Galton Carvalho Vasconcelos

Avaliação da visão funcional para crianças com baixa visão de dois a seis anos de idade - estudo comparativo

PURPOSE: The Functional Vision Assessment (AVIF-2 to 6 years)s capacity to differentiate visual ability levels in children with low vision was analyzed. The AVIF-2 to 6 years was created at the Infantile Low Vision Sector from Sao Geraldo Hospital, Brazil. METHODS: After a debate among professionals from different areas regarding the appropriateness of the test items, AVIF-2 to 6 years was applied to 40 children aged from 2 to 6 years; twenty children with low vision (Group 1) and twenty without it (Group 2) were assessed. Group 1 was recruited from the Infantile Low Vision Sector from Sao Geraldo Hospital. Group 2 comprised children from two different public day care centers and children were matched by age, gender and social level with group 1. Seven domains were studied: visual fixation, visual following, visual field confrontation, eye-hand coordination and surrounding locomotion, contrast vision and color vision discrimination. Group 1 children were submitted to a complete ophthalmologic exam and group 2 to ophthalmologic screening. Children with low vision and neurologic disease were excluded. Comparative analyzes were performed for both groups and for distinct subgroups classified by age (24 to 35 months, 36 to 59 months and 60 to 78 months) and by visual acuity subgroups ( 1.0 logMAR). RESULTS: The scores at total AVIF-2 to 6 years and its domains were statistically significant (p<0.05), except for the contrast vision and color vision discrimination domains. The total AVIF- 2 to 6 years median was lower for group 1 at the three interval ages. CONCLUSION: AVIF- 2 to 6 years can discriminate different levels of functional vision of low vision children, however the authors emphasize that although the results are encouraging, further studies shall be done until the test is ready for clinical use.

Causes of visual impairment in children seen at a university-based hospital low vision service in Brazil

PURPOSE To evaluate the epidemiologic characteristics of patients 0-7 years of age with visual impairment registered at a university hospital low vision service in Brazil. METHODS The medical records of visually impaired patients were retrospectively reviewed for sociodemographic characteristics and ocular and associated deficiencies. In addition to biographical information, the following data were collected: ocular disorders, diagnosis, affected anatomic region, etiology, and avoidable or unavoidable causes. RESULTS A total of 229 patients were included, 65% of whom were referred from rural health centers. The mean age at first appointment was 39.4 months. Associated nonophthalmic disorders were present in 47% of patients. The most prevalent disorders were congenital cataract (14%), toxoplasmosis (14%), and congenital glaucoma (13%). The most commonly affected anatomic regions were the retina (18%) and lens (15%); 33% had a normal-appearing globe. Using World Health Organization classifications, the most prevalent underlying etiologies were undetermined (43%), perinatal/neonatal factors (22%), and intrauterine factors (20%). Avoidable causes were found in 64% of the children. CONCLUSIONS The three leading causes of infant blindness in our patient cohort were congenital cataract, toxoplasmosis, and congenital glaucoma. The most commonly affected anatomic regions were retina, lens, and normal-appearing globe. The percentage of avoidable causes of impairment was high and the mean age at first appointment was late.

Vision Status in Older Adults: The Brazilian Amazon Region Eye Survey

Older adults living in remote areas with limited access to health services are at higher risk to develop visual impairment and blindness. We conducted a population-based survey to determine the vision status in subjects 45 years of age and older from urban and rural areas of Parintins city, Brazilian Amazon Region. Participants underwent ophthalmic examination, including uncorrected (UCVA), presenting (PVA) and best-corrected visual acuity (BCVA). Vision status was described as lines of visual acuity (VA) impairment and lines of VA improvement from UCVA to BCVA and from PVA to BCVA in the better-seeing eye. A total of 2384 subjects were enumerated, 2041 (85.6%) were examined, with reliable VA measurements obtained from 2025 participants. Vision status in lines of VA impairment was (mean ± standard deviation): 3.44 ± 3.53 for UCVA, 2.85 ± 3.52 for PVA and 1.50 ± 3.51 for BCVA. Female gender, older age and lower education were associated with ≥6 lines of UCVA impairment. Lines of improvement ≥3 was found in 626 (30.9%) participants and associated with female gender and rural residency. In conclusion, a third of participants could have at least three lines of VA improvement with proper refraction. Strategies to improve access to eye care and affordable glasses are needed.

Instruments for evaluation of functionality in children with low vision: a literature review

We conducted a literature review of tools used to evaluate functionality in children with low vision with the aim of analyzing the applicability, advantages, and disadvantages for children <6 years of age, an age at which visual development is mostly complete. Publications in Portuguese, English and, Spanish describing functional evaluation tools for children aged 0-18 years with low vision in the following databases were included: Web of Science, Virtual Health Library, Cochrane, Scielo, and PubMed. A total of 181 articles were collected, 15 of which were included in this review. Thirteen tools were identified, nine of which evaluated overall functionality and quality of life through questionnaires. The other 4 instruments, using a observational test model, evaluated functionality and they were elected. Observational tests chosen for their accuracy and lower selection bias were used to evaluate visual functionality. Of these, the Functional Vision Assessment up to 6 years seems to be promising. In conclusion, we observed a lack of tools for evaluating functionality in children with low vision. This type of evaluation is necessary for planning visual rehabilitation to improve quality of life in children with low vision.

Adjustable versus non-adjustable suture techniques for concomitant horizontal strabismus: a comparative study

PURPOSE To compare the surgical results of adjustable and non-adjustable horizontal strabismus surgery for concomitant horizontal strabismus. METHODS The charts of 231 patients, who underwent horizontal strabismus surgery, selected using probabilistic sampling, were retrospectively reviewed. Patients were divided into two groups according to the surgical technique used and strabismus type. The adjustable suture technique was used for 107 patients (Group 1), and non-adjustable or conventional surgery was performed in the remaining 124 patients (Group 2). Patients with esotropia (ET) or exotropia (XT) of <55 prism diopters (PD) at distance were included. The following exclusion criteria were applied: all intermittent or vertical deviations, anisotropias >5 PD, syndromes, restrictive or paretic strabismus, reoperations, botulinum toxin injection, and patients postoperatively followed up for <3 months. Surgical success was set to a range between orthotropia and an esodeviation of up to 10 PD for both ET and XT. RESULTS An amblyopia rate >50% was present in all subgroups. Significant differences between strabismus groups submitted to adjustable technique and non-adjustable on postoperative day 1 were observed (p=0.00 for ET and p=0.01 for XT) and at the last visit for the XT group with a follow-up of at least 1 year (p=0.05). CONCLUSION The adjustable suture technique produced a higher success rate than non-adjustable strabismus surgery for both ET and XT groups on postoperative day 1. For XT patients, the adjustable suture technique appears to produce better surgical results than non-adjustable surgery, when the surgical goal is long-lasting maintenance of a small hypercorrection.

Current treatment of amblyopia: where are we?

Desde os primeiros contatos com a oftalmologia aprendemos a diagnosticar a ambliopia e iniciar pronta-mente seu tratamento. Apesar de valiosos os conhecimentos recebidos nesse processo de aprendizado, parte do que aprendemos de terapeuticas empregadas no tratamento da ambliopia, passado as sucessivas geracoes de oftalmologistas, carece ainda de evidencia. Embora seja uma das doencas do desenvolvimento mais antigas e tenha suas caracteristicas basicas conhecidas com maior profundidade pelos trabalhos experimentais dos premios Nobel Hubel e Wiesel, parte de sua fisiopatologia ainda e desconhecida, permanecendo como uma das mais enigmaticas e interessantes doencas visuais do desenvolvimento

Síndrome de Möbius: achados clínicos e cirúrgicos em 7 pacientes

Purpose: To evaluate clinical features, pregnancy and labour abnormalities and the results of strabismus surgery in patients with Mobius syndrome. Methods: The authors studied retrospectively 7 patients with Mobius syndrome, of whom 6 were submitted to strabismus surgery. Results: In addition to the classical findings that characterize the syndrome, pregnancy and labour insults were observed in all cases. In 2 patients a posterior medial rectus insertion was found during surgery. Due to cross-fixation, these patients usually do not develop amblyopia. Conclusions: Surgery should consist of muscle recessions, but recessing them less than it would be done for similar isolated abducens palsy.

Diplopia vertical persistente pós-facectomia e tireoidopatia associadas

The authors report a case of a 69 year-old woman who developed persistent vertical deviation and diplopia after extracapsular cataract surgery and had a positive past history of thyroid disease. The authors emphasize the need of for detailed orbit propedeutics in order to rule out restrictive strabismus associated with post-facectomy diplopia.

Acquired restrictive strabismus in infancy associated with neurofibromatosis type 2

Dear Editors: We would like to add some new information regarding the patient described in the paper entitled, “Surgical treatment of acquired restrictive strabismus in infancy: case report”, published in Arquivos Brasileiros de Oftamologia in 2009. We stated that the diagnosis in the reported case was unclear despite extensive investigations. After surgical treatment of acquired restrictive strabismus, the child described remained stable with no other symptoms for approximately 7 years. By the age of 14 years, he developed left hand palsy and skin tumors. One year later, he started experiencing the beginnings of a hearing loss. Magnetic resonance imaging (MRI) of the brain revea led bilateral tumors indicative of vestibular schwannoma (Figure 1). Subsequently, the patient was referred to the Neurofibromatosis Reference Center of the Universidade Federal de Minas Gerais for further evaluation. Diagnosis of neurofibromatosis type 2 (NF2) was then established according to MRI demonstrating bilateral vestibular schwannomas associated with cutaneous schwannomas. NF2 is a dominant, autosomal disease characterized by bilateral vestibular schwannomas with multiple nervous system and skin tumors and is often associated with ocular abnormalities. Although classically considered a disease of adults, the initial signs and symptoms of NF2 may be evident in childhood and often goes unre cognized. Diagnosis is difficult in the majority of cases because of its rarity. Initial manifestations of NF2 differ between children and adults. The first sign of disease severity in patients with early-onset NF2 predominantly comprise ocular presentations and weakness in lower motor neuron extremities as opposed to impairment of the eighth nerve in cases of late disease onset. Approximately 50% of NF2 patients present with strabismus, ty pically associated with tumors and palsies of cranial nerves III, IV, and VI. Although restrictive strabismus is not commonly reported in patients with NF2, it is possible that it was associated with early onset of NF2 in our patient.

Oliver Sacks and his legacy to vision science and ophthalmology

A little boy enchanted by chemistry and the periodic table elements, a motorcycle young man who crossed a continental country in so many directions, scuba diver and olympic weightlifter, an obsessive re searcher and a dedicated physician. These are some facets of a brilliant human being. Oliver Wolf Sacks was born in London in July 9, 1933, graduated in Medicine at Oxford University, England, specialized in Neurology in California, USA, and worked most of his life in New York City, USA. The reason to bring him to an editorial in ABO (Arquivos Brasileiros de Oftalmologia), a journal dedicated to vision and ophthalmology, is because early in his professional career he became a writer, describing neurological patients, with particular and talented reports on ocular conditions, visual symptoms and neuro-ophthalmologic correlations in his writings. Talented clinicians are becoming rare, talented clinicians with writing talent are even more so. Dr. Oliver Sacks must be known by the present and future generations of physicians as a writer that wrote in a way that allowed the reader to know about the disease, but, more importantly, to know how the patient felt and dealt with his condition, through poetic lines of his numerous books and articles He became a bestselling and awarded author all over the world, with writings that gave voice, face and action to patients with chronic, sometimes uncommon, and severe diseases. He published 14 books and authored or co-authored 58 papers. So far, 14 of his writings became documentaries and three of his tales, including the famous “Awakenings” inspired films. Overall, he taught the physicians to consider the patient’s perspective in the first place. In his recent published autobiography “On the Move: a life”, he revealed that his style was inspired by medical writers of the XIX century. This influence was clear in references used in his books, in particular in “An Anthropologist on Mars”, where in seven dramatic stories, he revealed his deep sensitivity to the vision complaints of his patients. The first case described the suffering of a painter who became color blind after a car accident. The fourth case described a middle age individual who experienced to see again after decades of blindness. In the fifth and sixth cases he described patients with different conditions that had in common an intense visual memory and capacity to draw these views. All of those reports were fulfilled with beautiful wording and illustrations, as well as detailed local descriptions and medical references, dating back to the beginning of the XVIII century. Among the visual symptoms addressed in his papers were visual hallucinations, metamorphosis and visual agnosia. These papers are strongly recommended reading, not just because of the clear and thoughtful presentation, but also because these subjects are challenging and usually neglected during medical training. For those who read the “The Island of Colorblind” it will be always engraved on our minds the intriguing condition of a society where total congenital colorblindness is the norm, and how adaptation may occur. These reflections may teach how to cope with patient fragilities face to a condition that leads to visual deficiency and how adaptation and acceptance may improve their lives. Other books, including “Migraine”, his first one, addressed the visual symptoms of this condition with a rich description and interpretation of the mechanisms, but even for those not related to the eye care, it is certainly worthwhile reading (Table 1). As he wrote in his autobiography “It seems to me that I discover my thoughts through the act of writing, in the act of writing”. To understand his patients conditions profoundly he used to search their symptoms and diseases pathways. This was beautifully reflected in the many partnership he had along his career, such as Crick, Hubel, Wiesel and Edelman; Nobel laureates who were also important contributors in his works, as many other that influenced him such as Thom Gun, Luria and Auden. He showed a wonderful way to go further and a great example to be followed by researchers and clinicians. His last book was originated by articles published in the New York Times, describing his joy with the life experience apart from his own drama fighting against an ocular melanoma, first diagnosed in 2006, which revealed metastases on January 2015. It was called “Gratitude” and was a posthumous publication. Sadly, Dr. Oliver Sacks died on August 30 of 2015. Based on the last words of his autobiography, it is clear that his literature legacy is not yet finished.