Derretimiento corneal como complicación de queratitis ulcerativa periférica en un paciente con artritis reumatoide / Corneal melt as a complication of a peripheral ulcerative keratitis in a patient with rheumatoid arthritis

RESUMEN Las manifestaciones oculares de la artritis reumatoide son manifestaciones graves que requieren manejo agresivo. En el presente reporte presentamos un caso de queratitis asociada a derretimiento corneal desencadenado por suspensión abrupta de su medicación reumatológica y cirugía no ocular, que respondió de forma favorable al manejo con metil-prednisolona y ciclofosfamida.

ABSTRACT Ocular signs of rheumatoid arthritis are severe extra-articular manifestations, which usually require aggressive management. In this report, A case is presented here of patient with peripheral ulcerative keratitis associated with corneal melt syndrome triggered by abrupt suspension of antirheumatic medication and non-ocular surgery. They symptoms responded favourably to methylprednisolone and cyclophosphamide.

Cardiopulmonary effects and eyeball centralization with low-dose atracurium in spontaneously breathing, anesthetized dogs / Avaliação cardiopulmonar e da centralização do globo ocular em cães com baixas doses de atracúrio mantidos em anestesia inalatória sob ventilação espontânea

The objective was to determine the cardiopulmonary effects and eyeball centralization time obtained with 15 or 30µg kg-1 of atracurium in anesthetized dogs under spontaneous breathing. Eighteen healthy adult mixed-breed dogs were used, which received 0.1mg kg-1 acepromazine and 0.5mg kg-1 morphine IM, followed by 4mg kg-1 propofol IV and maintained on isoflurane anesthesia with spontaneous breathing. Animals received 1mL 0.9 percent NaCl IV (CG), 15µg kg-1 (G15) or 30µg kg-1 (G30) of atracurium IV. Eyeball centralization time was measured; heart rate (HR), systolic (SAP), mean (MAP) and diastolic (DAP) arterial pressures, respiratory rate (RR), tidal volume (Vt) and minute volume (Vm) were determined every 5min, and pH, arterial CO2 pressure (PaCO2 ), arterial O2 pressure (PaO2 ), hemoglobin oxygen saturation (SaO2 ), bicarbonate (HCO3-) and base excess (BE) every 15min until 60min. Both doses of atracurium produced a similar period of eyeball centralization. Vt in groups treated with atracurium was lower than in CG up to 15min. Vm in G15 differed from CG up to 10min and in G30 up to 25min. No differences were observed for cardiovascular parameters, RR, SaO2, PaO2, HCO3- and BE. pH decreased in CG between 30 and 60min and in G15 and G30 at 15min. G30 differed from CG between 15 and 30min. PaCO2 in GC differed from baseline between 30 and 60min and in G15 differed at 15min. Atracurium at the dose of 15µg kg-1 is adequate for short corneal procedures in inhalant-anesthetized dogs under spontaneous breathing.

Objetivou-se determinar os efeitos cardiopulmonares e o tempo de centralização do globo ocular obtidos com 15 ou 30µg kg-1 de atracúrio em cães anestesiados sob ventilação espontânea. Dezoito cães adultos foram pré-medicados com 0,1mg kg-1 de acepromazina e 0,5mg kg-1 de morfina IM, anestesiados com 4mg kg-1 de propofol IV e mantidos sob anestesia inalatória com isofluorano em ventilação espontânea. Os animais receberam 1mL de NaCl 0,9 por cento IV (GC), 15µg kg-1 (G15) ou 30µg kg-1 de atracúrio IV. Mensuraram-se o tempo de centralização do globo ocular, a frequência cardíaca (FC), as pressões arteriais sistólica (PAS), média (PAM) e diastólica (PAD), a frequência respiratória (f), o volume corrente (Vt) e o volume minuto (Vm) a cada 5min, e o pH, as pressões arteriais de CO2 (PaCO2) e O2 (PaO2), a saturação de oxigênio nas hemoglobinas (SaO2), o bicarbonato (HCO3-) e o excesso de base (BE) a cada 15min, até 60min. Ambas as doses de atracúrio produziram similar período de centralização. Os grupos tratados com atracúrio apresentaram menores valores para Vt até 15min. O Vm, no G15, diferiu do GC até 10min e do G30 até 25min. Não foram observadas alterações nos parâmetros cardiovasculares f, SaO2, PaO2, HCO3- e EB. O pH diminuiu no GC entre 30 e 60min e em G15 e G30 aos 15min. A PaCO2 elevou-se no GC entre 30 e 60min e no G15 aos 15min. A dose de 15µg kg-1 de atracúrio demonstrou ser adequada para centralização do globo ocular, podendo ser utilizada em procedimentos corneanos de curta duração em cães anestesiados com isoflurano e mantidos sob ventilação espontânea.

Úlcera de Mooren bilateral / Bilateral Mooren's ulcer

Objetivo: describir el caso de un paciente con úlcera de Mooren bilateral en el Hospital de San José. Metodología: revisión y análisis de historia clínica. Resultados: paciente de 21 años sin antecedentes sistémicos, de ocupación carnicero, que consultó por ojo rojo, fotofobia y lagrimeo en ojo izquierdo y ardor en el derecho de dos días de evolución. Refería haber presentado seis episodios similares en los últimos seis meses. Al examen se encontró una úlcera corneana periférica en OD entre meridianos 9:00 y 11:00 y en el OI entre 1:00 y 6:00, de forma alargada, con borde anterior serpiginoso, levantado, infiltrado y socavado, y con compromiso parcial del epitelio. Se diagnosticó úlcera de Mooren bilateral, se inició tratamiento tópico con prednisona, ciclosporina, diclofenaco, lubricantes, inhibidor de la colagenasa y lente de contacto terapéutico. Se solicitaron exámenes paraclínicos y valoración por medicina interna, descartando enfermedad sistémica asociada. Después se solicitaron linfocitos totales, linfocitos CD2, CD4 y CD8, C3, C4, IgA total sérica, anticuerpos anticisticerco y coproscópico seriado. Conclusiones: por la rareza de esta entidad en nuestro medio y por interés académico presentamos este caso, cuyo diagnóstico fue clínico, haciendo énfasis en las características biomicroscoscópicas de esta patología.

Objective: to describe the case of one man with bilateral Mooren´s ulcer diagnosed at Hospital de San José. Methodology: review and analysis of clinical record. Results: the patient is a 21-year old man with no systemic antecedents, he is a butcher and presented with a 2-day history of: red eye, photophobia and increased tears on left eye and burn sensation in right eye. He refers six similar episodes in the last six months. Medical examination revealed peripheral corneal ulcers located between meridians 9:00 and 11:00 in the right eye and between 1:00 and 6:00 in the left eye; ulcers were: elongated, sinuous, elevated, infiltrative, excavated and partially compromised the overlying epithelium. Diagnosis was: bilateral Mooren´s ulcers. Treatment with topical prednisone, cyclosporine, diclofenac, lubricants, collagenase inhibitors and therapeutic contact lenses was initiated. Lab work-up and internal medicine consultation ruled out associated systemic disease. Further lab work-up including total lymphocyte, CD2, CD4 and CD8 lymphocyte count, determination of C3, C4, total serum IgA, and cysticercoids antibodies and serial stool examination was requested. Conclusions: we report this case for this condition rarely occurs in our setting and for being of academic interest. The diagnosis was clinical, and biological/ microscopic features of this condition are highlighted.