Objetivo: Avaliar o desenvolvimento da Acuidade Visual (AV) de resolução de grades e a Sensibilidade ao Contraste (SC) de recém-nascidos de termo pequenos para a idade gestacional (PIG). Método: Medimos a AV e a SC de 126 recém-nascidos de termo com o potencial visual evocado de varredura (PVEv; Norcia & Tyler 1985). 73 recém-nascidos (Média de Idade = 11,3 ± 4,3 semanas) nasceram com o peso adequado para a idade gestacional - AIG (percentil 10; Alexander et al., 1996) e 53 recém-nascidos (Média de Idade = 9,2± 3,8 semanas) nasceram pequenos para a idade gestacional - PIG (percentil <10). Mediu-se o PVEv com o sistema PowerDiva (Norcia & Tyler, 1985; Chen et al., 2005) o qual gerou os estímulos e analisou as respostas provocadas. O PVEv foi registrado com três canais unipolares colocados em O1, Oz, and O2 relacionados ao eletrodo de referência no vertex. Utilizaram-se os estímulos de grades senoidais verticais em reversão de fase em 6 Hz com a luminância média de 161 cd/m2. Para medir a AV, o contraste de 80% era mantido fixo e a freqüência espacial aumentava linearmente em intervalos de 1 segundo, durante 10 segundos. Para avaliar a SC, a freqüência espacial de 0,5 cpg era mantida fixa e o contraste aumentava logaritmicamente em intervalos de 1 segundo, durante 10 segundos. Os resultados de ambas as funções visuais foram baseados na média vetorial de pelo menos três tentativas do PVEv. Analisou-se, também, a média do ruído e quatro medidas supralimiares: amplitude máxima (Amáx), razão sinal-ruído em Amáx (SNRmáx), fase em Amáx (máx) e a inclinação da reta do PVEv. Considerou-se o canal que registrou a AV e a SC mais alta, satisfazendo o critério rigoroso de fase e amplitude para assegurar que as respostas corticais eram confiáveis e significativamente acima do ruído. Resultados: O teste Qui-quadrado mostrou que uma proporção significativa de recém-nascidos PIG menores de 9 semanas de idade apresentava valores de AV e SC abaixo da média do grupo AIG com o peso ao nascimento igual ou acima do percentil 50 (P50). Além disso, nas medidas de AV, uma proporção significativa de recémnascidos PIG de 5 a 24 semanas de idade apresentava valores de Amáx, ruído médio e SNRmáx significativamente menores que a média do grupo AIG (P50). A ANOVA fatorial confirmou que a AV, SC, ruído médio e todas as medidas supralimiares apresentaram um desenvolvimento significativo, isto é, as médias dos valores para os recém-nascidos abaixo de 10 semanas de idade apresentavam-se significativamente menores do que as médias dos valores entre 10 e 24 semanas de idade. Além disso, a taxa de desenvolvimento de máx era semelhante para os dois grupos, assim como para os dados de desenvolvimento de fase de Hamer e Norcia (1994). Conclusões: Os recém-nascidos de termo pequenos para a idade gestacional apresentaram alterações no desenvolvimento da acuidade visual de resolução de grades e sensibilidade ao contraste para frequência espacial baixa, principalmente nos 2 primeiros meses de vida quando as alterações nos limiares foram mais evidentes. Além disso, as alterações significativas encontradas para o ruído médio e amplitudes supralimiares durante os seis primeiros meses de vida, mostram que mesmo se os limiares de acuidade visual e contraste não fossem afetados, efeitos neuronais significantes ocorreriam nas vias visuais que conduzem a resposta gerada pelo PVEv (Mirabella et al., 2006) / Objectives: To evaluate the development of cortical grating acuity (VA) and contrast sensitivity (CS) in term infants born small for gestational age (SGA). Methods: Using the sweep visual evoked potential (sVEP; Norcia & Tyler 1985), we measured cortical VA and CS in 126 term infants. Seventy-three (average age = 11.3 ± 4.34 weeks) were born with birthweight within normal limits (> 10th percentile; Alexander et al., 1996). 53 infants were born SGA (average age = 9.2 ± 3.8 weeks). sVEPs were measured using the PowerDiva system (Norcia & Tyler, 1985; Chen et al., 2005) which generated the stimuli and analyzed the evoked responses. The sVEP was recorded using 3 unipolar channels placed at O1, Oz, and O2 with a reference electrode at the vertex. Stimuli were vertical sinewave luminance gratings phase-reversing at 6 Hz with a mean luminance of 161 cd/m2. To measure VA, spatial frequency (SF) was swept linearly from low to high during a 10-second trial, generating ten 1-sec time bins of sVEP data. Grating contrast was fixed at 80% during the SF sweep. To evaluate CS, SF was fixed at 0.5 c/deg, and contrast was increased logarithmically across 10 1-sec recording epochs. The resulting sVEP data from both protocols were based on a vector average of a minimum of 3 sVEP trials. In addition to thresholds, we analyzed average noise (Nav), and 4 suprathreshold measures - peak amplitude (Apeak), signal-to-noise ratio at Apeak (SNRpeak), phase at Apeak (peak) and slope of the rising phase of the sVEP (m). The data used were those obtained from the recording channel generating the highest VA or CS while satisfying strict phase and amplitude criteria to ensure that the responses were reliable and significantly above the noise. Results: A Chi-squared test showed that a significant proportion of the young ( 9 weeks) SGA infants had values of VA and CS that were below the mean of control infants (with birthweights above the international 50th percentile). In addition, mean Nav, Apeak and SNRpeak for the whole group of SGA infants were below the means of control infants across the whole age range tested. A factorial ANOVA confirmed that VA, CS, Nav and all the suprathreshold measures underwent significant development; that is, the mean values prior to 10 weeks were significantly different than the mean values between 10 and 24 weeks. In addition, the rate of development of peak was similar for the two groups as well as to prior phase-development data Hamer and Norcia (1994). Conclusions: Birth at term with weight small for gestational age appears to significantly affect development of both cortical grating acuity and contrast sensitivity for low-SF gratings. Effects on thresholds are most evident in the first 2 months. Moreover, the significant effects we found in Nav and suprathreshold amplitudes throughout the first 6 months of life show that, even if acuity and contrast thresholds are not affected, significant neuronal effects occur in the visual pathways leading to the sVEP signal (Mirabella et al., 2006)

Objetivo: Avaliar os efeitos da desnutrição intra-uterina na acuidade visual (AV) de resolução de grades pelo Potencial Visual Evocado de Varredura (PVEv) e Cartões de Acuidade de Teller (CAT). Método: Avaliamos a AV de resolução de grades, binocularmente, de 41 recém-nascidos com idade estacional 37 semanas, destes 23 nasceram com o peso adequado para a idade gestacional (AIG - Idade: 14,3 ± 7,5 semanas) e 18 nasceram pequenos para a idade gestacional (PIG - Idade: 10,7 ± 4,1semanas). A AV foi determinada usando ambas as técnicas psicofísica (CAT) e eletrofisiológica (PVEv). Durante o teste dos CAT foram apresentados cartões contendo em um dos lados grades de ondas quadradas pretas e brancas com freqüência espacial entre 0,23 e 19 ciclos por grau de ângulo visual a 55 cm do participante. O teste iniciou com o cartão com a freqüência espacial mais baixa com orientação randômica desconhecida pelo experimentador. Cartões contendo freqüências espaciais mais altas foram apresentados gradativamente até que uma resposta incorreta ocorresse, então o cartão anterior era apresentado novamente. A AV foi definida pela média aritmética das freqüências espaciais contidas nos cartões para 4 reversões. Para o registro do PVEv, o sistema PowerDiva (Brosnahan et al., 1998) foi usado para gerar todos os estímulos e analisar as repostas provocadas. Estímulos de grades senoidais em reversão de fase em 3, 6 ou 10 Hz foram apresentados em monitor de vídeo monocromático de 21 polegadas com luminância média de 161,13 cd/m2. Registramos o eletroencefalograma com três eletrodos ativos (O1, Oz, O2) relacionados ao eletrodo de referência no vertex. Durante cada tentativa com duração de 10 segundos, resentávamos uma faixa de freqüência espacial que aumentava linearmente. Para cada condição (freqüência temporal - FT) foram usadas no mínimo três tentativas para estimar o limiar. Consideramos o canal que registrou a AV mais alta com boa razão sinal-ruído (SNR>3:1), fase constante e critério estatístico. Resultados: Não encontramos diferenças significativas na AV entre os grupos para nenhum dos métodos. Para o PVEv, não encontramos diferenças significativas na AV, amplitude, ruído ou SNR entre os grupos para nenhuma das FT. Análises intra-grupos mostraram que os valores de amplitude, SNR e ruído foram significativamente diferentes entre as freqüências temporais apenas para os PIG. Entretanto, os PIG até 8 semanas de idade mostraram uma tendência para amplitudes e SNR mais altas para a FT de 3 Hz comparadas aos AIG. Esses mesmos PIG mostraram uma tendência para valores de fase maiores respostas lentas) em comparação aos AIG. Entretanto, a taxa de desenvolvimento da fase foi maior para os PIG do que para os AIG em todas as FT. Conclusão. Não há alteração significativa na AV de recém-nascidos PIG, entretanto as informações de medidas supra-limiares são consistentes com a hipótese que a desnutrição intra-uterina torna as respostas visuais mais lentas entre a retina e o córtex visual. Os dados também sugerem de forma sutil que tais efeitos são passageiros afetando primariamente o grupo de recém-nascidos mais jovens e que o sistema visual dos PIG tem plasticidade suficiente para atingir rapidamente os níveis normais. Mais dados serão necessários para validar esta interpretação. / Objective: To evaluate the effects of intra-uterine malnutrition on grating visual acuity (VA) using Sweep VEP and Teller Acuity Cards (TAC). Method: Binocular grating acuity was evaluated in 41 newborns with gestational age 37 weeks. Twentythree were born with appropriate weight for gestational age (AGA age: 14.3 ± 7.5 weeks) and 18 were born small for gestational age (SGA age: 10.7 ± 4.1 weeks). Visual acuity was determined using both psychophysical (Teller Acuity Cards) and electrophysiological (sVEP) techniques. For the TAC evaluation, cards having calibrated black and white square waves gratings at spatial frequencies (SFs) between 0.23 and 19 cycles/degree were presented 55 cm from the subject. The test began with the lowest SF card in random orientation to which the experimenter was blind. Subsequent cards were presented in order of increasing SF until an incorrect response was made, at which time the prior (lower-SF) card was presented again. Visual acuity was defined as the average of the SF values for 4 reversals. For the sVEP recordings, the PowerDIVA VEP system (Brosnahan et al., 1998) was used to generate all stimuli and analyze the evoked responses. Stimuli were spatial luminance sinewave gratings presented on a 21-inch monochromatic high-resolution monitor (1600x1200 pixels) with an average luminance of 161.1 cd/m2. Gratings were phase-reversed at either 3, 6 or 10 Hz. The electroencephalogram was recorded using 3 active electrodes (O1,Oz,O2) related to the reference electrode at vertex. During each 10-sec sVEP trial a linear sweep of increasing SF was presented. Sweep ranges were selected according to the subjects age. For each condition (each TF), a minimum of 3 trials were used to estimate thresholds, but the majority of measures were the result of a vector average of 5 to 10 trials. For each condition, the acuity estimate used derived from the channel with the highest acuity with statistically significant signal-to-noise ratio (>3:1) and stable phase during the high-SNR portion of the response. Results: There were no statistical differences in visual acuity between the two groups (SGA and AGA) for either method (sVEP or TAC). For the sVEP, acuities were not statistically different for the different TFs. There were also no statistical differences between groups for the sVEP measures of amplitude, phase, noise or signal-to-noise ratio. Intra-group analysis of the sVEP measures at the three TFs revealed statistical differences for amplitude, noise and signal-to-noise ratio, but only for SGA group. However, the SGA subjects less than or equal to 8 weeks of age showed a tendency for higher amplitudes and SNR for 3Hz temporal frequency compared to AGA subjects, and these same SGA subjects showed tendency for larger phase values (slower responses) compared to AGA. However, phase development rate was faster for SGA than for AGA for all temporal frequencies. Conclusion: There were no significant alterations of visual acuity in SGA babies, but the data from suprathreshold measures are consistent with the hypothesis that intrauterine malnutrition results in slower visual responses between retina and cortex. The data obtained so far suggest that such affects are transient, affecting primarily the younger group of infants, and that the visual system in SGA infants has sufficient plasticity to recover rapidly to normal levels. More data is needed to validate this interpretation of the results.

Abstract available through Journal of Neurologic Physical Therapy.

Age-related macular degeneration (AMD) is one of the leading causes of blindness in the United States in people who are 50 and older. The safety and efficacy of aflibercept for the treatment of late stage neovascular AMD (NAMD) has been demonstrated by clinical trials among several populations; however, it is unclear whether all NAMD patients respond in the same manner as was studied in the clinical trials. The purpose of this study was to examine if populations of patients treated with aflibercept for the treatment of NAMD were significantly different from one another in terms of health characteristics, treatment regimens, and treatment outcomes. The burden of treatment theory was used to guide this study. Data collected from electronic medical records were used to investigate NAMD characteristics 199 patients from 3 private, retinal practices in the United States. Data were analyzed using one-way ANOVA, 2, Spearman's correlation, and point-biserial correlation tests. The results of this study showed the specific retinal practice populations of NAMD patients treated with aflibercept were generally similar with respect to selected health characteristics, treatment regimens, and treatment outcomes. By using the information reported from this research, public health initiatives can be developed that focus on the need for early detection of AMD to capture changes that represent NAMD and move to early treatment for better outcomes. The positive social change that could result from this research is that retinal specialists may gain insight into the use and outcomes of aflibercept treatment.

O Zika virus (ZIKV) é um flavívirus, tal qual o virus da dengue e, assim como esse, também é transmitido pelos mosquitos do gênero Aedes, especialmente o Aedes aegipty Restrito ao continente africano até 2007, o ZIKV chegou as Américas em 2013, com os primeiros registros brasileiros da infecção datando de 2014 - 2015. Em 2016, a OMS classificou o surto de ZIKV como Emergência de Saúde Mundial. O ZIKV pode acarretar na Sindrome Congênita do ZIka Vírus (SCZ) em bebês que sofreram infecção gestacional. Além da manifestação mais temida e marcante, a microcefalia, e de demais danos neurológicos, a SCZ tem sido principalmente associada com anomalias visuais e oftalmológicas. Entretanto, poucas informações se encontram disponíveis na literatura sobre o impacto da infecção por ZIKV nas funções visuais e desenvolvimento visual em crianças sem microcefalia. Pouco se conhece também do impacto da infecção em diferentes populações brasileiras, de localidades distintas. Dessa forma, o presente trabalho se propôs a preencher essa lacuna, avaliando a acuidade visual (AV) e desenvolvimento da acuidade visual em crianças expostas gestacionalmente ao ZIKV, utilizando-se o Teste dos Cartões de Acuidade de Teller (CAT). As crianças avaliadas vieram de duas populações distintas da região Sudeste do Brasil, a cidade de Jundiaí (SP) e a cidade do Rio de Janeiro (RJ). A Coorte Zika Jundiaí foi composta de 118 crianças divididas entre grupo controle saudável (ZC) com 63 crianças, grupo experimental, dividido em dois subgrupos, baseado em exame de RT- qPCR, sorologia ou avaliação clínica, o subgrupo Exposto (ZE) com 23 crianças, em que apenas as mães tiveram infecção confirmada por ZIKV e o subgrupo Infectado (ZI), com 24 crianças no qual mãe e criança tiveram infecção confirmada. Oito crianças formaram o grupo Controle Postivo (M), com crianças com microcefalia em decorrência de outras causas. A Coorte IFF Fiocruz Rio de Janeiro foi composta de 32 crianças, todas com infecção confirmada pelo ZIKV (ZI), por exame de RT-qPCR, sorologia ou avaliação clínica. Os resultados do presente trabalho mostram que a exposição gestacional ao ZIKV, na ausência de infecção, parece não ter efeito sobre a AV ou seu desenvolvivemento. No entanto, quando ocorre infecção gestacional por ZIKV, pode haver prejuízos à AV mesmo quando a criança não apresenta anomalias neurológicas e/ou oftalmológicas aparentes. Esse trabalho, entretanto, concorda com estudos anteriores que mostram uma maior chance de haver perdas de AV concomitantementes a um comprometimento cognitivo e/ou oftalmologico. As análises do subgrupo ZI de Jundiaí dão suporte a noção de que crianças gestacionalmente infectadas por ZIKV tendem a apresentar um desenvolvimento anormal (mais lento) da AV. Esse achado, se reproduzido, possuí repercussões mais gerais, dado que quaisquer danos à função visual podem indicar deficiências no sistema nervoso central. Assim sendo, tais achados tem importantes repercussões na saúde pública. Além disso, as taxas diferentes de danos à AV, bem como de incidência de microcefalia e comprometimento oftalmológico entre as populações estudadas neste trabalho, apoiam a hipótese da existência de demarcadas diferenças regionais entre as linhagens de ZIKV circulantes no país, assim como de diferenças de suscetibilidade de hospedeiros entre as populações estudadas / The Zika virus (ZIKV) is a flavivirus, such as the dengue virus, and like the dengue virus is also transmitted by the Aedes osquitoes, especially the Aedes aegipty Restricted to the African Country until 2007, the ZIKV arrived in the Americas in 2013, with the first brazillian cases of the infection dating to 2014 - 2015. In 2016, WHO classified the ZIKV spread as a World Health Emergency. The ZIKV, in gestationally exposed children, can lead to Congenital Zika Syndrome (CZS). Beyond its most marked and feared manifestation, microcephaly, and its other neurological damages, CZS is mostly associated with visual and ophthalmologic anomalies. However, little information is available on the literature about the impact of the ZIKV infection in the visual function and on the visual development in infected children without microcephaly. Little is also known about the impact of the infection in different brazillian populations from distinct areas. With that in mind, the present work intends to fill this gap in literature, evaluating the visual acuity (VA) and visual acuity development in children gestationally exposed to the ZIKV, using the Teller Acuity Cards Test (TAC). The evaluated children were from two different populations of the Southeast region of Brazil, the city of Jundiaí (SP) and the city of Rio de Janeiro (RJ). The Zika Jundiaí Cohort was composed of 118 children divided between the healthy control group (ZC) with 63 children and the experimental group, divided in two subgroups based on RT-qPCR, sorology or clinical evaluation, the Exposed subgroup (ZE) with 23 children, which only the mothers had ZIKV confirmed and the Infected subgroup (ZI), with 24 children, wich both mother and children had ZIKV confirmed infection. Eight children formed the Positive Control Group (M), composed of children with microcephaly due to other causes. The IFF Fiocruz Rio de Janeiro Cohort was composed of 32 children, all with confirmed ZIKV infection (ZI), either by RT-qPCR/sorology exam or by clinical evaluation. The results of the present work show that ZIKV exposition in absence of infection, does not seem to affect VA or its development. However when theres a gestational ZIKV infection, it may lead to VA damages even when the children does not show any apparent neurologic/ophtalmologic anomalies. This work, nonetheless, is in agreement with former studies that show a higher chance of VA losses when the children also have cognitive and/or ophtalmologic deficits. The Jundiaí ZI Subgroup analisies support the notion that ZIKV gestationally infected children tend to have an abnormal (slower) VA development. This finding, if replicated, has more general repercussions given that any visual function damages may indicate central nervous system deficiencies. Thus, these findings have important repercussions in the public health area. Furthermore, the different rates of VA damages as well as the different rates of microcephaly incidencies and ophthalmologic deficits between the populations studied in this work support the hypothesis of marked regional differences between the brazillian ZIKV strains, as well as host suscepitibilitiess differences between the studied populations

Bakgrund: Diabetes är en av de främsta orsakerna till synnedsättning och blindhet. Dåförekomsten av diabetes ökar utgör de synrelaterade komplikationerna ett växande globalt hälsoproblem. En ökad förståelse för hur personer med diabetesretinopati upplever att synnedsättning påverkar deras dagliga kan vara till stor hjälp i mötet med dessa personer. Syfte:Syftet med studien var att beskriva personers upplevelser av att leva med diabetesretinopati. Metod: Studien genomfördes som en allmän litteraturstudie. Vetenskapliga, empiriska studier med kvalitativ och kvantitativ ansats ligger till grund för studien. Resultat: Studiens resultat redovisas utifrån tre olika teman: känsla av delaktighet, känsla av begränsningar och känsla av otillräcklighet. Diskussion: Sjuksköterskan bör vara professionell i mötet med patienten. Kommunikation, undervisning och en helhetssyn av personens upplevelse av sin livssituation ligger till grund för personens vård och behandling. Det är viktigt med hälsofrämjande insatser för att kunna förebygga komplikationer. / Background: Diabetes is one of the leading causes of vision loss and blindness. Since the prevalence of diabetes is increasing, the sight-related complications are a growing global health problem. A better understanding of how people with diabetic retinopathy are experiencing vision loss that affects their daily may be helpful in meeting with these people. Purpose: The purpose of this study was to describe people's experiences of living with diabetic retinopathy. Method: The study was conducted as a general literature review. Scientific, empirical studies using qualitative and quantitative approach is the basis for the study. Results: The results are reported from three different themes: sense of ownership, sense of limitations and feelings of inadequacy. Discussions: Nurse should be professional in the meeting with the patient. Communication, education and a holistic view of the person's experience of their lives is the basis for the person's care and treatment. It is important with health promotion efforts to prevent complications.

Objectif : L'évaluation de l'acuité visuelle (AV) chez la personne âgée atteinte de troubles cognitifs peut être limitée par le manque de collaboration ou les difficultés de communication du patient. Très peu d'études ont examiné l'AV chez les patients atteints de déficits sévères de la cognition. L’objectif de cette étude était d’évaluer l'AV chez la personne âgée vulnérable ayant des troubles cognitifs à l'aide d'échelles variées afin de vérifier leur capacité à répondre à ces échelles. Méthodes: Trois groupes de 30 sujets chacun ont été recrutés. Le premier groupe était constitué de sujets jeunes (Moy.±ET: 24.9±3.5ans) et le second, de sujets âgés (70.0±4.5ans), ne présentant aucun trouble de la cognition ou de la communication. Le troisième groupe, composé de sujets atteints de démence faible à sévère (85.6±6.9ans), a été recruté au sein des unités de soins de longue durée de l’Institut Universitaire de Gériatrie de Montréal. Le test du Mini-Mental State Examination (MMSE) a été réalisé pour chaque sujet afin de déterminer leur niveau cognitif. L’AV de chaque participant a été mesurée à l’aide de six échelles validées (Snellen, cartes de Teller, ETDRS-lettres,-chiffres,-Patty Pics,-E directionnel) et présentées selon un ordre aléatoire. Des tests non paramétriques ont été utilisés afin de comparer les scores d’AV entre les différentes échelles, après une correction de Bonferroni-Holm pour comparaisons multiples. Résultats: Le score moyen au MMSE chez les sujets atteints de démence était de 9.8±7.5, alors qu’il était de 17.8±3.7 et 5.2±4.6 respectivement, chez les sujets atteints de démence faible à modérée (MMSE supérieur ou égal à 13; n=11) et sévère (MMSE inférieur à 13; n=19). Tous les sujets des groupes 1 et 2 ont répondu à chacune des échelles. Une grande majorité de sujets avec démence ont répondu à toutes les échelles (n=19) alors qu’un seul sujet n’a répondu à aucune échelle d’AV. Au sein du groupe 3, les échelles d’AV fournissant les scores les plus faibles ont été les cartes de Teller (20/65) et les Patty Pics (20/62), quelque soit le niveau cognitif du sujet, alors que les meilleurs scores d’AV ont été obtenus avec les échelles de Snellen (20/35) et les lettres ETDRS (20/36). Une grande proportion de sujets avec démence sévère ont répondu aux cartes de Teller (n=18) mais le score d’AV obtenu était le plus faible (20/73). Au sein des trois groupes, l’échelle de lettres-ETDRS était la seule dont les scores d’AV ne différaient pas de ceux obtenus avec l’échelle de Snellen traditionnelle. Conclusions: L’acuité visuelle peut être mesurée chez la personne âgée atteinte de troubles cognitifs ou de la communication. Nos résultats indiquent que les échelles les plus universelles, utilisant des lettres comme optotypes, peuvent être utilisées avec de bons résultats chez les personnes âgées atteintes de démence sévère. Nos résultats suggèrent de plus que la mesure d’acuité visuelle doit être tentée chez toutes les personnes, peu importe leur niveau cognitif. / Purpose: The evaluation of visual acuity (VA) in cognitively impaired older individuals may be limited by a reduced ability to cooperate or communicate. To date, no study has been performed to guide the clinician as to which VA chart to use in older individuals with moderate to severe dementia. This is important knowing that dementia affects more than 30% of seniors above 85 yrs of age, many of whom will be affected by the most severe stages of the disease. The objective of this research was to assess VA in older institutionalized individuals with moderate to severe dementia, using various acuity charts, and to verify their ability to respond to each of these charts. Methods: Three groups of 30 subjects each were recruited. The first group consisted of young subjects (Avg ± SD: 24.9 ± 3.5 yrs) and the second one, older subjects (70.0 ± 4.5 yrs) with no history of cognitive or communication disorders. The third group (85.6 ± 6.9 yrs) included subjects with mild to severe dementia residing in long-term care units. The Mini Mental-State Examination (MMSE) was performed for each institutionalized subject to verify their cognitive level. The VA of each participant was measured using six validated VA charts (Snellen, Teller cards, ETDRS-letters, -numbers, -Patty Pics, -Tumbling E's) presented in random order. Non parametric tests were used to compare VA scores obtained between the various charts, after Bonferroni-Holm corrections for multiple comparisons Results: The average MMSE scores of subjects with dementia was 9.8 ± 7.5, while it was 17.8 ± 3.7 and 5.2 ± 4.6, for those with mild to moderate (MMSE ≥ 13; n=11) and severe (MMSE < 13; n= 19) dementia. All subjects in groups 1 and 2 responded to each of the charts. A large proportion of subjects with dementia responded to all charts (n= 19) while only one did not respond to any chart. In group 3, VA charts with the lowest scores were the Teller cards (20/65) and Patty Pics (20/62), regardless of the level of dementia, while the best VA scores were obtained with the Snellen (20/35) and ETDRS-letter (20/36) charts. More subjects with severe dementia responded to the Teller cards (n= 18) but the VA obtained was the lowest (20/73). Across all groups, the ETDRS-letter chart was the only one whose scores did not differ from those obtained with the standard Snellen chart. Time to read the letter charts was faster than for the other optotypes. Conclusions: Visual acuity can be measured, and should at least be attempted, in older cognitively impaired individuals having a reduced ability to communicate. Our results indicate that the most universal scales, using letters as optotypes, can be used with good results in people with more severe dementia. Testing requires, however, more time and encouragement in individuals with more severe cognitive deficits in order to obtain and maintain their collaboration.

Functional vision refers to the use of vision to perform day-day tasks and is assessed by the ability to perform these tasks. Assessment of functional vision is an integral component of the management of children with visual impairment. The results of the assessment help in designing appropriate educational and rehabilitation intervention strategies. The L V Prasad-Functional Vision Questionnaire (LVP-FVQ) is a reliable and valid tool for assessing self-reported functional vision performance (FVP) in children. Self-reports are obviously the child's perception of his or her ability to perform certain tasks but they may not reflect actual performance. Various studies of FVP in adults have used actual performance measures of everyday tasks, but very few studies, even in adults with visual impairment, have compared self-reports and performance measures and none have included identical tasks on the 2 methods of assessment. To date, no study has assessed FVP using performance measures of daily tasks in the paediatric population. Therefore, the aims of the current study were: (1) To develop performance measures of FVP and compare them with self-reports of FVP from the LVP-FVQ in a prospective cohort of Indian school-going children with visual impairment. (2) To investigate the effect of a psychological attribute, self-concept, on self-reports, performance measures and the relationships between the 2 measures. (3) To investigate the relationship between clinical measures of vision and FVP. Performance measures of FVP for children with visual impairment were developed for 17 day to day tasks for comparison with self-reports of the same tasks for the LVP-FVQ. The LVP-FVQ was verbally administered by the researcher to 178 Indian school-going children aged between 8 and 17 years with visual impairment. Similarly, the performance of each of the tasks by these children was measured by the researcher. The performance measures for most of these tasks were recorded on continuous scales and later categorized to match the ordinal ratings from the LVP-FVQ. The self-report and performance measure ratings for the 17 tasks were then converted into the same metric using a Rasch model allowing an accurate picture of whether and how these two measures of FVP compared with each other. Rasch analysis was used to estimate the person ability and item difficulty for FVP from the 2 methods of assessment. Self-reports showed stronger correlations with performance measures of FVP than were hypothesized. Similar to some studies in adults, binocular high-contrast visual acuity was found to be the single most significant predictor of a child's functional vision performance. Contrary to expectations, self-concept did not have a significant effect on the relationship between the 2 measures. A few reasons for the stronger than expected relationship between the 2 methods of assessment of FVP in children with visual impairment are suggested. Firstly, the use of identical tasks for self-reports and performance measures of FVP is likely to improve the relationship. Secondly, the LVP-FVQ was developed using focus groups of children with visual impairment, their parents, low vision specialists and rehabilitation professionals leading to good content validity. Since children were included in the development of the LVP-FVQ, the tasks were representative of a child's typical daily life. Thus, the performance measures were also suited to the day-day tasks of school-going children but were not tapping any social and psychological issues relating to visual impairment. Thirdly, the use of Rasch analysis which addresses many of the issues of unequal measurement and defines a hierarchy of items for self-reports and performance measures could have led to higher correlations in the present study. Finally, the high reliability and validity of self-reports and performance measures of FVP in the present study may have contributed to the higher than expected correlations. None of the demographic variables or self-concept affected the relationship between self-reports and performance measures of FVP, but self-concept had a weak significant association with self-reports. This result is unique to this study and warrants further investigation. Binocular high-contrast visual acuity alone, the most common visual function measured in ophthalmic clinics, explained between one-third and two-thirds of the variance in functional vision performance. This confirms the expected trend that with worse visual impairment, FVP is lower. The addition of the variable, self-concept, resulted in a very small increase in the variability explained for self-reported FVP. Similarly, the addition of other clinical measures of vision such as binocular low contrast visual acuity and colour vision resulted in a small increase in the variability explained for performance measures of FVP. The correlation between binocular high-contrast visual acuity and performance measures of FVP was statistically significantly higher than that between binocular high-contrast visual acuity and self-reports of FVP. There are a few possible reasons for this higher correlation. Firstly, performance measures are considered to be a more "objective" form of assessment, while self-reports are a child's perception of his or her ability and therefore lack a context, which may result in either over-estimation or under-estimation of actual ability. Furthermore, performance measures include dimensions such as the time taken to perform a task or other criteria specific to a task, while self-reports do not use such qualifiers. Secondly, the higher correlation may be the result of the visual complexity of some of the tasks. While self-concepts of children with visual impairment played a small but significant role in the self-reported FVP, studies in adults with visual impairment have suggested that other psychological factors such as mood, anxiety, motivation etc. are associated with an individual's perception of visual performance. Future studies are required to explore the possible role of these and other factors in FVP in Indian school-going children with visual impairment. This thesis makes a significant contribution to the field of paediatric low vision rehabilitation by providing performance measures of FVP and relating them to self-reports in children with visual impairment and their relationship with common measures of visual function. With self-reports, the child is reporting his or her perception of ability to complete a task, where performance measures examine the child's ability to complete a task by observing his or her performance. Thus, although the two methods are comparable, it is because of the different yields from each of these measures that they are not considered interchangeable. A combination of the 2 measures where practical would perhaps provide a richer depiction of the FVP of children with visual impairment. As developing countries such as India have limited resources allocated for eye care services where less than seven percent of the gross national product is spent on health care, self-reports can be utilized together with clinical measures of vision (mainly visual acuity) to assess the FVP in children with visual impairment in a community setting. However, both methods of assessment of FVP together with clinical measures of vision are essential if a comprehensive assessment of FVP is to be carried out in children with visual impairment. Information from these assessments can help clinicians better understand the functioning of children with visual impairment and incorporate them in the management of low vision in school-going children with visual impairment in India.

O estudo teve como objetivos verificar em dois grupos de pacientes com visão monocular (grupo 1) e com visão binocular (grupo 2), a serem submetidos à cirurgia de catarata no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, opiniões, expectativas e reações emocionais em relação ao problema ocular, à qualidade da visão e à cirurgia de catarata; influência da característica de apresentar visão mono ou binocular nas reações emocionais relacionadas à cirurgia de catarata. Foi realizado estudo transversal e comparativo, de forma consecutiva, por meio de questionário estruturado, aplicado por entrevista a pacientes, elaborado a partir de estudo exploratório e medidas acuidade visual e causa da perda visual. A amostra foi constituída por 96 indivíduos do grupo 1 (50,0% homens; 50,0% mulheres, com idade entre 41 e 91 anos, média 69,3 anos ± 10,4 anos) e 110, do grupo 2 (40,9% homens; 59,1% mulheres, com idade entre 40 e 89 anos, média 68,2 anos ± 10,2 anos). A maioria dos indivíduos de ambos os grupos apresentava baixa escolaridade. Não houve diferença estatisticamente significante entre os grupos em relação ao sexo (p = 0,191), à idade (p = 0,702) e à escolaridade (p = 0,245). Não exerciam atividade laboral 95,8% dos indivíduos do grupo 1 e 83,6%, do grupo 2 (p = 0,005) e 30,4% do grupo 1 mencionaram não ter possibilidade de trabalhar por causa da deficiência visual. Observou-se acuidade visual do olho a ser operado menor que 0,05 em 40,6% (grupo 1) e 33,6% (grupo 2), entre 0,25 e 0,05. Quase a totalidade dos indivíduos de ambos os grupos afirmou ter dificuldade para realização das atividades de vida diária e qualificou como insuficiente a respectiva acuidade visual; 71,9% dos entrevistados do grupo 1 e 71,6%, do grupo 2 mencionaram saber a causa da visão fraca; desses, 87,1% do grupo 1 e 83,3% do grupo 2 referiram a catarata como causa da baixa acuidade visual. No que se refere ao medo, 40,6% dos indivíduos do grupo 1 e 22,7%, do grupo 2, relataram ter medo do procedimento cirúrgico (p = 0,009). As causas de medo mais referidas foram: possibilidade de perder a visão; piorar a visão; sofrer alguma complicação na cirurgia; morrer durante a cirurgia. Os sentimentos mais preponderantes entre os grupos foram: satisfação por saber que a catarata pode ser operada e melhorar a visão, alívio por saber que vai ser operado, dúvida quanto a ter bom resultado, nervosismo. Referiram esperar que mudanças ocorressem na vida após a cirurgia 90,6% (grupo 1) e 84,6% (grupo 2). Quanto às atividades que esperavam realizar após a cirurgia mencionaram: realizar serviços de casa; ler; sair sozinho. Concluiu-se que: os indivíduos de ambos os grupos tiveram acesso à cirurgia de catarata com acuidade visual menor do que a idealmente indicada; os pacientes com visão monocular apresentaram acuidade visual significativamente menor em relação aos com visão binocular; a maioria dos entrevistados de ambos os grupos referiu dificuldades para realizar atividades cotidianas como conseqüência da baixa visão; os indivíduos com visão monocular referiram mais dúvida em relação aos resultados cirúrgicos do que os com visão binocular; muitos indivíduos de ambos os grupos desconheciam a causa da dificuldade visual ou a atribuíram a outra causa que não a catarata; indivíduos de ambos os grupos apontaram expectativas positivas em relação à reabilitação após a cirurgia. / The purpose of the study was to verify in two groups of patients with monocular vision (group 1) and with binocular vision (group 2) to be submitted to cataract surgery in Hospital das Clínicas, São Paulo University Medical School, opinions, expectances and emotional reactions related to the ocular problem, to the quality of vision and to cataract surgery, the influence of monocular or binocular vision in the emotional reactions related to cataract surgery. A transversal comparative and consecutive study was performed using a structured questionnaire applied by interview of patients. The questionnaire was elaborated from a previous exploratory study, the visual acuity and cause of the visual loss were evaluated. The sample was constituted by 96 persons of group 1 (50% males; 50% females, ages ranging from 41 to 91 years old; average 69,3 years ± 10,4 years) and 110 persons of group 2 (40,9% males; 59,1% females, ages ranging from 40 to 89 years old; average 68,2 years ± 10,2 years). The majority of persons of both groups presented low educational level. There was no statistically significant difference between the groups in relation to gender (p = 0,191), age (p = 0,702) and educational level (p = 0,245). No work activity was mentioned in 95,8% of the persons of group 1 and 83,6% of group 2 (p = 0,005) and 30,4% of group 1 informed the impossibility to work due the visual deficiency. It was observed that the visual acuity of the eye to be operated was less than 0,05 in 40,6% (group 1) and in 33,6% (group 2), presented visual acuity ranging from 0,05 to 0,25. Almost the totality of the persons of both groups informed difficulties to perform activities of daily life and qualified as insufficient their visual acuities; 71,9% of the patients of group 1 and 71,6% of group 2 informed to know the reason of low vision; among these, 87,1% of group 1 and 83,3% of group 2 mentioned cataract as the reason of low visual acuity. Concerning fear, 40,6% of patients of group 1 and 22,7% of group 2 informed about fear of the surgical procedure (p = 0,009). The causes of fear more frequently reported were: possibility of loss of vision; worsening of vision; complications during the surgical procedure and to die during the surgery. The more preponderant feelings in both groups were: satisfaction knowing that a cataract can be operated with improvement of vision, relief knowing that will be submitted to surgery, doubt about a good result, nervousness. Changes in the life after surgery were mentioned by 90,6% (group 1) and by 84,6% (group 2) of the persons. Housework activities, reading and moving around without help were the mentioned activities expected to be performed after surgery. It was concluded that the patients of both groups were submitted to cataract surgery with visual acuities less than the visual acuity ideally indicated; the patients with monocular vision showed visual acuities significantly less in relation to the patients with binocular vision; the majority of the patients of both groups mentioned difficulties to perform daily activities as a consequence of low vision; patients with monocular vision mentioned doubts in relation to the surgical results as compared with the patients with binocular vision; many patients of both groups did not know the cause of the visual difficulty or explained the visual difficulty by other cause than the cataract; patients of both groups were positively expectant in relation to the visual rehabilitation after the surgery.

Objetivo: Analisar a influência da espessura corneana central na acuidade visual (AV) corrigida após transplante de córnea endotelial lamelar profundo (TCELP). Métodos: Foram estudados de forma prospectiva 155 olhos de 127 pacientes portadores de ceratopatia bolhosa ou distrofia endotelial de Fuchs no sexto mês de pós-operatório do TCELP, entre março de 2000 e março de 2005. Foram excluídos pacientes com outras alterações oculares que justificassem baixa AV. Todos os pacientes foram submetidos à avaliação oftálmica, quando foram determinadas AV corrigida, por meio de exame refratométrico, e espessura corneana central, através da paquimetria ultra-sônica. As técnicas usada foram previamente descritas. Os olhos foram agrupados de acordo com as medidas de AV: grupo I (20/20 - 20/30), grupo II (20/40 - 20/50), grupo III (20/60 - 20/80), grupo IV (20/100 - 20/400). Para correlação com paquimetria e análise estatística, as medidas de AV foram convertidas da tabela de Snellen para a tabela logarítmica (logMAR). Foram criadas variáveis categóricas para expressar status de faixa de normalidade de espessura corneana (entre 495 e 651 ?m), usando como pontos de corte valores encontrados na literatura. Resultados: A média, o desvio padrão e a variação da paquimetria foi: grupo I (n=38) 571 ±80 um, 408 a 784 um; grupo II (n=79) 598 ±80 um, 437 a 816 um; grupo III (n=30) 605 ±99 um, 454 a 945 um e grupo IV (n=8) 607 ±120 ?m, 410 a 781 ?m. Analisando o resultado da AV e a porcentagem de casos com espessura corneana acima de 651 um, foi observada associação linear significativa (P=0,037; ?2 de tendência linear) entre o aumento da paquimetria e a piora da AV. Analisando a associação entre os grupos de AV e a porcentagem de casos com espessura corneana abaixo da faixa de normalidade (<495 um), não foi encontrada significância estatística (P=0,92; x2 de Pearson). Quando analisado o resultado visual do grupo I em relação ao resultado dos grupos II+III+IV em conjunto, observou-se que somente 13% dos casos do grupo I e 30% dos casos dos demais grupos apresentaram espessura corneana maior do que 651 ?m. Essa correlação demonstrou significância estatística limítrofe (P=0,066; x2 de Pearson com correção de Yates). Conclusão: Observou-se associação linear significativa entre piora da AV corrigida e aumento da espessura corneana central. Quando analisados somente casos com paquimetria abaixo da faixa de normalidade, não foi observada associação significativa entre piora da AV corrigida e espessura corneana central / Purpose: To analyze the influence of central corneal thickness in the corrected visual acuity (VA) after deep lamellar endothelial corneal keratoplasty (DLEK). Methods: Retrospective study of 155 eyes of 127 patients 6 months post-op DLEK between March 2000 and March 2005. These patients had been previously diagnosed with either bullous keratopathy or Fuch\'s endothelial dystrophy. Patients with other ophthalmic conditions that could cause loss of vision were excluded. All patients underwent ophthalmic evaluation to determine corrected VA by means of refraction and central corneal thickness by means of ultrasonic pachymetry. Eyes were grouped according to visual acuity into 4 groups: I (20/20 - 20/30), II (20/40 - 20/50), III (20/60 - 20/80), IV (20/100 - 20/400). For statistical analysis and corelation with pachymetry, VA measurements were converted to logMAR. Categorical variables were created to express normal range corneal thickness status (from 495 to 651 um) using values published on the literature. Results: Mean and standart deviation pachymetry values were: group I (n=38) 571 ±80 ?m, ranging from 408 to 784 um; group II (n=79) 598 ±80 um, ranging from 437 to 816 ?m; group III (n=30) 605 ±99 um, ranging from 454 to 945 um and group IV (n=8) 607 ±120 um, ranging from 410 to 781 ?m. Analyzing the VA results and the percentage of cases with corneal thickness above 651 um, a significant linear correlation between higher pachymetry and worse VA was observed (P=0.037; linear trend). Analyzing the association between the different groups and the percentage of cases with corneal thickness bellow 495 um, there was no statistical significance (P=0.92; Pearson\'s x2). When analyzing the visual results of group I compared to groups II+III+IV together, it was observed that only 13% of group I cases and 30% of cases from the other groups presented corneal thickness greater then 651 um. This correlation showed borderline statistical significance (P=0.066; Pearson\'s x2 with Yates\' correction). Conclusions: A significant linear correlation between increased corneal thickness and worse VA was observed. When analyzing only cases bellow normal pachymetry, there was no correlation between corneal thickness and worse VA