Avaliação do conhecimento em Oftalmologia na Graduação Médica / Evaluation of Ophthalmology knowledge in Medical Graduation

Objetivo: avaliar o nível de conhecimento oftalmológico dos estudantes de medicina sobre achados do fundo de olho e alterações da retinopatia diabética, assim como o interesse destes alunos por um maior aprendizado sobre o assunto. Materiais e Métodos: A amostra foi constituída por alunos do curso de medicina do Centro Universitário Christus (Unichristus), na cidade de Fortaleza ­ Ceará ­ Brasil, durante os meses de novembro e dezembro de 2018. Eles responderam a um questionário composto por 20 questões de múltipla escolha, com quatro itens cada, contendo apenas um único item correto, com assuntos relacionados à fundoscopia e à retinopatia diabética. Foram escolhidos o quinto semestre (s5), por ter finalizado recentemente o módulo de oftalmologia, e o sétimo semestre (s7), para avaliação da retenção de conteúdo após um ano do término da disciplina. O questionário também abordou o interesse dos alunos em obter maior aprendizado sobre o assunto. Resultados: o questionário foi aplicado em 120 alunos (62 alunos do s5 e 58 alunos do s7). Houve um maior número de acertos no s5, com média de 57,2% de acertos, em relação ao s7, cuja média de acertos foi de 49,9%. Conclusão: Diante de uma média de acertos abaixo do desejável, e do interesse da maioria dos alunos em obter maior aprendizado, fica clara a demanda por uma maior inserção da disciplina de oftalmologia na graduação médica, por meio das instituições de ensino, dando a devida relevância ao tema, oferecendo aos seus alunos suporte para um aprendizado concreto e contínuo.

Objective: to evaluate the level of ophthalmological knowledge of medical students about fundus findings and changes in diabetic retinopathy, as well as the interest of these students in greater learning on the subject. Materials and Methods: The sample consisted of medical students from the Centro Universitário Christus (Unichristus), in the city of Fortaleza - Ceará - Brazil, during the months of November 2018 and December 2018. They answered a questionnaire composed of 20 multiple-choice questions, with four items each, containing only one correct item, with subjects related to fundus findings and changes in diabetic retinopathy. The fifth semester (s5) was chosen, for having recently completed the ophthalmology module, and the seventh semester (s7), to assess content retention one year after the end of the course. The questionnaire also addressed the students' interest in obtaining greater learning on the subject. Results: the questionnaire was applied to 120 students (62 students from s5 and 58 students from s7). There was a greater number of correct answers in s5, with an average of 57.2% of correct answers, compared to s7, whose average of correct answers was 49.9%. Conclusion: Given an average of hits below the desirable, and the interest of most students to obtain greater learning, it is clear the demand for a greater insertion of the discipline of ophthalmology in medical graduation, through educational institutions, giving due importance to the theme, offering its students support for learning concrete and continuous.

Custo-utilidade da retinografia digital portátil como tecnologia auxiliar na triagem da retinopatia da prematuridade no Sistema Único de Saúde / Cost-utility of wide-field imaging as a complementary technology for retinopathy of prematurity screening from the Brazilian Public Health Care

Objetivo: O objetivo do estudo foi realizar uma análise de custo-utilidade da retinografia digital portátil como tecnologia auxiliar na triagem da retinopatia da prematuridade (ROP) no Brasil, sob a perspectiva do Sistema Único de Saúde (SUS). Introdução: A ROP é uma das principais causas de cegueira infantil evitável no mundo e no Brasil. Os recém-nascidos (RN) prematuros e de baixo peso estão em risco de desenvolver ROP grave que, quando não precocemente tratada, leva a cegueira irreversível. A triagem atual da ROP no Brasil é realizada com a oftalmoscopia binocular indireta, por um oftalmologista especializado, mas com cobertura incompleta dos RN em risco. A nova estratégia de triagem é a combinação da retinografia digital portátil, realizada por técnicos de enfermagem, com a oftalmoscopia indireta, em casos suspeitos. Métodos: Um modelo de árvore de decisão foi criado para estimar a razão de custo-utilidade do manejo da ROP (triagem, tratamento e acompanhamento oftalmológico). As duas estratégias de triagem comparadas foram: 1. oftalmoscopia indireta; 2. retinografia digital portátil para toda a população elegível e oftalmoscopia indireta para confirmação de casos suspeitos. A população de referência incluiu RN com idade gestacional inferior ou igual a 32 semanas e/ou peso de nascimento inferior ou igual a 1.500 gramas. O horizonte temporal foi toda a vida. A perspectiva adotada foi a do SUS. Parâmetros e pressupostos foram incorporados ao modelo a partir da revisão da literatura, consulta aos especialistas e técnica de microcusto. A utilidade foi estimada a partir da acuidade visual decimal e os benefícios foram estimados em quality-adjusted life years (QALY). Os custos incluíram insumos, equipamentos e recursos humanos. Duas técnicas de enfermagem foram treinadas para executarem a retinografia e tiveram seus tempos cronometrados antes e ao final do treinamento. Duas oftalmologistas especialistas em ROP tiveram seus tempos de interpretação de imagens cronometrados. Foram realizadas análises de sensibilidade determinística univariada e probabilística. Resultados: Com uma cobertura de 90% da população elegível a estratégia nova se mostrou cost-saving. Os custos estimados por exame foram: 1. Triagem com a oftalmoscopia binocular indireta - R$ 203,18 reais; 2. Triagem com a combinação - R$ 87,10 reais; 3. Tratamento - R$2.529,83 reais. O custo do acompanhamento por RN ao longo da vida variou de R$273,16 a R$1.130,41 reais dependo da função visual desenvolvida pelo RN. A razão de custo por QALY incremental resultou em uma economia de R$ 3.378,18/ QALY ganho por RN triado. Conclusão: A nova triagem da ROP, utilizando a combinação da retinografia com a oftalmoscopia, foi custo-efetiva e pode universalizar o acesso dos recém-nascidos em risco de ROP à assistência neonatal ocular básica. Este estudo poderá contribuir para a tomada de decisão na área da saúde neonatal e fornecer subsídios para outras pesquisas de avaliações econômicas em saúde.

Purpose: The present study was aimed to evaluate the cost-utility of wide-field imaging as a complementary technology for retinopathy of prematurity (ROP) screening from the Brazilian Public Health Care system perspective. Introduction: ROP is a leading cause of avoidable childhood blindness worldwide, especially in middle income countries, such as Brazil. It affects preterm and low birth weight newborns. The current ROP screening involves indirect binocular ophthalmoscopy by an experienced ophthalmologist. It has been suggested the insufficient ROP screening coverage with this current practice. An alternative screening strategy, which could enhance preterm access, is the combination of DR by two nurse technicians with ophthalmoscopy for suspected images. Methods: Deterministic decision-tree simulation model was built to estimate cost-utility ratio for ROP management (screening, treatment and follow-up). Two screening strategies were compared: 1. indirect binocular ophthalmoscopy; 2. wide-field imaging of all eligible preterm babies and indirect ophthalmoscopy of suspected cases. The eligible population included preterm under 32 weeks of gestational age or birth weight equal to or less than 1.500 grams. The temporal horizon was lifetime. The perspective was from Brazilian Public Health Care System. Parameters and assumptions were based on published literature, observational experience or specialist's opinion. Visual outcome data was converted to utility based on published literature and the health benefits were estimated in quality-adjusted life years (QALY). Costs were estimated considering staff, equipment, maintenance and inputs. It was used a microcost technique for wide-field imaging. Two technician's nurses were trained for wide-field imaging execution and had their time evaluated before and after the training. Two ROP specialists' ophthalmologists had their time evaluated for imaging interpretation. One-way sensitivity analysis and probabilistic sensitivity analysis were performed. Results: The new ROP screening strategy resulted in a cost-saving program considering 90% ROP screening coverage. The costs per exam were: 1. Screening with ophthalmoscopy: R$ 203,18. 2. Screening with combination: R$ 87,1. 3. Treatment: R$2.529,83. 4. Long term follow-up: from R$273,16 to R$1.130,41 according to the newborn´s visual function. The incremental cost per QALY gained was R$3.378,18 saved per infant with the new screening strategy. Conclusion: The combined strategy for ROP screening showed a cost-effective result. It could enhance preterm access for appropriate ROP management in middleincome countries and diminish opportunity cost of ophthalmologists. This study enables others economic evaluations and could help public health managers in sustainable and appropriate decision making.

Comparison of Blue and Green Confocal Scanning Laser Ophthalmoscope Imaging to Detect Retinal Nerve Fiber Layer Defects

PURPOSE: We detected retinal nerve fiber layer (RNFL) defects using a confocal scanning laser ophthalmoscopy (CSLO) with both blue and green laser sources and evaluated image quality based on laser wavelength. METHODS: This was a retrospective observational case study. Blue and green CSLO images of 181 eyes with suspected glaucoma were evaluated and compared. Three independent observers identified the presence of RNFL defects and determined which CSLO imaging source provided superior visibility of the defect. After assessing the defect imaging by laser source, demographics and image quality indices of optical coherence tomography between blue better and green better groups were analyzed. RESULTS: Both blue and green CSLO showed high discriminating ability for RNFL defects. The discriminating ability of blue CSLO was significantly greater than that of green CSLO (p = 0.004). Among eyes with a detectable RNFL defect, 61.8% were better visualized with the blue laser compared to the green laser. Compared with the blue better group, the green better group was significantly older (p = 0.009), had a greater proportion of females (p = 0.005), had poorer best-corrected visual acuity (p = 0.001), more severe cataracts (p = 0.001), lower signal strength (p = 0.003), and poor image quality indices (p = 0.001). CONCLUSIONS: Both blue and green CSLO imaging was useful for detecting RNFL defects, but blue CSLO was superior to green CSLO in quality of RNFL defect imaging in most patients with clear media.

Scleral Buckling under a Slit-lamp Illumination System with a Contact Wide-angle Viewing Lens Compared with an Indirect Ophthalmoscope

PURPOSE: To investigate the outcomes of scleral buckling surgery performed under a slit-lamp illumination system (Visulux) with a contact wide-angle viewing lens (Mini Quad) in patients with rhegmatogenous retinal detachment (RRD) and to compare these outcomes with those of surgery performed under an indirect ophthalmoscope. METHODS: By retrospective review of electronic medical records, patients with RRD who had undergone scleral buckling surgery were identified. Scleral buckling surgeries were performed with two illumination instruments, a slit-lamp (SL group) and an indirect ophthalmoscope (IO group). Subretinal fluid drainage, cryopexy, and intravitreal gas injection were performed optionally. At 6 months after surgery, anatomical and functional outcomes were evaluated and compared between the two groups. Operation time was also compared between the two groups. RESULTS: Of the 45 total patients (45 eyes), 28 were included in the SL group, and 17 were included in the IO group. In the SL and IO groups, the primary anatomical success rate was 89.3% and 88.2%, respectively (p = 0.92). The logarithm of the minimal angle of resolution change, which reflects improvement in best-corrected visual acuity after surgery, was −0.19 ± 0.38 in the SL group and −0.21 ± 0.63 in the IO group; this difference was not statistically significant (p = 0.91). The mean operation time was significantly shorter in the SL group (78.9 ± 11.8 minutes) than in the IO group (100.0 ± 13.9 minutes, p < 0.001), especially for patients who underwent additional procedures such as subretinal fluid drainage and cryopexy (81.4 ± 12.9 and 103.5 ± 12.3 minutes, respectively, p < 0.001). CONCLUSIONS: Scleral buckling surgery performed under a slit-lamp illumination system yielded a similar anatomical success rate and similar functional improvement in RRD compared with surgery performed under an indirect ophthalmoscope. The slit-lamp system could save time, especially in bullous RRD, which requires additional subretinal fluid drainage.

Uso clínico del tomógrafo de coherencia óptica Spectralis en la evaluación del glaucoma / Use of the Spectralis optical coherence tomography scanner to evaluate glaucoma

La evolución reciente de las herramientas de imagen ha mejorado notablemente la determinación objetiva y cuantitativa de los cambios estructurales en el glaucoma. El tomógrafo de coherencia óptica de dominio espectral, disponible comercialmente, y su módulo Glaucoma Premium Edition recientemente incorporado, ofrece beneficios en la evaluación del glaucoma, por presentar una mayor resolución axial, velocidades de exploración más rápidas, reproducibilidad mejorada, compensación de movimientos oculares, supresión de interferencia y algoritmos avanzados de segmentación. La presente revisión describe las características técnicas, los parámetros de fiabilidad, los protocolos de estudio, la interpretación de los resultados y los principales artefactos que afectan sus medidas. Esta información permite a la comunidad médica realizar un uso y una evaluación adecuada de esta tecnología, y en consecuencia ajustar la gestión clínica según sea necesario(AU)

The recent evolution of imaging tools has notably improved the objective, quantitative determination of structural changes in the glaucoma. The spectral domain optical coherence tomography scanner, commercially available, and its recently incorporated Glaucoma Module Premium Edition, facilitate evaluation of the glaucoma, due to their greater axial resolution, faster exploration speeds, improved reproducibility, eye movement compensation, interference suppression, and advanced segmentation algorithms. The present review describes the technical features, reliability parameters, study protocols, interpretation of results and main artifacts affecting its measurements. Such information will make it possible for the medical community to adequately use and evaluate this technology, adjusting clinical management as required(AU)

Toxoplasmosis ocular recurrente. Presentación de 3 casos y revisión de la literatura / RECURRENT OCULAR TOXOPLASMOSIS: REPORT OF 3 PATIENTS AND REVISION OF THE LITERATURE

La toxoplasmosis ocular recurrente es la forma más común de toxoplasmosis ocular. Las lesiones se localizan adyacentes a una cicatriz coriorretinal resultado de una infección previamente adquirida. La retinitis por toxoplasma provoca una respuesta inflamatoria variable, ocasionando vasculitis, vitreítis, coroiditis y uveítis anterior. El diagnóstico se realiza examinando el fondo de ojo, y su etiología debe considerarse cuando en un adulto joven inmunocompetente, se observa en la fundoscopía la presencia de una lesión retinal focal, asociada a una cicatriz coriorretinal. La retinografía permite documentar los hallazgos observados en el fondo de ojo. El examen serológico para identificar anticuerpos anti toxoplasma de clase IgM e IgG solo confirma la exposición al parásito pero no constituyen pruebas diagnósticas confirmatorias. Se presentan 3 casos de toxoplasmosis ocular recurrente en pacientes adultos cuyos diagnósticos se realizaron mediante el examen fundoscópico y la retinografía.

Recurrent ocular toxoplasmosis is the most common form of ocular toxoplasmosis. Lesions are located adjacent to a chorioretinal scar as a result of a previously acquired infection. Toxoplasma retinitis produces a variables inflammatory response, leading to vasculitis, vitreitis, choroiditis and anterior uveities. Diagnosis is performed by fundoscopy and its ethiology must be considered when fundoscopy shows the presence of a focal retinal lesion associated to a chorioretinal scar in a young immunocompetent adult. Retinography allows documenting findings from the fundoscopy. Serological examination to identify anti toxoplasma antibodies classes IgM and IgG only confirms exposure to the parasite but do not constitute confirmatory diagnostic evidence. We present 3 cases of recurrent ocular toxoplasmosis in adult patients that were diagnosis by fundoscopic examination and retinography

Fundus Photography with a Smartphone

PURPOSE: To evaluate the clinical usefulness, convenience, and possibility of using the medical records of fundus photography with a smartphone. METHODS: We used an ophthalmoscope to examine the images using a smartphone (iphone 6, Apple Inc., Cupertino, CA, USA) and +20D and +28D condensing lenses. Twenty-four subjects were selected for comparison with the conventional funduscopic camera. The posterior pole of the 45° range of the right eye and the fundus photograph taken using the smartphone were analyzed. We measured the distances between specific points on three photographs taken of the patient and calculated the photographing range. RESULTS: The +20 D lens was 0.80 ± 0.06 times smaller than that of the fundus camera and +1.12 ± 0.06 times bigger than that of the fundus photograph. When the area of the funduscope was converted to 45°, +20 D could visualize an area of 36.10 ± 2.82°, and +28 D could visualize a 50.56 ± 2.68° area. CONCLUSIONS: Without expensive equipment, a smart phone and a condensing lens can be used to easily perform fundus examination without the need for a special technique. Therefore, this technique is not only useful clinically, but also is very convenient for keeping medical records as fundus photographs.

Retinal Hemorrhage Incidence of Newborn with Intra-uterine Growth Retardation in Korea

PURPOSE: We report 3 cases of patients with retinal hemorrhage among 27 newborns with intrauterine growth retardation. CASE SUMMARY: Twenty-seven newborns with intrauterine growth retardation were examined using the indirect ophthalmoscope for confirming retinal hemorrhage which was observed in 3 patients. The mean gestational age and birth weight (g) of the 3 patients were 37⁺⁶ weeks and 2,086.7 g, respectively. Among the 3 newborns, 1 patient's mother had oligohydramnios. Two patients were delivered vaginally and 1 by cesarean section. All 3 patients had no birth trauma and the retinal hemorrhage was resolved within 2 weeks after the first eye examination. CONCLUSIONS: We observed 3 cases with retinal hemorrhage in neonates with intrauterine growth retardation which improved within 2 weeks.

Scleral Buckling Using a Non-contact Wide-Angle Viewing System with a 25-Gauge Chandelier Endoilluminator

PURPOSE: To report the outcome of scleral buckling using a non-contact wide-angle viewing system with a 25-gauge chandelier endoilluminator. METHODS: Retrospective analyses of medical records were performed for 17 eyes of 16 patients with primary rhegmatogenous retinal detachment (RRD) without proliferative vitreoretinopathy who had undergone conventional scleral buckling with cryoretinopexy using the combination of a non-contact wide-angle viewing system and chandelier endoillumination. RESULTS: The patients were eight males and five females with a mean age of 26.8 ± 10.2 (range, 11 to 47) years. The mean follow-up period was 7.3 ± 3.1 months. Baseline best-corrected visual acuity was 0.23 ± 0.28 logarithm of the minimum angle of resolution units. Best-corrected visual acuity at the final visit showed improvement (0.20 ± 0.25 logarithm of the minimum angle of resolution units), but the improvement was not statistically significant (p = 0.722). As a surgery-related complication, there was vitreous loss at the end of surgery in one eye. As a postoperative complication, increased intraocular pressure (four cases) and herpes simplex epithelial keratitis (one case) were controlled postoperatively with eye drops. One case of persistent RRD after primary surgery needed additional vitrectomy, and the retina was postoperatively attached. CONCLUSIONS: Scleral buckling with chandelier illumination as a surgical technique for RRD has the advantages of relieving the surgeon's neck pain from prolonged use of the indirect ophthalmoscope and sharing the surgical procedure with another surgical team member. In addition, fine retinal breaks that are hard to identify using an indirect ophthalmoscope can be easily found under the microscope by direct endoillumination.

Rotura ocular posterior traumática / Traumatic posterior ocular rupture

El trauma ocular es una causa importante de morbilidad oftalmológica en el mundo con implicaciones socioeconómicas importantes para el paciente y sus familiares. Ocurre generalmente en adultos jóvenes, con una buena agudeza visual al inicio del evento traumático, la cual se verá comprometida según la severidad del trauma, las estructuras oculares que afecte y las complicaciones que puedan aparecer. Presentamos dos pacientes con rotura escleral posterior secundario a trauma ocular a globo abierto contuso. Se describe el manejo personalizado el seguimiento en cada caso y sus resultados visuales(AU)

The ocular trauma is an important cause of ophthalmological morbidity in the world with significant socio-economic implications for the patient and its relatives. It generally occurs in young adults, with good visual acuity at the beginning of the traumatic event, which may be affected by the trauma severity, the ocular structures that it affects and the possible complications. This is the report on two patients with posterior scleral rupture secondary to blunt open-globe ocular trauma. The customized management, the follow-up of each case and the visual results achieved were all described(AU)

Multimedia interactiva para el desarrollo de habilidades en el uso del oftalmoscopio indirecto / Interactive Multimedia development skills in the use of indirect ophthalmoscope

El oftalmoscopio indirecto es un medio diagnóstico y terapéutico muy necesario y con una amplia utilidad para todos los oftalmólogos, pues este contribuye al desarrollo del proceso de enseñanza-aprendizaje de la asignatura Oftalmología y en especial del segmento posterior del ojo. El objetivo es presentar una multimedia interactiva "Oftalmoscopio indirecto" para el desarrollo de las habilidades profesionales en el uso correcto de este medio diagnóstico en los residentes del Servicio Oftalmológico del Hospital Militar Central "Dr. Carlos J. Finlay". La multimedia contiene diferentes acápites relacionados con el examen oftalmológico, historia, videos, simuladores, posturas y ventajas del oftalmoscopio indirecto. La implementación de esta herramienta de trabajo, a partir del cumplimiento de las acciones que se establecen en la guía elaborada al efecto, permitirá a los residentes que se encuentran en ejercicio o en formación autoprepararse y contribuir a resolver los problemas que detecten a través del oftalmoscopio indirecto en el diagnóstico y tratamiento oportuno de afecciones oftalmológicas que constituyen un problema de salud en Cuba.

The indirect ophthalmoscope is a very necessary diagnostic and therapeutic tool, widely used by all ophthalmologists, as this contributes to the development of teaching and learning Ophthalmology in general and particularly the posterior segment of the eye. Our purpose was to present the interactive multimedia "Indirect Ophthalmoscope" for the development of professional skills in residents of the ophthalmology Service at the Central Military Hospital concerning the proper use of this diagnostic tool. The multimedia contains different headings related to eye exam, history, videos, simulators, positions and advantages of indirect ophthalmoscope. From the fulfillment of the actions set out in the guide produced for this purpose, the implementation of this tool will allow residents to prepare themselves and help to solve problems detected through the indirect ophthalmoscope when diagnosing and treating eye conditions that constitute a health problem in Cuba.

Prevalence of disc cupping in non-glaucomatous eyes

This study assessed optic disc size and cupping, using a commercially available ophthalmoscope, in order to show norms of these values for clinical practice. Subjects were office-workers referred from their respective workplaces for a routine medical examination, which included eye examination. The optic disc size was classified as small, medium or large, for having a diameter < 1.0, 1.0-1.5, or > 1.5 times (respectively) the diameter of the ophthalmoscope's selected light spot on the posterior pole. The cupping was classified as the ratio of the vertical cupping diameter and the vertical disc diameter on a relative decimal scale from 0.0 to 1.0.This study included 184 subjects with a mean age of 40.5 ± 9.5 years; 149 (81%) were males. Their mean ocular pressure was 12.4 ± 1.5 mmHg (range 10-17 mmHg). There was a high correlation between optic disc sizes and cupping in the right and left eyes (Pearson Correlation r = 0.866, p < 0.001); therefore, for simplicity only the data for right eyes are presented. According to our definition, the optic discs in these eyes comprised 27 (14.7%) small, 141 (76.6%) medium and 16 (8.7%) large. The small optic discs were rarely cupped, and the large optic discs were always cupped. Optic disc cupping greater than 0.7 was rarely found and should be suspect of glaucoma. Clinical doctors should be aware of this and refer those subjects with abnormal cupping to the specialist.

Este estudio fue concebido para desarrollar normas clínicas sobre el tamaño y la excavación de la papila usando un simple oftalmoscopio en una población emétrope sin glaucoma. Los sujetos fueron oficinistas enviados al Centro Médico San Luis para un chequeo general de salud que incluye el examen oftalmológico. El tamaño de la papila o disco óptico fue clasificado en tres diámetros (pequeño, mediano y grande) comparando con el tamaño de la proyección retinal de la luz de un oftalmoscopio de bolsillo. La excavación papilar fue clasificada como la relación entre el diámetro horizontal de la excavación y el diámetro horizontal de la papila en escala decimal de 0.0 a 1.0. El estudio incluye 184 sujetos (edad media de 40.5 ± 9.5 años) y 149 (81%) fueron varones. Su presión ocular promedio fue de 12.4 ± 1.5 mmHg (entre 10-17 mmHg). La correlación tanto de los tamaños de disco óptico como de su excavación, fue alta entre ambos ojos (Correlación de Pearson, r = 0.866, p < 0.001) de modo que se presentan solamente datos de los ojos derechos. Según nuestra definición de tamaños papilares hubo 27 (14.7%) papilas pequeñas, 141 (76.6%) medianas y 16 (8.7%) grandes. Las papilas pequeñas rara vez tuvieron excavación y las grandes estuvieron siempre excavadas. Fue raro hallar papilas ópticas con una excavación mayor a 0.7, las que deberían hacer sospechar una lesión por glaucoma. Los clínicos avezados en oftalmoscopia deberían tener esto en cuenta para referir los sujetos con excavaciones grandes al especialista para su estudio oftalmológico.

The Characteristics of Non-Retinal Lesions in the Ultra-Wide Field Scanning Laser Ophthalmoscope Image

PURPOSE: To evaluate various types and; characteristics of non-retinal lesions associated with ultra-wide field scanning laser ophthalmoscope images. METHODS: This retrospective study included 139 eyes of 139 patients with non-retinal lesions observed on color images obtained using Optomap 200Tx (Optos PLC, Dunfermline, Scotland, UK). The non-retinal lesion is a hyperreflective or hyporeflective shadow due to anterior segment of the eye or vitreous except the retina. Types and characteristics of red laser separation, green laser separation and autofluorescence images of non-retinal lesions were evaluated. RESULTS: All non-retinal lesions in images were categorized into 2 groups according to the location of non-retinal lesions. The anterior non-retinal lesions group included corneal opacity, cataract and posterior capsular opacity. The posterior non-retinal lesions group included asteroid hyalosis, posterior vitreous detachment, vitreous opacity and vitreous hemorrhage. Anterior non-retinal lesions were more often hyporeflective in red and green laser separation images (p < 0.001). Posterior non-retinal lesions were more often hyperreflective in green laser separation images and hyporeflective in red laser separation images (p < 0.001). CONCLUSIONS: Ultra-wide field scanning laser ophthalmoscope images can frequently have various shadows from anterior or posterior lesions of the eye. These shadows show a difference in reflectivity depending on their origins. To understand the difference helps in the interpretation of the fundus images.

Use of Fundus Autofluorescence Images to Evaluate the Progression of Geographic Atrophy: Two-Year Follow-Up Study

PURPOSE: We evaluated the progression of geographic atrophy (GA) based on fundus autofluorescence (FAF) pattern and atrophy size using the fundus camera in non-exudative age-related macular degeneration (ARMD). METHODS: We acquired FAF images in non-exudative ARMD patients over a 2-year period. According to The Fundus Autofluorescence in Age-related Macular Degeneration (FAM) study, FAF patterns of geographic atrophy were classified into 5 categories. Examiners quantified the areas of GA in FAF images and analyzed the progression of atrophy based on FAF pattern and atrophy size. RESULTS: In 86 non-exudative ARMD eyes, elderly patients had faster progression rate of GA. The growth rates of GA were 1.51 mm2/year in 'Diffuse', 1.49 mm2/year in 'Banded', 1.05 mm2/year in 'Patchy', 0.59 mm2/year in 'Focal' and 0.16 mm2/year in 'None' pattern groups. In addition, the growth rate was 0.38 mm2/year in which initial the GA area was smaller than 1 disc area. This was the slowest progression rate among all categories according to initial GA area. CONCLUSIONS: As a result of evaluating the progression of geographic atrophy using FAF over a 2-year period, the growth rate of GA was the fastest in the 'Diffuse' pattern group. Additionally, as the initial GA area became smaller, the progression of GA atrophy was slower (p < 0.002). Although limitations such as short follow-up period and measurement error of GA atrophy area using fundus photography were compensated, the results in the present study were similar to the outcomes of studies on progression of GA based on FAF pattern using the scanning laser ophthalmoscope over several years and the fundus camera for 1 year. In conclusion, the fundus camera is a useful tool for the prediction of long-term progression of GA in patients with non-exudative ARMD.

Epiretinal membrane formation associated with idiopathic macular telangiectasia: case report / Formação de membrana epirretiniana associada a telangectasia macular idiopática: relato de caso

A 46-year-old woman complained of blurred and distorted vision in both eyes. Ophthalmic examination showed that visual acuity was 20/200 for the right eye and counting fingers left eye. Fundoscopy revealed perimacular hemorrhages, aneurismal dilatation of the vessels in the posterior pole, and a white and elevated lesion adjacent to vascular changes. We report a case of idiopathic macular telangiectasia and epiretinal membrane that occurs concomitantly. To our knowledge, this is the first report that describes an association between idiopathic macular telangiectasia and epiretinal membrane formation.

Paciente feminina de 46 anos apresentando queixa de embaçamento visual e visão distorcida em ambos os olhos. Ao exame oftalmológico, sua acuidade visual era 20/200 no olho direito e conta dedos a 5 metros no olho esquerdo. A fundoscopia revelou hemorragias perimaculares, dilatação aneurismática dos vasos no polo posterior e uma lesão elevada e esbranquiçada ao lado das alterações vasculares. Relatamos um caso de telangectasia macular idiopática e membrana epirretiniana que ocorreram concomitantemente. Até o momento, não existem relatos de associação entre telangiectasia macular e membrana epirretiniana.

Identifiable Peripheral Retinal Lesions Using Ultra-Widefield Scanning Laser Ophthalmoscope and Its Usefulness in Myopic Patients

PURPOSE: To investigate identifiable peripheral retinal lesions in patients with myopia or high myopia and to evaluate the usefulness of ultra-widefield scanning laser ophthalmoscope in retina clinic settings. METHODS: We evaluated fundus images of 149 patients acquired using an ultra-widefield scanning laser ophthalmoscope. Manual fundus examination by a retinal specialist was performed and sensitivity and specificity were calculated by comparing the findings of the two different fundus examination methods. RESULTS: Variable peripheral retinal lesions were observed: lattice degeneration (24.1% in myopia, 36.6% in high myopia), white without pressure (17.7% in myopia, 20.7% in high myopia), retinal break (5.1% in myopia, 7.5% in high myopia) and retinal detachment (1.3% in myopia, 4.2% in high myopia). The incidence of lattice degeneration was significantly higher in myopic eyes than in highly myopic eyes (p = 0.043). The examination sensitivities were as follows: lattice degeneration (84.2% in myopia, 91.0% in high myopia), white without pressure (100.0% in both myopia and high myopia), retinal break (75.0% in myopia, 43.8% in high myopia) and retinal detachment (100.0% in myopia, 66.7% in high myopia). The examination specificities were 100.0% in all cases. CONCLUSIONS: Diagnostic sensitivities of ultra-widefield scanning laser ophthalmoscope were 90.8% in patients with myopia, 91.0% in patients with high myopia and 90.9% in totally myopic patients, which were relatively high values. Therefore, the ultra- widefield scanning laser ophthalmoscope is useful as auxiliary equipment for myopic patients in retina clinic settings.

Identifiable Peripheral Retinal Lesions Using Ultra-Widefield Scanning Laser Ophthalmoscope and Its Usefulness in Myopic Patients

PURPOSE: To investigate identifiable peripheral retinal lesions in patients with myopia or high myopia and to evaluate the usefulness of ultra-widefield scanning laser ophthalmoscope in retina clinic settings. METHODS: We evaluated fundus images of 149 patients acquired using an ultra-widefield scanning laser ophthalmoscope. Manual fundus examination by a retinal specialist was performed and sensitivity and specificity were calculated by comparing the findings of the two different fundus examination methods. RESULTS: Variable peripheral retinal lesions were observed: lattice degeneration (24.1% in myopia, 36.6% in high myopia), white without pressure (17.7% in myopia, 20.7% in high myopia), retinal break (5.1% in myopia, 7.5% in high myopia) and retinal detachment (1.3% in myopia, 4.2% in high myopia). The incidence of lattice degeneration was significantly higher in myopic eyes than in highly myopic eyes (p = 0.043). The examination sensitivities were as follows: lattice degeneration (84.2% in myopia, 91.0% in high myopia), white without pressure (100.0% in both myopia and high myopia), retinal break (75.0% in myopia, 43.8% in high myopia) and retinal detachment (100.0% in myopia, 66.7% in high myopia). The examination specificities were 100.0% in all cases. CONCLUSIONS: Diagnostic sensitivities of ultra-widefield scanning laser ophthalmoscope were 90.8% in patients with myopia, 91.0% in patients with high myopia and 90.9% in totally myopic patients, which were relatively high values. Therefore, the ultra- widefield scanning laser ophthalmoscope is useful as auxiliary equipment for myopic patients in retina clinic settings.

Diagnóstico diferencial de edema de papila óptica / Differential diagnosis of optic disc swelling

Isoladamente, o edema de papila não costuma causar sintomatologia, porém, ao ser encontrado, pode auxiliar no diagnóstico de algumas condições clínicas. Neste capítulo serão descritas as principais causas do seu achado, além da técnica da realização do exame fundoscópico.

Lonely, papilledema doesn't causes symptoms, but, when we find it, it may help us doing diagnosis of some diseases. In this chapter we will find the leading causes of the origin of this disorder and the correct execution of fundoscopic exam.