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    Avaliação da medida da hipotenusa da escavação vertical do nervo óptico utilizando o modo de imagem profunda realçada da tomografia de coerência óptica de domínio espectral: um potencial novo parâmetro estrutural na propedêutica do glaucoma
    (Universidade Federal de São Paulo (UNIFESP), 2016-08-30) Lavinsky, Fabio [UNIFESP]; Mello, Paulo Augusto de Arruda [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    Purpose: To evaluate the measurement of the hypotenuse of the vertical optic nerve head cupping (HVOC) with the enhanced depth imaging (EDI) mode of the spectral domain optic coherence tomography (SD-OCT) as a novel structural parameter for glaucoma evaluation. Methods: We conducted a prospective, cross-sectional study with patients diagnosed with glaucoma and controls. Patients underwent SD-OCT evaluating the mean thickness of the retinal nerve fiber layer (RNFL) and the HVOC. One leg of the triangle represented the depth and the other leg represented the length of the cupping. These legs were manually measured. Patients also underwent color pictures and standard automated perimetry (SAP). The evaluation was performed in 85 patients (156 eyes). Patients were divided into three groups: 1) MD < -7 dB, 2) MD > -7 dB, and 3) patients without glaucoma. The structure-function evaluation and the evaluation with the receiving operating curve (ROC) excluded eyes with the vertical diameter of the optic nerve > 2.0 and < 1.5. Results: The mean and median SD-OCT RNFL values were: group 1) 62.0±3.3 ?m, 54.0 (49.0; 75.8); group 2) 84.4±1.8 ?m, 85.0 (74.0; 94.0), and group 3) 96.6±2.3 ?m, 97.0 (90.5; 102.0) (p<0.001). The mean of the MD were: group 1) -16.7 dB, group 2) -2.5 dB, and group 3) -1.7 dB (p<0.001). The correlation of the SD-OCT RNFL and the SAP was statistically significant (p<0.0001 and r=0.681). The means of the HVOC were divided in three different vertical optic nerve diameter (VD) ranges (<1.5 mm, 1.51-2.00 mm, and >2.00 mm). Within each nerve diameter range the difference of the HVOC from the different groups was statistically significant. For the structural-functional correlation and for the evaluation of the ROC curves only nerves with a VD of 1.51-2.00 mm were evaluated (120 eyes). The HVOCs were divided into four percentile groups with the following medians in ?m: 925 (298-1,079); 1,162 (1,085-1,271); 1,415 (1,273-1,522); and 1,624 (1,527-1,993). There was a statistically significant difference of the values of the MD in each percentile group between group 1 and 3 (p<0.03), group 1 and 4 (p<0.001), group 2 and 3 (p<0.02), and between group 2 and 4 (p<0.001). In those eyes, the correlation between the HVOC and the SD-OCT RNFL was r =-.64 (p<0.001). The areas under the curve (AUC) of the ROC curve and the 95%CI evaluating the HVOC were: for positive cases with MD < -3 dB = 0.76 (0.64-0.85), MD < -6 dB = 0.77 (0.68-0.87), and MD < -12 dB= 0.79 (0.70-0.89). The ROC curves of the SD-OCT RNFL were compared with the HVOC using the DeLong test. There was no statistically significant difference, for positive cases determined as MD < -12 dB, there was a borderline difference (p=0.06). Conclusions: The HVOC provides a simple numeric parameter obtained from two important hallmarks of the glaucomatous nerve: the vertical length of the cupping and the depth of the cupping. In our study, we found a structural-functional correlation of the HVOC with the MD of the SAP, as well as with the RNFL. The AUCs of the HVOC were comparable with those of the RNFL. The HVOC has a potential to be used as an additional topographic parameter of the structural evaluation of glaucoma.
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    O sistema de escala de probabilidade de dano do disco óptico e a estimativa da contagem das células ganglionares da retina no glaucoma
    (Universidade Federal de São Paulo (UNIFESP), 2016-04-27) Senra, Andrea Cotait Kara Jose [UNIFESP]; Tavares, Ivan Maynart Tavares [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
    Purposes: This study was conducted in two stages, with the following purposes: 1) to compare the diagnostic accuracies of and to determine the correlations between the disc damage likelihood scale (DDLS), cup-to-disc (C/D) ratio, standard automated perimetry (SAP) mean deviation (MD) index, time and spectral-domain optical coherence tomography (TD and SD?OCT), GDx?VCC scanning laser polarimetry, and HRT II (software 3.1.2) confocal scanning laser ophthalmoscope for the detection of glaucoma; 2) to evaluate the diagnostic accuracy of estimates of retinal ganglion cell (RGC) counts, obtained by combining data from standard automated perimetry (SAP) and SD?OCT. Methods: Healthy individuals and primary open-angle glaucoma (POAG) patients were included in this observational, cross-sectional, prospective study. All eyes underwent 24-2 SITA standard SAP and imaging structural tests. Firstly, glaucoma specialists evaluate DDLS system scores and C/D ratios for every enrolled individual. DDLS sensitivity and specificity, with 95% confidence intervals, and the area under the receiver operating characteristic curve (AROC) for DDLS and various parameters of the diagnostic tests were calculated. The DDLS system?s accuracy was compared to the other parameters. Spearman?s rank correlation test was used to evaluate correlations among parameters. Secondly, estimates of RGC counts were obtained using a previously described algorithm (Medeiros et al. Am J Ophthalmol. 2012;154:814-24), which combines the estimates of the number of RGC derived from SAP sensitivity thresholds and SD?OCT RNFL average thickness. AROCs of estimates of RGC counts, OCT RNFL average thickness and SAP MD were calculated and compared. Linear regression analysis was performed between the estimates of the number of RGC derived from both SAP and OCT. Data were adjusted for age and correlation between eyes (ROC regression model). Results: At the DDLS study, one eye of each of 101 participants was evaluated. Fifty-four eyes (53%) were healthy, and 47 eyes (47%) had POAG, including 16 eyes (34%) with preperimetric glaucoma. A DDLS score > 5 had a sensitivity of 74% (95% CI: 60%?86%), and a speficity of 88% (95% CI: 77%?96%). The DDLS system had excelent diagnostic accuracy (AROC 0.92) in distinguishing healthy from glaucomatous eyes. This acuracy was better than the accuracies of HRT II parameters (0.62-0.83), Stratus (0.61-0.79) and Spectralis (0,69-0,83) OCT RNFL thickness; and SAP MD (0.74). There was no statistically significant difference between the accuracies of the DDLS, the vertical (0.94) and horizontal (0.91) C/D ratios; the Stratus OCT C/D area ratio (0.89), vertical (0.89) and horizontal (0.86) C/D ratios; and the GDx?VCC NFI parameter (0.81). The DDLS system had significant strong correlations with vertical (r = 0.79) and horizontal (0.74) C/D ratios, and with the parameters vertical C/D ratio and C/D area ratio from HRT II (0.77 and 0.77, respectively) and TD?OCT (0.75 and 0.72). The DDLS had significant moderate correlations with most of the other structural and functional parameters. At the estimates of RGC counts study, one hundred nineteen eyes of 77 participants were evaluated: seventy-five eyes (63%) from 48 healthy individuals, and 44 eyes (37%) from 29 POAG patients. The estimates of RGC counts performed better than the isolated parameters SD?OCT RNFL average thickness and SAP MD (AROC 0.98, 0.92 and 0.79, respectively; P<0.001), for discriminating healthy from glaucomatous eyes, even in a subgroup with milder disease (0.97, 0.88 and 0.75, respectively; P<0.001). However, after adjustment for age and correlation between eyes, the differences between the three measurements accuracies showed a borderline statistical significancy (P=0.05) when considered all eyes, and a reduced significancy in the mild disease subgroup (P=0.04). There was a strong and significant correlation between estimates of the RGC counts derived from SAP and SD?OCT (R2 = 0.74; P<0.001). Conclusions: The DDLS system and the vertical and horizontal C/D ratios had excellent diagnostic accuracies to distinguish healthy from glaucomatous eyes. The DDLS system had significant moderate correlations with most of the evaluated structural and functional parameters. The estimates of RGC counts obtained from combining structure and function tests had an excelent diagnostic accuracy for discriminating healthy from glaucomatous eyes, and performed better than isolated structural and functional parameters.