{"id":4608,"date":"2016-12-07T10:19:31","date_gmt":"2016-12-07T12:19:31","guid":{"rendered":"https:\/\/sbglaucoma2.websiteseguro.com\/medico\/?p=4608"},"modified":"2016-12-07T10:19:31","modified_gmt":"2016-12-07T12:19:31","slug":"structural-and-functional-progression-in-the-early-manifest-glaucoma-trial","status":"publish","type":"post","link":"https:\/\/www.sbglaucoma.org.br\/medico\/structural-and-functional-progression-in-the-early-manifest-glaucoma-trial\/","title":{"rendered":"Structural and Functional Progression in the Early Manifest Glaucoma Trial"},"content":{"rendered":"

Structural and Functional Progression in the Early Manifest Glaucoma Trial <\/h3>\n
\n
\"\"Jayme R. Vianna<\/strong><\/p>\n<\/div>\n
Alexandre S. C. Reis<\/strong>
\n<\/span>\n<\/div>\n<\/div>\n

Ref.: \u00d6hnell H, Heijl A, Brenner L, Anderson H, Bengtsson B. Structural and Functional Progression in the Early Manifest Glaucoma Trial. Ophthalmology. E-pub March 2016. <\/strong><\/p>\n

 <\/p>\n

Detectar progress\u00e3o \u00e9 uma tarefa essencial no manejo do glaucoma, mas ainda se mant\u00e9m um desafio. Diversos testes e formas de an\u00e1lise est\u00e3o dispon\u00edveis para avaliar progress\u00e3o estrutural e funcional, entretanto n\u00e3o h\u00e1 consenso sobre a melhor forma de utiliz\u00e1-los. Neste artigo, \u00d6hnell e colaboradores avaliaram pacientes inclu\u00eddos no Early Manifest Glaucoma Trial (EMGT) para determinar a rela\u00e7\u00e3o temporal entre a progress\u00e3o detectada atrav\u00e9s de exames de campo visual ou fotografias de disco \u00f3ptico. Ou seja, qual dos m\u00e9todos foi capaz de detectar progress\u00e3o primeiro ao longo do estudo.<\/p>\n

No EMGT, 255 pacientes rec\u00e9m-diagnosticados com glaucoma e defeito de campo visual no olho de estudo foram randomizados entre: (1) tratamento com trabeculoplastia (laser de arg\u00f4nio) e betaxolol, ou (2) sem tratamento at\u00e9 progress\u00e3o. O artigo em quest\u00e3o reporta o seguimento de at\u00e9 11 anos (mediana de 8 anos), com fotografias monosc\u00f3picas e perimetria automatizada acrom\u00e1tica, realizados a cada 6 meses, em ambos os olhos (incluindo olhos sem dano glaucomatoso). A progress\u00e3o pelo campo visual foi definida como redu\u00e7\u00e3o da sensibilidade no gr\u00e1fico do Pattern Deviation em 3 ou mais pontos, repetidos em 3 exames consecutivos (o crit\u00e9rio adotado pelo Glaucoma Change Probability, do per\u00edmetro Humphrey, baseado no gr\u00e1fico do Pattern Deviation). <\/p>\n

Vale a pena ressaltar que os autores tiveram o cuidado de n\u00e3o incluir como progress\u00e3o os olhos que eventualmente n\u00e3o sustentassem tal redu\u00e7\u00e3o de sensibilidade em exames subsequentes aos quais foi detectada a progress\u00e3o.<\/strong> A progress\u00e3o pela fotografia do disco \u00f3ptico foi avaliada por 3 examinadores independentes e casos de n\u00e3o concord\u00e2ncia eram discutidos para consenso. <\/p>\n


\nO principal resultado foi que, em olhos com defeito perim\u00e9trico (MD m\u00e9dio no in\u00edcio do estudo -4.0 dB) j\u00e1 estabelecido no momento da inclus\u00e3o do estudo, a progress\u00e3o foi detectada primeiramente com o campo visual 4 vezes mais frequentemente do que com a fotografia do disco \u00f3ptico. Outro achado importante foi que, em olhos sem defeito perim\u00e9trico no in\u00edcio do seguimento, a progress\u00e3o foi detectada com a mesma frequ\u00eancia com o campo visual e com a fotografia do disco \u00f3ptico. <\/span><\/p>\n

O principal resultado foi que, em olhos com defeito perim\u00e9trico (MD m\u00e9dio no in\u00edcio do estudo -4.0 dB) j\u00e1 estabelecido no momento da inclus\u00e3o do estudo, a progress\u00e3o foi detectada primeiramente com o campo visual 4 vezes mais frequentemente do que com a fotografia do disco \u00f3ptico. Outro achado importante foi que, em olhos sem defeito perim\u00e9trico no in\u00edcio do seguimento, a progress\u00e3o foi detectada com a mesma frequ\u00eancia com o campo visual e com a fotografia do disco \u00f3ptico.<\/p>\n

Os achados desse estudo t\u00eam bastante for\u00e7a devido ao desenho prospectivo, longo tempo de seguimento e grande amostra. Entretanto \u00e9 importante ressaltar que as conclus\u00f5es s\u00f3 se aplicam \u00e0 mesma forma de avalia\u00e7\u00e3o realizada no estudo. O dano glaucomatoso estrutural foi avaliado com fotografias monosc\u00f3picas do disco \u00f3ptico. Uma limita\u00e7\u00e3o dessa t\u00e9cnica \u00e9 depender de avalia\u00e7\u00e3o subjetiva que pode variar mesmo entre especialistas. Para ilustrar incertezas que podem ocorrer na avalia\u00e7\u00e3o de fotografias de nervo \u00f3ptico, sugerimos aos leitores acessarem o material suplementar do artigo, que cont\u00e9m exemplos de fotografias com progress\u00e3o (www.aaojournal.org).<\/a> Al\u00e9m disso, como n\u00e3o foram realizadas fotografias estereosc\u00f3picas, pequenas mudan\u00e7as no contorno da rima neurorretiniana e escava\u00e7\u00e3o podem ter sido perdidas. A camada de fibras nervosas tamb\u00e9m n\u00e3o foi avaliada neste estudo, o que poderia ter sido feito com fotografias red free. Al\u00e9m disso, \u00e9 poss\u00edvel que a avalia\u00e7\u00e3o automatizada com exames de imagem, como a tomografia de coer\u00eancia \u00f3ptica, detecte progress\u00e3o estrutural antes de fotografias de nervo \u00f3ptico, por\u00e9m tal tecnologia n\u00e3o estava t\u00e3o difundida e com os mesmos artif\u00edcios que apresenta hoje.<\/p>\n

O estudo conclui que, em situa\u00e7\u00f5es de recursos limitados, o exame de campo visual deve ter prefer\u00eancia em rela\u00e7\u00e3o \u00e0 fotografias do disco \u00f3ptico. Por\u00e9m, vale ressaltar que em 27% dos olhos que j\u00e1 apresentavam defeito de campo visual no in\u00edcio do estudo, a progress\u00e3o foi detectada primeiramente com fotografias do disco \u00f3ptico, e este n\u00famero n\u00e3o deve ser ignorado. Se analisados apenas os pacientes sem defeito de campo visual no in\u00edcio do seguimento (como suspeitos de glaucoma ou hipertensos oculares), esse valor aumenta para 54%. Desse modo, outra importante conclus\u00e3o \u00e9 que, se realizarmos apenas exames de campo visual, n\u00e3o estaremos detectando progress\u00e3o precocemente em significativa fra\u00e7\u00e3o dos pacientes.<\/p>\n

Como mensagem para pr\u00e1tica cl\u00ednica, esse estudo refor\u00e7a a necessidade de que se poss\u00edvel, fa\u00e7amos tanto exames funcionais quanto estruturais para adequado manejo do glaucoma.<\/span><\/p>\n

Como mensagem para pr\u00e1tica cl\u00ednica, esse estudo refor\u00e7a a necessidade de que se poss\u00edvel, fa\u00e7amos tanto exames funcionais quanto estruturais para adequado manejo do glaucoma.<\/p>\n

Em rela\u00e7\u00e3o ao debate estrutura e fun\u00e7\u00e3o, mais especificamente sobre qual exame detecta primeiramente a progress\u00e3o do glaucoma, devemos tentar n\u00e3o confundir discord\u00e2ncia entre os exames, de pobre capacidade preditiva, como sugerido por Medeiros e Tatham, em editorial sobre o artigo.1 Se os m\u00e9todos estruturais e funcionais para avaliar progress\u00e3o concordassem perfeitamente, n\u00e3o haveria necessidade de ambos para monitorar a progress\u00e3o, um teste seria suficiente. Talvez seja a hora de darmos um passo adiante sobre o antigo debate estrutura e fun\u00e7\u00e3o, no sentido de aproveitar ao m\u00e1ximo o que cada teste tem a oferecer, e com isso detectar mais precocemente o surgimento e a progress\u00e3o da doen\u00e7a.<\/p>\n

\n
\n

\"\"Refer\u00eancias<\/h3>\n
\n
\n
\n
    \n
  1. Medeiros FA, Tatham AJ. Structure versus Function in Glaucoma: The Debate That Doesn’t Need to Be. Ophthalmology 2016;123:1170-1172.<\/li>\n<\/ol>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

    Structural and Functional Progression in the Early Manifest Glaucoma Trial Jayme R. Vianna Alexandre S. C. Reis Ref.: \u00d6hnell H, Heijl A, Brenner L, Anderson H, Bengtsson B. Structural and Functional Progression in the Early Manifest Glaucoma Trial. Ophthalmology. E-pub March 2016.   Detectar progress\u00e3o \u00e9 uma tarefa essencial no manejo do glaucoma, mas ainda […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_joinchat":[],"footnotes":""},"categories":[1],"tags":[],"class_list":["post-4608","post","type-post","status-publish","format-standard","hentry","category-sem-categoria"],"acf":[],"yoast_head":"\nStructural and Functional Progression in the Early Manifest Glaucoma Trial - SBG - Sociedade Brasileira de Glaucoma<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.sbglaucoma.org.br\/medico\/structural-and-functional-progression-in-the-early-manifest-glaucoma-trial\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Structural and Functional Progression in the Early Manifest Glaucoma Trial - SBG - Sociedade Brasileira de Glaucoma\" \/>\n<meta property=\"og:description\" content=\"Structural and Functional Progression in the Early Manifest Glaucoma Trial Jayme R. 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