Ophthalmologic findings in hepatitis C patients treated with pegylated interferon α-2b and ribavirin / Achados oftalmológicos nos pacientes portadores de hepatite C em tratamento com interferon peguilado α-2b e ribavirina

Purpose: To identify the effect of pegylated interferon α-2b and ribavirin treatment in the ocular fundus examination, visual acuity, and visual field. Methods: Prospective observational study was performed at the Hepatology Clinic of São José Regional Hospital and at the Vitreoretinal Department at the Sadalla Amin Ghanem Eye Hospital in patients with chronic hepatitis C before and during treatment with pegylated interferon α-2b together with ribavirin. Results: Six (37.5%) of 16 patients developed retinopathy during the treatment, two of which (12.5%) presented retinal hemorrhage, and four patients (6 eyes) presented cotton-wool spots (25%) that regressed during the treatment. One patient (6.25%) presented transient decrease in visual acuity during the treatment and recovered spontaneously without specific therapy. Conclusion: Recommended treatment methods for hepatitis C may cause transient retinopathy, commonly without any damage to visual function in most patients. Although ocular involvement is rare, follow-up with an ophthalmologist is recommended during the course of the hepatitis C medication. .

Objetivo: Identificar possíveis mudanças no exame de fundo de olho após o início do tratamento, bem como alterações na acuidade visual e campo visual. Métodos: Estudo observacional prospectivo realizado na Clínica de Hepatologia do Hospital Regional de São José e no Departamento de Vítreo e Retina do Hospital de Olhos Sadalla Amin Ghanem, em pacientes com hepatite C crônica antes e durante o tratamento com interferon peguilado α-2b associado à ribavirina. Resultados: Six (37,5%) dos 16 participantes desenvolveram retinopatia durante o tratamento, dois dos quais (12,5%) apresentaram hemorragia retiniana unilateral, e quatro pacientes com exsudatos algodonosos (25%), seis olhos, que regrediu durante o tratamento. Um participante (6,25%) apresentou diminuição transitória da acuidade visual durante o tratamento com recuperação espontaneamente sem tratamento específico. Conclusão: O tratamento recomendado para a hepatite C pode estar associado com o desenvolvimento de retinopatia transitória, geralmente sem dano à função visual na maioria dos pacientes. Embora o envolvimento ocular seja raro, o acompanhamento com o médico oftalmologista é recomendado durante todo o uso da medicação. .

Comparing the Efficacy of Latanoprost (0.005%), Bimatoprost (0.03%), Travoprost (0.004%), and Timolol (0.5%) in the Treatment of Primary Open Angle Glaucoma

PURPOSE: To compare the efficacy and safety of latanoprost, bimatoprost, travoprost and timolol in reducing intraocular pressure (IOP) in patients with primary open angle glaucoma. METHODS: This was a prospective study conducted at a tertiary-care centre. One hundred and forty patients with newly diagnosed primary open angle glaucoma were randomly assigned to treatment with latanoprost (0.005%), bimatoprost (0.03%), travoprost (0.004%) or timolol gel (0.5%); 35 patients were assigned to each group. All patients were followed for 2, 6, and 12 weeks. The main outcome measure studied was the change in IOP at week 12 from the baseline values. Safety measures included recording of adverse events. RESULTS: The mean IOP reduction from baseline at week 12 was significantly more with bimatoprost (8.8 mmHg, 35.9%) than with latanoprost (7.3 mmHg, 29.9%), travoprost (7.6 mmHg, 30.8%) or timolol (6.7 mmHg, 26.6%) (ANOVA and Student's t-tests, p < 0.001). Among the prostaglandins studied, bimatoprost produced a maximum reduction in IOP (-2.71; 95% confidence interval [CI], -2.25 to -3.18) followed by travoprost (-1.27; 95% CI, -0.81 to -1.27) and latanoprost (-1.25; 95% CI, -0.79 to -1.71); these values were significant when compared to timolol at week 12 (Bonferroni test, p < 0.001). Latanoprost and travoprost were comparable in their ability to reduce IOP at each patient visit. Ocular adverse-events were found in almost equal proportion in patients treated with bimatoprost (41.3%) and travoprost (41.9%), with a higher incidence of conjunctival hyperemia (24.1%) seen in the bimatoprost group. Timolol produced a significant drop in heart rate (p < 0.001) at week 12 when compared to the baseline measurements. CONCLUSIONS: Bimatoprost showed greater efficacy when compared to the other prostaglandins, and timolol was the most efficacious at lowering the IOP. Conjunctional hyperemia was mainly seen with bimatoprost. However, the drug was tolerated well and found to be safe.

Chlorogenic Acid Supplementation Improves Multifocal Electroretinography in Patients with Retinitis Pigmentosa

To evaluate the effect of chlorogenic acid supplementation in patients with retinitis pigmentosa, we evaluated objective change in visual function with multifocal electroretinography, along with visual acuity, visual field, standard electroretinography, and contrast sensitivity. Eighteen patients diagnosed with retinitis pigmentosa were enrolled in this prospective, non-comparative, single-arm study. Multifocal electroretinography, best-corrected visual acuity in Early Treatment Diabetic Retinopathy Study letters, total point score on visual field examination with Humphrey Field Analyzer II, electroretinography, and contrast sensitivity were measured and repeated after 3 months supplementation with chlorogenic acid. The amplitude of ring 5 was significantly higher on multifocal electroretinography after 3 months of chlorogenic acid supplementation (7.2 +/- 9.5 vs 8.3 +/- 10.8 nV/deg2, mean +/- standard deviation, P = 0.022). There were no significant changes in the best-corrected visual acuity, total point score on Humphrey Field Analyzer, 30 Hz flicker amplitude on standard electroretinography, or contrast sensitivity. Chlorogenic acid may have a beneficial effect on the peripheral area at the margins of retinal degeneration, and should be considered as an anti-oxidant for the management of retinitis pigmentosa.

Management of ischemic optic neuropathies.

Ischemic optic neuropathies (IONs) consist primarily of two types: anterior ischemic optic neuropathy (AION) and posterior ischemic optic neuropathy (PION). AION comprises arteritic AION (A-AION: due to giant cell arteritis) and non-arteritic AION (NA-AION: due to other causes). PION consists of arteritic PION (A-PION: due to giant cell arteritis), non-arteritic PION (NA-PION: due to other causes), and surgical PION (a complication of several systemic surgical procedures). These five types of ION are distinct clinical entities etiologically, pathogenetically, clinically and from the management point of view. In the management of AION, the first crucial step with patients aged 50 and over is to identify immediately whether it is arteritic or not because A-AION is an ophthalmic emergency and requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. Patients with NA-AION, when treated with systemic corticosteroid therapy within first 2 weeks of onset, had significantly better visual outcome than untreated ones. Systemic risk factors, particularly nocturnal arterial hypotension, play major roles in the development of NA-AION; management of them is essential in its prevention and management. NA-PION patients, when treated with high-dose systemic steroid therapy during the very early stages of the disease, showed significant improvement in visual acuity and visual fields, compared to untreated eyes. A-PION, like A-AION, requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. There is no satisfactory treatment for surgical PION, except to take prophylactic measures to prevent its development.

Métodos diagnósticos para retinopatia induzida pelo difosfato de cloroquina nos portadores de lúpus eritematoso sistêmico / Diagnostic methods for chloroquine diphosphate induced retinopathy in systemic lupus erythematosus

OBJETIVOS: Avaliar diferentes métodos diagnósticos para a avaliação de pacientes portadores de lúpus eritematoso sistêmico, usuários crônicos do difosfato de cloroquina (DFC) e, portanto, com alto risco para retinopatia tóxica. MÉTODOS: Foram analisados 72 olhos de 36 pacientes consecutivos, seguidos no Serviço de Reumatologia do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, de julho de 2007 a abril de 2008. Dados demográficos e clínicos foram avaliados com o intuito de estudar os fatores de alto risco e comparar os seguintes métodos oftalmológicos: acuidade visual, biomicroscopia da córnea, biomicroscopia do fundo, retinografia, angiofluoresceinografia da retina, campo visual macular com mira branca. RESULTADOS: Dos 36 pacientes, 34 (94,4 por cento) eram mulheres. A média de idade foi 39,9 ± 9,8 anos, com tempo de doença igual a 13,9 ± 6,6 anos. Além do uso crônico da cloroquina, os pacientes apresentaram altas doses diárias (>3 mg/kg) e cumulativas. Não foi observada relação entre estes fatores de alto risco e maior prevalência de retinopatia. Foi encontrada prevalência de retinopatia igual a 38,9 por cento, confirmada por alterações bilaterais, centrais ou paracentrais e reprodutíveis no exame de campo visual. Outros exames indicados para seguimento, como acuidade visual, biomicroscopia de fundo e angiofluoresceinografia não foram capazes de diagnosticar a maioria das alterações confirmadas pelo campo visual. CONCLUSÃO: Foi observada alta prevalência de retinopatia por cloroquina entre os pacientes com alto risco, usuários crônicos do DFC, segundo os achados do campo visual. A avaliação desses pacientes deve considerar a realização do exame de campo visual em intervalos menores que os propostos, mesmo quando não há suspeita clínica.

PURPOSE: To evaluate different diagnostic methods for high risk chloroquine retinopathy due to prolonged use of chloroquine (more than 5 years) by systemic lupus erythematosus patients. Methods: Seventy-two eyes of 36 consecutive patients, followed in the Division of Rheumatology, School of Medicine, University of São Paulo, were analyzed from July 2007 to April 2008. Demographic and clinical data were evaluated in order to study risk factors and to compare the following different ophthalmological methods: visual acuity, biomicroscopy, fundus examination, retinography, fluorescein angiogram, visual field test and, color vision tests. RESULTS: From 36 patients, 34 (94.4 percent) were female. The mean age was 39.9 ± 9.8 years and the disease duration was 13.9 ± 6.6 years. Besides chronic use of chloroquine, patients also showed high daily and cumulative doses. These high risk factors were not related to a higher retinopathy prevalence. Visual field showed 38.9 percent of retinopathy prevalence. Other ophthalmological methods failed in detecting most cases. CONCLUSION: High prevalence of retinopathy in high risk patients was observed by visual field test, but other ophthalmological methods failed in detecting alterations. Ophthalmological assessment of these patients should include visual field, even in the absence of clinical alterations.

Efeitos da ibopamina 2 por cento tópica nos resultados da campimetria visual computadorizada / Effects of 2 percent ibopamine eye drops on computerized visual field results

OBJETIVO: Avaliar os efeitos do uso do colírio de ibopamina a 2 por cento nos resultados da campimetria visual computadorizada em indivíduos normais. MÉTODOS: Voluntários oriundos do CEROF-UFG, sem alterações ao exame oftalmológico que pudessem afetar o campo visual foram selecionados. Os indivíduos foram submetidos a exame de perimetria computadorizada SITA-standard 24-2 antes e após dilatação com o colírio de ibopamina a 2 por cento ou ciclopentolato, com intervalo mínimo de 3 dias entre si e em ordem aleatória. Índices globais e número de pontos alterados foram comparados entre os grupos. RESULTADOS: Foram avaliados 30 olhos de 30 indivíduos normais. Não houve diferença estatisticamente significativa entre o "mean deviation" (MD) nos pacientes não dilatados e nos mesmos após a instilação da ibopamina (MD: -1,05 ± 0,26 dB vs. -1,47 ± 0,20 dB, P=0,08), o que ocorreu após cicloplegia (MD: -3,19 ± 0,29 dB), P<0,001 para ambos. Na avaliação entre cicloplegia e pré-dilatação, nota-se significância para o "pattern standard deviation" (P=0,04), o que não ocorreu na avaliação com ibopamina. O número de pontos alterados no "pattern deviation" não apresentou diferença significativa entre todos os pares. Quanto ao número de pontos do "total deviation", houve diferença estatisticamente significativa antes da dilatação e após o uso do cicloplégico (n: 8,86 ± 1,51 vs. 25,72 ± 2,96 pontos, P<0,001) e entre olhos após a instilação do cicloplégico e da ibopamina (ibopamina: 9,75 ± 1,85 pontos, P<001). CONCLUSÃO: O colírio de ibopamina 2 por cento aparentemente não afeta os resultados da perimetria computadorizada em indivíduos normais.

PURPOSE: To evaluate the influence of 2 percent ibopamine eye drops on the results of computerized visual field exams. METHODS: Normal volunteers from CEROF-UFG were selected, with no variance in the ophthalmologic examination that could affect the visual field test. The volunteers underwent computerized visual field test before and after dilation with 2 percent ibopamine eye drop or cyclopentolate, with a minimum interval of three days between them and in a random order. Global indices and number of altered points were compared between the groups. RESULTS: Thirty eyes of 30 normal individuals were selected. There was no statistically significant difference on Mean Deviation (MD) before and after dilation with ibopamine (MD: -1.05 ± 0.26 dB vs. -1.47 ± 0.20 dB, P=0.08). However, after cycloplegia (MD: -3.19 ± 0.29 dB), there was a significant difference on MD (P<0.001 for both ibopamine and pre-dilation). No significant difference was detected in the Pattern Standard Deviation when comparing ibopamine with pre-dilation and cycloplegia values, but it was statistically significant comparing pre-dilation to cycloplegia (P=0.04). The number of altered points in the Pattern Deviation graphic were not significant comparing all pairs. There was a statistically significant difference in the number of altered points in the total deviation graphic before dilation and after cycloplegia (n: 8.86 ± 1.51 vs. 25.72 ± 2.96 points, P<0.001), and comparing cycloplegia with ibopamine (ibopamine: 9.75 ± 1.85 points, P<0.001). CONCLUSION: Ibopamine 2 percent eye drops seem to not modify the results of visual field tests in normal individuals.

Vigabatrin and Visual Field Defects in Pediatric Epilepsy Patients

We studied the prevalence, type and severity of vigabatrin (VGB)-attributed visual field defects (VFDs), and used these data to assess the associated risk factors in pediatric patients. Medical records were retrospectively reviewed for 67 pediatric patients who received VGB alone or in combination with other antiepileptic drugs, and who had undergone visual field examinations using a Humphrey visual field analyzer. Of the 67 patients, 15 had VGB-attributed VFDs: 13 had nasal arcuate type, 1 had nasal and temporal constricted type and 1 had nasal constricted type. In terms of severity, 7 patients had Grade I VGB-attributed VFDs, 5 had Grade II, 2 had Grade III, and 1 had Grade IV. Although there were no significant differences between the VFD and non-VFD groups with regards to all tested parameters, there were no cases of VGB-attributed VFDs in patients with total treatment durations <2 yr and cumulative doses <10 g/kg. In conclusion, the prevalence of VGB-attributed VFDs in VGB-treated pediatric epilepsy patients was 22%. The high frequency of VGB-attributed VFDs indicates that physicians should inform all patients of this risk prior to VGB treatment and perform periodic visual field examinations.

Avaliação da eficácia e tolerabilidade da vigabatrina na síndrome de West / Efficacy and tolerability of vigabatrin in West syndrome

A síndrome de West (SW) é uma epilepsia grave específica da infância, que se caracteriza pela tríade: espasmos em salvas, deterioração ou atraso neuropsicomotor e hipsarritmia ao eletrencefalograma. OBJETIVO: Avaliar a eficácia e segurança da vigabatrina (VGB) no tratamento da SW. MÉTODO: Foram sujeitos do estudo todos os pacientes com diagnóstico estabelecido de SW, que freqüentam ou freqüentaram o Ambulatório de Epilepsia Infantil do Hospital das Clínicas da UNICAMP, usam ou usaram VGB na tentativa de controlar as crises. Avaliamos sexo, idade, etiologia (sintomática ou criptogênica), doença(s) associada(s), idade do início dos espasmos, freqüência das crises antes e após o uso de VGB, achados de neuroimagem, EEG antes e depois do uso de VGB, medicações associadas, tempo para controle das crises, eletroretinograma, queixa visual após uso de VGB, efeitos adversos e história familial de epilepsia. RESULTADOS: Foram avaliados 23 pacientes, sendo 16 do sexo masculino. A idade variou entre 1ano e 3 meses a 11 anos e 5meses (média = 5anos e 3meses). Dezesseis (69,5 por cento) pacientes apresentaram controle completo das crises, 5 (22 por cento) tiveram controle parcial e em 2 (8,5 por cento) pacientes os espasmos não foram controlados. Apenas uma paciente teve retinopatia gabaérgica. Seis pacientes (26 por cento) apresentaram eventos adversos - sonolência, agressividade ou retinopatia. Os pacientes com o início da SW após 6 meses de idade apresentaram melhor resposta à VGB (p<0,05). Não houve diferença na resposta ao tratamento quanto ao tempo de introdução da VGB ou à etiologia (p>0,05). Após o tratamento com VGB, nenhum EEG apresentou hipsarritmia e 50 por cento normalizaram. CONCLUSÃO: Apesar do risco de retinopatia gabaérgica, os resultados acima mostram que o uso da VGB no controle dos espasmos infantis se justifica em pacientes com SW.

Estudo da circulaçäo retrobulbar e do campo visual após dose única oral de citrato de sildenafil (Viagra) / Study of retrobulbar circulation and visual field after oral single dose of sildenafil citrate (Viagra)

Objetivo: Estudar os efeitos na circulaçäo retrobulbar e no campo visual de uma dose oral única de 100 mg de citrato de sildenafil (Viagra). Métodos: Um estudo duplo-mascarado e controlado por placebo foi realizado em 10 voluntários do sexo masculino, com idade média de 27,7 ñ 5,68 anos. O olho direito de cada voluntário foi submetido aos exames de Doppler colorido de órbita e análise de campo visual por meio de perimetria computadorizada (Humphrey, programa 30-2, estratégia "Full Threshold") em 3 ocasiöes: "baseline",1 hora após placebo e 1 hora após 100 mg de sildenafil via oral. No campo visual, analisaram-se o limiar foveal e o "mean deviation" (MD) nas 3 ocasiöes. No Doppler colorido, medimos a velocidade sistólica máxima (VSM), a velocidade diastólica final (VDF) e o índice de resistência (IR) da artéria central da retina (ACR) e da artéria oftálmica (AO) nas 3 ocasiöes. Resultados: A administraçäo do sildenafil näo alterou significativamente o limiar foveal e o "mean deviation" em relaçäo ao "baseline" e ao placebo. Houve um aumento significativo da velocidade sistólica máxima e velocidade diastólica final na artéria oftálmica após a administraçäo do citrato de sildenafil (p<0,001). Näo houve alteraçäo significativa dos parâmetros hemodinâmicos na artéria central da retina e no índice de resistência da artéria oftálmica. Conclusöes: A administraçäo de 100 mg de citrato de sildenafil promoveu um aumento da velocidade de fluxo sanguíneo na artéria oftálmica de indivíduos normais e näo promoveu alteraçäo significativa no limiar foveal e "mean deviation" da campimetria computadorizada.

Estudio comparativo de sensibilidad macular en pacientes tratados con metotrexate y cloroquina, en artritis reumatoide / Comparative study of macular sensibility in subjects with theumatoid arthritis in pharmacological treatment with methotrexate and chloroquine

El metotrexate (MTX) es una droga de uso reciente en el tratamiento de artritis reumatoide (AR) a dosis de 10-15 mg/m2/semana, por su rápido efecto antiinflamatorio. En la actualidad los reportes sobre efectos secundarios a nivel ocular son escasos. Este es un estudio donde se han incluido pacientes de ambos sexos, con antecedentes de AR, colaboradores, orientados, con agudeza visual de 20/40 o mejor, sin otra enfermedad sistémica.

La prueba de sensibilidad de contraste y el campo visual central en el diagnóstico de retinopatía por cloroquina / The contrast sensitivity testing and central visual field in the diagnosis of chloroquine retinopathy

Objetivo. Determinar la respuesta de la prueba de sensibilidad de contraste Vistech en pacientes que reciben cloroquina y comparar esta prueba visual con la campimetría central mira roja, con el estudio de fondo de ojo y con la agudeza visual. Método. Se trata de un estudio observacional, transversal y prospectivo que se realizó en el Servicio de Oftalmología del Hospital General de México. Incluyó pacientes ambulatorios tratados con cloroquina por un año o más tiempo, debido a enfermedades del tejido conectivo. Practicamos exploración oftalmológica completa, además de fluorangiografía en casos de alteración retiniana. Se realizó campo visual con Humphrey mira roja III en los 10 grados centrales, considerado anormal la disminución de sensibilidad mayor de cinco decibeles en uno o más puntos. La prueba de sensibilidad de contraste se hizo en ambos ojos con agudeza visual corregida de 20/20, 20/25 y 20/30; comparando el resultado con una curva normal realizada con la misma visión. Resultados: Fueron estudiados 47 pacientes (46 mujeres y un hombre) con edad promedio de 39.2 años, cuyos diagnósticos de base fueron: artritis reumatoide, lupus eritematoso y dermatitis solar. La prueba de sensibilidad de contraste fueron más frecuentes que el daño retiniano (25.5 por ciento). La baja de agudeza visual no se relacionó con la dosis del medicamento. Conclusiones. Encontramos alta prevalencia de pruebas anormales con sensibilidad de contraste y en el campo visual central con mira roja. La prueba de sensibilidad de contraste es una poderosa herramienta que determina la capacidad del sistema visual para procesar información espacial y temporal sobre los objetos que cada día vemos; de acuerdo con los resultados de este estudio, es recomendable para evaluar la toxicidad por cloroquina

The influence of miotics on the visual field

This study reports the influence of miotics (pilocarpine) on the visual field by comparing two visual fields, one at the miotic state and the other at normal pupil size. The measurements from the Goldmann perimetry test of 10 ocular hypertensive eyes (7 patients) and 10 glaucomatous eyes (8 patients) were used. The visual field was analyzed using an Esterman grid for functional estimation and section paper for gross evaluation. The results were as follows; 1. A decrease in pupillary size eaused not only a decrease in the gross visual field but also a reduction in the functional visual field. 2. The pupillary size did not influence absolute scotoma.