There has been much discussion about the relationship between hormonal contraceptives and the development of pseudotumor cerebri (PTC). Some have claimed that progestin-containing contraceptives, such as levonorgestrel intrauterine devices, are linked to PTC. However, the relationship and mechanism of PTC following the use of progestin-containing contraceptives remain controversial. We present a case of PTC following implantation of Nexplanon® (etonogestrel) (Merck Sharp & Dohme BV, Haarlem, The Netherlands), a progestin contraceptive. Clinicians should be vigilant for visual disturbances, headache, nausea, and other signs of increased intracranial pressure in patients receiving progestin-containing contraceptives.

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OBJETIVO: Avaliar a capacidade do eletrorretinograma de padrão reverso (PERG) de campo total de detectar alterações funcionais da retina em olhos com papiledema resolvido de pacientes com a síndrome do pseudotumor cerebral (PTC). Utilizar a tomografia de coerência óptica de domínio Fourier (FD-OCT) para avaliar a espessura total e das camadas internas da retina (após segmentação dos dados) na área macular e a camada de fibras nervosas retinianas (CFNR) peripapilar em pacientes com PTC, e compará-las com aquelas de olhos normais. Estudar a correlação entre as amplitudes do PERG, as medidas da tomografia de coerência óptica (OCT) e a perda de campo visual (CV) avaliada pela perimetria computadorizada. MÉTODOS: Cinquenta e dois olhos com papiledema clinicamente resolvidos de 29 pacientes portadores de PTC foram submetidos a exame oftalmológico completo, CV, PERG e OCT. As seguintes medidas obtidas pelo OCT foram analisadas: a espessura da CFNR peripapilar, a espessura macular total (EMT), avaliada em oito setores, de acordo com o mapa do Early Treatment Diabetes Retinopathy Study, e medidas segmentadas na região da mácula da CFNR, da camada de células ganglionares (CCG) e da camada nuclear interna (CNI). Os resultados do CV foram avaliados, levando em consideração o mean deviation (MD) e os valores de diferentes regiões do CV divididos, de acordo com sua correspondência no nervo óptico, seguindo o mapa de Garway-Heath. Foram, também, calculados os desvios médios de 12 ou de 16 pontos centrais do CV, que estimulam áreas semelhantes àquelas avaliada pelo OCT macular e pelo PERG. Os achados foram comparados utilizando-se as equações de estimativas generalizadas para compensação da interdependência dos dois olhos de um mesmo indivíduo. Foram, também, calculadas e comparadas as áreas sob as curvas ROC (receiver operating characteristics). As correlações entre os achados do PERG, do OCT e do CV foram avaliadas pela correlação de Pearson ou Spearman. RESULTADOS: Comparadas aos controles, as espessuras do OCT, da CFNR peripapilar, CFNR macular, CCG macular e EMT foram significativamente menores em pacientes com PTC. Com relação ao PERG, houve redução da amplitude de N95 e P50+N95, e aumento do tempo de pico de N95, ambos para o estímulo de 48\', em olhos doentes, quando comparados ao grupo controle. Correlações estatisticamente significantes foram encontradas entre os valores de amplitude do PERG e da espessura retiniana do OCT. As reduções de espessura das camadas retinianas do OCT também foram significativamente associadas à perda de sensibilidade do CV. CONCLUSÕES: O PERG e o OCT foram capazes de demonstrar a perda anatômica e funcional dos doentes com papiledema decorrente de PTC, apresentando significativa correlação entre os métodos analisados. Tanto o OCT avaliando as medidas maculares como o PERG podem ser úteis na monitorização da perda neural retiniana de pacientes com papiledema decorrente da síndrome do PTC / PURPOSE: To evaluate the ability of the full field pattern electroretinogram (PERG) to detect functional changes of retina in eyes with resolved papiledema from patients with pseudotumor cerebri (PTC). To analyze full thickness macular measurements, peripapillary retinal nerve fiber layer (RNFL) thickness as well as segmented inner retinal layers in patients with PTC using of Fourier domain optical coherence tomography (FD-OCT) and compare them with normal eyes. To study the correlation between the PERG parameters, the optical coherence tomography (OCT) measurements and the visual field (VF) sensitivity loss, using standard automated perimetry. METHODS: Fifty-two eyes with resolved papilledema of 29 patients with PTC syndrome were submitted to a complete ophthalmic examination including VF, PERG and OCT. The following OCT measurements were analyzed: the peripapillary RNFL thickness, the total macular thickness (TMT), which was sub-divided in 8 sectors according to the Early Treatment Diabetes Retinopathy Study map, and the segmented inner macula layers, RNFL, the ganglion cell layer (GCL) and inner nuclear layer (INL). The VF results were analyzed through the mean deviation (MD) and the different sectors of the VF according to their correspondence to Garway-Heath optic nerve map. Central mean deviation, an average from VF sensitivity for the 12 and 16 central points, an area roughly equivalent to the area tested by macular cube scan protocol and PERG, was evaluated in patients and controls. Generalized estimating equation models accounting for inter-eye correlations were used to compare the results among different groups. Areas under ROC (receiver operating characteristics) curves were also calculated and compared. The correlations between the findings of the PERG, OCT and VF were assessed by Pearson correlation coefficients or Spearman\'s rank correlation coefficients. RESULTS: Compared to controls, the OCT thickness of the peripapillary RNFL, macular RNFL, macular GCL and TMT were significantly thinner in eyes with PTC. When PERG was studied, the amplitude of P50 and N95 + N95 were significantly reduced and N95 peak time increased, both based on 48 min check size, in patients when compared with normal controls. Significant correlations were found between the PERG amplitude and OCT retinal thickness. The decreased thickness of the OCT retinal layers was also significantly associated with VF sensitivity loss. CONCLUSIONS: PERG and OCT were able to demonstrate anatomical and functional loss in patients with resolved papiledema from PTC, showing significant correlation between the methods analyzed. It is known that the main morbidity of this disease is visual impairment. It is therefore of great importance to monitor the visual function during treatment. Whereas papilledema may be reversible at early stages, permanent visual loss may occur. These findings suggest that both measurements can be complementary in assessing axonal loss in patients with PTC

OBJETIVO: Avaliar a capacidade do eletrorretinograma de padrão reverso (PERG) de campo total de detectar alterações funcionais da retina em olhos com papiledema resolvido de pacientes com a síndrome do pseudotumor cerebral (PTC). Utilizar a tomografia de coerência óptica de domínio Fourier (FD-OCT) para avaliar a espessura total e das camadas internas da retina (após segmentação dos dados) na área macular e a camada de fibras nervosas retinianas (CFNR) peripapilar em pacientes com PTC, e compará-las com aquelas de olhos normais. Estudar a correlação entre as amplitudes do PERG, as medidas da tomografia de coerência óptica (OCT) e a perda de campo visual (CV) avaliada pela perimetria computadorizada. MÉTODOS: Cinquenta e dois olhos com papiledema clinicamente resolvidos de 29 pacientes portadores de PTC foram submetidos a exame oftalmológico completo, CV, PERG e OCT. As seguintes medidas obtidas pelo OCT foram analisadas: a espessura da CFNR peripapilar, a espessura macular total (EMT), avaliada em oito setores, de acordo com o mapa do Early Treatment Diabetes Retinopathy Study, e medidas segmentadas na região da mácula da CFNR, da camada de células ganglionares (CCG) e da camada nuclear interna (CNI). Os resultados do CV foram avaliados, levando em consideração o mean deviation (MD) e os valores de diferentes regiões do CV divididos, de acordo com sua correspondência no nervo óptico, seguindo o mapa de Garway-Heath. Foram, também, calculados os desvios médios de 12 ou de 16 pontos centrais do CV, que estimulam áreas semelhantes àquelas avaliada pelo OCT macular e pelo PERG. Os achados foram comparados utilizando-se as equações de estimativas generalizadas para compensação da interdependência dos dois olhos de um mesmo indivíduo. Foram, também, calculadas e comparadas as áreas sob as curvas ROC (receiver operating characteristics). As correlações entre os achados do PERG, do OCT e do CV foram avaliadas pela correlação de Pearson ou Spearman. RESULTADOS: Comparadas aos controles, as espessuras do OCT, da CFNR peripapilar, CFNR macular, CCG macular e EMT foram significativamente menores em pacientes com PTC. Com relação ao PERG, houve redução da amplitude de N95 e P50+N95, e aumento do tempo de pico de N95, ambos para o estímulo de 48\', em olhos doentes, quando comparados ao grupo controle. Correlações estatisticamente significantes foram encontradas entre os valores de amplitude do PERG e da espessura retiniana do OCT. As reduções de espessura das camadas retinianas do OCT também foram significativamente associadas à perda de sensibilidade do CV. CONCLUSÕES: O PERG e o OCT foram capazes de demonstrar a perda anatômica e funcional dos doentes com papiledema decorrente de PTC, apresentando significativa correlação entre os métodos analisados. Tanto o OCT avaliando as medidas maculares como o PERG podem ser úteis na monitorização da perda neural retiniana de pacientes com papiledema decorrente da síndrome do PTC / PURPOSE: To evaluate the ability of the full field pattern electroretinogram (PERG) to detect functional changes of retina in eyes with resolved papiledema from patients with pseudotumor cerebri (PTC). To analyze full thickness macular measurements, peripapillary retinal nerve fiber layer (RNFL) thickness as well as segmented inner retinal layers in patients with PTC using of Fourier domain optical coherence tomography (FD-OCT) and compare them with normal eyes. To study the correlation between the PERG parameters, the optical coherence tomography (OCT) measurements and the visual field (VF) sensitivity loss, using standard automated perimetry. METHODS: Fifty-two eyes with resolved papilledema of 29 patients with PTC syndrome were submitted to a complete ophthalmic examination including VF, PERG and OCT. The following OCT measurements were analyzed: the peripapillary RNFL thickness, the total macular thickness (TMT), which was sub-divided in 8 sectors according to the Early Treatment Diabetes Retinopathy Study map, and the segmented inner macula layers, RNFL, the ganglion cell layer (GCL) and inner nuclear layer (INL). The VF results were analyzed through the mean deviation (MD) and the different sectors of the VF according to their correspondence to Garway-Heath optic nerve map. Central mean deviation, an average from VF sensitivity for the 12 and 16 central points, an area roughly equivalent to the area tested by macular cube scan protocol and PERG, was evaluated in patients and controls. Generalized estimating equation models accounting for inter-eye correlations were used to compare the results among different groups. Areas under ROC (receiver operating characteristics) curves were also calculated and compared. The correlations between the findings of the PERG, OCT and VF were assessed by Pearson correlation coefficients or Spearman\'s rank correlation coefficients. RESULTS: Compared to controls, the OCT thickness of the peripapillary RNFL, macular RNFL, macular GCL and TMT were significantly thinner in eyes with PTC. When PERG was studied, the amplitude of P50 and N95 + N95 were significantly reduced and N95 peak time increased, both based on 48 min check size, in patients when compared with normal controls. Significant correlations were found between the PERG amplitude and OCT retinal thickness. The decreased thickness of the OCT retinal layers was also significantly associated with VF sensitivity loss. CONCLUSIONS: PERG and OCT were able to demonstrate anatomical and functional loss in patients with resolved papiledema from PTC, showing significant correlation between the methods analyzed. It is known that the main morbidity of this disease is visual impairment. It is therefore of great importance to monitor the visual function during treatment. Whereas papilledema may be reversible at early stages, permanent visual loss may occur. These findings suggest that both measurements can be complementary in assessing axonal loss in patients with PTC