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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.