Acupuncture for glaucoma-induced optic atrophy: a randomized controlled trial / 中国针灸

OBJECTIVE@#To observe the clinical effect of acupuncture for glaucoma-induced optic atrophy.@*METHODS@#A total of 70 patients (89 affected eyes) with glaucoma-induced optic atrophy were randomized into an observation group and a control group, 35 cases in each group. The control group was given basic western medicine treatment. In the observation group, on the basis of the treatment in the control group, acupuncture was applied at main acupoints i.e. Baihui (GV 20), Shangjingming (Extra), Chengqi (ST 1), Fengchi (GB 20), Zusanli (ST 36), combined with supplementary acupoints based on syndrome differentiation, once every three days, twice a week. The treatment for 3 months was required in both groups. Before treatment, after treatment and in follow-up of 6 months after treatment, the best corrected visual acuity (BCVA), intraocular pressure (IOP), indexes of visual field (visual field index [VFI], mean deviation [MD], pattern standard deviation [PSD]) and mean thickness of retinal nerve fiber layer (RNFL) were observed in the two groups.@*RESULTS@#Compared before treatment, BCVA was decreased after treatment and in follow-up in the control group (P<0.05); in the follow-up, BCVA in the observation group was higher than that in the control group (P<0.05). On each time point before and after treatment, there was no significant difference within or between the two groups (P>0.05). After treatment and in the follow-up, the mean thickness of RNFL was larger than the control group (P<0.05).@*CONCLUSION@#On the basis of the basic western medicine treatment, acupuncture can delay the decline of vision and the thinning of retinal nerve fiber layer in patients with glaucoma-induced optic atrophy.

Trauma ocular a globo cerrado en la edad pediátrica / Closed globe injuries in pediatric age

Los traumas oculares son frecuentes en las urgencias de oftalmología. El tratamiento constituye un reto para el oftalmólogo, pues se enfrenta a un daño integral y complejo. Se presenta un paciente de 16 años, el cual fue hospitalizado en el Instituto Cubano de Oftalmología Ramón Pando Ferrer hace cuatro años por haber recibido un trauma contuso en ojo derecho el cual provocó hifema total. Durante su estadía hospitalaria se realiza lavado de cámara anterior ya que no se logró la reabsorción espontánea del mismo. Al visualizarse todas las estructuras oculares se diagnostican complicaciones como subluxación del cristalino, catarata, panuveítis, hemovítreo, desgarro retiniano y glaucoma traumáticos. Se bloquea el desgarro con láser y una vez compensado el cuadro inflamatorio, es egresado bajo tratamiento y seguimiento por oftalmología pediátrica. No se logra controlar el glaucoma y se implanta dispositivo de drenaje Molteno lo que estabiliza la tensión ocular. Se realiza posteriormente cirugía de catarata, manteniéndose compensado del glaucoma sin tratamiento y con calidad visual(AU)

Ocular traumas are frequent in ophthalmology emergencies. Treatment is a challenge for the ophthalmologist, as he faces a comprehensive and complex damage. A 16-year-old patient is presented, who was hospitalized at the Cuban Institute of Ophthalmology Ramón Pando Ferrer 4 years ago for having received a blunt trauma to the right eye which caused total hyphema. During his hospital stay, anterior chamber lavage was performed since spontaneous reabsorption was not achieved. When all ocular structures are visualized, complications such as lens subluxation, cataract, panuveitis, hemovitreous, traumatic retinal tear and glaucoma are diagnosed. The tear was blocked with a laser and once the inflammatory condition was compensated, he was discharged under treatment and monitoring by pediatric ophthalmology. The glaucoma could not be controlled and a Molteno drainage device was implanted, which stabilizes the ocular tension. Cataract surgery was subsequently performed, keeping the glaucoma compensated without treatment and with visual quality(AU)

Esclerectomía profunda no penetrante en el glaucoma avanzado / Non-penetrating deep sclerectomy in advanced glaucoma

El tratamiento del glaucoma se realiza con el objetivo de disminuir los niveles de presión intraocular, único factor tratable hasta el momento, y debe ser individualizado. Se presenta un paciente masculino de 54 años de edad, de piel mestiza, intelectual, con antecedentes de aparente salud y diagnóstico de glaucoma desde hace 10 años. Se realizó trabeculectomía con antimetabolito (mitomicina C) en el ojo izquierdo en el año 2012 por daño glaucomatoso avanzado. En el año 2016 acudió a nuestra consulta y refirió mala visión y descontrol de la presión intraocular de ambos ojos. Se constataron cifras muy elevadas de presión intraocular en ambos ojos, superiores a 30 mmHg; en el ojo derecho la unidad de visión con su mejor corrección y un daño campimétrico muy avanzado limitado a una isla de visión central con caída hasta los 5° centrales, y el ojo izquierdo no alcanzaba la percepción luminosa. Después de combinar 3 líneas farmacológicas con la dosis máxima, los valores de la presión intraocular no eran protectores. Surgió la disyuntiva entre realizar una cirugía filtrante, temiendo al riesgo quirúrgico elevado y tratándose de un ojo único, o no practicar cirugía alguna y solo continuar con el tratamiento farmacológico a pesar de no conseguirse valores de presión intraocular meta. Se decidió realizar esclerectomía profunda no penetrante con antimetabolito (mitomicina C al 0,02 por ciento). No se presentaron complicaciones asociadas y se consiguió el descenso de la presión intraocular a 24 mmHg, por lo que al mes de la cirugía se realizó goniopuntura. Se obtuvo la presión intraocular objetivo, sin progresión del daño glaucomatoso y hubo conservación de la agudeza visual(AU)

Treatment for glaucoma is aimed at reducing the levels of intraocular pressure. This is the only factor that may be treated so far, and it should be individualized. A case is presented of a male 54-year-old mulatto patient, intellectual, with a history of apparently good health who was diagnosed with glaucoma ten years ago. Trabeculectomy with antimetabolite (mitomycin C) was performed on the patient's left eye in the year 2012 due to advanced glaucomatous damage. In the year 2016 the patient attended our service and reported poor vision and uncontrolled intraocular pressure in both eyes. Very high intraocular pressure values above 30 mmHg were confirmed in both eyes. In the right eye the vision unit with its best correction, and very advanced campimetric damage limited to a central vision island with a fall to 5° central, whereas the left eye did not achieve light perception. After combining 3 drug lines at their maximum dosage, intraocular pressure values were not protective. The dilemma arose whether to perform filtration surgery, fearing the high surgical risk, being as it was a single eye, or not to perform any surgery and just go on with the drug treatment despite not having achieved target intraocular pressure values. It was decided to perform non-penetrating deep sclerectomy with antimetabolite (0.02 percent mitomycin C). No associated complications occurred and intraocular pressured fell to 24 mmHg. Therefore, goniopuncture was performed one month after surgery. The target intraocular pressure was obtained without glaucomatous damage progression and visual acuity was preserved(AU)

Pseudoexfoliación ocular: un signo de alerta temprana de enfermedades sistémicas / Ocular pseudoexfoliation: an early warning signal in systemic diseases

El síndrome pseudoexfoliativo es una enfermedad relacionada con la edad, que afecta a la población mayor de 60 años y tiene una distribución mundial. Se caracteriza por la producción y la acumulación progresiva de un material fibrilar extracelular a nivel de las distintas estructuras del ojo, con repercusiones significativas sobre la salud ocular de los pacientes y, además, conduce a complicaciones quirúrgicas. El material pseudoexfoliativo no solo se encuentra en el globo ocular, sino en distintas partes del organismo, como el corazón, los pulmones, el cerebro y los vasos sanguíneos, por lo que algunos estudios sugieren la relación de este síndrome con ciertas afecciones cardíacas. Se presenta un paciente de 74 años de edad, negro, con antecedentes de hipertensión arterial, que se ingresa por pérdida brusca de la visión de ambos ojos, acompañado de dolor. Al examen oftalmológico, después del tratamiento hipotensor, se constató material pseudoexfolitivo y cristalino subluxado a cámara vítrea. Se diagnosticó glaucoma pseudoexfoliativo, disfunción asintomática del miocardio, hiperlipidemia, ateroma en la aorta abdominal e hipoacusia neurosensorial severa. Existen estudios que sugieren relación del síndrome pseudoexfoliativo con ciertas enfermedades y factores de riegos vasculares con alto impacto en la morbimortalidad a nivel mundial(AU)

Pseudoexfoliation syndrome is an aging-related disease of worldwide distribution affecting people aged over 60 years. It is characterized by progressive production and accumulation of extracellular fibrillar material in the different structures of the eye, with significant impacts on the patients' ocular health. It may also lead to surgical complications. Pseudoexfoliative material is not only found in the eyeball, but also in various parts of the body, such as the heart, the lungs, the brain and blood vessels, this being the reason why some studies suggest a relationship to certain heart conditions. A case is presented of a male black 74-year-old patient with a history of arterial hypertension, admitted due to sudden vision loss in both eyes, accompanied by pain. The ophthalmological examination performed after hypotensive treatment confirmed the presence of pseudoexfoliative material and crystalline subluxated to the vitreous chamber. The diagnosis was pseudoexfoliation glaucoma, asymptomatic myocardial dysfunction, hyperlipidemia, abdominal aorta atheroma and severe neurosensory hypoacusis. Some studies suggest a relationship between pseudoexfoliation syndrome and certain vascular diseases and risk factors with a high impact on worldwide morbidity and mortality(AU)

Manifestação ocular incomum em paciente com incontinência pigmentar / Unusual ocular manifestation in a patient with incontinentia pigmenti

RESUMO Incontinência pigmentar, também conhecida como síndrome de Bloch-Sulzberger, é uma doença rara de herança dominante ligada ao X cujas manifestações clínicas incluem lesões dermatológicas típicas combinadas com acometimento neurológico, oftalmológico e dentário. Alterações oculares são comuns e variadas, sendo o acometimento da retina o mais frequente e associado a perda visual severa. Foi relatado um caso de uma criança com perda visual grave decorrente de glaucoma, sem alteração retiniana significativa.

ABSTRACT Incontinentia pigmenti, also known as Bloch-Sulzberger syndrome, is a rare dominant X-linked inheritance disease whose clinical manifestations include typical dermatological lesions combined with neurological, ophthalmic and dental involvement. Ocular involvment is common and diverse and retinal changes are the most frequent and associated with serious visual loss. We reported a case of a child with severe visual loss due to glaucoma, with no significant retinal changes.

Nuevas constelaciones de medicamentos para el glaucoma / New drug constellations for glaucoma

La presente revisión tiene como objetivo presentar las nuevas opciones terapéuticas para el tratamiento del glaucoma. El tratamiento médico del glaucoma ha experimentado una evolución sorprendente a partir de la aparición de nuevos colirios hipotensores. Diferentes firmas investigan actualmente las opciones terapéuticas más sencillas, eficaces y mejor toleradas por los pacientes. Los análogos de las prostaglandinas se consideran la primera línea de tratamiento; sin embargo, se desarrollan nuevas drogas con resultados prometedores, como latanoprostene bunod (Vesneo), netarsudil 0,02 por ciento (Rhopressa), trabodenoson (Inotek Pharmaceutical) y otros compuestos de liberación sostenida. Se han generado innumerables ensayos clínicos, así como publicaciones que se refieren al tema en los Estados Unidos, la Unión Europea y Japón, los cuales curiosamente han sido denominados con nombres de planetas o constelaciones(AU)

The present review is aimed at presenting the new therapeutic options to treat glaucoma. Medical treatment of glaucoma has undergone surprising progress as of the emergence of new hypotensive collyriums. Various firms are currently conducting research into the simplest, most effective and best tolerated therapeutic alternatives. Prostaglandin analogues are considered to be the first line therapy, but new, promising drugs are also being developed, such as latanoprostene bunod (Vesneo), netarsudil 0.02 percent (Rhopressa), trabodenoson (Inotek Pharmaceuticals) and other sustained release compounds. A large number of clinical assays have been implemented and many publications have been made in the United States, the European Union and Japan which, curiously enough, have been given names of planets or constellations(AU)

Beneficios y riesgos de dispositivos de drenaje para tratamiento de glaucoma / Benefits and risks of glaucoma drainage devices for glaucoma treatment

En el tratamiento del glaucoma se suele iniciar con medicamentos. En segunda instancia, se recurre a cirugías o implante de dispositivos de drenaje. Los dispositivos de drenaje son usados para tratar glaucomas refractarios (no responden a tratamiento médico o cirugías), cuando la trabeculectomía o cualquier cirugía falla en el control de la presión intraocular. En la actualidad existe una gama de diseños que básicamente consisten en un tubo que drena humor acuoso desde la cámara anterior o posterior a un plato ubicado en la zona ecuatorial del ojo. Asimismo, los dispositivos de drenaje han tenido un avance significativo en los últimos años, y han variado el mecanismo de acción, los materiales, las dimensiones y las indicaciones de uso. Este trabajo proporciona información sobre el estado del arte del glaucoma, así como una revisión sistemática de la literatura sobre los dispositivos de drenaje, que describe su mecanismo de funcionamiento, las principales ventajas, la efectividad medida según la variación de la presión intraocular y las complicaciones más importantes halladas en cada estudio(AU)

The glaucoma treatment may be started with drugs, followed by surgeries or implantation of drainage devices. Drainage devices are used to treat refractory glaucomas (they do not respond to medical treatment or surgeries) when trabeculectomy fails to control intraocular pressure. There is a range of designs that basically consist of a tube that drains aqueous humor from the anterior or posterior chamber to a plate located in the equatorial area of the eye. Likewise, drainage devices have made significant progress in recent years, varying the mechanism of action, materials, dimensions and indications of use. This paper provides information on the state of the art of glaucoma, as well as a systematic literature review on the main drainage devices, describing its mechanism of operation, main advantages, effectiveness measured according to the variation of intraocular pressure and the most important complications found in each study(AU)

Custo-efetividade no glaucoma. Conceitos, resultados e perspectiva atual / Cost-effectiveness in glaucoma. Concepts, results and current perspective

RESUMO O glaucoma é a principal causa de cegueira irreversível no Brasil. Sua prevalência e incidência tendem a aumentar significativamente no futuro, principalmente devido ao aumento da população e ao seu envelhecimento. A escassez de recursos para a saúde associada ao aumento da disponibilidade e dos custos das tecnologias em saúde exige uma análise parametrizada destas tecnologias e uma alocação eficiente dos recursos. Os estudos de custo-efetividade e custo-utilidade são importantes, pois permitem uma comparação entre diferentes alternativas tanto em termos de seus custos quanto de seus resultados. Para isto, modelos matemáticos (como modelagem de Markov) são comumente utilizados como método de análise. Existem na literatura muitas evidências de custoefetividade e custo-utilidade no glaucoma, inclusive no Brasil. Este artigo se propõe a revisar de maneira prática os conceitos de avaliação econômica em saúde, os tipos de estudos econômicos em saúde, bem como os resultados dos estudos de custo-efetividade e custo-utilidade na área de glaucoma na literatura.

ABSTRACT Glaucoma is the leading cause of irreversible blindness in Brazil. Its prevalence and incidence tend to increase significantly in the future, mainly due to the population increase and aging. The scarcity of health care resources and the increasing costs in health require a balanced analysis of health interventions and an efficient allocation of resources. The cost-effectiveness and cost-utility studies are important because they allow a comparison between different alternatives in terms of both their costs and their results. For this purpose, mathematical modeling (such as Markov modeling) is commonly used as the analytical method. The literature, including in Brazil, has plenty of evidence of cost-effectiveness and cost-utility in glaucoma. This article aims to review in a practical way the concepts of economic evaluation in health, describe the different types of health economic studies, as well as the results of cost-effectiveness and cost-utility studies in glaucoma in the literature.

“I will not cut, even for the stone”: origins of urology in the hippocratic collection

The Hippocratic Collection, including the most of ancient Greek medicine, remains still interesting, despite the recent advances that transformed definitely the urological healing methods. Considering the patient as a unique psycho-somatic entity and avoiding high risk surgical manipulations were the leading principles dictating the everyday practice. Contemporary physicians can still learn from the clinical observations in times of complete absence of laboratory or imaging aid, from the prognostic thoughts, the ethics, and the philosophical concepts, represented by the Hippocratic writings, tracing into them the roots of Rational Medicine in general and Urology in particular.

Comparación en la medición de presión intraocular con los tonómetros de Goldmann, Pascal® y ORA (Ocular Response Analyzer) / Intraocular pressure measurement with Goldmann, Pascal and ORA tonometers

Introducción: el glaucoma es la principal causa de ceguera irreversible en el mundo, siendo la presión intraocular alta el factor de riesgo más importante para desarrollarlo, por eso la importancia de realizar una adecuada medición de la presión intraocular (PIO) durante el examen oftalmológico. Objetivo: evaluar la concordancia de la medida de la presión intraocular tomada con los tonómetros de Goldmann, Pascal® y ORA, en pacientes con glaucoma de la consulta externa del servicio de oftalmología del Hospital de San José. Diseño: estudio descriptivo, de corte transversal y concordancia. Métodos: se compararon las medidas de Goldmann corregido, Pascal® y ORA corregido en 90 pacientes (167 ojos) con diagnóstico de glaucoma que asisten a consulta de oftalmología del Hospital de San José. Resultados: el coeficiente de correlación y concordancia de Lin entre Goldmann corregido y Pascal® es de 0.61; entre Goldmann corregido y ORA corregido de 0.64 y entre Pascal® y ORA corregido de 0.81. Conclusiones: se encontró una concordancia moderada para los tres tonómetros en la medición de la PIO en los ojos con glaucoma del servicio de oftalmología del Hospital de San José. Los tres métodos no son reemplazables, por lo tanto el seguimiento de los pacientes siempre debe ser tomado con un mismo método.

Introduction: glaucoma is the leading cause of worldwide irreversible blindness, high intraocular pressure remains the most important risk factor; because of that, it is essential to measure accurately the intraocular pressure (IOP). Objective: to evaluate the intraocular pressure correspondence of Goldmann-correlated IOP, Pascal® dynamic contour tonometer and Reichert Ocular Response Analyzer ORA tonometers in patients with glaucoma diagnosis at Ophthalmology Service, Hospital de San José. Design: a descriptive, cross-sectional and matching. Methods: measurements of Goldmann correlated IOP, Pascal® and ORA corneal compensated IOP were compared, in patients (167 eyes) diagnosed with glaucoma attending at ophthalmology Hospital San José. Results: the correlation coeffi cient and concordance Lin between Goldmann correlated IOP and Pascal® is 0.61; between ORA and Goldmann correlated IOP is 0.64 and between Pascal® and ORA is 0.81. Conclusions: we found a moderate agreement for the three tonometers for measuring IOP in eyes glaucoma attending at ophthalmology Hospital San José. The three methods are not replaceable, therefore monitoring of patients should always be taken with the same method.

Evaluación del complejo ganglionar celular mediante tomografía de coherencia óptica en pacientes con hipertensión ocular / Ganglion cell complex evaluation with optical coherence tomography in patients with ocular hypertension

Objetivos: determinar el espesor del complejo ganglionar celular (CGC) mediante tomografía de coherencia óptica de dominio de Fourier (FD-OCT) en pacientes con diagnóstico de hipertensión ocular previa clasificación del riesgo de conversión a glaucoma utilizando la regla STAR (Scoring Tool For Assessing Risk). Materiales y Métodos: mediante la revisión de historias clínicas, se seleccionaron pacientes con diagnóstico previo de hipertensión ocular (HTO). A cada paciente se le realizó una valoración oftalmológica completa, medición del espesor del CGC mediante OCT y calculo del STAR. Los datos obtenidos se relacionaron con variables demográficas, presión intraocular, paquimetría central y perimetría computarizada. Resultados: se analizaron 106 ojos de 53 pacientes con HTO. La PIO promedio fue de 23.55 ± 0.69 mmHg. La regla STAR fue aplicada en 96 ojos. El 65.6% (63 ojos) se categorizó en alto riesgo de conversión a glaucoma en los próximos cinco años. Los pacientes de este grupo presentaron un espesor del CGC significativamente menor que el de los otros grupos. El valor promedio del espesor del complejo ganglionar superior e inferior fue de 83 ± 4.5 micras y 82.09 ± 4.98 micras respectivamente. Conclusión: los pacientes clasificados en el grupo de alto riesgo STAR tienen espesores del CGC significativamente menores. La disminución del espesor del CGC se correlacionó positivamente con las anormalidades registradas en la perimetría computarizada.

Objective: to determine the thickness of the ganglion cell complex (GCC) by Fourier domain optical coherence tomography (FDOCT) in patients diagnosed with ocular hypertension who were classified with the STAR rule (Scoring Tool for Assessing Risk) to determine the risk of conversion to glaucoma. Methods: patients with ocular hypertension previously diagnosed were selected from medical records. Each patient underwent a complete ophthalmic evaluation, measurement of the thickness of the CGC by FD-OCT (Nidek RS-3000) and calculation of the STAR. Data recorded was related to demographic variables, intraocular pressure, central corneal thickness and computerized perimetry. Results: 106 eyes of 53 patients with ocular hypertension were analyzed. The average intraocular presure was 23.55 ± 0.69 mmHg. The STAR rule was applied in 96 eyes. 65.6% (63 eyes) were categorized into high risk of conversion to glaucoma in the next five years. Patients in this group had a significantly lower thickness of the CGC than the other groups. The average value of the thickness of the upper and lower CGC was 83 ± 4.5 microns and 82.09 ± 4.98 microns respectively. Conclusion: patients classified in the STAR high risk group have a signifi cantly lower thickness of the CGC. The thinning of the CGC was positively correlated with abnormalities recorded in the computerized perimetry.

Manejo e diagnóstico do glaucoma agudo de ângulo fechado na emergência / Management and diagnosis of acute closed angle glaucoma in emergency

O presente trabalho destina-se a auxiliar o médico clínico no diagnóstico do glaucoma agudo, visando o encaminhamento e manejo precoce da patologia, evitando dano importante ao nervo óptico com perda irreversível da acuidade visual.

This paper is dedicated to assist in the diagnosis of acute glaucoma, aiming the early treatment of the patology, and avoiding important damage to the optical nerve, which could cause irreversible visual loss.

Level of agreement among Latin American glaucoma subspecialists on the diagnosis and treatment of glaucoma: results of an online survey / Nível de concordância entre subespecialistas de glaucoma latino-americanos sobre o diagnóstico e tratamento do glaucoma: resultados de uma pesquisa digital

PURPOSE: The aim of this research was to assess the level of agreement among glaucoma experts in Latin America on key practices related to treatment and diagnosis of glaucoma. METHODS: An online questionnaire was sent to a multinational panel of glaucoma experts. The questionnaire contained 107 statements on the medical treatment (Part 1) and diagnosis (Part 2) of glaucoma, and was developed in Spanish and translated into English. Agreement was defined as >70% of respondents. RESULTS: Fifty participants from 14 countries completed the questionnaire. For the medical treatment of glaucoma, nearly all respondents (98% or greater) confirmed that medical treatment as first-line therapy is preferred to surgery, prostaglandin analogs are the medication of first choice for primary open-angle glaucoma (POAG), longitudinal monitoring of efficacy should include intraocular pressure, structural and functional status, as well as if patients' quality of life is impaired by the high cost of medication. For the diagnosis of glaucoma section, all respondents confirmed that, after initial examination, gonioscopy should be repeated over time, standard automated perimetry is the most important functional examination for diagnosis and monitoring of primary open-angle glaucoma, central corneal thickness is important in assessment of glaucoma, and computerized imaging tests help in clinical evaluation of optic disc. CONCLUSIONS: This survey shows a high level of agreement on most aspects of glaucoma diagnosis and treatment among Latin American glaucoma experts. Areas of disagreement highlight the need for further evidence or education. These findings will be useful for guiding future efforts to optimize glaucoma practice by clinicians in Latin America.

OBJETIVO: Avaliar o nível de concordância entre os especialistas de glaucoma na América Latina sobre as práticas mais importantes relacionadas ao tratamento e diagnóstico de glaucoma. MÉTODOS: Um questionário digital foi enviado a um painel multinacional de especialistas em glaucoma. O questionário continha 107 declarações sobre o tratamento médico (Parte 1) e diagnóstico (Parte 2) de glaucoma, e foi desenvolvido em espanhol e traduzido para o Inglês. Concordância foi definida como > 70% dos entrevistados. RESULTADOS: Cinquenta participantes de 14 países responderam ao questionário. Para o tratamento médico de glaucoma, quase todas as respostas (98% ou mais), confirmaram que o tratamento médico como terapia de primeira linha é preferido para a cirurgia, os análogos das prostaglandinas são os medicamentos de primeira escolha para o glaucoma primário de ângulo aberto (GPAA), a monitoração longitudinal eficácia deve incluir a pressão intraocular o estado estrutural e funcional além da qualidade de vida do paciente ser prejudicada pelo alto custo da medicação. Para a seção sobre o diagnóstico de glaucoma, todos os entrevistados confirmaram que, após análise inicial, a gonioscopia deve ser repetida ao longo do tempo, a perimetria automatizada padrão é o exame funcional mais importante para o diagnóstico e monitoramento do glaucoma primário de ângulo aberto, a espessura corneana central é importante na avaliação do glaucoma e exames de imagem computadorizados ajudam na avaliação clínica do disco óptico. CONCLUSÕES: Este estudo mostra um alto nível de concordância na maioria dos aspectos do diagnóstico e tratamento de glaucoma entre os especialistas em glaucoma latino-americanos. Áreas de desacordo destacam a necessidade de novas evidências ou educação. Estes resultados serão úteis para orientar futuros esforços na otimização de práticas em relação ao glaucoma por médicos da América Latina.

Actualización en el tratamiento médico del glaucoma pediátrico / Updating on the medical treatment of pediatric glaucoma

En la actualidad no existen suficientes estudios para valorar la seguridad y eficacia de los medicamentos hipotensivos oculares en el glaucoma pediátrico. El uso de medicamentos para reducir la presión intraocular en niños, se considera desacertado principalmente en glaucomas congénitos primarios y en los asociados a anomalías oculares. En otros tipos de glaucomas, como los juveniles no asociados a goniodisgenesias y secundarios, se suele comenzar con tratamiento medicamentoso, aunque por los efectos adversos de este y el no control adecuado de la tensión ocular, un porcentaje importante necesita tratamiento quirúrgico. Se realiza una revisión bibliográfica actualizada con el objetivo de describir el mecanismo de acción, dosificación y efectos indeseables de los medicamentos hipotensores oculares en niños con glaucoma

Nowadays, there are few studies that assess safety and effectiveness of hypotensive ocular medications for pediatric glaucomas. Use of drugs to reduce the intraocular pressure (IOP) in children is considered ineffective mainly in congenital primary glaucoma and in associated ocular anomalies. In other types of glaucomas such as juvenile glaucoma unrelated to goniodysgenesis and secondary ones, drug treatment is the initial therapy, but because of adverse reactions and inadequate control, a significant percentage of cases require surgical treatment. An updated literature review was made, with the objective of describing the mechanism of action, dosage and undesirable effects of hypotensive ocular drugs in glaucomatous children

Glaucoma in developing countries.

Objective: To describe the background and strategy required for the prevention of blindness from glaucoma in developing countries. Materials and Methods: Extrapolation of existing data and experience in eye care delivery and teaching models in an unequally developed country (India) are used to make recommendations. Results: Parameters like population attributable risk percentage indicate that glaucoma is a public health problem but lack of simple diagnostic techniques and therapeutic interventions are barriers to any effective plan. Case detection rather than population-based screening is the recommended strategy for detection. Population awareness of the disease is low and most patients attending eye clinics do not receive a routine comprehensive eye examination that is required to detect glaucoma (and other potentially blinding eye diseases). Such a routine is not taught or practiced by the majority of training institutions either. Angle closure can be detected clinically and relatively simple interventions (including well performed cataract surgery) can prevent blindness from this condition. The strategy for open angle glaucoma should focus on those with established functional loss. Outcomes of this proposed strategy are not yet available. Conclusions: Glaucoma cannot be managed in isolation. The objective should be to detect and manage all potential causes of blindness and prevention of blindness from glaucoma should be integrated into existing programs. The original pyramidal model of eye care delivery incorporates this principle and provides an initial starting point. The routine of comprehensive eye examination in every clinic and its teaching (and use) in residency programs is mandatory for the detection and management of potentially preventable blinding pathology from any cause, including glaucoma. Programs for detection of glaucoma should not be initiated unless adequate facilities for diagnosis and surgical intervention are in place and their monitoring requires reporting of functional outcomes rather than number of operations performed.

Cannabinoides y su posible uso en el glaucoma / Cannabinoids and their possible use in the treatment of glaucoma

Aunque la planta Cannabis sativa ha sido empleada desde la más remota antigüedad con fines medicinales, uno de sus derivados, la marihuana, se ha convertido en la droga de uso ilegal más consumida en el mundo. Asimismo tanto el Cannabis como sus cannabinoides se emplean como terapéutico en pocas enfermedades generalmente neurológicas. Se realizó una revisión bibliográfica para exponer el posible uso de los cannabinoides en la terapéutica del glaucoma. Para ello se tuvo en cuenta la literatura disponible sobre el tema, durante el período enero a septiembre de 2010. Se ha comprobado el efecto hipotensor ocular de los cannabinoides al disminuir la producción de humor acuoso, y aumentar la excreción de humor acuoso a través de la malla trabecular y la vía uveoescleral, efecto compatible con el hallazgo de elevadas concentraciones de receptores de cannabinoides rCB1 y rCB2; además, el tetrahidrocannabinol ha demostrado disminuir el efecto neurodegenerativo en modelos de isquemia cerebral en ratas y se evidenció también el efecto beneficioso de los cannabinoides al disminuir la degeneración secundaria asociada al glaucoma mediada por la excitotoxicidad del glutamato. Estos hallazgos sobre el efecto beneficioso de los cannabinoides como hipotensores oculares y por su efecto neuroprotector, transmiten un mensaje esperanzador sobre la función que estos podrían desempeñar en el campo del glaucoma, aunque para mayor seguridad y eficacia serían necesarios ensayos clínicos encaminados a valorar su aplicabilidad en la práctica clínica diaria

Although the Cannabis Sativa plant has been used since the most remote ancient times for medicinal purposes, one of its derivatives, marijuana, has become the most commonly used illegal drug in the world. Similarly, both Cannabis and the cannabinoids are used therapeutically in a small number of general neurological pathologies. Literature review was made to set forth the possible use of cannabinoids in the treatment of Glaucoma. To this end, t the available literature on the subject from January to September 2010 was taken into account. The cannabinoid´s antihypertensive occular effect has been found to decrease aqueous humor production, and to increase the excretion of aqueous humor through the trabeculary mesh and the route uveoscleral pathway. This effect is compatible with the high concentrations of rCB1 and rCB2 cannabinoid receptors found. Besides, tetrahydrocannabinol has proved to reduce the neurodegenerative effect in models of cerebral ischemia in rats and the beneficial effect of cannabinoids to reduce gluthamate excitotoxicity-mediated secondary degeneration associated with glaucoma. These findings about the beneficial effect of cannabinoids as ocular antihypertensives and its neuroprotective effect convey a hopeful message about the role they could play in the treatment of glaucoma; however, it would be necessary to perform further clinical trials to assess their applicability in our daily clinical practice for greater safety and efficiency

Síndrome de Sturge-Weber e suas repercussões oculares: revisão da literatura / Sturge-Weber syndrome and its ocular effects: a review

A síndrome de Sturge-Weber (SSW) é uma desordem neuro-oculocutânea, rara e congênita. Esta facomatose, também conhecida como angiomatose encéfalotrigeminal, é definida pela tríade clássica: hemangiomas cutâneo, meníngeo e ocular. Apesar de sua apresentação típica, formas incompletas não são incomuns. O glaucoma está frequentemente presente e seus mecanismos fisiopatológicos permanecem incertos. Talvez por isso, o manejo clínico e cirúrgico do glaucoma associado à síndrome de Sturge-Weber (GSSW) seja um desafio para a prática oftalmológica, muitas vezes com resultados desapontadores. Apresentamos uma revisão da literatura com ênfase no GSSW, sua patogênese e perspectivas terapêuticas.

The Sturge-Weber syndrome (SWS) is a rare congenital neuro-oculocutaneous disorder. This phacomatosis, also known as encephalotrigeminal angiomatosis, is defined by the classic triad: cutaneous, meningeal and ocular hemangiomas. Despite its typical presentation, incomplete forms are not uncommon. Glaucoma is often present and their pathophysiological mechanisms remain uncertain. Pherhaps this is why the clinical and surgical management of glaucoma associated with Sturge-Weber syndrome (GSSW) is a challenge for the ophthalmic practice, often with disappointing results. We present a literature review with emphasis on GSSW, its pathogenesis and therapeutic perspectives.