Mudanças entre as edições de "Glaucoma"

Edição das 14h36min de 29 de maio de 2025

INTRODUÇÃO

O glaucoma é uma neuropatia óptica com repercussão característica no campo visual, cujo principal fator de risco é o aumento da pressão intraocular (PIO) e cujo desfecho principal é a cegueira irreversível. O fator de risco mais relevante e estudado para o desenvolvimento da doença é a elevação da PIO (1). Os valores normais situam-se entre 10-21 mmHg. Quando a PIO está aumentada, mas não há dano evidente do nervo óptico nem alteração no campo visual, o paciente é caracterizado como portador de glaucoma suspeito por hipertensão ocular (HO). Quando a PIO está normal e o paciente apresenta dano no nervo óptico ou alteração no campo visual, ele é classificado como portador de glaucoma de pressão normal (GPN). Exceto no glaucoma de início súbito, chamado glaucoma agudo, a evolução é lenta e principalmente assintomática.

Essa doença afeta mais de 67 milhões de pessoas no mundo, das quais 10% são cegas (acuidade visual corrigida no melhor olho de 0,05 ou campo visual com menos de 10 graus no melhor olho com a melhor correção óptica) (2). Após a catarata, o glaucoma é a segunda causa de cegueira, além de ser a principal causa de cegueira irreversível (3). No Brasil, há escassez de informações quanto à prevalência do glaucoma. A maior parte dos estudos é restrita, antiga e mostra prevalência de 2% - 3% na população acima de 40 anos, com aumento da prevalência conforme o aumento da idade (4-6). O Conselho Brasileiro de Oftalmologia adota a prevalência de 1% na população total, como em recente trabalho conjunto com o Ministério da Saúde.

Vários fatores de risco, além da PIO aumentada, já foram identificados: idade acima de 40 anos, escavação do nervo óptico aumentada, etnia (negra para o de ângulo aberto e amarela para o de fechamento angular), história familiar, ametropia (miopia para o de ângulo aberto e hipermetropia para o de fechamento angular), pressão de perfusão ocular diminuída, diabetes melito tipo 2, fatores genéticos e outros fatores especificados (7).

Inúmeros trabalhos mostraram que a prevalência do glaucoma se eleva significativamente com o aumento da idade, particularmente em latinos e afrodescendentes (8-14). A prevalência é três vezes maior e a chance de cegueira pela doença é seis vezes maior em indivíduos latinos e afrodescendentes em relação aos caucasianos.

Com relação à história familiar, estudos revelaram que basta um caso familiar de glaucoma para aumentar significativamente a chance de o indivíduo desenvolver a doença.

CLASSIFICAÇÕES DO GLAUCOMA

(CID-10)

• H 40.1 Glaucoma primário de ângulo aberto;

• H 40.2 Glaucoma primário de ângulo fechado;

• H 40.3 Glaucoma secundário a traumatismo ocular;

• H 40.4 Glaucoma secundário a inflamação ocular;

• H 40.5 Glaucoma secundário a outros transtornos do olho;

• H 40.6 Glaucoma secundário a drogas;

• H 40.8 Outro glaucoma;

• Q15.0 Glaucoma congênito.

DIAGNÓSTICO

A avaliação oftalmológica do paciente deve ser binocular e abordar os seguintes itens para o diagnóstico do glaucoma e para a determinação da sua gravidade:

• anamnese;

• medida da acuidade visual (AV) com melhor correção;

• exame pupilar para avaliação de reatividade à luz e procura de defeito pupilar aferente relativo;

• biomicroscopia de segmento anterior para avaliação da profundidade da câmara anterior, de doenças corneanas ou de causas secundárias para o aumento da PIO;

• aferição da PIO, idealmente medida com tonometria de aplanação de Goldmann, em diferentes dias e horários, para reconhecimento da flutuação diária; e avaliação do nervo óptico e da camada de fibras nervosas (CFN) para o fornecimento de informações estruturais sobre o dano glaucomatoso. O nervo óptico deve ser avaliado com biomicroscopia de fundo e fundoscopia sob midríase e ser documentado, idealmente, com retinografia colorida binocular.

Exames complementares

A gonioscopia avalia o ângulo iridocorneano, identificando a amplitude do ângulo da câmara anterior, o grau de pigmentação, a altura da inserção iriana e a configuração da íris. O diagnóstico de GPAA requer uma gonioscopia para excluir o fechamento angular e outras causas de aumento da PIO, como recesso angular, dispersão pigmentar, sinéquias anteriores periféricas, neovascularização de ângulo e precipitados inflamatórios.

A paquimetria ultrassônica avalia a espessura corneana central e influencia a estimativa da PIO.

A campimetria visual (campimetria computadorizada estática acromática) é o exame padrão-ouro para detectar o dano funcional do glaucoma e para monitorizar sua progressão.

Deve ser realizada documentação do nervo óptico e análise da CFN, conforme já referido, principalmente nos casos suspeitos ou confirmados de glaucoma. A retinografia colorida estereoscópica é superior à técnica simples por permitir uma melhor quantificação do anel neural. O uso do filtro aneritra contribui para uma melhor análise qualitativa da CFN. Entretanto, a retinografia simples pode ser suficiente para o seguimento (79,123-132). Não há evidência científica suficiente que embase o uso da tomografia de coerência óptica (OCT) para o acompanhamento dos pacientes com glaucoma.

CRITÉRIOS DIAGNÓSTICOS no PCDT (Protocolo clínico de diretrizes terapêuticas do Ministério da Saúde)

Serão incluídos neste Protocolo pacientes com diagnóstico de glaucoma que apresentem pelo menos dois dos seguintes itens:

- PIO média sem tratamento acima de 21 mmHg;

- dano típico ao nervo óptico com perda da rima neurorretiniana identificado por biomicroscopia de fundo (escavação igual ou acima de 0,5); ou

- campo visual compatível com o dano ao nervo óptico.

CRITÉRIOS DE EXCLUSÃO:

Serão excluídos deste Protocolo pacientes que apresentarem hipersensibilidade ou contraindicação aos medicamentos nele preconizados.

7 TRATAMENTO

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