness (RNFL) of amblyopic and normal fellow eyes. Design: Prospective, cross-sectional, observational case series. Methods: Forty patients age 12 to 41 years (mean 23.73 ± 6.42) with unilateral amblyopia were studied. Among them, 11(28.2%) patients had amblyopia secondary to strabismus and 29(71.8 %) had anisometropic amblyopia. Optical coherence tomography (OCT) of the peripapillary RNFL thickness of amblyopic and fellow eyes was performed. RNFL thickness measurements were taken from the superior, inferior, nasal and temporal quadrants in the peripapillary region. Also, subfoveal choroidal thickness (SFCT) was measured using spectral domain optical coherence tomography (SD-OCT). Results: Mean global RNFL thickness of the amblyopic and fellow eyes was 104.48 microns and 102.83 microns, respectively. The difference between the two groups was not statistically significant (p>0.05%). The thicknesses of the superior, inferior, nasal and temporal quadrants of the retinal nerve fiber layer between the amblyopic and normal fellow eyes showed no statistically significant difference (p>0.05%). However, the SFCT of amblyopic eye was 11 or more microns thicker than the fellow eye and this was statistically significant different (p<0.05%). Conclusions: This study demonstrated SFCT in amblyopic eyes was significantly thicker than the normal fellow eyes. The amblyopic process may involve the choroid, but not the prepapillary NFL.

RESUMO Objetivo: comparar a espessura da coroide subfoveal (CSF) e da camada de fibra nervosa retinal (CFNR) de olhos amblíopes e normais. Design: série de casos prospectivos, transversais e observacionais. Métodos: Quarenta pacientes com idade entre 12 e 41 anos (média 23,73 ± 6,42) com ambliopia unilateral foram estudados. Entre eles, 11 (28,2%) pacientes apresentavam ambliopia secundária a estrabismo e 29 (71,8%) apresentavam ambliopia anisometrópica. Foi realizada tomografia de coerência óptica (TCO) da espessura da CFNR peripapilar do olho amblíope e do outro olho. As medidas de espessura da CFNR foram realizadas nos quadrantes superior, inferior, nasal e temporal na região peripapilar. Além disso, a espessura da coroide subfoveal (CSF) foi medida através de tomografia de coerência óptica de domínio espectral (TCO-DE). Resultados: A espessura média global da CFNR do olho amblíope e do outro olho foi de 104,48 mícrons e 102,83 mícrons, respectivamente. A diferença entre os dois grupos não foi estatisticamente significativa (p > 0,05%). As espessuras dos quadrantes superior, inferior, nasal e temporal da camada de fibras nervosas da retina entre o olho amblíope e o normal não apresentaram diferença estatisticamente significativa (p > 0,05%). No entanto, a CSF do olho amblíope foi 11 mícrons mais espessa (ou mais) do que a do outro olho - essa diferença foi estatisticamente significativa (p < 0,05%). Conclusões: Este estudo demonstrou que a CSF dos olhos amblíopes foi significativamente mais espessa do que a dos olhos normais. O processo amblíope pode envolver a coroide, mas ele não envolve a CFNR peripapilar.

The effect of panretinal photocoagulation on confocal laser scanning ophthalmoscopy and stereo photographic parameters of optic disk topography in patients with diabetic retinopathy / Efeito da panfotocoagulação retiniana na oftalmoscopia confocal de varredura a laser e parâmetros da estereofotografia do disco óptico em pacientes com retinopatia diabética

ABSTRACT Purpose: To determine the effect of panretinal photocoagulation on optic disk topographic parameters in non-glaucomatous patients with proliferative diabetic retinopathy. Methods: This was a prospective, single-center, observational study. Thirty-eight eyes of 26 patients with diabetes underwent panretinal photocoagulation for proliferative diabetic retinopathy. Stereoscopic disk photographs and optic nerve head parameters were evaluated using the Zeiss fundus camera and the confocal scanning laser ophthalmoscope (Heidelberg Retinal Tomograph), respectively, at baseline and 12 months after the completion of panretinal photocoagulation. Results: Thirty-eight eyes of 26 patients (15 female) with a mean age of 53.7 (range 26-74) years were recruited. No significant difference was found between the stereo photography determined mean horizontal and vertical cup-to-disk ratio before and after panretinal photocoagulation treatment (p=0.461 and 0.839, respectively). The global values of the optic nerve head parameters analyzed with the HRT3 showed no significant change from baseline to 12 months, including the disk area, cup area, rim area, cup volume, rim volume, cup-to-disk area ratio, linear cup-to-disk ratio, mean cup depth, maximum cup depth, cup shape measure, height variation contour, mean retinal nerve fiber layer thickness, and cross-sectional area. Conclusion: Our results suggest that panretinal photocoagulation does not cause morphological optic disk changes in patients with diabetic proliferative retinopathy after 1 year of follow-up.

RESUMO Objetivo: Determinar o efeito da panfotocoagulação retiniana nos parâmetros topográficos do disco óptico em pacientes não glaucomatosos com retinopatia diabética proliferativa. Métodos: Este é um estudo observacional pros­pectivo e unicêntrico. Trinta e oito olhos de 26 pacientes dia­béticos foram submetidos à panfotocoagulação retiniana para retinopatia diabética proliferativa. As estereofotografias e os parâmetros do disco óptico foram avaliados usando o retinógrafo Visucam da Zeiss e o oftalmoscópio confocal de varredura a laser (Heidelberg Retinal Tomograph), respectivamente, no início e 12 meses após a conclusão da panfotocoagulação. Resultados: Trinta e oito olhos de 26 pacientes (15 mulheres) com média de idade de 53,7 anos (intervalo de 26-74) foram recrutados. Nenhuma diferença significativa foi encontrada entre a média horizontal e vertical para relação escavação/disco óptico determinadas pelas estereo­fotografias antes e após o tratamento com panfotocoagulação retiniana (p=0,461 e 0,839, respectivamente). Os valores globais dos parâmetros do disco óptico analisados com a tomografia de varredura a laser não mostraram nenhuma mudança significativa entre o início até os 12 meses, incluindo disk area, cup area, rim area, cup volume, rim volume, C/D area ratio, linear C/D ratio, mean cup depth, maximum cup depth, cup shape measure, height variation contour, mean retinal nerve fiber layer thickness e cross-sectional area. Conclusão: Nossos resultados sugerem que a panfotocoagulação retiniana não causa alterações morfológicas no disco óptico em pacientes com retinopatia diabética proliferativa após um ano de seguimento.

Optic nerve involvement in ocular toxoplasmosis: 12 year data from a tertiary referral center in Turkey / Acometimento de nervo óptico na toxoplasmose ocular: um relato de 12 anos de um centro de referência terciário na Turquia

ABSTRACT Purpose: To evaluate the prevalence, clinical characteristics, and types of optic nerve involvement in patients with ocular toxoplasmosis. Methods: For this retrospective cross-sectional study, we examined all patients with active ocular toxoplasmosis referred to our Uveitis Section during the last 12 years, and we included patients with optic nerve involvement in the study. The primary outcome was the prevalence of optic nerve involvement, and secondary outcomes included the types of optic nerve involvement and the final best-corrected visual acuity after treatment. Results: The prevalence of optic nerve involvement was 14.4%, with the leading cause being the activation of a juxtapapillary lesion (70.5%). We found papillitis in two eyes and neuroretinitis in two eyes (11.7% for each). We only detected one optic nerve involvement secondary to a distant active lesion (5.8%). Sixteen patients (94.1%) had unilateral ocular toxoplasmosis. The overall final best-corrected visual acuity after treatment was 10/10 (LogMAR = 0.0) excluding the three patients with a juxtapapillary scar involving the macula. Conclusions: Optic nerve involvement was common in patients with ocular toxoplasmosis. The main type of optic nerve involvement was caused by activation of an old juxtapapillary lesion. Treatment was quickly effective, but the best-corrected visual acuity was dependent on the presence of a scar in the papillomacular bundle.

RESUMO Objetivos: Avaliar a prevalência, características clínicas e tipos de acometimento do nervo óptico em pacientes com toxoplasmose ocular. Métodos: Para este estudo retrospectivo transversal, examinamos todos os pacientes com toxoplasmose ocular ativa encaminhados ao nosso Setor de Uveíte nos últimos 12 anos, e incluímos pacientes com comprometimento do nervo óptico no estudo. O resultado primário foi a prevalência do envolvimento do nervo óptico, e os resultados secundários incluíram os tipos de envolvimento do nervo óptico e a acuidade visual final melhor corrigida após o tratamento. Resultados: A prevalência de acometimento do nervo óptico foi 14,4%, sendo a principal causa a ativação de uma lesão justapapilar (70,5%). Encontramos papilite em dois olhos e neuroretinite em dois olhos (11,7% para cada um). Apenas detectamos um comprometimento do nervo óptico secundário a uma lesão ativa distante (5,8%). Dezesseis pacientes (94,1%) apresentavam toxoplasmose ocular unilateral. A acuidade visual final com melhor correção após o tratamento foi 10/10 (LogMAR= 0,0) excluindo os três pacientes com uma cicatriz justapapilar envolvendo a mácula. Conclusões: O comprometimento do nervo óptico foi comum em pacientes com toxoplasmose ocular. O principal tipo de comprometimento do nervo óptico foi causado pela ativação de uma lesão justapapilar antiga. O tratamento foi rapidamente eficaz, mas a acuidade visual final com melhor correção foi dependente da presença de uma cicatriz no feixe papilomacular.

Association between Chagas disease and changes in the optic nerve and retinal nerve fiber layer / Associação entre doença de Chagas e alterações do nervo óptico e camada de fibras nervosas

ABSTRACT Purpose: To test the hypothesis that Chagas disease predisposes to optic nerve and retinal nerve fiber layer alterations. Methods: We conducted a cross-sectional study including 41 patients diagnosed with Chagas disease and 41 controls, paired by sex and age. The patients underwent ophthalmologic examinations, including intraocular pressure measurements, optic nerve and retinal nerve fiber layer screening with retinography, optical coherence tomography, and standard automated perimetry. Results: All of the patients with Chagas disease had a recent cardiologic study; 15 (36.6%) had heart failure, 14 (34.1%) had cardiac form without left ventricular dysfunction, and 12 (29.3%) had indeterminate form. Optic nerve/retinal nerve fiber layer alterations were observed in 24 patients (58.5%) in the Chagas disease group and 7 controls (17.1%) (p£0.01). Among these, optic nerve pallor, optic nerve alterations suggestive of glaucoma, notch, peripapillary hemorrhage, and localized retinal nerve fiber layer defect were detected. Alterations were more prominent in patients with Chagas disease and heart failure (11 patients), although they also occurred in those with Chagas disease without left ventricular dysfunction (7 patients) and those with indeterminate form (6 patients). Optical coherence tomography showed that themean of the average retinal nerve fiber layer thickness measured 89 ± 9.7 mm, and the mean of retinal nerve fiber layer superior and inferior thickness measured 109 ± 17.5 and 113 ± 16.8 mm, respectively were lower in patients with Chagas disease. In controls, these values were 94 ± 10.6 (p=0.02); 117 ± 18.1 (p=0.04), and 122 ± 18.4 mm (p=0.03). Conclusion: Changes in optic nerve/ retinal nerve fiber layer were more prevalent in patients with Chagas disease.

RESUMO Objetivo: Testar a hipótese de que a doença de Chagas predispõe a alterações no nervo óptico e camada de fibras nervosas peripapilar. Métodos: Foi realizado um estudo transversal com 41 pacientes diagnosticados com doença de Chagas e 41 controles, pareados por sexo e idade. Os pacientes foram submetidos a exames oftalmológicos, incluindo medida da pressão intraocular, avaliação do nervo óptico e camada de fibras nervosas através de retinografia, tomografia de coerência óptica e perimetria automatizada padrão. Resultados: Todos os pacientes com doença de Chagas apresentavam estudo cardiológico recente; 15 pacientes (36,6%) apresentavam insuficiência cardíaca; 14 (34,1%) forma cardíaca sem disfunção de ventrículo esquerdo e 12 (29,3%), forma indeterminada. Alterações do nervo óptico/camada de fibras nervosas foram observadas em 24 pacientes (58,5%) do grupo com doença de Chagas e 07 controles (17,1%) (p£0,01). Dentre estas, palidez do nervo óptico, alterações do nervo óptico sugestivas de glaucoma, entalhe, hemorragia peripapilar e defeito da camada de fibras localizado foram detectados. As alterações foram mais proeminentes nos pacientes com doença de Chagas e insuficiência cardíaca (11 pacientes) embora também ocorressem naqueles com doença de Chagas sem disfunção de ventrículo esquerdo (7 pacientes) e com forma indeterminada (6 pacientes). A tomografia de coerência óptica mostrou que a média da espessura da camada de fibras nervosas da retina mediu 89 ± 9,7 mm), e a média da espessura da camada de fibras nervosas superior e inferior mediu 109 ± 17,5 e 113 ± 16,8 mm, respectivamente, foi menor em pacientes com doença de Chagas. Nos controles, esses valores foram de 94 ± 10,6 mm (p=0,02); 117 ± 18,1 (p=0,04) e 122 ± 18,4 mm (p=0,03). Conclusão: Alterações do nervo óptico/camada de fibras nervosas da retina foram mais prevalentes nos pacientes com doença de Chagas.

Análisis biomecánico del disco óptico bajo la variación de presión intraocular y rigidez escleral / Biomechanical analysis of the optic disc under variations in intraocular pressure and scleral rigidity

INTRODUCCIÓN: el incremento de la presión intraocular y las alteraciones detectadas en la apariencia de la cabeza del nervio óptico constituyen factores importantes en la determinación de la progresión del daño glaucomatoso. OBJETIVO: analizar el comportamiento del disco óptico bajo el efecto de la variación de la presión intraocular y de la rigidez escleral, a través de un modelo biomecánico. MÉTODOS: se emplea el método de los elementos finitos. Se definieron varios módulos de rigidez para la esclerótica de 3, 6 y 9 MPa y para la lámina cribosa 0,3 y 0,6 MPa. Todos los tejidos modelados fueron asumidos como materiales isotrópicos con comportamiento elástico e incompresible. RESULTADOS: la mayor concentración de tensiones se localizó en las zonas de la esclerótica peripapilar y en las paredes del canal escleral. Los máximos de tensión (97,523 kPa) y desplazamiento (95,64 µm) se obtuvieron cuando la esclerótica y la lámina cribosa fueron menos rígidas y con la mayor presión intraocular. CONCLUSIONES: la biomecánica del disco óptico influye en el desarrollo de la neuropatía óptica glaucomatosa. El mayor desplazamiento se encuentra en la zona central del disco óptico y está asociado a la pérdida de fibras nerviosas de la retina o al incremento de la excavación papilar en el mecanismo de daño glaucomatoso.

INTRODUCTION: Increase in intraocular pressure and alterations in the appearance of the optic nerve head are important factors in determining the progress of glaucomatous damage. OBJECTIVE: Analyze the behavior of the optic disc under the effect of variations in intraocular pressure and scleral rigidity using a biomechanical model. METHODS: The finite element method was used to define several rigidity modules for the sclera at 3.6 and 9 MPa and for the lamina cribosa at 0.3 and 0.6 MPa. All the tissues modeled were assumed to be isotropic materials with elastic, incompressible behavior. RESULTS: The highest concentration of tensions was located in areas of the peripapillary sclera and scleral canal walls. Tension and displacement peaks (97.523 kPa and 95.64 µm, respectively) were obtained when the sclera and the lamina cribosa were less rigid and intraocular pressure was highest. CONCLUSIONS: The biomechanical characteristics of the optic disc influence the development of glaucomatous optic neuropathy. The greatest displacement is found in the central area of the optic disc, and it is associated with the loss of retinal nerve fibers or an increase in papillary excavation in the mechanism of glaucomatous damage.

Visual function and macular architecture in patients with inactive zone 2 and 3 toxoplasmic retinochoroiditis / Função visual e arquitetura macular em pacientes com retinocoroidite toxoplásmica inativa nas zonas 2 e 3

ABSTRACTPurpose:To evaluate the visual function and architecture of the central and peripapillary retina in patients with inactive toxoplasmic retinochoroiditis outside the macular and peripapillary regions (zones 2 and 3).Methods:Cross-sectional study of 20 eyes (18 patients) with zone 2 and 3 toxoplasmic scars and visual acuity ≥20/25. Patients underwent Humphrey 10-2 perimetry, contrast sensitivity (Mars test), and color vision testing (L'Anthony desaturated D-15). The retinal nerve fiber layer (RNFL) and macular thicknesses were determined by optical coherence tomography.Results:The patients' mean age was 27.4 ± 10.3 years, and the mean duration of remission was 6.15 ± 5.19 months. Abnormal contrast sensitivity and color vision were observed in three (15.0%) and four eyes (20.0%), respectively. Mean deviation (MD) and pattern standard deviation (PSD) fell outside the 95% normal confidence limits of the perimeter's database in 14 (70.0%) and seven eyes (35.0%), respectively. Foveal and mean RNFL thicknesses were within the normal limits in all eyes. Eyes with zone 2 retinochoroiditis had lower foveal sensitivity than eyes with zone 3 lesions (p=0.041). Eyes with a longer duration of remission had a higher MD (r=0.575; p=0.013) and a lower PSD (r=-0.593; p=0.010).Conclusions:Despite normal central and peripapillary retinal architecture, eyes with inactive zone 2 and 3 toxoplasmic retinochoroiditis can present with abnormal color, contrast, and macular perimetric sensitivity. Zone 2 retinochoroiditis was associated with lower foveal sensitivity, and a longer duration of retinochoroiditis remission was associated with better perimetric parameters (MD and PSD).

RESUMOObjetivo:Avaliar a função visual e arquitetura da retina central e peripapilar em pacientes com retinocoroidite toxoplásmica inativa fora da região macular e peripapilar (zonas 2 e 3).Métodos:Estudo transversal de 20 olhos (18 pacientes) com cicatrizes toxoplásmicas nas zonas 2 e 3 com acuidade visual ≥20/25. Os pacientes foram submetidos à perimetria Humphrey 10-2, teste de sensibilidade ao contraste (Teste Mars) e teste de visão de cores (L'Anthony D-15 dessaturado). As espessuras da camada de fibras nervosas da retina (CFNR) e da mácula foram determinadas pela tomografia de coerência óptica.Resultados:A média de idade dos pacientes foi 27,4 ± 10,3 anos, e a duração média da remissão da retinocoroidite foi de 6,15 ± 5,19 meses. Alterações na sensibilidade ao contraste e cores foram observada em, respectivamente, 3 olhos (15,0%) e 4 olhos (20,0%). Os índices perimétricos mean deviation (MD) e pattern standard deviation (PSD) estiveram fora do intervalo de confiança de 95% do perímetro em 14 olhos (70,0%) e 7 olhos (35,0%), respectivamente. A espessura foveal e da CFNR média estiveram dentro do limite da normalidade em todos os olhos. Olhos com retinocoroidite na zona 2 tiveram menor sensibilidade foveal que olhos com lesões na zona 3 (p=0,041). Olhos com remissão de longa duração tiveram um MD mais alto (r=0,575; p=0,013) e um PSD mais baixo (r=-0,593; p=0,010).Conclusão:Apesar da arquitetura normal da retina central e peripapilar, olhos com retinocoroidite inativa nas zonas 2 e 3 podem apresentar anormalidades da visão de cores, sensibilidade ao contras e perimetria macular. A retinocoroidite na zona 2 está associada a uma menor sensibilidade foveal. Longos intervalos de remissão da retinocoroidite estiveram associados a melhores parâmetros perimétricos (MD e PSD).

Relationship between Peripapillary Retinal Nerve Fiber Layer Thickness Measured by Optical Coherence Tomography and Visual Field Severity Indices

PURPOSE: Though there are many reports regarding the structure-function relationship in glaucoma, they are too complicated to apply to the routine clinical setting. The aim of this study was to investigate the direct relationship between peripapillary retinal nerve fiber layer (RNFL) thickness measured by optical coherence tomography (OCT) and visual field (VF) severity indices computed by standard automated perimetry. METHODS: This cross-sectional comparative study included 104 glaucomatous patients and 59 healthy subjects. Peripapillary RNFL thickness was measured by spectral domain (SD) and time domain (TD) OCTs. Four glaucoma VF severity indices, including mean deviation (MD), pattern standard deviation (PSD), Collaborative Initial Glaucoma Treatment Study (CIGTS) VF score, and Advanced Glaucoma Intervention Study (AGIS) VF score, were calculated using standard automated perimetry. The Pearson's correlation coefficients (r) between the average and quadrants of peripapillary RNFL thicknesses and the four VF severity indices were calculated. RESULTS: In glaucomatous eyes, the r value between the average RNFL thickness measured by SD OCT and each VF severity index were 0.562, -0.514, -0.577, and -0.567 for the MD, PSD, CIGTS VF score, and AGIS VF score, respectively (all p < 0.001). Among each quadrant, the inferior RNFL thickness showed the largest r value; 0.587, -0.552, -0.613, and -0.598 for the MD, PSD, CIGTS VF score, and AGIS VF score, respectively (all p < 0.001). Measurements by TD OCT showed similar strengths of association with SD OCT. CONCLUSIONS: Moderate correlation was identified between peripapillary RNFL thicknesses measured by SD/TD OCT and glaucoma VF severity indices. Among each quadrant, the inferior RNFL thickness showed the greatest association with glaucoma VF severity indices. There was no significant difference according to the type of VF severity index or the type of OCTs.

Optic neuritis complicating herpes zoster ophthalmicus in an immunocompetent patient / Zoster optic neuritis in immunocompentent

A 58-year-old woman presented with rash over the left side of the face and intense acute uveitis. Following careful review of the symptoms and dilated fundus examination unilateral optic neuritis was discovered. The rash was typical of varicella zoster dermatitis. Patients presenting with herpes zoster ophthalmicus should always undergo dilated fundus examination, as there is a potential risk of unexpected posterior segment inflammation. Early diagnosis and prompt treatment can avoid visual sequelae.

Paciente de 58 anos de idade apresentando erupção cutânea no lado esquerdo da face e intensa uveíte unilateral. Após cuidadosa revisão dos sintomas e exame de fundo do olho foi detectada neurite óptica. O rash era típico de dermatite por varicella zoster. Pacientes apresentando quadro de herpes zoster oftálmico devem ser submetidos ao exame de fundo do olho devido ao risco de inesperada inflamação do segmento posterior. Diagnóstico precoce e tratamento imediato podem evitar danos visuais.

Relevância da biomecânica da córnea no glaucoma / Relevancy of corneal biomechanical in glaucoma

Relato de caso de uma paciente, com córnea espessa, por distrofia de Fuchs em fase inicial, ainda com transparência corneana preservada (edema corneano subclínico), associado à pressão intraocular (PIO) normal por tonometria de aplanação de Goldman (TAG), que teve entretanto, o diagnóstico de glaucoma primário de ângulo aberto com base em alterações estruturais do nervo óptico. O estudo tomográfico demonstrou padrão de paquimetria espacial compatível com edema subclínico. O estudo biomecânico da córnea com o ORA (Ocular Response Analyzer, ® Reichert), associado à medida corrigida da PIO, possibilitou o entendimento da influência da córnea, que apesar de mais espessa, levava a uma TAG falsamente reduzida (hipoestimada). O estudo da PIO com sistema de tonografia digital de contorno (PASCAL) corroborou com os achados do ORA. Este exemplo ressalta a importância de novas tecnologias na avaliação de pacientes com suspeita de glaucoma, e destaca que a correção da TAG, com base em algoritmos lineares relacionados com a paquimetria central apenas, pode determinar sérios erros de interpretação clínica.

Case report of a patient, with a thick cornea, for Fuchs dystrophy in its early stages, yet with preserved corneal transparency (subclinical corneal edema), associated with normal intraocular pressure (IOP) by Goldman applanation tonometry (GAT), which was however, the diagnosis of primary open-angle glaucoma on the basis of structural changes of the optic nerve. The tomographic study showed a pattern of spatial pachymetry compatible with subclinical edema. The corneal biomechanical study with ORA (Ocular Response Analyzer, Reichert ®) associated with corrected IOP measurement, allowed the understanding of the corneal influence, which, although thicker, leading to a falsely low TAG (underestimated). The IOP study with tonography system digital (PASCAL) corroborated with the findings of ORA. This example highlights the importance of new technologies in patients' evaluation with suspected glaucoma, and highlights that the correction of TAG, based on linear algorithms related to central corneal thickness alone, can determine serious errors in clinical interpretation.

The Effect of Pattern Scan Laser Photocoagulation on Peripapillary Retinal Nerve Fiber Layer Thickness and Optic Nerve Morphology in Diabetic Retinopathy

PURPOSE: To evaluate the effect of pattern scan laser (PASCAL) photocoagulation on peripapillary retinal nerve fiber layer (RNFL) thickness, central macular thickness (CMT), and optic nerve morphology in patients with diabetic retinopathy. METHODS: Subjects included 35 eyes for the PASCAL group and 49 eyes for a control group. Peripapillary RNFL thickness, cup-disc area ratio and CMT were measured before PASCAL photocoagulation and at 2 and 6 months after PASCAL photocoagulation in the PASCAL or control groups. RESULTS: The average RNFL thickness had increased by 0.84 microm two months after and decreased by 0.4 microm six months after PASCAL photocoagulation compared to baseline, but these changes were not significant (p = 0.83, 0.39). The cup-disc area ratio was unchanged after PASCAL photocoagulation. CMT increased by 18.11 microm (p = 0.048) at two months compared to baseline thickness, and partially recovered to 11.82 microm (p = 0.11) at six months in the PASCAL group. CONCLUSIONS: PASCAL photocoagulation may not cause significant change in the peripapillary RNFL thickness, CMT, and optic nerve morphology in patients with diabetic retinopathy.

Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined' / Assimetria do diametro da bainha do nervo optico como fator prognostico apos cranioplastia em pacientes portadores da 'sindrome do trefinado'

Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the “syndrome of the trephined” (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. Objective To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. Method We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. Results Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. Conclusion It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty. .

A craniectomia descompressiva (CD) tem papel fundamental no tratamento da hipertensão intracraniana refratária, mas não é isenta de complicações. Uma complicação rara é a “síndrome do trefinado” (ST). Ela ocorre quando as forças gravitacionais se sobrepõem à pressão intracraniana. Objetivo Determinar a utilidade do diâmetro da bainha do nervo óptico (DBNO) como fator prognóstico após cranioplastia. Método Foram acompanhados 5 pacientes trefinados portadores da ST. Estes pacientes foram submetidos à ressonância magnética com medida do diâmetro da bainha do nervo óptico (DBNO). Resultados Dois pacientes apresentaram uma assimetria do DBNO, sendo o diâmetro maior do lado craniectomizado. Para nossa surpresa estes evoluíram melhor do que os que apresentavam o DBNO simétrico. Estes pacientes se tornaram independentes uma semana após, e estatisticamente mais cedo do que os outros. Conclusão Há evidências de que a assimetria do DBNO sirva como fator de bom prognóstico após cranioplastia no pacientes portadores da ST. .

Ocular masquerade syndrome associated with extranodal nasal natural killer/T-cell lymphoma: case report / Síndrome ocular mascarada associada ao linfoma extranodal nasal natural killer/células T: relato de caso

A 33-year-old woman complained of unilateral eyelid edema and blurred vision. Initial ophthalmic examination disclosed anterior chamber reaction with keratic precipitates on the cornea, without posterior abnormalities. Anterior uveitis was treated. Despite that, patient showed rapidly progressive unilateral vision loss with optic nerve swelling. Systemic workup was inconclusive, as well as cranial magnetic resonance imaging and cerebrospinal fluid examination. Based on the hypothesis of optic neuritis, intravenous methylprednisolone pulse was performed with no success. During the following days, the patient presented pericardial effusion and cardiac tamponade, progressing to death. Necropsy was performed and diagnosis of extranodal natural killers/T-cell lymphoma, nasal type with ocular involvement was confirmed by immunohistochemistry.

Paciente feminina de 33 anos apresentando edema palpebral unilateral com baixa acuidade visual. Ao exame oftalmológico inicial apresentava reação de câmara anterior com precipitados ceráticos corneano, sem alterações no fundo de olho. Foi instituído tratamento para uveíte anterior e solicitado exames sistêmicos para investigação. Após alguns dias, paciente apresentou piora da acuidade visual, com edema de disco óptico unilateral. Sendo então solicitada ressonância nuclear magnética de crânio. Ambos exames de imagem e investigação sistêmica foram inconclusivos. Em vista da piora progressiva da acuidade visual e sob hipótese diagnóstica de neurite óptica, foi iniciado pulso intravenoso de metilprednisolona por 3 dias sem sucesso. A paciente apresentou dos dias seguintes, derrame pericárdico e tamponamento cardíaco, evoluindo para óbito. A necrópsia confirmou o diagnóstico de linfoma extranodal de células T e natural killers do tipo nasal com envolvimento ocular, através de imunoistoquímica.

Avaliação da camada de fibras nervosas da retina nas afecções neuroftalmológicas da via óptica anterior / Retinal nerve fiber evaluation in neuro-ophthalmic diseases of the anterior visual pathway

A avaliação da camada de fibras nervosas da retina tem grande importância no diagnóstico e acompanhamento de várias afecções da via óptica anterior. Nesta revisão, discutiremos os principais métodos de análise clínica e instrumental da camada de fibras nervosas da retina e revisamos os principais achados encontrados nas afecções da via óptica anterior incluindo lesões inflamatórias, isquêmicas, tóxicas, hereditárias, compressivas e traumáticas do nervo óptico, as lesões do quiasma óptico, as do trato óptico e aquelas do corpo geniculado lateral.

Retinal nerve fiber evaluation is important in the diagnosis and management of several diseases of the anterior visual pathway. In this report we review the clinical findings and the current techonologies avalilable to analyse the retinal nerve fiber layer. We furthermore review the main findings in several disease of the anterior visual pathways including inflammatory, ischemic, toxics, hereditary, compressive and traumatic optic neuropathies as well as lesion of the optic chiasm, optic tract and lateral geniculate body.

Relevância da biomecânica da córnea no glaucoma / Relevancy of corneal biomechanical in glaucoma

Relato de caso de uma paciente, com córnea espessa, por distrofia de Fuchs em fase inicial, ainda com transparência corneana preservada (edema corneano subclínico), associado à pressão intraocular (PIO) normal por tonometria de aplanação de Goldman (TAG), que teve entretanto, o diagnóstico de glaucoma primário de ângulo aberto com base em alterações estruturais do nervo óptico. O estudo tomográfico demonstrou padrão de paquimetria espacial compatível com edema sub-clínico. O estudo biomecânico da córnea com o ORA (Ocular Response Analyzer, ® Reichert), associado à medida corrigida da PIO, possibilitou o entendimento da influência da córnea, que apesar de mais espessa, levava a uma TAG falsamente reduzida (hipoestimada). O estudo da PIO com sistema de tonografia digital de contorno (PASCAL) corroborou com os achados do ORA. Este exemplo ressalta a importância de novas tecnologias na avaliação de pacientes com suspeita de glaucoma, e destaca que a correção da TAG, com base em algoritmos lineares relacionados com a paquimetria central apenas, pode determinar sérios erros de interpretação clínica.

Case report of a patient, with a thick cornea, for Fuchs dystrophy in its early stages, yet with preserved corneal transparency (subclinical corneal edema), associated with normal intraocular pressure (IOP) by Goldman applanation tonometry (GAT), which was however, the diagnosis of primary open-angle glaucoma on the basis of structural changes of the optic nerve. The tomographic study showed a pattern of spatial pachymetry compatible with subclinical edema. The corneal biomechanical study with ORA (Ocular Response Analyzer, Reichert ®) associated with corrected IOP measurement, allowed the understanding of the corneal influence, which, although thicker, leading to a falsely low TAG (underestimated). The IOP study with tonography system digital (PASCAL) corroborated with the findings of ORA. This example highlights the importance of new technologies in patients' evaluation with suspected glaucoma, and highlights that the correction of TAG, based on linear algorithms related to central corneal thickness alone, can determine serious errors in clinical interpretation.

Autoimmune optic neuropathy as the first manifestation of systemic lupus erythematosus / Neuropatia óptica autoimune como primeira manifestação do lúpus eritematoso sistêmico

We described a 35 years old female patient with bilateral visual loss and pain on eye movement, mild papillary edema in acute phase, arcuate scotoma and complementary test positive for antinuclear antibodies that did not respond to corticosteroid therapy. The lack of clinical criteria for systemic lupus erythematosus (SLE) didn't prevent the institution of the specific treatment with corticosteroids and azathioprine. After seven months the diagnosis was made after a skin manifestation of the disease. This case shows the value of the ocular complaints in systemic diseases. And how the ophthalmologic exam can help the clinician elaborating a diagnosis. It is also very important for ophthalmologists and rheumatologists due to the fact that it calls the attention to another diagnostic hypothesis in patients with nonspecific optic neuritis, even with inconclusive laboratory tests. Maybe some ocular findings deserve to be included to the diagnostic criteria already established for SLE.

Descrevemos caso de um paciente de 35 anos do sexo feminino, com perda visual bilateral associada à dor à movimentação ocular, edema papilar moderado na fase aguda, escotoma arqueado e exame complementar positivo para anticorpos antinucleares, que não responderam à terapia com corticosteróides. A falta de critérios clínicos para o lúpus eritematoso sistêmico (LES) não impediu a instituição do tratamento específico com corticosteróides e azatioprina. Depois de sete meses, o diagnóstico foi feito após uma manifestação da doença de pele. Este caso mostra o valor das queixas oculares em doenças sistêmicas e como o exame oftalmológico pode ajudar o clínico na elaboração de um diagnóstico. Também é muito importante para oftalmologistas e reumatologistas, devido ao fato de que chama a atenção para outra hipótese diagnóstica em pacientes com neurite óptica não-específica, mesmo com os testes laboratoriais conclusivos. Talvez alguns achados oculares merecem ser incluídos com os critérios de diagnóstico já estabelecido para o LES.

structure of the optic nerve after the administration of interferon alpha-2a in adult male albino rats and the role of alpha-lipoic acid supplementation

Interferon alpha [IFN-alpha] therapy is used considerably in Egypt because of a high prevalence rate of chronic hepatitis C virus infection. Alpha-Lipoic acid [ALA] has been found to play a neuroprotective role in many insults. The aim of this study is to observe the histological structure of the topic nerve of rats after an injection of IFN-alpha and to determine the role of ALA supplementation. Forty adult male albino rats were divided equally into four groups. Group I served as the control group. Group II included rats that received ALA alone [100mg/kg/day, intraperitoneally]. Group III included rats that received IFN-alpha alone [100000 IU/kg/three times/week, intraperitoneally]. Group IV included rats that received both IFN-alpha and ALA. After 8 weeks, the optic nerves were extirpated and processed for light and electron microscope examination. Optic nerves of the group that received IFN-alpha showed nerved damage manifested as axonal damage and changes in the myelin sheath. Neuroglia showed vacuolation in their cytoplasm and heterochromatic nuclei. Morphometric and statistical analyses showed a significant increase in the surface area of positive glial fibrillary acidic protein astrocytes, indicating reactive astrogliosis. Blood capillaries were distorted with ill-defined walls and protrusion of the endothelial cells into their lumina. These changes were limited by concomitant ALA supplementation with IFN-alpha. IFN-alpha exerted a deleterious effect on the histological structure of the optic nerve in rats and ALA supplementation minimized these effects

Meningioma de la vaina del nervio óptico: colaterales optociliares y quiste aracnoideo perióptico / Meningioma of the optic nerve sheath: collateral optociliary veins and the perioptic arachnoidal cyst

En la década sesenta, antes del advenimiento de la tomografía computarizada de las órbitas, los meningiomas de la vaina del nervio óptico eran considerados de rara ocurrencia y su diagnóstico positivo solo era posible en aquellos casos en que por su tamaño producían proptosis ocular, la que conducía a su estirpación quirúrgica. El tumor de crecimiento tubular, comprime el nervio en forma progresiva hasta atrofiarlo por completo. Sus manifestaciones clínicas incluyen la pérdida gradual de la agudeza visual hasta alcanzar la ceguera, edema del nervio óptico y luego atrofia del mismo, y presencia de venas colaterales optociliares. Este complejo signológico se designa como triada de Hoyt-Spencer. Un hecho patológico distintivo de estos tumores objetivado mediante resonancia magnética de órbitas con administración de gadolinio y supresión de grasa, es la presencia de una dilatación quística del espacio subaracnoideo perióptico entre el limite distal del tumor y el polo posterior del ojo. Presentamos el caso de un paciente ilustrativo con demostración histopatológica de las colaterales venosas y del quiste aracnoideo

During the 1970s, before the advent of computerized tomography of orbits, optic nerve sheath meningiomas were considered of rare ocurrence and their positive diagnosis was only posible in those cases in which its size produced ocular proptosis, which led to its surgical removal. Tumor growths in a tubular, compreses progressively the optic nerve and in time produces its atrophic thinning. Clinical manifestation include gradual visual acuity loss until total blindness, optic nerve edema and then optic atrophy, and the presence of collateral optociliary veins. This complex clinical picture is designated as the triad of Hoyt-Spencer. A distinctive fact in these tumors is the presence of a cystic dilatation of the perioptic subarachnoid space between the distal adge of the tumor and the posterior pole, which can be defined using magnetic resonance imaging of the orbits with fat supression following intravenous gadolinium administration. We present the case of a patient with histopatological demostration of the collateral veins and the distal aracnoidal cyst