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Advisor(s)
Abstract(s)
O presente relatório de estágio, elaborado em substituição da dissertação de Mestrado em Optometria e Ciências da Visão, foi realizado na Clínica Oftalmológica das Antas, ao longo dos meses de outubro de 2017 a maio de 2018. Este visa retratar a condição patológica e as intervenções realizadas num paciente do género masculino, com 79 anos de idade. O paciente apresentava edema macular cistóide após facoemulsificação num olho com glaucoma crónico simples. Foram administradas diversas injeções de Avastin (injeção intravítrea de anti-angiogénicos), para diminuição da proliferação de novos vasos retinianos e tratamento do edema macular, para além de terem sido substituídos colírios anti-glaucomatosos que este já aplicava, a fim de diminuir a pressão intraocular (PIO).
O glaucoma, é uma neuropatia ótica progressiva com alterações estruturais características na cabeça do nervo ótico (N.O), frequentemente acompanhadas por modificações correspondentes no campo visual (CV), que pode levar a cegueira irreversível.
Modificações no aspeto do disco ótico (D.O) e da camada de fibras nervosas da retina (CFNR) antecedem o aparecimento de defeitos de CV no glaucoma, o que faz com que a avaliação destas estruturas seja imprescindível para o diagnóstico precoce e prevenção da perda visual nesta doença.
Apesar PIO ser o principal fator de risco para o desenvolvimento de glaucoma, défices micro-circulatórios, imunidade alterada, além de outros fatores, também podem estar envolvidos, tanto isoladamente quanto de forma combinada. Uma cascata de eventos específicos (compressão e abaulamento posterior da lâmina crivosa, interrupção no transporte axonal e degeneração subsequente das fibras nervosas) leva ao dano glaucomatoso do nervo ótico. Diversos fatores de risco presentes no glaucoma podem originar outro tipo de manifestações para além do dano ao disco ótico.
O glaucoma afeta vários parâmetros da função visual, sendo a deterioração progressiva do campo visual o mais importante. A perda de CV inicia-se na médio e periferia, avançando para a forma tubular, chegando muitas vezes a uma ilha de campo visual nos casos avançados da doença.
O diagnóstico de glaucoma apresenta-se como um desafio para o profissional de saúde. O caráter insidioso da doença, que em geral não apresenta sintomas até tarde na sua evolução, frequentemente resulta em atraso considerável na sua deteção e início do tratamento, sendo, portanto, fundamental obter diversas informações sobre o historial do paciente, assim como diversos exames de diagnóstico para confirmação da neuropatia.
O edema macular cistóide pseudofáquico (EMCP) permanece como uma das causas mais frequentes de baixa visão após facoemulsificação, desenvolvendo-se devido à quebra das barreiras hematorretinianas e hematoaquosas, causando o acúmulo de líquido no espaço extracelular da retina e formação de cistos nas camadas plexiforme externa e nuclear interna. A sua incidência varia consideravelmente na literatura, dependendo da sua definição, técnica cirúrgica, método de diagnóstico utilizado, entre outros fatores.
Os dois mecanismos mais estreitamente implicados na formação de EMC pós-operatório estão ligados à tração vítrea sobre a mácula, devido à adesão vitreorretiniana, e ao aumento da produção de prostaglandinas secundárias à isquemia do segmento anterior.
Dois métodos fundamentais na avaliação destas duas patologias, resumem-se à tomografia de coerência ótica (OCT) e à angiografia fluoresceínica (AF). O OCT possui várias vantagens em comparação com a AF, tais como rapidez, conforto, reprodutibilidade, obtenção de imagens de elevada resolução, entre outros.
A qualidade de vida dos pacientes com deficiência visual é geralmente pobre, uma vez que estes tendem a apresentar distúrbios psicológicos. O conhecimento da doença por parte do paciente, leva-o a uma melhor adesão ao tratamento diminuindo assim as perturbações, melhorando drasticamente a qualidade de vida deste.
The actual internship report, developed in substitution of the Master's thesis Degree in Optometry and Vision Sciences, was held at the Antas Clinic Ophthalmology, from October 2017 to May 2018. It aims to portray the pathological condition and the interventions performed in a male patient with 79 years old. The patient presented cystoid macular edema after phacoemulsification in an eye with simple chronic glaucoma. Several injections of Avastin (intravitreal injection of anti-angiogenic) have been given to reduce the proliferation of new retinal vessels and to treat macular edema. Anti-glaucomatous eye drops, were replaced in order to decrease intraocular pressure (IOP). Glaucoma is a progressive optic neuropathy with characteristic structural changes in the head of the optic nerve (ON), often accompanied by corresponding changes in the visual field (VF), which can lead to irreversible blindness. Modifications in the appearance of the optic disc (OD) and in the retinal nerve fiber layer (RNFL) precede the appearance of VF defects in glaucoma, which makes that the evaluation of these structures is essential for early diagnosis and prevention of visual loss in this disease. Although IOP to be the main risk factor for the development of glaucoma, microcirculatory deficits, impaired immunity, and other factors may also be involved, as in isolation and in combination. A cascade of specific events (compression and posterior bulging of the cryptic lamina, interruption in axonal transport and subsequent degeneration of nerve fibers) leads to glaucomatous damage of the optic nerve. Several risk factors present in glaucoma can lead to other manifestations besides damage to the optic disc. Glaucoma affects several parameters of visual function, and the progressive deterioration of the visual field are being the most important. The VF loss begins in the mid and periphery, advancing to the tubular form, often reaching an island of visual field in advanced cases of the disease. The diagnosis of glaucoma presents itself as a challenge for the health professional. The insidiousness of the disease, which usually does not show symptoms until late in its evolution, often results in a considerable delay in its detection and initiation of treatment, and it is therefore fundamental to obtain various information about the patient's history as well as several diagnostic tests to confirm the neuropathy. Pseudophakic cystoid macular edema (PCME) remains one of the most frequent causes of low vision after phacoemulsification. It develops due to the breakdown of the hematoretinal and hemato-vascular barriers, causing accumulation of fluid in the retinal extracellular space and formation of cysts in the external and internal nuclear plexiform layers. Its incidence varies considerably in the literature, depending on its definition, surgical technique, diagnostic method used, among other factors. The two mechanisms most closely involved in the formation of postoperative CMEs are linked to vitreous traction on the macula due to vitreoretinal adhesion, and increased secondary prostaglandin production to anterior segment ischemia. Two fundamental methods in the evaluation of these two pathologies are summarized optic coherence tomography (OCT) and fluorescein angiography (FA). OCT has several advantages compared to FA, such as speed, comfort, reproducibility, obtaining high resolution images, among others. Quality of life of patients with visual impairment is generally poor, since they tend to present with psychological disorders. Knowledge of the disease on the part of the patient, leads to a better adherence to the treatment thus reducing the disorders, drastically improving the quality of life of the patient.
The actual internship report, developed in substitution of the Master's thesis Degree in Optometry and Vision Sciences, was held at the Antas Clinic Ophthalmology, from October 2017 to May 2018. It aims to portray the pathological condition and the interventions performed in a male patient with 79 years old. The patient presented cystoid macular edema after phacoemulsification in an eye with simple chronic glaucoma. Several injections of Avastin (intravitreal injection of anti-angiogenic) have been given to reduce the proliferation of new retinal vessels and to treat macular edema. Anti-glaucomatous eye drops, were replaced in order to decrease intraocular pressure (IOP). Glaucoma is a progressive optic neuropathy with characteristic structural changes in the head of the optic nerve (ON), often accompanied by corresponding changes in the visual field (VF), which can lead to irreversible blindness. Modifications in the appearance of the optic disc (OD) and in the retinal nerve fiber layer (RNFL) precede the appearance of VF defects in glaucoma, which makes that the evaluation of these structures is essential for early diagnosis and prevention of visual loss in this disease. Although IOP to be the main risk factor for the development of glaucoma, microcirculatory deficits, impaired immunity, and other factors may also be involved, as in isolation and in combination. A cascade of specific events (compression and posterior bulging of the cryptic lamina, interruption in axonal transport and subsequent degeneration of nerve fibers) leads to glaucomatous damage of the optic nerve. Several risk factors present in glaucoma can lead to other manifestations besides damage to the optic disc. Glaucoma affects several parameters of visual function, and the progressive deterioration of the visual field are being the most important. The VF loss begins in the mid and periphery, advancing to the tubular form, often reaching an island of visual field in advanced cases of the disease. The diagnosis of glaucoma presents itself as a challenge for the health professional. The insidiousness of the disease, which usually does not show symptoms until late in its evolution, often results in a considerable delay in its detection and initiation of treatment, and it is therefore fundamental to obtain various information about the patient's history as well as several diagnostic tests to confirm the neuropathy. Pseudophakic cystoid macular edema (PCME) remains one of the most frequent causes of low vision after phacoemulsification. It develops due to the breakdown of the hematoretinal and hemato-vascular barriers, causing accumulation of fluid in the retinal extracellular space and formation of cysts in the external and internal nuclear plexiform layers. Its incidence varies considerably in the literature, depending on its definition, surgical technique, diagnostic method used, among other factors. The two mechanisms most closely involved in the formation of postoperative CMEs are linked to vitreous traction on the macula due to vitreoretinal adhesion, and increased secondary prostaglandin production to anterior segment ischemia. Two fundamental methods in the evaluation of these two pathologies are summarized optic coherence tomography (OCT) and fluorescein angiography (FA). OCT has several advantages compared to FA, such as speed, comfort, reproducibility, obtaining high resolution images, among others. Quality of life of patients with visual impairment is generally poor, since they tend to present with psychological disorders. Knowledge of the disease on the part of the patient, leads to a better adherence to the treatment thus reducing the disorders, drastically improving the quality of life of the patient.
Description
Keywords
Atrofia do Nervo Ótico Edema Macular Edema Macular Cistóide Glaucoma Pressão Intra-Ocular Tomografia de Coerência Ótica