Problématique : L’édentement et les troubles du sommeil sont des affections chroniques fréquentes chez les personnes âgées et qui peuvent avoir des conséquences défavorables sur le bien-être de ces personnes, ainsi que sur leur qualité de vie. L’édentement pourrait perturber le sommeil par la modification de la structure crânio-faciale et des tissus mous environnants. Cependant, cette relation n'est pas suffisamment documenté. Objectifs : Le but de cette étude pilote était de préparer la mise en œuvre d’une étude clinique randomisée contrôlée concernant l’effet du port nocturne des prothèses complètes sur la qualité du sommeil. Méthodologie : Treize aînés édentés ont participé à cette étude clinique randomisée contrôlée de type croisé. L’intervention consistait à dormir avec ou sans les prothèses durant la nuit. Les participants à l'étude ont été assignés à porter et ne pas porter leurs prothèses dans des ordres alternatifs pour des périodes de 30 jours. La qualité du sommeil a été évaluée par la polysomnographie portable et le questionnaire Pittburgh Sleep Quality Index (PSQI). Les données supplémentaires incluent la somnolence diurne, évaluée par le questionnaire Epworth Sleepiness Scale (ESS), et la qualité de vie liée à la santé buccodentaire, évaluée par le questionnaire Oral Health Impact Profile 20 (OHIP-20). De plus, à travers les examens cliniques et radiologiques, les données des caractéristiques sociodémographiques, de la morphologie oropharyngée, des caractéristiques buccodentaires et des prothèses ont été recueillies. Les modèles de régression linéaire pour les mesures répétées ont été utilisés pour analyser les résultats. Résultats : L’étude de faisabilité a atteint un taux de recrutement à l’étude de 59,1% et un taux de suivi de 100%. Le port nocturne des prothèses dentaires augmentait l’index d'apnée-hypopnée (IAH) et le score PSQI par rapport au non port nocturne des prothèses : (IAH : Médiane = 20,9 (1,3 - 84,7) versus 11,2 (1,9 - 69,6), p = 0,237; le score PSQI : Médiane = 6,0 (3,0 - 11,0) versus 5,0 (1,0 - 11,0), p = 0,248). Cependant, ces différences n'étaient pas statistiquement significatives, sauf que pour le temps moyen d’apnée (plus long avec des prothèses) (p < 0,005) et le temps de ronflement relatif (moins élevé avec des prothèses) (p < 0,05). La somnolence diurne excessive et la qualité de vie liée à la santé buccodentaire étaient semblables pour les deux interventions (le score ESS : Médiane = 4,0 (3,0-10,0) versus 5,0 (2,0-10,0), p = 0,746; le score OHIP-20: Médiane = 31,0 (20,0-64,0) versus 27,0 (20,0-49,0), p = 0,670). L’impact néfaste du port nocturne des prothèses complètes sur le sommeil a été statistiquement significatif chez les personnes souffrant de l’apnée-hypopnée moyenne à sévère (p < 0,005). Conclusion : L’essai clinique pilote a montré que le port nocturne des prothèses complètes a un impact négatif sur la qualité du sommeil des gens âgés édentés, surtout chez les personnes avec l’apnée obstructive du sommeil modérée à sévère. Les résultats doivent être confirmés par l’étude clinique randomisée contrôlée de phase II. / Problem: Edentulism and sleep disturbance are common chronic conditions in older people and may have adverse consequences on well-being of these persons, as well as their quality of life. Indeed, edentulism can modify the craniofacial structure and surrounding soft tissue, and lead to sleep disturbance in edentate individuals. However, this relationship is not sufficiently documented. Objectives: The aim of this study was to prepare a pilot randomized controlled trial on the effect of nocturnal complete denture wear on sleep quality. Methods: Thirteen edentate elders participated in this randomized cross-over clinical trial. The intervention consisted of sleeping with or without dentures at night. The study participants were assigned to wear and not wear their denture in alternate orders for periods of 30 days. Sleep quality was assessed by portable polysomnography and the Pittsburgh Sleep Quality Index (PSQI). Additional data included: daytime sleepiness assessed by the Epworth Sleepiness Scale (ESS) and oral-health-related quality of life assessed by the Oral Health Impact Profile 20 (OHIP-20). Furthermore, through the clinical and radiographic examinations, data on sociodemographic, oropharyngeal morphology, and oral and prosthesis characteristics were gathered. Linear regression models for repeated measures were used to analyze the data. Results: The recruitment rate for this study was 59.1% and the follow-up rate was 100%. Sleeping with dentures resulted in higher apnea-hypopnea index (AHI) and higher PSQI score when compared with sleeping without dentures (AHI: Median = 20.9 (1.3-84.7) vs. 11.2 (1.9-69.6), p = 0.237; PSQI score: Median = 6.0 (3.0-11.0) vs. 5.0 (1.0-11.0), p = 0.248). However, these differences were not statistically significant, except for the mean apnea time (more with dentures) (p < 0.005) and the relative snoring time (less with dentures) (p < 0.05). Excessive daytime sleepiness and the oral-health-related quality of life were similar for two interventions (ESS score: Median = 4.0 (3.0-10.0) vs. 5.0 (2.0-10.0), p = 0.746; OHIP-20 score: Median = 31.0 (20.0-64.0) vs. 27.0 (20.0-49.0), p = 0.670). The negative impact of sleeping with complete dentures wear was statistically significant in individuals suffering from moderate and severe apnea-hypopnea index (p < 0.005). Conclusion: The pilot clinical trial showed that wearing complete dentures at night has negative effects on the sleep quality of edentate elders, especially in individuals with moderate and severe obstructive apnea sleep. The results need to be confirmed with phase-II randomized clinical trial.

A Síndrome da Apneia Obstrutiva do Sono (SAOS) é caracterizada por episódios repetitivos de obstrução da Via Aérea Superior (VAS) e sua patogênese está relacionada a anormalidades anatômicas da VAS. Algumas alterações esqueléticas da face favorecem a perda de permeabilidade da VAS, incluindo a inclinação do plano oclusal maior que a norma. A Cirurgia de Avanço Maxilomandibular (CAMM) já teve sua eficácia comprovada no tratamento da SAOS. O objetivo deste trabalho foi avaliar a influência da rotação anti-horária do plano oclusal na CAMM para tratamento de indivíduos portadores da SAOS e quantificar as alterações morfométricas produzidas na VAS e seus efeitos na SAOS. O método adotado foi o ensaio clínico prospectivo, com uma amostra composta por 38 participantes, sendo 23 homens (60,5%) e 15 mulheres (39,5%) com idades entre 21,7 e 55,4 anos (37,4 ± 9,2). Os indivíduos foram divididos em dois grupos: CAMM com rotação do plano oclusal CR (n=19) e CAMM sem rotação do plano oclusal SR (n=19). Todos os participantes realizaram uma tomografia computadorizada (TC) da VAS e polissonografia de noite toda, no pré e pós-operatório. No Grupo CR, a relação da influência da rotação anti-horária do plano oclusal no movimento do ponto B no eixo X mostrou forte correlação (r=0,78). A regressão linear foi estatisticamente significante (p<0,0001) e mostrou proporção de 0,71mm de avanço para cada grau de rotação anti-horária do ângulo do plano oclusal. A avaliação dos índices polissonográficos mostrou diferença na condição tempo pré e pós-cirúrgico, porém não houve diferença estatística entre os grupos. O volume total aumentou 44,7% no Grupo CR e 30,3% no Grupo SR. O volume retropalatal e volume retrolingual aumentaram 49% e 40,9% no Grupo CR e 42,9% e 15,2% no Grupo SR, respectivamente. A menor área axial no Grupo CR aumentou 91,7% na região RP e 97,4% na região RL; no Grupo SR, o aumento foi de 76,4% e 31%, respectivamente. A altura da via aérea diminuiu 5,9% e 2,6% nos grupos CR e SR, respectivamente. O Grupo CR, com rotação anti-horária do plano oclusal na CAMM, obteve melhores resultados em relação ao Grupo SR em todos os parâmetros morfométricos analisados: volume, área e medidas lineares na faringe, principalmente na região retrolingual. No sentido sagital, a cada grau de rotaçãoanti-horária do plano oclusal ocorreu a projeção de 0,71mm da mandíbula, justificando a maior abertura da região retrolingual da faringe, bem como uma maior redução do IAH, IA e IH / Obstructive Sleep Apnea Syndrome (OSAS) is characterized by repetitive episodes of upper airway (UAW) obstruction, and its pathogenesis is related to anatomical abnormalities of the UAW. Some skeletal changes in the face favor the loss of UAW permeability, including inclination of the occlusal plane greater than the norm. Maxillomandibular Advancement Surgery (MMAS) has already proven its efficacy in the treatment of OSAS. The objective of this study was to evaluate the influence of the counterclockwise rotation of the occlusal plane in the MMAS for treatment of individuals with OSAS, and to quantify the morphometric changes produced in the UAW and its effects on OSAS. The method used was the prospective clinical trial, with a sample composed of 38 participants, of which 23 were men (60.5%) and 15 were women (39.5%), between 21.7 and 55.4 years of age (37.4% ± 9.2). The individuals were divided into two groups: MMAS with rotation of the occlusal plane CR (n=19) and MMAS without rotation of the occlusal plane SR (n=19). All par-ticipants performed a UAW computed tomography (CT) and all-night polysomnography, pre and postoperatively. In the CR group, the relation of the influence of the counterclockwise rotation of the occlusal plane on the movement of point B on the X axis showed a strong correlation (r=0.78). The linear regression was statistically significant (p<0.0001) and showed a proportion of 0.71 mm of advance for each degree of counterclockwise rotation of the angle of the occlusal plane. The evaluation of polysomnographic indices showed a difference in pre and postsurgical time, but there was no statistical difference between the groups. The total volume increased 44.7% in the CR group and 30.3% in the SR group. The retropalatal (RP) volume and retrolingual (RL) volume increased 49% and 40.9% in the CR group and 42.9% and 15.2% in the SR group, respectively. The smaller axial area in the CR group increased 91.7% in the RP region and 97.4% in the RL region; in the SR group the increase was 76.4% and 31%, respectively. The airway height decreased 5.9% and 2.6% in the CR and SR groups, respectively. The CR group obtained better results in relation to the SR group in all the morphometric parameters analyzed: volume, area and linear measurements in the pharynx, mainly in the RL region. In the sagittal sense, at each degree of counterclockwise rotation of the occlusal plane, the projection of 0.71 mm of themandible occurred, justifying the greater opening of the RL region of the pharynx, as well as a greater reduction of AHI, IA and HI

Dentre as células ganglionares da retina existe uma pequena população de células que contem melanopsina e respondem diretamente à luz. Estas são as células ganglionares intrinsecamente fotossensíveis (ipRGCs), cujas funções são principalmente não visuais. Dentre as funções não visuais das ipRGCs sua influência na resposta pupilar dependente da luz foi o objeto central desta tese. Tanto a retina interna, através das ipRGCs, quanto a retina externa, através dos bastonetes e cones, fornecem uma informação neural que regula a resposta pupilar à luz (RPL). Este estudo avaliou a integridade das ipRGCs através do RPL em pacientes com glaucoma primário de ângulo aberto (GPAA), leve, moderado e avançado, e em pacientes com síndrome da apnéia obstrutiva do sono (SAOS), moderada e grave. Também foi avaliada a discriminação cromática e a sensibilidade ao contraste espacial de luminância (SC), a perimetria visual e a espessura da retina avaliada por tomografia de coerência óptica (OCT). Foram avaliados 98 participantes: 45 pacientes com GPAA ( 27, 18; idade média = 65,84 + 10,20), 28 pacientes com SAOS ( 14, 14; idade média = 52,93 + 7,13), e 25 controles ( 17, 8; idade média = 54,27 + 8,88). Após o exame oftalmológico foram avaliadas a SC de grades e a discriminação de cores através do Cambridge Colour Test (CCT). A avaliação do RPL foi feita apresentando-se flashes de 470 e 640 nm, de 1s de duração, em 7 luminâncias desde -3 até 2.4 log cd/m2 em um Ganzfeld Q450 SC (Roland Consult). O RPL foi registrado pelo sistema de eye tracker View Point System (Arrington Research Inc.). Os testes foram realizados em ambos os olhos, de forma monocular e no escuro. Para a comparação dos dados entre os grupos, utilizou-se um modelo de equações de estimação generalizada (GEE), para correção da dependência entre os dois olhos. O RPL dos pacientes com GPAA moderado e avançado apresentou redução significativa na amplitude do pico, dependente da severidade do glaucoma, nas diferentes luminâncias tanto para 470 nm quanto para 640 nm, evidenciando redução das contribuições dos cones e bastonetes ao RPL. As contribuições das ipRGCs ao RPL (avaliadas pela amplitude da resposta sustentada entre 6-8 s) foram também significativamente menores em GPAA moderado e avançado. No estado inicial do GPAA as contribuições das ipRGCs para o RPL encontram-se preservadas. No entanto, o GPAA parece afetar o processamento espacial desde o inicio da doença. Nos pacientes com GPAA leve foi observada uma perda acentuada nas faixas baixas de frequência espacial, compatível com prejuízo seletivo das células ganglionares do tipo M. A SC de pacientes com GPAA moderado e avançado mostrou perdas nas faixas baixas e altas de frequência espacial, apontando um prejuízo nas vias parvo- e margnocelulares. Uma perda significativa da discriminação de cores no eixo azul-amarelo foi observada em todos os estágios do GPAA. O RPL nos pacientes com SAOS está parcialmente preservado, não obstante, as respostas da amplitude do pico para o flash de 470 nm diminuem conforme aumenta a severidade da SAOS. As contribuições dos fotorreceptores da retina externa ao RPL, foram significativamente menores em algumas das luminâncias. Não foram observadas diferenças significativas de SC ou discriminação de cores nos pacientes com SAOS. Em conclusão, no estágio moderado e avançado do glaucoma tanto as contribuições das ipRGCs ao RPL quanto as vias M e P, se encontram mais afetadas do que no inicio do GPAA, quando a via parvocelular e as contribuições das ipRGCs ao RPL parecem estar mais preservadas / Among the retina ganglion cells there are a small population of cells containing melanopsin and which respond directly to light. They are the intrinsically photosensitive ganglion cells (ipRGCs), whose functions are mainly non-visual. Among these non-visual functions of the ipRGCs, their influence on the pupillary response as a function of light was the central subject of this thesis. Both the inner retina through the ipRGCs and the outer retina through the rods and cones, provide neural information that regulates the pupillary light response (PLR) to light. This study evaluated the integrity of ipRGCs through PLR in patients with Primary Open Angle Glaucoma (POAG), mild, moderate and advanced, and in patients with Obstructive Sleep Apnea Syndrome (OSAS), moderate and severe. We evaluated also the color discrimination and achromatic spatial contrast sensitivity (CS), visual perimetry and retinal thickness evaluated by Optical Coherence Tomography (OCT). 98 participants were evaluated, 45 patients with POAG ( 27 18; mean age = 65.84 + 10.20), 28 with OSAS ( 14 14; mean age = 52.93 + 7.13) and 25 controls ( 17 8; mean age = 54.27 + 8.88). After the ophthalmological exam it was evaluated the contrast sensitivity and color discrimination measures using the Cambridge Colour Test (CCT). Pupil responses were elicited by Ganzfeld (Q450 SC, Roland Consult) presentation of 1-sec flashes of 470- and 640-nm at 7 luminance from -3 to 2.4 log cd/m2. PLR was measured with the eye tracker system View Point (Arrington Research Inc.). The tests were performed monocularly, on both eyes, in a darkened room. In order to compare data across groups, we used a General Estimating Equations (GEE) to adjust for within subject inter-eye correlations. Patients with moderate and advanced POAG had a significantly decreased PLR that depends on the severity of the glaucoma, for both the 470- and 640-nm stimuli, making evident the reduction of the contributions of the cones and rods to the PLR. The contributions of ipRGCs to PLR (assessed by the amplitude of the sustained response between 6 8 sec) were also significantly lower in patients with moderate and advanced POAG. In the initial and mild stages of POAG the contribution of ipRGCs to the PLR is preserved. However, POAG appears to affect spatial processing from the early stages of the disease. Mild-POAG patients showed a marked loss in the low spatial frequency bands, compatible with selective loss of magnocellular ganglion cells. The CS of patients with moderate and advanced POAG showed losses at both low and high spatial frequencies, suggesting a loss in both parvo- and margnocellular channels. A significant loss of color discrimination along the blue-yellow axis was observed in all stages of POAG. The PLR in patients with OSAS is partially preserved, however the peak amplitude responses for the 470-nm flash decreased with increased severity of OSAS. The contributions of the photoreceptors of the outer retina to the PLR were significantly lower at some of the luminance. Significant differences in CS or color discrimination were not observed in patients with OSAS. In conclusion, in moderate and advanced stages of glaucoma, both the contributions of ipRGCs to PLR as well as the M- and P channels, were found more affected than at the beginning of POAG, in contrast the parvocellular channel and the contributions of ipRGCs on the PLR would be more preserved

Made available in DSpace on 2016-01-26T12:51:37Z (GMT). No. of bitstreams: 1 nelsoncolombini_tese.pdf: 1052278 bytes, checksum: 65caf5c2304f80f9167fa51d736325f5 (MD5) Previous issue date: 2010-03-22 / To describe the results obtained by the Maxillo Mandibular Advancement (MMA), associated to a glossectomy of Medium Line (GML) to CO2 Laser in the surgical treatment of Obstructive Sleep Apnea-Hypoapnea Syndrome (ASOSH), from moderate to severe, with adequate analysis of macroscstruture e microstructure of the sleep. Casuistics and Method: In the period from February 2005 to December 2008, 22 sequencial patients with ASOSH, from moderate to severe, with or without maxillary mandibular bone alterations, were selected. These patients were submitted to MMP plus GML using a CO2 laser. All patients underwent clinical, polissonographic and cephalometric evaluations. The polissonographic parameters used were: IAH, MD, Minimum SAT O2% < measured in minutes, sleep stages N1, N2, N3 and REM, preoperative and postoperative. The cephalometric parameters used were: SNA, SNB, PAS, PP2 PP2, preoperative and postoperative. Results: Evaluation of eventual differences in the preoperative and postoperative moments were investigated with the appropriate statistical tools. The surgical treatment proved to be effective in 8, out of 22 of the cases (36.36%), according to international criteria of normality. On the other hand, in these patients the IAH was not the best parameter to evaluate the therapeutic success. The MD (68.18% of improvement), stage N3 (59.09% of improvement) and Minimum SAT O2% < 90 measured in minutes (81.81% of improvement) demonstrated that they were the best instruments for characterizing the laboratorial control of the disease. Discussion: The MMA has expanded the dimensions of the pharynx and the hypopharynx. The GLM was associated in order to maximize the VAS, improve the stability of the dental occlusion, as well as the function of the temporomandibular joint, reducing the morbidity of the procedure. A postoperative evaluation with polysomnography showed improvements of the parameters in both macro and microarchitecture of the sleep (in relation to preoperative findings), besides proving that the IAH is not the best parameter for a postoperative evaluation (this applies to the patients of this series). Conclusions: The surgical treatment performed with MMA, associated to the GLM with CO2 laser was effective to treat patients with from ASOSH : - The improvement using the most accepted parameter by the international community (IAH < 5/ hour) was 8 out of the 22 (36.36%); - The IAH was not the best instrument to evaluate the control of the disease; - Were MD, stage N3 and Minimum SAT O2% < 90 measured in minutes showed that they are good indicators of the control of the disease (postoperative moment); - The Minimum SAT O2% < 90 measured in minutes was the best parameter in the evaluation of the surgical treatment (18/22 or 81.81%). / Descrever os resultados obtidos pelo Avanço Maxilo- Mandibular (AMM) associados à Glossectomia de Linha Média (GLM) a Laser CO2 no tratamento cirúrgico da Síndrome da Apnéia/Hipopnéia Obstrutiva do Sono (SAHOS) moderada e severa, usando instrumentos estatísticos que avaliem a arquiquetura do sono quanto à macro e micro estrutura para adequada e real avaliação dos resultados obtidos pelo tratamento proposto. Casuística e Método: No período de fevereiro de 2005 a dezembro de 2008 foram selecionados 22 pacientes seqüenciais portadores de SAHOS moderada e severa, com ou sem alterações esqueléticas maxilo-mandibulares. Estes pacientes foram submetidos à AMM, mais GLM com laser de CO2. Todos pacientes tiveram avaliação clínica, polissonográfica e cefalométrica. Os parâmetros polissonográficos utilizados foram: IAH, MD, SAT O2 % Mínima < 90 medida em minutos, estágios do sono N1, N2, N3 e REM, pré e pósoperatório. Os parâmetros cefalométricos utilizados foram: SNA, SNB, PAS, PP2 PP2 pré e pós-operatório. Resultados: Avaliação de eventuais diferenças nos momentos pré e pós-operatório foram investigadas com ferramenta estatística apropriada. O tratamento cirúrgico mostrou-se eficaz em 8/22 (36,36%) dos casos, segundo critérios internacionais de normalidade. Por outro lado nestes pacientes o IAH não foi o melhor parâmetro para avaliar sucesso terapêutico. MD (68,18% melhora), estágio N3 (59,09% de melhora) e SAT O2% Mínima < 90 medida em minutos (81,81% de melhora) mostraram-se melhores instrumentos para caracterizar controle laboratorial da enfermidade.Discussão: O AMM ampliou as dimensões da faringe e hipofaringe. A GLM foi associada para maximizar a VAS, aumentar a estabilidade da oclusão dentária e função da articulação têmporo-mandibular, reduzindo a morbidade do procedimento. Avaliação pós-operatória com polissonografia demonstrou melhora de parâmetros de macro e micro-arquitetura do sono (em relação aos achados pré-operatórios), além de comprovar não ser o IAH o melhor parâmetro para avaliação pós-operatória (isto para os pacientes desta série). Conclusões: O tratamento cirúrgico com AMM associado à GLM com laser de CO2 foi eficaz para tratar pacientes com SAHOS: A melhora utilizando o parâmetro mais aceito pela comunidade internacional (IAH < 5/hora) foi de 8/22 (36,36%); IAH não foi o melhor instrumento para avaliação do controle da enfermidade; MD, estágio N3 e SAT O2% Mínima < 90 medida em minutos mostraram-se bons indicadores de controle da enfermidade (momento pósoperatório); SAT O2% Mínima < 90 medida em minutos foi o melhor parâmetro na avaliação do tratamento cirúrgico (18/22 ou 81,81%).

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Endocrine and Metabolic Aspects of Various Sleep Disorders MUDr. Zuzana Vimmerová Lattová Abstract: Recent epidemiological and experimental data suggest a negative influence of shortened or disturbed night sleep on glucose tolerance. However, no comparative studies of glucose metabolism have been conducted in clinical sleep disorders. Dysfunction of the HPA axis may play a causative role in some sleep disorders and in other sleep disorders it may be secondary to the sleep disorder. Moreover, dysfunction of the HPA axis is regarded as a possible causative factor for the impaired glucose sensitivity associated with disturbed sleep. However, data on HPA system activity in sleep disorders are sparse and conflicting. We studied 25 obstructive sleep apnea (OSA) patients, 18 restless legs syndrome (RLS) patients, 21 patients with primary insomnia and compared them to 33 healthy controls. We performed oral glucose tolerance test and assessed additional parameters of glucose metabolism. The dynamic response of the HPA system was assessed by the DEX-CRH-test which combines suppression (dexamethasone) and stimulation (CRH) of the stress hormone system. Compared to controls, increased rates of impaired glucose tolerance were found in OSA (OR: 4.9) and RLS (OR: 4.7), but not in primary insomnia. In addition, HbA1c...

Dentre as células ganglionares da retina existe uma pequena população de células que contem melanopsina e respondem diretamente à luz. Estas são as células ganglionares intrinsecamente fotossensíveis (ipRGCs), cujas funções são principalmente não visuais. Dentre as funções não visuais das ipRGCs sua influência na resposta pupilar dependente da luz foi o objeto central desta tese. Tanto a retina interna, através das ipRGCs, quanto a retina externa, através dos bastonetes e cones, fornecem uma informação neural que regula a resposta pupilar à luz (RPL). Este estudo avaliou a integridade das ipRGCs através do RPL em pacientes com glaucoma primário de ângulo aberto (GPAA), leve, moderado e avançado, e em pacientes com síndrome da apnéia obstrutiva do sono (SAOS), moderada e grave. Também foi avaliada a discriminação cromática e a sensibilidade ao contraste espacial de luminância (SC), a perimetria visual e a espessura da retina avaliada por tomografia de coerência óptica (OCT). Foram avaliados 98 participantes: 45 pacientes com GPAA ( 27, 18; idade média = 65,84 + 10,20), 28 pacientes com SAOS ( 14, 14; idade média = 52,93 + 7,13), e 25 controles ( 17, 8; idade média = 54,27 + 8,88). Após o exame oftalmológico foram avaliadas a SC de grades e a discriminação de cores através do Cambridge Colour Test (CCT). A avaliação do RPL foi feita apresentando-se flashes de 470 e 640 nm, de 1s de duração, em 7 luminâncias desde -3 até 2.4 log cd/m2 em um Ganzfeld Q450 SC (Roland Consult). O RPL foi registrado pelo sistema de eye tracker View Point System (Arrington Research Inc.). Os testes foram realizados em ambos os olhos, de forma monocular e no escuro. Para a comparação dos dados entre os grupos, utilizou-se um modelo de equações de estimação generalizada (GEE), para correção da dependência entre os dois olhos. O RPL dos pacientes com GPAA moderado e avançado apresentou redução significativa na amplitude do pico, dependente da severidade do glaucoma, nas diferentes luminâncias tanto para 470 nm quanto para 640 nm, evidenciando redução das contribuições dos cones e bastonetes ao RPL. As contribuições das ipRGCs ao RPL (avaliadas pela amplitude da resposta sustentada entre 6-8 s) foram também significativamente menores em GPAA moderado e avançado. No estado inicial do GPAA as contribuições das ipRGCs para o RPL encontram-se preservadas. No entanto, o GPAA parece afetar o processamento espacial desde o inicio da doença. Nos pacientes com GPAA leve foi observada uma perda acentuada nas faixas baixas de frequência espacial, compatível com prejuízo seletivo das células ganglionares do tipo M. A SC de pacientes com GPAA moderado e avançado mostrou perdas nas faixas baixas e altas de frequência espacial, apontando um prejuízo nas vias parvo- e margnocelulares. Uma perda significativa da discriminação de cores no eixo azul-amarelo foi observada em todos os estágios do GPAA. O RPL nos pacientes com SAOS está parcialmente preservado, não obstante, as respostas da amplitude do pico para o flash de 470 nm diminuem conforme aumenta a severidade da SAOS. As contribuições dos fotorreceptores da retina externa ao RPL, foram significativamente menores em algumas das luminâncias. Não foram observadas diferenças significativas de SC ou discriminação de cores nos pacientes com SAOS. Em conclusão, no estágio moderado e avançado do glaucoma tanto as contribuições das ipRGCs ao RPL quanto as vias M e P, se encontram mais afetadas do que no inicio do GPAA, quando a via parvocelular e as contribuições das ipRGCs ao RPL parecem estar mais preservadas / Among the retina ganglion cells there are a small population of cells containing melanopsin and which respond directly to light. They are the intrinsically photosensitive ganglion cells (ipRGCs), whose functions are mainly non-visual. Among these non-visual functions of the ipRGCs, their influence on the pupillary response as a function of light was the central subject of this thesis. Both the inner retina through the ipRGCs and the outer retina through the rods and cones, provide neural information that regulates the pupillary light response (PLR) to light. This study evaluated the integrity of ipRGCs through PLR in patients with Primary Open Angle Glaucoma (POAG), mild, moderate and advanced, and in patients with Obstructive Sleep Apnea Syndrome (OSAS), moderate and severe. We evaluated also the color discrimination and achromatic spatial contrast sensitivity (CS), visual perimetry and retinal thickness evaluated by Optical Coherence Tomography (OCT). 98 participants were evaluated, 45 patients with POAG ( 27 18; mean age = 65.84 + 10.20), 28 with OSAS ( 14 14; mean age = 52.93 + 7.13) and 25 controls ( 17 8; mean age = 54.27 + 8.88). After the ophthalmological exam it was evaluated the contrast sensitivity and color discrimination measures using the Cambridge Colour Test (CCT). Pupil responses were elicited by Ganzfeld (Q450 SC, Roland Consult) presentation of 1-sec flashes of 470- and 640-nm at 7 luminance from -3 to 2.4 log cd/m2. PLR was measured with the eye tracker system View Point (Arrington Research Inc.). The tests were performed monocularly, on both eyes, in a darkened room. In order to compare data across groups, we used a General Estimating Equations (GEE) to adjust for within subject inter-eye correlations. Patients with moderate and advanced POAG had a significantly decreased PLR that depends on the severity of the glaucoma, for both the 470- and 640-nm stimuli, making evident the reduction of the contributions of the cones and rods to the PLR. The contributions of ipRGCs to PLR (assessed by the amplitude of the sustained response between 6 8 sec) were also significantly lower in patients with moderate and advanced POAG. In the initial and mild stages of POAG the contribution of ipRGCs to the PLR is preserved. However, POAG appears to affect spatial processing from the early stages of the disease. Mild-POAG patients showed a marked loss in the low spatial frequency bands, compatible with selective loss of magnocellular ganglion cells. The CS of patients with moderate and advanced POAG showed losses at both low and high spatial frequencies, suggesting a loss in both parvo- and margnocellular channels. A significant loss of color discrimination along the blue-yellow axis was observed in all stages of POAG. The PLR in patients with OSAS is partially preserved, however the peak amplitude responses for the 470-nm flash decreased with increased severity of OSAS. The contributions of the photoreceptors of the outer retina to the PLR were significantly lower at some of the luminance. Significant differences in CS or color discrimination were not observed in patients with OSAS. In conclusion, in moderate and advanced stages of glaucoma, both the contributions of ipRGCs to PLR as well as the M- and P channels, were found more affected than at the beginning of POAG, in contrast the parvocellular channel and the contributions of ipRGCs on the PLR would be more preserved

Introduction : Plusieurs effets secondaires sont associés au traitement de l’apnée obstructive du sommeil (AOS) par appareil d’avancement mandibulaire (AAM). Pour minimiser leur occurrence, plusieurs professionnels préconisent l’utilisation d’une attelle de repositionnement matinal (ARM) malgré le manque d’évidences valides soutenant cette approche. Objectifs : L’objectif principal de cette étude pilote randomisée contrôlée est d’évaluer l’utilisation d’une ARM comme moyen d’atténuer les effets secondaires à court terme associés au traitement par AAM. Méthode : 9 sujets souffrant d’AOS nécessitant un traitement par AAM ont été inclus et assignés aléatoirement au groupe témoin (n=5) et au groupe traitement (n=4). Tous les participants ont été traités avec un AAM fabriqué sur mesure et ajustable (SomnoDent Flex, SomnoMed, USA). Les sujets du groupe traitement ont également reçu une qu’ils devaient porter 1 heure le matin suivant le retrait de leur AAM. La participation comprenait 6 visites échelonnées sur une période approximative de 8 mois durant lesquelles plusieurs variables ont été évaluées, notamment les changements occlusaux, les effets secondaires et l’adhérence au traitement. Résultats : Des tendances de réduction des surplombs horizontaux et verticaux, de la distance intermolaire maxillaire et de la longueur d’arcade totale supérieure ont été observées uniquement au sein du groupe témoin (p=0,063). Six mois suivant la fin de la période de titration, les problèmes masticatoires étaient plus fréquemment rapportés dans le groupe témoin. 60% des sujets traités uniquement avec un AAM en rapportaient sur une base hebdomadaire comparativement à ceux recevant conjointement une ARM, où la survenue était rare, voire absente. Conclusion : Nos résultats suggèrent que l’ajout d’une ARM pourrait être bénéfique au traitement de l’AOS par AAM en réduisant la survenue de certains effets secondaires à court terme. D’autres études bien construites sont nécessaires pour confirmer nos observations. / Introduction: There are several side-effects associated with mandibular advancement devices (MAD) used to treat obstructive sleep apnea (OSA). Despite the lack of evidence supporting their use, some providers advocate the use of morning repositioning splints (MRS) to minimize these side effects. Objectives: The main objective of this randomized controlled pilot study is to evaluate MRS-use as a means of mitigating MAD-associated short-term side-effects. Methods: 9 subjects with OSA requiring MAD-use were included in this study and were randomized into a control group (n=5) and a treatment group (n=4). All participants were treated with a customized adjustable MAD (SomnoDent Flex, SomnoMed, USA). Subjects in the treatment group also received an MRS that was to be used every morning for 1 hour after removal of their MAD. Follow-up consisted of 6 appointments over approximately 8 months. During this time, variables including occlusal changes, side effects and treatment adherence were evaluated. Results: A tendency for overjet and overbite reduction as well as maxillary intermolar distance reduction and superior arch length shortening were observed in the control group only (P=0.063). Six months after completion of MAD titration, masticatory problems were more frequently reported by subjects in the control group. 60% of these subjects reported masticatory problems on a weekly basis whereas subjects in the treatment group never or rarely reported these issues. Conclusion: Our results suggest that MRS-use can minimize short-term side effects associated with MADs used to treat OSA. Additional, well-constructed, studies are needed to confirm these findings.