Actualización diagnóstica y terapéutica sobre la úlcera corneal / Diagnostic and therapeutic updating about the corneal ulcer

Se realizó una revisión bibliográfica exhaustiva sobre la anatomía de la córnea, a fin de profundizar en los principales factores predisponentes de la úlcera corneal, sus causas, cuadro clínico, evolución, complicaciones y tratamiento. Se analizó conceptualmente la enfermedad y se propuso incluir en su concepto el método clínico como premisa. Actualmente, en la provincia de Santiago de Cuba, la curación de estas úlceras constituye un problema de salud a resolver, puesto que los tratamientos convencionales no siempre permiten una evolución estable de los pacientes diagnosticados, razón por la cual surge la necesidad de buscar medicamentos y alternativas terapéuticas para tratar a dichos pacientes.

An exhaustive literature review on the cornea anatomy was carried out in order to deepen in the main predisposing factors of the corneal ulcer, their causes, clinical picture, clinical course, complications and treatment. The disease was conceptually analyzed and it was suggested to include in its concept the clinical method as premise. At the moment, in Santiago de Cuba province, the cure of these ulcers constitutes a health problem to solve, since the conventional treatments not always allow a stable clinical course of the diagnosed patients, reason why there is a necessity of searching medicines and therapeutic alternatives to treat them.

Abscesos de córnea bilaterales en una paciente con SIDA. Presentación de un caso y revisión de la literatura / Corneal Abscess in a patient with aids: case report and literature review

El epitelio corneal es una importante barrera de defensa que impide el ingreso de una gran variedad de microorganismos. Cualquier alteración de la superficie ocular facilita la invasión bacteriana de la córnea. El germen más frecuentemente identificado es Staphylococcus aureus. Se presenta una paciente con enfermedad debida al virus de la inmunodeficiencia humana (VIH) con diagnóstico de sida, absceso corneal bilateral y lesiones cutáneas. S.aureus meticilino resistente se aisló en hemocultivos y en material obtenido por raspado de la córnea. El absceso corneal es una entidad poco frecuente en pacientes con infección por VIH y síndrome de inmunodeficiencia adquirida.

The corneal epithelium is an important defense barrier that prevents the entry of great variety of microorganisms. Any alteration of the ocular surface facilitates bacterial invasion of the cornea. The most frequently reported germ is Staphylococcus aureus. Here, we present a patient with a diagnosis of HIV/ AIDS disease, who developed bilateral corneal abscess and skin lesions. Methicillin-resistant Staphylococcus aureus was isolated from blood cultures and corneal scrapings. Corneal abscess is a rare entity in patients with HIV and acquired immunodeficiency syndrome

Ozonoterapia como tratamiento coadyuvante en la úlcera corneal grave bacteriana / Ozone therapy as adjunctive treatment in severe bacterial corneal ulcer / Ozonoterapia como tratamento adjuvante em úlcera bacteriana da córnea grave

Introducción: La evolución espontánea o los casos mal tratados de la úlcera corneal conllevan el riesgo de extensión de la infección, con severa afectación visual e integridad estructural del ojo. Objetivo: Describir las características clínico-epidemiológicas de pacientes con úlcera corneal grave bacteriana tratada con ozonoterapia local coadyuvante al tratamiento protocolizado. Método: Se realizó un estudio observacional, descriptivo y transversal con 48 pacientes ingresados en el servicio de Oftalmología del Hospital General Docente "Dr. Juan Bruno Zayas Alfonso", de Santiago de Cuba, en el periodo de enero de 2017 a diciembre de 2019. Las variables del estudio fueron: edad, sexo, factores predisponentes, microorganismos, signos de mejoría clínica, resultados al tratamiento y complicaciones. Para la validación estadística se utilizó prueba Chi-cuadrado. Resultados: La edad promedio de los pacientes fue de 54,1 años, el 62,5 % eran hombres. Predominó el trauma ocular (63,3 %) en el sexo masculino y enfermedades oculares (44,4 %) en el femenino. La mejoría de los signos fue más representativa a los 14 días. Se logró resultados satisfactorios en el 100 % de los pacientes con microorganismos grampositivos. El 10,4 % presentó perforación corneal. Conclusiones: La ozonoterapia es una terapia válida como tratamiento en la úlcera corneal grave de etiología bacteriana y responde a la búsqueda de alternativas para pacientes con resistencia a los tratamientos antibacterianos que se ofertan en el cuadro básico de salud.

ABSTRACT Introduction: Spontaneous evolution or poorly treated cases of corneal ulcer carry the risk of extension of the infection, with severe visual impairment and damage to the structural integrity of the eye. Objective: To describe the clinical-epidemiological characteristics of patients with severe bacterial corneal ulcer treated with local ozone therapy as an adjunct to the standard protocol treatment. Method: An observational, descriptive and cross-sectional study was carried out on 48 patients admitted to the Ophthalmology service of the Hospital General Docente "Dr. Juan Bruno Zayas Alfonso", from Santiago de Cuba, in the period from January 2017 to December 2019. The study variables were: age, gender, predisposing factors, microorganisms, signs of clinical improvement, treatment results and complications. Chi-square test was used for statistical validation. Results: The average age of the patients was 54.1 years; 62.5% of them were men. Ocular trauma (63.3%) predominated in males, and ocular diseases (44.4%) in females. The improvement of the signs was more common after 14 days. Satisfactory results were achieved in 100% of patients with gram-positive organisms. 10.4% presented corneal perforation. Conclusions: Ozone therapy is valid as a treatment for severe corneal ulcer of bacterial etiology, and responds to the search for alternatives for patients with resistance to the antibacterial treatments that are offered in the basic health system.

RESUMO Introdução: A evolução espontânea ou casos mal tratados de úlcera de córnea trazem o risco de extensão da infecção, com comprometimento visual grave e integridade estrutural do olho. Objetivo: Descrever as características clínico-epidemiológicas de pacientes com úlcera bacteriana de córnea grave tratados com ozonioterapia local como coadjuvante ao tratamento protocolizado. Método: Foi realizado um estudo observacional, descritivo e transversal com 48 pacientes internados no serviço de Oftalmologia do Hospital General Docente "Dr. Juan Bruno Zayas Alfonso", de Santiago de Cuba, no período de janeiro de 2017 a dezembro de 2019. As variáveis do estudo foram: idade, sexo, fatores predisponentes, microrganismos, sinais de melhora clínica, resultados do tratamento e complicações. O teste do qui-quadrado foi usado para validação estatística. Resultados: A idade média dos pacientes foi de 54,1 anos, 62,5% eram homens. O trauma ocular (63,3%) predominou no sexo masculino e as doenças oculares (44,4%) no feminino. A melhoria da sinalização foi mais representativa aos 14 dias. Resultados satisfatórios foram alcançados em 100% dos pacientes com organismos gram-positivos. 10,4% apresentaram perfuração corneana. Conclusões: A ozonioterapia é uma terapia válida como tratamento para úlcera de córnea grave de etiologia bacteriana e responde à busca de alternativas para pacientes com resistência aos tratamentos antibacterianos que são oferecidos no quadro básico de saúde.

Allogenic platelet-rich plasma in induced ulcers in rat's cornea / [Plasma rico em plaquetas alogênico em úlceras de córnea induzidas em ratos]

The objective in this study was to evaluate the clinic effect of applying allogenic platelet-rich plasma (PRP) heated or not, for treating cornea ulcers, including the dosage of PDGF-BB in the cornea. The ulcers were induced, standardizing the left eye from 81 rats (Ratus norvegicus, albinus variety), assigned randomly into three groups (N=27): control group (CG) which did not receive any topic treatment; heated PRP group (GA) and PRP group (GP), which received topical treatment every eight hours for five days. Each group underwent evaluation at 24 hours (M1), three days (M3) and five days (M5). The clinical exam evaluated the opacity, vascularization and corneal repair. The corneal PDGF-BB was dosed through the ELISA method. The corneal opacity was decreased in PRP-treated animals (GA and GP) and corneal repair time reduced when compared to CG at M1 and M5. Furthermore, GP showed greater vascularization at M3 compared to M1. Applied allogenic PRP eye drops, heated or not, speed up corneal healing, and reduce corneal repair time. However, the corneal PDGF concentration was not altered in any of the treatments.(AU)

Objetivou-se avaliar o efeito clínico da aplicação de plasma rico em plaquetas alogênico (PRP) aquecido ou não, no tratamento de úlceras de córnea, como a dosagem de PDGF-BB na córnea. As úlceras foram induzidas, padronizando-se o olho esquerdo de 81 ratos (Rattus norvegicus, variedade albinus), aleatoriamente, nos três grupos (N = 27): grupo controle (CG), que não recebeu nenhum tratamento tópico; grupo PRP aquecido (GA) e grupo PRP (GP), que receberam tratamento tópico a cada oito horas, durante cinco dias. Cada grupo foi subdividido em 24 horas (M1), três dias (M3) e cinco dias (M5). O exame clínico avaliou a opacidade, a vascularização e o reparo corneano. O PDGF-BB corneano foi dosado pelo método Elisa. Houve diminuição da opacidade da córnea nos animais tratados com PRP (GA e GP) e diminuição do tempo de reparo da córnea em comparação com CG, M1 e M5. Além disso, foi observada maior vascularização no GP no momento M3 em relação ao M1. A aplicação de colírios de PRP alogênico, aquecidos ou não, acelera a cicatrização da córnea, além de reduzir o tempo de reparo da córnea. No entanto, a concentração de PDGF na córnea não se alterou em nenhum dos tratamentos.(AU)

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.

Alternativas terapéuticas de la úlcera corneal infecciosa / Therapeutic alternativesfor the infectious corneal ulcer

Introducción: La úlcera corneal infecciosa es una afección frecuente en la consulta de oftalmología. Su resolución es un problema de salud a resolver, pues los tratamientos convencionales no siempre garantizan una evolución favorable de los casos diagnosticados debido a la resistencia microbiana, por lo que se siguen buscando alternativas terapéuticas. Objetivo: Describir las alternativas de tratamiento en la úlcera corneal infecciosa para minimizar sus secuelas y disminuir la ceguera por esta enfermedad. Desarrollo: La administración tópica de antibióticos de amplio espectro sigue siendo el método preferido para el tratamiento farmacológico de las úlceras corneales infecciosas, a pesar de los informes de fracasos clínicos por la resistencia a los antibióticos, por lo que se investiga acerca del uso de nuevas alternativas terapéuticas que minimicen las secuelas de esta enfermedad.Se realizó una revisión sistemática de la evidencia científica en los últimos diez años en diversos artículos, en los que se constató la aplicación de diferentes sustancias como tratamiento alternativo. Conclusiones: En la úlcera corneal infecciosa el tratamiento protocolizado combinado con sustancias alternativas, que tienen en común una actividad de amplio espectro, resultaría ser ventajoso por ser productos económicos y seguros, que han demostrado un gran poder bactericida. Se propone generalizar el uso de estos compuestos, dada la resistencia de los microorganismos al tratamiento convencional; lo que hace que la úlcera corneal sea un problema de salud a resolver.

Introduction: The infectious corneal ulcer is a frequent disorder in the ophthalmology outpatient department, its solution is a health problem to be solved, as the conventional treatments don't always guarantee a favorable clinical course of the diagnosed cases. Because of the microbial resistance, so that therapeutic alternatives are still looked for. Objective: To describe the treatment alternatives in the infectious corneal ulcer for minimizing their sequelae and to decrease blindness due to this disease. Development: The topical administration of wide spectrum antibiotics continues being the favorite method for the pharmacological treatment of the infectious corneal ulcers, in spite of the clinical failures reports caused by the resistance to antibiotics, that is why the use of new therapeutic alternatives minimizing the sequels of this disease is investigated. Method: A systematic review of the scientific evidence in the last ten years was carried out on several works, in which it was evidenced the use of different substances as alternative treatment. Conclusions: In the infectious corneal ulcer the protocolized treatment combined with alternative substances which have in common a wide spectrum activity would turn out to be advantageous as they are economic and sure products which have demonstrated a great power against bacteria. The use of these compounds could be generalized, given the resistance of organisms to the conventional treatment; what makes the corneal ulcer a health problem to be solved.

Clinical characteristics and risk factors of rheumatoid arthritis with ulcerative keratitis / 北京大学学报(医学版)

OBJECTIVE@#To investigate the clinical characteristics, risk factors and prognosis of ulcerative keratitis (UK) in patients with rheumatoid arthritis (RA).@*METHODS@#Sixteen patients with UK (the UK group) were screened among 4 773 RA patients hospitalized at Peking University People's Hospital from January 2003 to May 2021, and 72 patients with RA without UK in the control group were selected by propensity score matching (PSM). The clinical features, laboratory data and medications between the two groups were collected and analyzed.@*RESULTS@#The average age of the patients with RA was 60 years at the time of the complication of UK. UK appeared on average in the 16th year of RA, with the majority of UK occurring in the 7th year of RA and beyond (14 cases), however, a minority of UK was the first symptom of RA (1 case). UK associated with RA manifested as simple marginal UK in 8 cases, marginal UK with perforation in 5 cases, marginal UK with uveitis in 2 cases and central UK with perforation in 1 case. The number of swollen joints was significantly higher in the UK group than in the control group [6.0(2.5, 23.0) vs. 3.0(1.0, 9.8), Z=-2.047, P=0.041], and the proportion of secondary Sjögren syndrome (SS, 37.5% vs. 6.9%, χ2=11.175, P=0.004) and interstitial lung disease (ILD, 37.5% vs. 8.3%, χ2=9.456, P=0.008) were significantly higher in the RA patients with UK than the patients without UK. The uses of sulfasalazine (12.5% vs. 48.6%, χ2=7.006, P=0.008), leflunomide (31.3% vs. 63.9%, χ2=5.723, P=0.017) and gold salt(6.3% vs. 33.8%, χ2=4.841, P=0.032)were significantly lower in the UK group than in the control group. However, there was no statistically significant comparison between the two groups for the 28-joint disease activity score-erythrocyte sedimentation rate (5.3±1.8 vs. 5.1±1.6, t=0.309, P=0.761). Logistic analysis showed the number of swollen joints (OR=1.148), secondary SS (OR=79.118), complicated with ILD (OR=6.596) and the use of sulfasalazine (OR=0.037) were independent relevant factors (P < 0.05) for UK in RA patients.@*CONCLUSION@#The number of swollen joints, secondary SS, complicated with ILD and the use of sulfasalazine are independent relevant factors for UK in patients with RA.

Úlceras corneales en pacientes atendidos en el Hospital General Docente "Dr. Agostinho Neto", Guantánamo 2014-2019 / Corneal ulcers in patients treated at the General Teaching Hospital "Dr. Agostinho Neto", Guantanamo 2014-2019 / Úlceras de córnea em pacientes atendidos no Hospital Geral de Ensino "Dr. Agostinho Neto ", Guantánamo 2014-2019

RESUMEN Introducción: Las úlceras corneales no se han caracterizado en el Hospital General Docente "Dr. Agostinho Neto" de Guantánamo. Objetivo: Caracterizar la úlcera corneal en pacientes atendidos en el Servicio de Oftalmología de este hospital en el período de enero 2014 a julio 2019. Método: Se realizó un estudio descriptivo, retrospectivo y longitudinal con 40 pacientes. Se estudiaron las variables: sexo, edad, procedencia, ocupación, factores de riesgo, etiología, tratamiento y complicaciones de este tipo de úlcera y las modificaciones de la agudeza visual de acuerdo al tratamiento que se les aplicó. Resultados: El 75,0 % de los pacientes fue del sexo masculino que tenían 65 o más años de edad (47,5 %), procedían de áreas rurales (72,5 %) y realizaban actividades agrícolas (45,0 %). El trauma corneal fue el factor de riesgo más usual (25,0 %). En el 47,5 % la úlcera fue de etiología micótica. El 100 % recibió tratamiento farmacológico, sobre todo con colirio antibiótico fortificado (25,0 %). Se le aplicó tratamiento quirúrgico al 27,5 %, la técnica más común fue el recubrimiento conjuntival (15,0 %). La agudeza visual mejoró en el 75,0 % de los pacientes luego del tratamiento. Conclusiones: En el Hospital General Docente "Dr. Agostinho Neto" la úlcera corneal no es un problema de salud, pero sí determina la agudeza visual de los pacientes afectados, en los que es más común la etiología micótica y la necesidad del uso de colirios fortificados.

ABSTRACT Introduction: Corneal ulcers have not been characterized in the General Teaching Hospital "Dr. Agostinho Neto" from Guantanamo. Objective: To characterize the corneal ulcer in patients treated in the Ophthalmology Service of this hospital in the period from January 2014 to July 2019. Method: A descriptive, retrospective and longitudinal study was carried out with 40 patients. The variables were studied: sex, age, origin, occupation, risk factors, etiology, treatment and complications of this type of ulcer and the modifications of visual acuity according to the treatment applied to them. Results: 75.0% of the patients were male who were 65 years of age or older (47.5%), came from rural areas (72.5%) and carried out agricultural activities (45.0%). Corneal trauma was the most usual risk factor (25.0%). In 47.5% the ulcer was of fungal etiology. 100% received drug treatment, especially with fortified antibiotic eye drops (25.0%). Surgical treatment was applied to 27.5%, the most common technique was the conjunctival lining (15.0%). Visual acuity improved in 75.0% of patients after treatment. Conclusions: In the General Teaching Hospital "Dr. Agostinho Neto" corneal ulcer is not a health problem, but it does determine the visual acuity of affected patients, in which the fungal etiology and the need for the use of fortified eye drops are more common.

RESUMO Introdução: As úlceras de córnea não foram caracterizadas no Hospital Geral de Ensino "Dr. Agostinho Neto "de Guantánamo. Objetivo: Caracterizar a úlcera de córnea nos pacientes atendidos no Serviço de Oftalmologia deste hospital no período de janeiro de 2014 a julho de 2019. Método: Estudo descritivo, retrospectivo e longitudinal, realizado com 40 pacientes. As variáveis estudadas foram: sexo, idade, procedência, ocupação, fatores de risco, etiologia, tratamento e complicações desse tipo de úlcera e as modificações da acuidade visual de acordo com o tratamento a elas aplicado. Resultados: 75,0% dos pacientes eram homens com 65 anos ou mais (47,5%), procedentes de áreas rurais (72,5%) e realizando atividades agrícolas (45,0%). O trauma corneano foi o fator de risco mais comum (25,0%). Em 47,5%, a úlcera era de etiologia fúngica. 100% receberam tratamento medicamentoso, especialmente com colírios antibióticos fortificados (25,0%). O tratamento cirúrgico foi aplicado em 27,5%, a técnica mais comum foi o revestimento conjuntival (15,0%). A acuidade visual melhorou em 75,0% dos pacientes após o tratamento. Conclusões: No Hospital Geral de Ensino "Dr. A úlcera de córnea de Agostinho Neto não é um problema de saúde, mas determina a acuidade visual dos pacientes afetados, nos quais a etiologia fúngica e a necessidade do uso de colírios fortificados são mais comuns.

De la conjonctivite à l'ulcère de Mooren : errance diagnostique ou insuffisance des spécialistes

Nous rapportons une observation d'un homme âgé de 25 ans, mélanoderme sans antécédent médico-chirurgical connu, qui a consulté pour douleur oculaire,larmoiement, baisse de l'acuité visuelle, photophobie évoluant depuis environ huit mois, l'examen ophtalmologique note une hyperhémie conjonctivale, une ulcération cornéenne marginale compliquée de perforation cornéenne avec hernie de l'iris rongeant la moitié de la cornée, une excavation papillaire asymétrique.Le diagnostic d'ulcère de Mooren bilatéral est fortement suspecté, puis retenu sur la base d'argument épidémiologique ; clinique ophtalmologique (kératite ulcéreuse chronique inflammatoire qui affecte initialement la périphérie de la cornée, avec progression circonférentielle et centrale, puis perforation) ; paraclinique (la négativité de tous les examens complémentaires : les facteurs rhumatoïdes, les sérologies de l'hépatite B, C, VIH et de la syphilis, l'examen parasitologique des selles, la protéinurie de 24 h …) mais aussi après avoir exclu un certain nombre de diagnostics,notamment les maladies systémiques, les maladies infectieuses, les atteintes traumatiques des yeux.La collaboration entre ophtalmologiste et interniste a abouti à la mise en route immédiate d'un traitement à base de corticothérapie locale, d'antibiothérapie et des topiques locaux. L'évolution a été favorable avec récupération progressive de l'acuité visuelle au niveau des deux yeux deux semaines après la mise en route du traitement

Corneal Collagen Cross-linking for Corneal Ulcer from Moraxella Group

PURPOSE: To report a case of corneal collagen cross-linking for corneal ulcer caused by the Moraxella group.CASE SUMMARY: A 77-year-old male had decreased visual acuity for several days in his right eye. The patient showed severe stromal ring infiltrates with a corneal epithelial defect measuring (5.0 × 7.0 mm), a corneal endothelial plaque, and a hypopyon measuring less than 1.0 mm in height in the anterior chamber of the right eye. There was no abnormal finding in the right eye using B-scan ultrasonography. Before starting treatment, a corneal culture was conducted. The culture tests showed the presence of the Moraxella group. Because the patient was diagnosed with a corneal ulcer caused by the Moraxella group, corneal collagen cross-linking (CXL) was performed. The antimicrobial susceptibility test confirmed that this Moraxella group was sensitive to ceftazidime, so the patient was treated with 5% ceftazidime eye drops and 0.5% moxifloxacin eye drops every 2 hours for 9 months after corneal collagen CXL. The uncorrected visual acuity was 0.1 in the right eye, and there was almost no corneal stromal melting on anterior segment optical coherence tomography.CONCLUSIONS: This is the first known case of a corneal ulcer, in the Republic of Korea, caused by the Moraxella group and treated with corneal collagen CXL. Corneal collagen CXL should be considered as a surgical treatment for patients who have an impending corneal perforation due to a corneal ulcer because it is a simple procedure and causes fewer serious complications than other treatments.

The challenging approach to a combined neurotrophic and exposure corneal ulcer / Abordagem desafiante de uma úlcera de córnea neurotrófica e por exposição

ABSTRACT This study aims to describe a challenging clinical case of a patient with a neurotrophic and exposure corneal ulcer. A 75-year-old male patient, with history of right eye (RE) limbic stem-cell insuficiency due to complications of recurrent herpetic keratitis, underwent successful limbic stem-cell transplantation in 2008. In 2010, an uneventful penetrating keratoplasty was performed. After a cataract phacoemulsification surgery with intraocular lens implantation done in 2011, best corrected visual acuity was 20/20, and remained stable until 2015. In July 2015, the patient developed right facial nerve palsy and two months later, presented with an extensive central corneal ulcer, with a significant thinning of central stroma, without infection signs, but with an imminent risk of perforation. Treatment with topical ofloxacin and intensive ocular lubrification was started in association with permanent ocular oclusion. Due to lack of any clinical improvement, treatment with RGTA [Poli (carboximetilglucose) sulfate, dextrano T40] (Cacicol®, Thea) was started. After two weeks of treatment, a complete reepithelization and partial stromal filling was observed. Continued monitoring and treatment with artificial tears was maintained, with no recurrence observed. There is an unmet need for a medical therapy that could help corneal neurotrophic ulcers to heal. The presented clinical case shows that the approach of targeting extracellular matrix can be effective in the reepithelialization of neurotrophic and exposure corneal ulcer that do not respond to conventional treatments.

RESUMO Este trabalho relata um caso clínico desafiante de doente com uma úlcera de córnea neurotrófica e de exposição. Doente do sexo masculino, de 75 anos, com antecedentes de queratites herpéticas de repetição no olho direito (OD), complicadas com o desenvolvimento de uma insuficiência límbica, foi submetido com sucesso a transplante de células límbicas em 2008. Em 2010 foi submetido a queratoplastia penetrante e em 2011, após realização de cirurgia de catarata, apresentava uma melhor acuidade visual corrigida (MAVC) de 20/20. A MAVC manteve-se estável até Julho de 2015, altura em que desenvolveu paresia facial periférica à direita. Dois meses depois, o doente desenvolveu uma úlcera de córnea central extensa, com adelgaçamento significativo do estroma central, sem sinais de infeção, mas com risco iminente de perfuração. Foi iniciado tratamento tópico com ofloxacina, lubrificação intensiva e oclusão ocular contínua. Por ausência de melhoria clínica, foi iniciado tratamento tópico com um RGTA [Poli (carboximetilglucose) sulfato, dextrano T40] (Cacicol®, Thea). Após duas semanas de tratamento, observou-se uma reepitelização completa e regeneração parcial do estroma. Foi mantida monitorização regular e tratamento com lágrimas artificiais, sem recidiva do quadro clínico. Há uma grande necessidade de tratamentos médicos que possam ajudar na regeneração de úlceras de córnea neurotróficas e de exposição. O caso clínico apresentado sugere que os fármacos que têm por alvo a matrix extracelular poderão ser eficazes na reepitelização de úlceras de córnea neurotróficas e de exposição que não respondem ao tratamento convencional.

Factores predisponentes a queratoplastia terapéutica en los pacientes con úlcera grave de la córnea / Predisposing factors for therapeutic keratoplasty in patients with severe corneal ulcer

RESUMEN Objetivo: Describir los factores predisponentes a la queratoplastia terapéutica en los pacientes con úlcera grave de la córnea. Métodos: Se realizó un estudio descriptivo, transversal, con una muestra de 64 pacientes que fueron operados en el Servicio de Córnea del Instituto Cubano de Oftalmología Ramón Pando Ferrer, de enero del año 2011 a diciembre de 2014. Resultados: La muestra se caracterizó según las variables sociodemográficas edad (promedio de 51,3 ± 2,9); sexo (el 67,2 por ciento correspondió al masculino); y grupos etarios de riesgo (el 83,3 por ciento fueron agricultores y el 74,6 por ciento urbanos). Los traumatismos más frecuentes fueron ocasionados por cuerpos extraños (26,6 por ciento), lentes de contacto (9,4 por ciento) y quemaduras por agentes químicos (6,3 por ciento). Los pacientes recibieron tratamiento en el 82,8 por ciento durante 22,5 ± 4,6 días previos al ingreso y 6,9 días antes de la queratoplastia. Los resultados microbiológicos revelaron un 88,2 por ciento de positividad. Los hongos filamentosos y las bacterias fueron los aislamientos más frecuentes. Conclusiones: El sexo masculino, las labores agrícolas, el tratamiento ambulatorio con un tiempo de duración previo a la queratoplastia entre 18 y 27 días y los hongos filamentosos como agente etiológico se consideran factores de riesgo a queratoplastia terapéutica en las úlceras corneales(AU)

ABSTRACT Objective: Describe the predisposing factors for therapeutic keratoplasty in patients with severe corneal ulcer. Methods: A descriptive cross-sectional study was conducted of a sample of 64 patients admitted to the Cornea Service of Ramón Pando Ferrer Cuban Institute of Ophthalmology from January 2011 to December 2014. Results: The sample was characterized according to the following sociodemographic variables: age (mean of 51.3 ± 2.9); sex (67.2 percent were male), and risk age groups (83.3 percent were farmers and 74.6 percent were urban). The most common traumas were caused by foreign bodies (26.6 percent), contact lenses (9.4 percent) and chemical burns (6.3 percent). 82.8 percent of the patients received treatment during 22.5 ± 4.6 days before admission and 6.9 days before keratoplasty. Microbiological results revealed 88.2 percent positivity. Filamentous fungi and bacteria were the most common isolates. Conclusions: Male sex, farming, outpatient treatment for 18 to 27 days before keratoplasty and filamentous fungi as etiological agents, are considered to be risk factors for therapeutic keratoplasty in corneal ulcers(AU)

Úlcera corneal bilateral en un anciano con pénfigo vulgar / Bilateral corneal ulcer in an old man with pemphigus vulgaris

Se describe el caso clínico de un paciente de 72 años de edad, con diagnóstico de pénfigo vulgar, quien fue asistido en la consulta de Oftalmología del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba porque padecía enrojecimiento ocular, unido a disminución de la visión y secreciones abundantes de aproximadamente 5 días de evolución. En el examen oftalmológico se confirmó la presencia de úlcera corneal bilateral por perforación infecciosa. Se indicó tratamiento con colirios de antibióticos (ceftazidima y amikacina), antiinflamatorio no esteroideo, agentes antihipertensivos y lente de contacto, con lo cual mejoraron las lesiones de ambos ojos. El proceso infeccioso pudo deberse a cierta susceptibilidad a los esteroides e inmunosupresores sistémicos, como terapia asociada al pénfigo vulgar, o al mecanismo autoinmune característico de esta dermatopatía.

The case report of a 72 years patient is described, with diagnosis of pemphigus vulgaris who went to the Ophthalmology Service of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba because he suffered from ocular redness, together with a decrease vision and abundant secretions of approximately 5 days of history. In the ophthalmological examination the presence of bilateral corneal ulcer was confirmed due to infectious perforation. Treatment was indicated with antibiotic eyewashes (ceftazidime and amikacine), non esteroidal anti-inflammatory drugs, antihypertensive agents and contact lens, with which the injuries of both eyes improved. The infectious process could be due to certain susceptibility to the steroids and systemic inmunosupressors, as therapy associated with pemphigus vulgaris, or to the autoinmune mechanism characterizing this dermatopathy.

Características clínico-epidemiológicas y evolución del tratamiento en pacientes con úlceras corneales / Clinical-epidemiological characteristics and treatment evolution of patients with corneal ulcer

Las úlceras corneales de origen infeccioso son una emergencia oftalmológica que amenaza la visión y la integridad estructural del ojo, causando ceguera en 1,5 a 2 millones de casos al año por lo que requiere tratamiento inmediato. El objetivo fue determinar el patrón epidemiológico, factores de riesgo y efectividad del tratamiento en pacientes con úlcera corneal en la Fundación Visión en el periodo 2015-2017. Estudio de cohorte prospectivo donde se evaluó 53 pacientes con úlcera corneal de causa infecciosa que consultaron en la Fundación Visión en el periodo 2015-2017, y tuvieron un seguimiento mínimo de 4 meses. Se encontró un predominio del sexo masculino (69,8%), edad 45-65 años (49,1%), casados (54,7%), de condición socioeconómica baja (56,6%), agricultores (26,4%), con antecedente de traumatismo corneal (69,8%) o uso de lentes de contacto (17%). El agente etiológico fue bacteriano en el 49,1% y micótico en el 37,7%; para los de origen bacteriano el tratamiento más empleado fueron colirios fortificados de Cefazolina + Gentamicina y Natamicina/Fluconazol en caso de ser micótico. La evolución fue favorable en 90,9% y 80,0% de los bacterianos y micóticos, respectivamente. Los grupos de riesgo detectados fueron pacientes varones, agricultores, de condición socioeconómica baja, con antecedente de traumatismo corneal o uso de lentes de contacto. La efectividad del tratamiento utilizado fue mayor al 80%, siendo en su mayoría patógenos bacterianos(AU)

Accelerated collagen cross-linking in the management of advanced Acanthamoeba keratitis / Cross-linking acelerado de colágeno no controle da ceratite por Acanthamoeba avançada

ABSTRACT Purpose: To report our initial experience in the treatment of Acanthamoeba keratitis with accelerated corneal collagen cross-linking. Methods: Retrospective chart review of patients diagnosed with Acanthamoeba keratitis with progressive corneal melting who were treated with accelerated collagen cross-linking. Results: A total of 6 eyes (5 patients) were reviewed. All the patients received adjuvant therapy with moxifloxacin and chlorhexidine. In 4 cases, the ulcer healed with a mean interval to epithelialization of 108.8 days (range 59-217). In 2 eyes, there was a persistent neurotrophic ulcer. The melting was not progressive in any case, nor did any eye required emergency penetrating keratoplasy. Conclusion: This study suggests a beneficial effect of accelerated collagen cross-linking in cases of Acanthamoeba keratitis with corneal melting. Thus, collagen cross-linking may be considered as adjuvant treatment for Acanthamoeba keratitis.

RESUMO Objetivo: Relatar nossa experiência inicial no tra tamento da ceratite por Acanthamoeba com reticulação acelerada de colágeno corneano. Métodos: Revisão retrospectiva de prontuários de pacientes diagnosticados com ceratite por Acanthamoeba, com deformação progressiva da córnea, tratados com reticulação acelerada de colágeno. Resultados: Seis olhos (5 pacientes) foram incluídos. Todos os pacientes receberam terapia adjuvante com moxifloxacina e clorexidina. Em 4 casos, a úlcera cicatrizou com uma média de epitelização de 108,8 dias (amplitude de 59-217 dias). Em dois pacientes, a úlcera apresentou um comportamento neurotrófico. A deformação não foi progressiva em nenhum dos pacientes e nenhum dos olhos exigiu ceratoplastia penetrante de emergência. Conclusão: Este estudo sugeriu um efeito benéfico da reticulação acelerada de colágeno em casos de ceratite por Acanthamoeba infecciosa com deformação corneal. A reticulação de colágeno parece ser uma alternativa coadjuvante possível para casos de ceratite por Acanthamoeba.

Correlation between pathogenic species and clinical findings, disease severity, and visual outcome in patients with fungal keratitis / Correlação entre espécies patogênicas e achados clínicos, gravidade da doença e desfecho visual em pacientes com ceratite fúngica

ABSTRACT Purpose: To determine whether a correlation exists between pathogenic species and clinical findings, disease severity, and visual outcome in patients with keratitis and fungal growth in microbiological culture. Methods: A retrospective study of patients with fungal growth in the microbiological culture of corneal scrapings. Patients were treated at an ophthalmologic reference center in Southeastern Brazil from January 1992 to October 2015. Results: Medical records of 181 patients (131 males and 50 females) with a mean age of 47 ± 18 years were analyzed. The three most common etiologies were Fusarium sp. (38.7%), Aspergillus sp. (15%), and Candida sp. (13.2%). Among these, Fusarium sp. was the most frequent in patients aged £50 years (p=0.002) and in those with a recent history of a foreign body and/or ocular trauma (p=0.01). Candida sp. was the most frequent etiology in patients aged >50 years (p=0.002), in those with postoperative ocular surgery (p=0.002); in those with a previous ocular pathology (p=0.0007); and in immunodepressed patients (p=0.0004). Conclusion: Fusarium sp. was predominant in patients aged £50 years and those with a recent history of foreign body and/or ocular trauma, whereas Candida sp. was predominant in older adults, in those with a postoperative ocular surgery, in those with a previous ocular pathology, and in immunodepressed patients.

RESUMO Objetivo: Determinar se existe uma correlação entre espécies patogênicas e achados clínicos, gravidade da doença e resultado visual em pacientes com ceratite e crescimento de fungos em cultura microbiológica. Métodos: Estudo retrospectivo de pacientes com crescimento de fungos na cultura microbiológica de raspado de córnea. Os pacientes foram tratados em um centro de referência oftalmológica no Sudeste do Brasil de janeiro de 1992 a outubro de 2015. Resultados: Foram analisados registros médicos de 181 pacientes (131 homens e 50 mulheres) com idade média de 47 ± 18 anos. As três etiologias mais comuns foram Fusarium sp. (38,7%), Aspergillus sp. (15%) e Candida sp. (13,2%). Entre estas, Fusarium sp. foi a mais frequente em pacientes com idade £50 anos (p=0,002) e naqueles com história recente de corpo estranho e/ou trauma ocular (p=0,01). Candida sp. foi a etiologia mais frequente em pacientes com idade >50 anos (p=0,002), naqueles com cirurgia ocular pós-operatória (p=0,002); naqueles com patologia ocular prévia (p=0,0007); e em pacientes imunodeprimidos (p=0,0004). Conclusão: Fusarium sp. foi predominante em pacientes com idade £50 anos e naqueles com história recente de corpo estranho e/ou trauma ocular; enquanto Candida sp. foi predominante em adultos mais velhos, naqueles com cirurgia ocular pós-operatória, naqueles com patologia ocular prévia e em pacientes imunodeprimidos.

Queratitis herpética atípica multifocal secundaria a corticoides tópicos / Multifocal atypical herpetic keratitis secondary to topical corticosteroids / Ceratite herpética multifocal atípica secundária a corticoides tópicos

Figura A. OI: fotografía en lámpara de hendidura con filtro de azul de cobalto. La tinción con fluoresceína permite apreciar dos úlceras separadas de aspecto dendrítico (flechas blancas) que comprometen la media periferia, tanto superonasal (meridiano de las 9 y 10:30 horas), como superior (meridiano de las 12 y las 2 horas). Adicionalmente, lesión ulcerativa con compromiso estromal de aproximadamente de 3x2 mm con adelgazamiento de más del 50 % del espesor corneal (óvalo blanco). Figura B. OI: tomografía de coherencia óptica de la córnea. Se observa área de adelgazamiento (remanente estromal respetado de 171 µm) con quiste epitelial sobre el área de ulceración estromal. Figura C. OI: fotografía en lámpara de hendidura con filtro de azul de cobalto. La tinción de fluoresceína permite apreciar solo mínima captación del colorante sobre las áreas de las úlceras dendríticas epiteliales, así como cicatrización casi completa de la ulceración estromal. Figura D. OI: tomografía de coherencia óptica de la córnea. Epitelización completa del área adelgazada (que alcanza ahora 276 µm de espesor) con desaparición casi total del quiste epitelial. [Galvis V, Tello A, Rodríguez L, Ardila L, Pedraza-Concha A, Niño C. Queratitis herpética atípica multifocal secundaria a corticoides tópicos. MedUNAB. 2019;22(1):12-15. doi: 10.29375/01237047.3637].

Figure A. OS: Slit-lamp biomicroscopy photograph with Cobalt Blue Filter. Fluorescein staining reveals two separate dendritic ulcers (white arrows) compromising the mid-periphery, both superonasal (at 9 and 10:30 o'clock), and superior (at 12 and 2 o'clock). Additionally, an ulcerative lesion with stromal compromise of about 3x2 mm with thinning of more than 50% of the total corneal thickness (white oval). Figure B. OS: optical coherence tomography of the cornea. An area of thinning (respected stromal remnant of 171 µm) with epithelial cyst on the stromal ulceration area. Figure C. OS: Slit-lamp biomicroscopy photograph with Cobalt Blue Filter. Fluorescein stain shows minimal staining on areas of epithelial dendritic ulcers, as well as almost complete healing of the stromal ulceration. Figure D. OS: optical coherence tomography of the cornea. Complete epithelialization of the thinned area (now reached thickness of 276 µm) and almost complete resolution of the epithelial cyst. [Galvis V, Tello A, Rodríguez L, Ardila L, Pedraza-Concha A, Niño C. Ceratite herpética multifocal atípica secundária a corticoides tópicos. MedUNAB. 2019;22(1):12-15. doi: 10.29375/01237047.3637]

Figura A. OE: fotografia com lâmpada de fenda com filtro azul cobalto. A coloração com fluoresceína revela duas úlceras dendríticas (setas brancas) que comprometem a periferia média, tanto superonasal (meridiano das 9 e 10:30 horas), quanto superior (meridiano das 12 e das 14 horas). Além disso, lesão ulcerativa com comprometimento do estroma de aproximadamente de 3x2 mm com afilamento de mais de 50% da espessura corneal (oval branco). Figura B. OE: tomografia de coerência óptica (OCT) de córnea. Observa-se uma área afinada (restos de estroma respeitados de 171 µm) com cisto epitelial sobre a área de ulceração do estroma. Figura C. OE: fotografía em lâmpada de fenda com filtro azul cobalto. A coloração com fluoresceína permite avaliar apenas a captação mínima do corante nas áreas das úlceras dendríticas epiteliais, bem como cicatrização quase completa da ulceração estromal. Figura D. OE: tomografía de coerência óptica (OCT) de córnea. Epitelização completa da área afinada (que agora atinge 276 µm de espessura) com quase total desaparecimento do cisto epitelial. [Galvis V, Tello A, Rodríguez L, Ardila L, Pedraza-Concha A, Niño C. Ceratite herpética multifocal atípica secundária a corticoides tópicos. MedUNAB. 2019;22(1):12-15. doi: 10.29375/01237047.3637]

Úlcera corneal micótica por Lasiodiplodia theobromae. Reporte de caso / Fungal corneal ulcer by Lasiodiplodia theobromae. Case report

Introducción: La úlcera corneal de etiología micótica por Lasiodiplodia theobromae es una patología infrecuente con menos de 50 casos de infección ocular por este patógeno reportados en la literatura. Objetivo: Dar a conocer un caso de una patología poco frecuente, haciendo una breve revisión de la literatura, y discutiendo el tratamiento elegido que resultó favorable. Diseño del estudio: Reporte de caso. Resumen del caso: Se presenta el caso de un paciente atendido en el Hospital Universitario de Santander (HUS) durante los años 2015 - 2017 con antecedente de trauma ocular con material vegetal quien desarrolla úlcera corneal micótica por Lasiodiplodia theobromae, que se confi rmó usando análisis microbiológico del frotis corneal. Se instauró tratamiento con una combinación de antimicóticos con un resultado final satisfactorio. Conclusión: L. theobromae es un patógeno oportunista. La importancia del diagnóstico precoz en estos casos, que requiere un alto índice de sospecha en pacientes con trauma vegetal, con la identificación del agente etiológico radica en evitar o minimizar consecuencias irreversibles mediante la instauración de un tratamiento oportuno.

Background: The corneal ulcer of mycotic etiology caused by Lasiodiplodia theobromae is an infrequent pathology with less than 50 cases of ocular infection by this pathogen reported in the literature. Objective: To present a case of a rare pathology, make a brief literature review, and discuss the chosen treatment that was favorable. Study design: Case report. Case summary: We present the case of a patient treated at the Hospital Universitario de Santander (HUS) during the years 2015 - 2017 with a history of ocular trauma with plant material who developed fungal corneal ulcer by Lasiodiplodia theobromae, which was confi rmed using microbiological analysis of the corneal smear. Treatment with a combination of antifungals was established with a satisfactory final result. Conclusion: L. theobromae is an opportunistic pathogen. The importance of early diagnosis in these cases, which requires a high index of suspicion in patients with plant trauma, with the identifi cation of the etiological agent lies in avoiding or minimizing irreversible consequences through the establishment of an opportune treatment.

Polymicrobial Keratitis of Pseudomonas aeruginosa, Acinetobacter baumannii, and Ochrobactrum anthropi

PURPOSE: To report polymicrobial keratitis involving Pseudomonas aeruginosa, Acinetobacter baumannii, and Ochrobactrum anthropi. CASE SUMMARY: A 53-year-old female complained of pain and secretion in her right eye, which started 6 weeks before her visit. She applied steroid ointment, which was received from the dermatologist, to her eyelid 7 days prior to her visit but this treatment worsened her symptoms. At the initial visit, the visual acuity of the right eye was light perception, and purulent secretions were observed. Using a slit lamp, severe conjunctival hyperemia, hypopyon, and a ring-shaped central corneal ulcer were observed. The anterior chamber and fundus were not observed due to corneal lesions but ultrasonography showed no intraocular inflammation. Infectious keratitis was suspected and cultured by corneal scraping. During the incubation period, 0.5% moxifloxacin, 2% voriconazole, and 1% cyclopentolate were administered. A total of 400 mg of moxifloxacin and 100 mg of doxycycline were given orally. In the primary culture, Pseudomonas aeruginosa and Acinetobacter baumannii were identified so 5% ceftazidime, which was sensitive for the antibiotic susceptibility results was further instilled. Thereafter, the keratitis improved but the keratitis again worsened while maintaining the topical treatment. A secondary culture was positive for Ochrobactrum anthropi. Treatment with 1.4% gentamicin, which was sensitive for the antibiotic susceptibility test was added and the keratitis improved. A conjunctival flap was performed because of the increased risk of perforation. CONCLUSIONS: We report polymicrobial keratitis involving Pseudomonas aeruginosa, Acinetobacter baumannii, and Ochrobactrum anthropi for the first time in the Republic of Korea.

Infectious Keratitis Caused by Shewanella Putrefaciens

PURPOSE: We report a case of infectious keratitis caused by Shewanella putrefaciens in a patient after fishing. CASE SUMMARY: A 75-year-old male with no underlying disease other than hypertension was admitted to our hospital because of decreased visual acuity and congestion in his left eye for 2 weeks. At the first ophthalmic examination, the best-corrected visual acuity (BCVA) of the left eye was counting fingers. Slit lamp examination showed stromal infiltrates with 2.0 × 2.0 mm corneal epithelial defects, endothelial inflammatory plaques and 1 mm height hypopyon with severe inflammation in the anterior chamber. Bacterial culture tests were performed by corneal scraping, which were positive for Shewanella putrefaciens, followed by treatment with moxifloxacin and ceftazidime topical antibiotics. After 2 months of treatment, the BCVA of the left eye improved to 0.4 and the corneal lesion clinically improved with residual mild stromal opacity. CONCLUSIONS: Shewanella putrefaciens should be considered as a causal pathogen of infectious keratitis in patients after fishing. We report a case of infectious keratitis caused by Shewanella putrefaciens, which has never previously been reported in the Republic of Korea.