Lesões vasculares orais: avaliações clínicas, diagnósticas e terapêuticas / Lesiones vasculares bucales: evaluaciones clínicas, diagnósticas y terapéuticas / Oral vascular lesions: clinical, diagnostic and therapeutic evaluations

Introdução: As patologias vasculares acometem com alta incidência as regiões de cabeça e pescoço. Quando essas acometem a região oral, nota-se predileção por lábios, língua e comissura bucal, com predominância no sexo feminino. Objetivo: Analisar sobre as lesões vasculares orais, enfatizando as características clínicas, métodos de diagnósticos e abordagem terapêutica. Métodos: Trata-se de uma revisão literária, com busca bibliográfica, realizada nas bases de dados eletrônicos PubMED/Medline, Lilacs, Science Direct e SciELO (Scientific Eletronic Library), utilizando os descritores: Hemangioma, Malformações vasculares, escleroterapia e fotocoagulação, em português, inglês e espanhol, obtendo 262 artigos completos, dos quais 18 foram utilizados como base científica apropriada para tal tema, obedecendo aos critérios de inclusão e exclusão. Resultados: As lesões vasculares orais caracterizam-se clinicamente como lesões únicas do tipo nódular ou mancha, cuja coloração varia do vermelho intenso ao roxo e de tamanho variável. Para diagnosticar essas lesões, utilizam-se comumente exames clínicos associados à diascopia, sem na maioria dos casos necessitarem de exames complementares. A intervenção terapêutica justifica-se devido às deformidades estéticas, possíveis sangramentos, ulcerações e infecções. Para tais alterações, existem diversas modalidades terapêuticas, incluindo escleroterapia, crioterapia, remoção cirúrgica e terapia de fotocoagulação a laser. Conclusão: As lesões vasculares orais exibem caracteristicas clinicas peculiares, apresentando-se como nódulos ou manchas, cuja coloração varia do vermelho intenso ao roxo. A diascopia é a manobra semiotécnica mais utilizada e confiável para o estabelecimento do diagnóstico clínico dessas lesões. A utilização de soluções esclerosantes apresenta-se como o tratamento mais descrito na literatura, seguido da fotocoagulação a laser(AU)

Introducción: Las enfermedades vasculares afectan con alta incidencia las regiones de cabeza y cuello. Cuando estas afectan la región bucal, se nota predilección por labios, lengua y comisura bucal, con predominio en el sexo femenino. Objetivo: Analizar sobre las lesiones vasculares bucales, enfatizando en las características clínicas, los métodos de diagnóstico y el enfoque terapéutico. Métodos: Se realizó una revisión bibliográfica en las bases de datos PubMED/Medline, Lilacs, Science Direct e SciELO. Se utilizaron los descriptores hemangioma, malformaciones vasculares, escleroterapia y fotocoagulación, en portugués, inglés y español. Se obtuvieron 262 artículos completos, de los cuales 18 fueron utilizados como base científica apropiada para tal tema, según los criterios de inclusión y exclusión. Resultados: Las lesiones vasculares bucales se caracterizan clínicamente como lesiones únicas del tipo nódular o mancha, cuya coloración varía del rojo intenso al púrpura y de tamaño variable. Para diagnosticar estas lesiones, se utilizan comúnmente exámenes clínicos asociados a la diascopia, sin que en la mayoría de los casos necesiten exámenes complementarios. La intervención terapéutica se justifica debido a las deformidades estéticas, posibles sangrados, ulceraciones e infecciones. Para estas alteraciones existen diversas modalidades terapéuticas, incluyendo escleroterapia, crioterapia, remoción quirúrgica y terapia de fotocoagulación láser. Conclusiones: Las lesiones vasculares bucales muestran características clínicas peculiares, presentándose como nódulos o manchas, cuya coloración varía del rojo intenso al púrpura. La diacopia es la maniobra semiotécnica más utilizada y confiable para el establecimiento del diagnóstico clínico de estas lesiones. El uso de soluciones claras se presenta como el tratamiento más descrito en la literatura, seguido de la fotocoagulación láser(AU)

Introduction: Vascular disorders affect the head and neck regions with high incidence. When they affect the oral region, there is a predilection for lips, tongue and mouth commissure, predominantly in the female. Objective: To analyze oral vascular lesions, emphasizing the clinical characteristics, diagnostic methods and therapeutic approach. Methods: A bibliographic review was carried out in the databases PubMED/Medline, Lilacs, Science Direct andSciELO (Scientific Electronic Library). We used the descriptors hemangioma, vascular malformations, sclerotherapy and photocoagulation, in Portuguese, English and Spanish. We obtained 262 complete articles, of which 18 were used as appropriate scientific basis for this topic, based on the inclusion and exclusion criteria. Results: Oral vascular lesions are clinically characterized as single lesions of the nodes or blotches, whose color varies from deep red to purple and are of variable size. In order to diagnose these lesions, clinical examinations associated with the periodontal disease are commonly used, although in most cases they do not require complementary examinations. The therapeutic intervention is justified due to aesthetic deformities, possible bleeding, ulcerations and infections. For such changes, there are several therapeutic modalities, including sclerotherapy, cryotherapy, surgical removal and laser photocoagulation therapy. Conclusions: Oral vascular lesions show peculiar clinical characteristics, presenting as nodules or spots, whose coloration varies from intense red to purple. Diascopy is the most used and reliable semi-technical method for establishing the clinical diagnosis of these lesions. The use of sclerosing solutions is the most described treatment in the literature, followed by laser photocoagulation(AU)

Hallazgos en el fondo de ojo de boxeadores cubanos activos asintomáticos / Funduscopy findings in Cuban active asymptomatic boxers

Objetivo: determinar los hallazgos del fondo de ojo en los boxeadores cubanos activos asintomáticos en dos grupos de estudio. Métodos: se efectuó un estudio observacional descriptivo y transversal en los boxeadores de la preselección nacional de boxeo, a quienes se les realizó un fondo de ojo anual, con pupila dilatada y oftalmoscopia binocular indirecta con depresión escleral, en el Servicio de Vítreo-Retina del Instituto Cubano de Oftalmología "Ramón Pando Ferrer". Se tomaron dos grupos, el primero comprendido entre los años 1995 y 2000 (115) y el segundo grupo después de formar parte de la franquicia de los domadores de Cuba en los años 2015 - 2016 (38), donde se realizaron cambios en el estilo de la competencia. Resultados: en los dos grupos estudiados la agudeza visual sin corrección fue mayor de 0,8. En ambos grupos se observó un aumento de la visibilidad de las fibras a nivel del vítreo periférico. Más de la mitad de los ojos de los atletas tenían una retina normal. El desprendimiento de retina se presentó en 1,3 y 2,6 por ciento, respectivamente. Existían lesiones en la retina periférica pero la frecuencia fue baja. No existieron diferencias significativas en ambos grupos. El tratamiento más frecuente realizado en los ojos con lesiones retinales en los dos grupos fue la fotocoagulación focal con láser de argón. Conclusiones: el chequeo anual oftalmológico de los boxeadores garantiza un diagnóstico precoz y un tratamiento oportuno profiláctico o quirúrgico. Así se alarga la vida profesional activa de los boxeadores y se mantiene una buena calidad de vida al concluir su vida deportiva(AU)

Objective: determine funduscopy findings in Cuban active asymptomatic boxers from two study groups. Methods: across-sectional observational descriptive study was conducted with boxers from the national boxing trial team, who underwent annual funduscopy with dilated pupils and indirect binocular ophthalmoscopy with scleral depression at the Vitreous-Retina Service of Ramón Pando Ferrer Cuban Institute of Ophthalmology. Two groups were formed: one corresponding to the period 1995-2000 (115) and the other after being part of the Cuban Domadores (Tamers) team in 2015-2016 (38), when changes were made to competition styles. Results: in the two groups studied, uncorrected visual acuity was above 0.8. In both an increase was observed in the visibility of peripheral vitreous fibers. More than half of the athletes' eyes had a normal retina. Retinal detachment was present in 1.3 percent and 2.6 percent, respectively. There were lesions on the peripheral retina, but their frequency was low. No significant differences were found in the groups. The most common treatment indicated in the two groups for eyes with retinal lesions was argon laser focal photocoagulation. Conclusions: annual ophthalmological examination of boxers ensures early diagnosis and timely prophylactic or surgical treatment with the purpose of lengthening their active professional life and maintaining a good quality of life upon retirement(AU)

Ablación de las neoplasias intraepiteliales escamosas anales de alto grado, precursoras del cáncer anal, con coagulación infrarroja / Ablation of high-grade anal squamous intraepithelial neoplasms, anal cancer precursors, with infrared coagulation

Introducción: Las neoplasias intraepiteliales anales de alto grado (AIN-AG) sin tratamiento progresan a carcinoma anal escamoso invasor (CAE) en 8-13% de los casos. Esto disminuye al 1,2% con la ablación dirigida por anoscopía de alta resolución (AAR). El tratamiento ideal de la AIN-AG no está establecido. Goldstone, en 2005 introdujo el coagulador infrarrojo (CIR) para la ablación de estas lesiones y demostró que tiene tanta efectividad como la cirugía, aunque menor morbilidad y la ventaja de no requerir quirófano. No hemos encontrado publicaciones con esta técnica en nuestro medio. El objetivo de este trabajo es evaluar los resultados de la ablación de las AIN-AG con CIR, las complicaciones del método y la recurrencia temprana. Diseño: Observacional, retrospectivo, con base de datos prospectiva. Pacientes y Método: Se incluyeron individuos con AIN-AG en conducto anal y/o región perianal diagnosticadas en el Consultorio de Detección Temprana de Displasia Anal del Hospital Juan A. Fernández mediante biopsia dirigida por AAR y tratadas con CIR con el aparato Redfield®, entre marzo 2013-agosto 2014 previo consentimiento informado escrito. Tras infiltración con anestesia local las lesiones fueron coaguladas con repetidos pulsos de 1,5 segundos hasta visualizar los vasos de la submucosa. Se controló entre los 3 y 6 meses con AAR y biopsia de lesiones sospechosas. Resultados: Fueron 14 pacientes (10 hombres que tienen sexo con hombres, todos VIH-positivos y 4 mujeres, 2 VIH-positivas). Edad mediana: 37,5 (rango 20-59) años. La AIN-AG se localizaba en el conducto anal en 11 pacientes y en la región perianal en 3. En la AAR diagnóstica todos presentaban sólo un área de AIN-AG. El procedimiento fue bien tolerado. Una paciente VIH-positiva presentó secreción purulenta a los tres días de la ablación, que se trató con antibióticos. Esta paciente y otro más tuvieron dolor post-procedimiento manejado con anti-inflamatorios no esteroides. En la AAR de control se hallaron 2 (14,3%) recurrencias, una interpretada como persistencia por margen insuficiente de una lesión extendida y otra diagnosticada al momento de realizar CIR, que no había sido observada en la AAR realizada 1 mes antes. La eficacia por lesión individual tratada fue del 92,9%. Conclusiones: El tratamiento de las AIN-AG en el consultorio mediante CIR es bien tolerado, tiene mínimas complicaciones y resulta efectivo en el corto plazo. Es necesario un seguimiento más prolongado para evaluar la tasa de recidiva y la utilidad para prevenir la progresión al CAE. (AU)

Background: High-grade anal intraepithelial neoplasia (HGAIN) without treatment progresses to invasive squamous cell carcinoma (SCC) in 8-13% of cases, and that incidence decreases to 1,2% with ablation targeted with high resolution anoscopy (HRA). The ideal treatment for HGAIN is not established yet. Goldstone, in 2005 introduced the infrared coagulator (IRC) for the ablation of these lesions, and with great experience demonstrated that it is as effective as surgery but has less morbidity and the advantage of not requiring the operating room. To our knowledge there are not publications with this technique in our country. The aim of this study is to assess the results of HGAIN ablation with CIR, the method complications, and early recurrence. Design: Observational, retrospective study, with prospective database. Patients and Methods: Individuals with HGAIN in the anal canal or the perianal region, diagnosed with biopsy targeted with HRA and treated with the IRC in the Anal Dysplasia Clinic of the Hospital Juan A. Fernández, between March 2013 and August 2014, were included. After written informed consent, HRA was repeated in the outpatient clinic to localize the area to be treated with the IRC Redfield®. After local anesthesia the lesions were coagulated with repeated 1.5 seconds pulses until the submucosa vessels were visualized. Control with HRA and biopsy of suspicious lesions was performed between 3-6 months of the procedure. Results: Fourteen patients (10 men who have sex with men, all HIV-positive, and 4 women, 2 HIV-positive). Median age: 37.5 (range 20-59) years. The HGAIN was localized at the anal canal in 11 patients, and in the perianal region in 3. In the diagnostic HRA all patients presented only one area of HGAIN. The procedure was well tolerated. Only one HIV-positive woman presented purulent discharge 3 days after ablation, and was treated with antibiotics. The latter and another patient had post-procedure pain, managed with non-steroidal anti-inflammatory drugs. In the control HRA, 2 (14,3%) recurrences were found, 1 was interpreted as persistency due to insufficient margin of a extended lesion, and 1 diagnosed during the CIR of other lesion, that had went unaware at the initial HRA performed one month before. The efficacy for individual lesion treated was 92.9%. Conclusions: The treatment of HGAIN with IRC in the outpatient department is well tolerated, has minimal complications, and is effective in the short term. It is necessary a longer surveillance to assess the recurrence rate and the usefulness for preventing progression to SCC. (AU)

Intravítrea de bevacizumab vs. bevacizumab y triamcinolona para el edema macular diabético / Intravitreal bevacizumab versus bevacizumab and triamcinolone for the diabetic macular edema

Objetivos: evaluar el uso de la inyección IV de bevacizumab, sola o combinada con triamcinolona, así como sus efectos adversos y la correlación entre la mejor agudeza visual corregida y el grosor macular central. Métodos: se realizó un estudio observacional, longitudinal, prospectivo de caso y control a doble ciegas a 90 pacientes en la consulta de Vítreo­Retina del Instituto Cubano de Oftalmología Ramón Pando Ferrer, con edema macular diabético no tratados previamente y sin tracción vítrea. Se dividieron al azar en 3 grupos de tratamientos: un grupo control tratado con láser, otro con intravítrea de bevacizumab (1,25 mg en 0,05 mL) y otro con bevacizumab y triamcinolona (1,25 mg en 0,05 mL más 4 mg en 0,1 mL respectivamente). Cada grupo estuvo formado por 30 pacientes, con evolución a las 6, 12, 18, 24, 30 semanas y al año. Resultados: la mejor agudeza visual corregida al año de tratamiento entre los tres grupos no tuvo significación estadística (p= 0,099). En el grupo de láser el 40 por ciento mejoró 2 o más líneas, seguido del grupo de bevacizumab (20 por ciento) y el de bevacizumab y triamcinolona (10 por ciento). Hubo diferencia significativa (p= 0,001), en la disminución del grosor macular central entre los grupos al año; el grupo del láser fue el de mayor disminución (60 por ciento). El grupo de intravítrea de bevacizumab y triamcinolona logró los mejores resultados en la disminución del grosor macular central, pero no se mantuvo al año; sin embargo, el efecto del láser logró una disminución del grosor macular más estable. Conclusión: el tratamiento con fotocoagulación macular para el edema macular diabético es más eficaz al año en la disminución de grosor macular y en la mejor agudeza visual corregida(AU)

Objective: to evaluate the use of intravitreal bevacizumab injection alone or combined with triamcinolone as well as the adverse effects and the correlation between the best corrected visual acuity and the central macular thickness. Methods: prospective, longitudinal and observational double-blinded case control study performed in 90 patients with untreated diabetic macular edema and no vitreous traction in the vitreous-retina service of Ramón Pando Ferrer Institute of Ophthalmology of Cuba. They were randomly divided into 3 groups for treatment: a control group treated with laser, another one with intravitreal bevacizumab (1,25 mg in 0,05 mL) and the other with bevacizumab plus triamcinolone (1,25 mg in 0,05 mL plus 4 mg in 0,1 mL, respectively). Each group had 30 patients, with progress evaluated at 6, 12, 16, 24, 30 weeks and one year. Results: the best corrected visual acuity after a year of treatment did not have statistical significant in any of the three groups (p= 0,099). In the laser-treated group, 40 percent improved two or more lines in the Snellen chart, followed by bevacizumab group (20 percent) and that of bevacizumab plus triamcinolone (10 percent). There was significant difference (p= 0,001) in the central macular thickness decrease after one year in the three groups, being the laser group the one with highest decrease rate (60 percent). The group treated with intravitreal bevacizumab plus triamcinolone achieved the best results in reducing the central macular thickness but this result did not remain after a year. However, the laser treatment showed a more stable reduction of the macular thickness. Conclusions: macular photocoagulation for the diabetic macular edema is more effective one year after treatment in reducing the macular thickness and achieving the best corrected visual acuity(AU)

Diffuse Unilateral Subacute Neuroretinitis in a Healthy Korean Male: The First Case Report in Korea

A 52-yr-old male was referred for progressive visual loss in the left eye. The decimal best-corrected visual acuity (BCVA) was 0.01. Fundus examination revealed diffuse retinal pigment epithelial degeneration, focal yellow-white, infiltrative subretinal lesion with fuzzy border and a live nematode within the retina. Diffuse unilateral subacute neuroretinitis (DUSN) was diagnosed and the direct laser photocoagulation was performed to destroy the live nematode. During eight months after treatment, BCVA gradually improved to 0.2 along with the gradual restoration of outer retinal layers on SD-OCT. We report on the first case of DUSN in Korea. DUSN should be included in the differential diagnosis of unexplained unilateral visual loss in otherwise healthy subjects.

Diffuse Unilateral Subacute Neuroretinitis in a Healthy Korean Male: The First Case Report in Korea

A 52-yr-old male was referred for progressive visual loss in the left eye. The decimal best-corrected visual acuity (BCVA) was 0.01. Fundus examination revealed diffuse retinal pigment epithelial degeneration, focal yellow-white, infiltrative subretinal lesion with fuzzy border and a live nematode within the retina. Diffuse unilateral subacute neuroretinitis (DUSN) was diagnosed and the direct laser photocoagulation was performed to destroy the live nematode. During eight months after treatment, BCVA gradually improved to 0.2 along with the gradual restoration of outer retinal layers on SD-OCT. We report on the first case of DUSN in Korea. DUSN should be included in the differential diagnosis of unexplained unilateral visual loss in otherwise healthy subjects.

Efectividad y seguridad de ranibizumab, comparado con implante intravítreo de dexametasona, fotocoagulación, triamcinolona, bevacizumab y aflibercept, en pacientes con edema macular secundario a oclusión de la vena central de la retina / Effectiveness and safety of ranibizumab compared to intravitreal implantation of dexamethasone, photocoagulation, triamcinolone, bevacizumab and aflibercept in patients with macular edema secondary to central retinal vein occlusion

Introducción: La oclusión de la vena central de la retina (OVCR) reduce las funciones individuales y la calidad de vida de aquellos individuos que la presentan; típicamente afecta a personas mayores y se considera que alrededor de un 90 % de los pacientes son mayores de 50 años al momento de inicio del cuadro. Es considerada la segunda causa más común de trastorno vascular de la retina después de la retinopatía diabética. Esta enfermedad puede conducir a pérdida visual severa a causa del edema o isquemia macular, hemorragia vítrea o glaucoma neovascular. Objetivo: examinar los beneficios y riesgos del uso de ranibizumab como uno de los criterios para informar la toma de decisiones relacionada con la posible inclusión de tecnologías en el Plan Obligatorio de Salud, en el marco de su actualización integral para el año 2015. Metodología la evaluación fue realizada de acuerdo con un protocolo definido a priori por el grupo desarrollador. Se realizó una búsqueda sistemática en MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, LILACS y Google, sin restricciones de idioma, fecha de publicación y tipo de estudio. Las búsquedas electrónicas fueron hechas en noviembre de 2014 y se complementaron mediante búsqueda manual en bola de nieve y consulta con expertos temáticos. La tamización de referencias se realizó por dos revisores de forma independiente y los desacuerdos fueron resueltos por consenso. La selección de estudios fue realizada mediante la revisión en texto completo de las referencias preseleccionadas, verificando los criterios de elegibilidad predefinidos. Las características y hallazgos de los estudios fueron extraídos a partir de las publicaciones originales. Resultados: efectividad triamcinolona, ranibizumab, bevacizumab, aflibercept, tienen alta probabilidad de presentar cambios en la mejor agudeza visual corregida comparado con placebo y con implante intravítreo de dexametasona. Los pacientes tratados con triamcinolona 4mg DEM 9,42 (IC 95 % 3,46-15,38), ranibizumab 0,5 mg DEM 14,06 (IC 95 % 10,46-17,65), bevacizumab 1,25 mg DEM 15,69 (IC 95 % 5,86-25,47), aflibercept 2 mg DEM 17,46 (IC 95% 14,37-20,57), tienen alta probabilidad de presentar cambio en la mejor agudeza visual corregida cuando se comparan con placebo. Cambios en la tomografía de coherencia óptica (grosor de la retina) Al mes de seguimiento : se presentó disminución significativa a favor de los inhibidores de VEGF cuando se comparan con placebo DEM - 264,67 (IC 95 % -377,00 ; -152,35), con una heterogeneidad extremadamente alta I2 94 %. A los seis meses se presentó disminución significativa a favor de los inhibidores de VEGF cuando se comparan con placebo DEM -224,52 (IC 95 % -377,77; -111,27), con una heterogeneidad extremadamente alta I2 93 %. A los doce meses: No se encontraron diferencias estadísticamente significativas. Conclusiones: efectividad triamcinolona, ranibizumab, bevacizumab, aflibercept, tienen alta probabilidad de presentar cambios en la mejor agudeza visual corregida comparado con placebo y con implante intravítreo de dexametasona. Además tienen alta probabilidad de ganar tres o más líneas comparado con placebo, así como, disminuir el grosor central de la retina. En relación con la seguridad del tratamiento para el edema macular secundario a oclusión de la vena central de la retina, se evidenció que el uso de corticoides como: la triamcinolona y la dexametasona incrementa la presión intraocular y la presencia de cataratas cuando se comparan con placebo; mientras que para los inhibidores de VEGF como: aflibercept, ranibizumab y bevacizumab no se reportaron de manera significativa eventos adversos oculares o sistémicos cuando se comparan con placebo. En esta revisión no se identificó evidencia que cumpliera con los criterios de inclusión para los desenlaces de grado de isquemia retiniana y mantenimiento de la ganancia en la agudeza visual, ni la comparación con láser.(AU)

Short Term Visual Prognosis After Retinal Laser Photocoagulation for Diabetic Retinopathy.

To assess the outcome of laser photocoagulation treatment for diabetic retinopathy in relation to various risk factors. Method: The change in visual acuity shortly after laser photocoagulation for diabetic retinopathy was assessed in 50 eyes of 25 patients and was compared to the age of onset of diabetes, type of retinopathy, pre treatment duration of diabetes, hypertension, microalbuminuria, smoking, dyslipedemia, associated complications of diabetes and type of treatment of diabetes. Results: Visual improvement was good in young diabetics, short duration of diabetes and parents having mild diabetic retinopathy. Factors having adverse effect on prognosis were longer duration of diabetes, hypertension, dyslipedemia, nephropathy and severe diabetic retinopathy. There was no significant influence of smoking, glycemic control, type of treatment, age of onset and sex of patients on visual outcome. Conclusion: Early diagnosis of retinopathy and initiation of specific treatment by laser photocoagulation at earlier stages with proper control of risk factors viz hypertension, dyslipidemia and nephropathy lead to a favourable visual outcome.

Vitrectomy Combined with Intravitreal Triamcinolone Acetonide Injection and Macular Laser Photocoagulation for Nontractional Diabetic Macular Edema

PURPOSE: To evaluate the efficacy of vitrectomy combined with intravitreal injection of triamcinolone acetonide (IVTA) and macular laser photocoagulation for the treatment of nontractional diabetic macular edema (DME) refractory to anti-vascular endothelial growth factor (VEGF) therapy. METHODS: Twenty-eight eyes from 28 subjects who were diagnosed with nontractional DME refractory to three or more sequential anti-VEGF injections underwent sequential vitrectomy, IVTA, and macular laser photocoagulation. Changes in best-corrected visual acuity (BCVA) and central subfield thickness (CST) during the six months following vitrectomy were evaluated. Additionally, the CST and BCVA outcomes were compared with those of 26 eyes treated with the same triple therapy for nontractional DME refractory to conventional treatment, such as IVTA or macular laser photocoagulation, or both. RESULTS: The mean logarithm of the minimum angle of resolution BCVAs before and one, three, and six months after vitrectomy were 0.44 +/- 0.15, 0.36 +/- 0.18, 0.31 +/- 0.14, and 0.34 +/- 0.22, respectively. The mean CSTs were 433.3 +/- 77.9, 329.9 +/- 59.4, 307.2 +/- 60.2, and 310.1 +/- 80.1 microns, respectively. The values of both BCVA and CST at one, three, and six months were significantly improved from baseline (p < 0.05). The extent of CST reduction during the first month after triple therapy was greater in eyes refractory to conventional treatment than in eyes refractory to anti-VEGF (p = 0.012). CONCLUSIONS: Vitrectomy combined with IVTA and macular laser photocoagulation had a beneficial effect on both anatomical and functional outcomes in eyes with nontractional DME refractory to anti-VEGF therapy.

Long term follow-up of acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome): case report / Síndrome de vasculite retiniana hemorrágica multifocal aguda (síndrome de Blumenkranz) com seguimento a longo prazo: relato de caso

PURPOSE: To report a 16-year long-term follow-up of a patient with acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome). A 21-year old male was seen in 1994 with acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome), first in the left eye, and later in the right eye. He was treated with retinal photocoagulation in areas of retinal ischemia and oral steroids, followed by sequential annual fundus examination and photography for 16 years. Vision improved to 20/25 in both eyes after retinal ischemic areas photocoagulation and oral steroids, and his vision has been maintained for 16 years. Photocoagulation of retinal ischemia and oral steroids are effective for the treatment of acute multifocal hemorrhagic retinal vasculitis (Blumenkranz syndrome).

Relato de caso com acompanhamento por 16 anos de um paciente com a vasculite hemorrágica multifocal aguda (síndrome de Blumenkranz). Um paciente de 21 anos de idade foi diagnosticado em 1994 com a vasculite hemorrágica multifocal aguda (síndrome de Blumenkranz), primeiro no olho esquerdo e depois no olho direito. Foi tratado com fotocoagulação retiniana nas áreas retinianas isquêmicas e corticosteroide oral e seguido por exames complementares da retina por 16 anos. A visão melhorou para 20/25 em ambos os olhos após a fotocoagulação retiniana nas áreas isquêmicas da retina e corticosteroide oral permanecendo assim até o momento por 16 anos. A fotocoagulação retiniana nas áreas isquêmicas e o uso de corticosteróide oral são tratamentos efetivos para a vasculite hemorrágica multifocal aguda (síndrome de Blumenkranz).

Update on congenital glaucoma.

Congenital glaucoma is a global problem and poses a diagnostic and therapeutic challenge to the ophthalmologist. A detailed evaluation under general anesthesia is advisable to establish the diagnosis and plan for management. Medical therapy has a limited role and surgery remains the primary therapeutic modality. While goniotomy or trabeculotomy ab externo is valuable in the management of congenital glaucoma, primary combined trabeculotomy–trabeculectomy offers the best hope of success in advanced cases. Trabeculectomy with antifibrotic agent and glaucoma drainage devices has a role in the management of refractory cases, and cyclodestructive procedures should be reserved for patients where these procedures have failed. Early diagnosis, prompt therapeutic intervention and proper refractive correction are keys to success. Management of residual vision and visual rehabilitation should be an integral part of the management of children with low vision and lifelong follow-up is a must.

Retinopatía de la prematuridad en el neonato con peso menor de 1 500 g / Retinopathy of prematurity in neonate weighing less than 1 500 g

INTRODUCCIÓN. La retinopatía del prematuro (ROP) es una retinopatía neovascular que se desarrolla hasta en el 84 por ciento de los niños prematuros. Es inversamente proporcional al peso y a la edad gestacional y muy frecuente en el menor de 1500 g. El objetivo de esta investigación fue conocer la incidencia de retinopatía de la prematuridad en los neonatos de menos de 1500 g de peso, así como algunos factores asociados. MÉTODOS. Se realizó un estudio prospectivo longitudinal en el cual se incluyeron 31 neonatos con peso menor de 1500 g, ingresados en la unidad de cuidados intensivos neonatales del Hospital Iván Portuondo entre enero del 2004 y diciembre del 2008. No se incluyeron los fallecidos en ese período. En todos los casos se realizaron pesquisas de ROP. Se tomó en cuenta el sexo y la edad gestacional menor de 36 semanas. Se valoraron algunos factores de riesgo para ROP. RESULTADOS. Se encontró ROP en el 25,8 por ciento de los 31 neonatos: el 6,5 por ciento con ROP I Y ROP II, el 9,7 por ciento con ROP III y el 3,2 por ciento con ROP IV. Se encontró retina inmadura en el 74,2 por ciento de los pacientes. El 9,7 por ciento de los casos y el paciente con grado IV recibieron tratamiento quirúrgico con rayos láser. Se encontró mayor incidencia en el sexo masculino y factores asociados como la dificultad respiratoria y la ventilación, en el 75 por ciento de los casos. CONCLUSIÓN. La incidencia de ROP fue baja en comparación con los resultados de otros estudios

INTRODUCTION: Retinopathy of prematurity (RP) is a neovascular retinopathy developing in the 84 percent of premature infants. It is proportional in inverse order to weight and to gestational age and its frequent in an infant weighing less than 1500 g. The aim of present research was to know the prematurity retinopathy incidence in neonates weighing less than 1500 g, s well as some related factors. METHODS: A longitudinal and prospective study was conducted including 31 neonates weighing less than 1500 g, admitted in neonatal intensive care unit of the Ivan Portuondo Hospital from January, 2004 to December, 2008. Those deceased weren't included. In all the cases authors carried out screening of RP, taking into account the sex and a gestational age lower than 36 weeks. Some risk factors for RP were assessed. RESULTS: RP was present in the 25,8 percent of the 31 neonates: the 6,5 percent with RP I and RP II, the 9,7 percent with RP III and the 3,2 percent with RP IV. We found immature retina in the 74,2 percent of patients. The 9,7 of cases and the patients with IV degree underwent surgical treatment using Laser rays. There was a greater incidence in male sex and related factors (respiratory failure and ventilation in the 75 percent of cases. CONCLUSION: RP incidence was low compared with the results from other studies

Comportamiento de la retinopatía de la prematuridad en el Hospital General Iván Portuondo en el año 2009 / Behavior of the retinopathy of prematurity in Ivßn Portuondo hospital in 2009

OBJETIVO: Conocer el comportamiento de la retinopatía de la prematuridad en los nacidos de menos de 1750 gramos o menos de 35 semanas. MÉTODOS: Estudio observacional descriptivo longitudinal prospectivo de todos los niños bajo peso nacidos en el Hospital General Iván Portuondo, desde enero de 2009 a diciembre de 2009, en el que se obtuvieron un total de 129 niños bajo peso. El protocolo de investigación está formado por los menores de 1 750 gramos de peso al nacer o con edad gestacional inferior a 35 semanas, además se valoraron algunos factores de riesgo. Se excluyeron del estudio los fallecidos en ese período. RESULTADOS: La incidencia fue de 0,24 por cada 10 000 nacidos vivos mediante examen oftalmológico. El 69,35 por ciento de los recién nacidos pesquisados nacieron entre las 32 y las 35 semanas de gestación y 40,32 por ciento con un peso entre 1 500-1 999 gramos. El 93,54 por ciento de los recién nacidos presentaron retina inmadura y un 3,22 por ciento desarrollaron retinopatía de la prematuridad. La misma cantidad de casos se trataron con láser y terapia tópica 50 por ciento, respectivamente. CONCLUSIÓN: Los valores sobre pacientes con retinopatía de la prematuridad en Cuba se encuentran dentro de los aceptados internacionales y estos se mueven a la par con el aumento de la supervivencia de los recién nacidos. Entre los factores que influyen proporcionalmente con esta enfermedad permanecen la edad gestacional y el peso al nacer. El láser se mantiene como estándar de tratamiento

OBJECTIVES: To learn about the behavior of the retinopathy of prematurity in newborns under 1750 grams of weight or 35 weeks of gestation. METHODS: Prospective longitudinal descriptive and observational study of all low birthweighed children at Iván Portuondo hospital, from January to December of 2009. A total of 129 low birth weight children were detected; the research protocol was formed by under 1 750 g birth weight or gestational age under 35 weeks in addition to assessing some risk factors. Those children who died in this period were excluded. RESULTS: The incidence was 0,24 per 10 000 live births according to the ophthalmologic exam. The 69,35 percent of the screened newborns were born at 32 to 35 weeks of gestation and 40,32 percent weighted 1500-1999 grams. Among these children, 93,54 percent presented with immature retina and 3,22 percent developed retinopathy of prematurity. The same number of cases was treated with laser and topical therapy (50 percent respectively) CONCLUSION: The values found in patients with retinopathy of prematurity in Cuba were within those internationally accepted figures and they change according to the increase in the survival of the newborns. Among the influential factors are the gestational age and the birth weight. Laser is considered as standard treatment

Selective fetoscopic laser photocoagulation of superficial placental anastomoses for the treatment of severe twin-twin transfusion syndrome

OBJECTIVE: To report our initial institutional experience with fetoscopic laser photocoagulation of placental anastomoses in severe twin-twin transfusion syndrome using a 1.0 mm endoscope. METHODS: Between July 2006 and June 2008, 19 monochorionic diamniotic twin pregnancies complicated by severe TTTS (Quintero stages III and IV) underwent fetoscopic laser therapy. Perinatal data were prospectively collected and compared according to the Quintero stages. RESULTS: Nine patients were classified as stage III and ten as stage IV. The Mean gestational ages at diagnosis and procedure were 20 (range: 17-25) and 22.0 (range: 19.0-26.0) weeks, respectively, with no statistical difference between the two groups. Preterm premature rupture of the membranes occurred in two cases (10.5 percent), and spontaneous preterm delivery in eight (42.1 percent). Overall mean gestational age at delivery was 32.1 (range: 26.0-38.0) weeks. Prematurity was more severe in stage IV patients (p<0.01). Among all cases, the overall survival rate was 52.6 percent, and the percentages of pregnancies with survival of both babies and at least one twin were 26.3 percent and 78.9 percent, respectively. In the case of stage III patients, the overall survival rate was 61.1 percent. Of the stage III pregnancies, 33.3 percent resulted in both babies surviving, and 88.9 percent of these pregnancies resulted in at least one surviving twin. For stage IV, as the corresponding statistics were 45.0 percent, 20.0 percent and 70.0 percent respectively. CONCLUSIONS: Our initial institutional experience with 1.0 mm fetoscopic laser therapy for severe TTTS showed results similar to those reported in the literature for larger endoscopes.

Rubber band ligation and infrared photocoagulation for the outpatient treatment of hemorrhoidal disease

PURPOSE: To compare the results of rubber band ligation and infrared photocoagulation for the treatment of hemorrhoidal disease through the analysis of the incidence of complications after each treatment and respective success rate. METHODS: Forty-eight patients with first, second or third degree hemorrhoidal disease were randomized to recieve treatment with either rubber band ligation (n=23) or infrared photocoagulation (n=25). Each patient was assessed at 1 week and 4 week intervals after treatment. We compared the incidence of complications and efficiency of each treatment modality and Qui-square, Fisher's Exact Test and Student's t Test were used to statistical analysis. RESULTS: Bleeding occured in eigth (34,7 percent) patients treated with rubber band ligation and in four (16,0 percent) after infrared photocoagulation (p=0,243). Thirteen (52,0 percent) patients felt pain during infrared photocoagulation and 9 (39,1 percent) after rubber band ligation (p=0,546). After rubber band ligation, 14 (60,8 percent) required medication for pain relief. One patient (4,0 percent) required medication after infrared photocoagulation (p<0,001). Three (13,0 percent) patients treated with rubber band ligator and 1 (4,0 percent) treated with infrared photocoagulation had symptomatic mucosal ulcers. Perianal dermatitis occured in two (8,0 percent) patients treated with infrared photocoagulation and one patient (4,3 percent) was observed to have prolapsed thrombosed piles after rubber band ligation. One month after treatment, 17 of 23 patients treated with rubber band ligation (73,9 percent) and 18 of 25 patients treated with infrared photocoagulation were asymptomatic. Rubber band ligation treated bleeding and prolapse in 90,0 percent and 82,4 percent respectively. Infrared photocoagulation treates bleeding and prolapse in 93,7 percent and 87,5 percent respectively. Those differences are not significant. CONCLUSION: Rubber band ligation causes significantly...

OBJETIVO: Comparar os resultados da ligadura elástica com os da fotocoagulação com radiação infravermelha no tratamento da doença hemorroidária através da análise de suas respectivas morbidades e eficácia. MÉTODOS: Foi realizado ensaio clínico casualisado com 48 pacientes portadores de doença hemorroidária graus I, II e III. Após randomização, os pacientes foram submetidos à ligadura elástica (n=23) ou fotocoagulação com radiação infravermelha (n=25). Os pacientes compareceram para consulta ambulatorial 1 semana e 4 semanas após o procedimento. A avaliação foi feita através da análise da incidência de morbidades após cada procedimento e eficácia, com quatro semanas de acompanhamento. As análises estatísticas foram realizadas através do teste do Qui-quadrado, Teste Exato de Fisher e Teste t de Student. RESULTADOS: Dos pacientes submetidos à ligadura elástica, 34,7 por cento (8/23) apresentou sangramento após o procedimento. Após fotocoagulação, 16,0 por cento (4/25) tiveram sangramento (p=0,243). A incidência de pacientes com dor no momento da aplicação do procedimento foi de 52,0 por cento (13/25) após fotocoagulação com radiação infravermelha e 39,1 por cento (9/23) após ligadura elástica (p=0,546). No entanto, ligadura elástica foi mais dolorosa após 48 horas do procedimento (p=0,044). Após ligadura elástica, 60,8 por cento (14/23) dos pacientes necessitaram de analgésicos contra 4,0 por cento (1/25) após fotocoagulação com radiação infravermelha (p<0,001). Um paciente submetido à ligadura elástica (4,3 por cento) evoluiu com trombose dos mamilos ligados. Três pacientes submetidos à ligadura elástica (13,0 por cento) e 1 (4,0 por cento) submetido à fotocoagulação com radiação infravermelha apresentaram úlceras sintomáticas após a aplicação dos tratamentos. Dois pacientes (8,0 por cento) submetidos à fotocoagulação com radiação infravermelha tiveram dermatite perianal. Em relação aos resultados terapêuticos 73,9 por cento dos pacientes...

Evaluación de la retinopatía diabética proliferativa después del tratamiento con láser / Evaluation of proliferative diabetic retinopathy after laser treatment

La fotocoagulación láser (panfotocoagulación) es indicación absoluta en la retinopatía diabética proliferativa (RDP) sin y con características de alto riesgo de pérdida visual severa. Con el objetivo de evaluar este tratamiento en la RDP, se realizó este estudio desde enero de 2004 a diciembre de 2005 en el Centro de Atención al Diabético del Instituto de Endocrinología. Se estudiaron 120 pacientes con RDP, que se fotocoagularon. Las variables estudiadas fueron: edad, sexo, tiempo de evolución de la diabetes y presencia de hipertensión arterial y/o neuropatía. Se realizó examen oftalmológico y se comparó la agudeza visual y el estadio de la retinopatía antes y después del tratamiento. Para el análisis estadístico se utilizó la prueba de chi cuadrado. La forma avanzada de RDP se encontró en pacientes con más de 20 años de evolución de la enfermedad. Después del tratamiento en las mujeres predominó la RDP sin características de alto riesgo (CAR) (38,1 por ciento) y en los hombres la RDP con CAR (38,9 por ciento); 11 pacientes pasaron a la forma de retinopatía diabética (RD) no proliferativa. La hipertensión arterial y la nefropatía diabética predominaron en la RDP con CAR y avanzada. Se concluye que la forma más grave de RD se asoció a mayor tiempo de evolución. La hipertensión arterial y la nefropatía son factores de riesgo asociados a las formas más severas de RD. La fotocoagulación no mejoró la visión de forma significativa, pero sí detiene la progresión de la retinopatía, e incluso, es capaz de modificar la severidad pasando a formas no proliferativas(AU)

Laser photocoagulation (panphotocoagulation) is an absolute indication in the proliferative diabetic retinopathy (PDR) without or with characteristics of high risk for severe visual loss. This study was undertaken at the Diabetic Care Center of the Institute of Endocrinology from January 2004 to December 2005 in order to evaluate this treatment in PDR. 120 patients with PDR that were photocoagulated were studied. The studied variables were: age, sex, time of evolution of diabetes and presence of arterial hypertension and/or neuropathy. An ophthalmologic examination was made, and visual acuity and the retinopathy staging were compared before and after the treatment. Chi square test was used for the statistical analysis. The advanced form of PDR was found in patients with more than 20 years of evolution of the disease. After the treatment, PDR without high risk characteristics predominated in females (38.1 per cent), whereas PDR with high risk characteristics prevailed in males (38.9 per cent). 11 patients passed to the form of nonproliferative diabetic retinopathy. Arterial hypertension and diabetic nephropathy predominated in the PDR with high risk characteristics and in advanced PDR. It was concluded that the most severe form of DR was associated with a longer time of evolution. Arterial hypertension and nephropathy are risk factors connected with the most severe forms of DR. Photocoagulation does not improve vision in a significant way, but it stops the progression of retinopathy, and it is capable of modifying severity, reaching nonproliferative forms(AU)

Comparação entre o laser endovenoso e a fleboextração total da veia safena interna: resultados em médio prazo / Comparison of endovenous laser therapy vs. conventional stripping of the great saphenous vein: midterm results

OBJETIVO: Comparar a fotocoagulação endovenosa com laser diodo e a fleboextração total da veia safena interna. MÉTODOS: Trata-se de um estudo prospectivo, controlado e cego de 20 pacientes com varizes sintomáticas e insuficiência bilateral da veia safena interna que foram operados entre março de 2002 e fevereiro de 2004. Para cada caso, foram realizadas aleatoriamente (sorteio) as duas técnicas, sendo uma em cada lado. A avaliação pós-operatória consistiu na aplicação de questionários, exame físico e fotografia digital em todos os pacientes desde o 7º dia de pós-operatório. Também foi realizado controle ultra-sonográfico no 30º dia de pós-operatório e pletismografia a ar no 60º dia após a cirurgia. Este projeto foi aprovado pela comissão de ética, e os pacientes foram incluídos ao assinarem o consentimento pós-informação. Os dados foram submetidos a análise estatística com os programas SPSS e SAS. RESULTADOS: A técnica que utilizou o laser endovenoso apresentou dor semelhante, mas menos edema e menos hematoma durante o pós-operatório. O índice de melhora estética e de satisfação com a cirurgia foi de 100 por cento para as duas técnicas, mas a maioria dos pacientes respondeu que o membro operado com o laser foi o mais beneficiado. Houve melhora do tempo de enchimento venoso nos dois grupos, mas sem diferença significativa entre eles. Durante o seguimento (média de 26 meses), houve um caso de parestesia leve e transitória do lado convencional e somente uma recanalização do lado laser. CONCLUSÃO: A fotocoagulação endovenosa para o tratamento da veia safena interna em pacientes com varizes de membros inferiores é segura e apresenta resultados comparáveis aos da fleboextração convencional.

OBJECTIVE: To compare endovenous diode laser photocoagulation and conventional stripping of the great saphenous vein. METHODS: A controlled and blind prospective study of 20 patients with symptomatic varicose veins and bilateral great saphenous vein insufficiency who underwent surgery between March 2002 and February 2004. For each case, both techniques were randomly performed, one at each side. The postoperative assessment consisted of questionnaires, physical examination and digital photography of all patients since the 7th postoperative day. Patients also underwent examination with duplex scan at the 30th postoperative day and air plethysmography 60 days after the surgery. This project was approved by the ethics committee, and the patients were included after signing the consent form. All data were submitted to statistical analysis using the software SPSS and SAS. RESULTS:: The endovenous laser technique presented similar pain, but less edema and less hematoma during the postoperative period. The index of esthetic improvement and satisfaction with the surgery was 100 percent for both techniques, but a minority of patients reported that the limb operated with the laser had better results. There was improvement in venous filling time in both groups, but with no significant difference. During the follow-up (average of 26 months), there was one case of mild and transient paresthesia at the conventional side and only one recanalization at the laser side. CONCLUSION: The endovenous photocoagulation for the treatment of the great saphenous vein in patients with lower limb varicose veins is safe and presents results comparable with the conventional stripping.

Oclusão combinada de artéria e veia central da retina associada a drusas de disco óptico / Combined central retinal artery and vein occlusion associated with optic disc drusen

Relatamos uma rara associação entre oclusão combinada de artéria e veia central da retina como drusas do nervo óptico. Descrevemos exames complementares que definiram o diagnóstico e o tratamento realizado. Foram feitos avaliação oftalmológica, clínica e laboratorial, retinografia, angiografia fluorosceínica, ultrasonografia ocular e tomografia computadorizada de órbita e crânio. O tratamento realizado foi vitrectomia via pars plana e endofotocoagulação. pacientes com perda súbita a visão no olho direito, apresentou na oftalmoscopia indireta drusas de nervo óptico, aumento da tortuosidade vascular, hemorragias vítreas e intra-retinianas, branqueamento e edema retiniano difuso. A angiografia fluoresceínica do olho direito mostrou lentificação dos tempos circulatórios e hiperfluoresc6encia por impregnação no nervo óptico. A ultrasonogafia ocualr mostrou estrutura de alta refletividade nos nervos ópticos, e calcificações na tomografia computadorizada de órbita, confirmando o diagnóstico das drusas. Devido a extensaisquemia, houve uma rápida evolução para neovasculização retiniana com episódios repetidos de hemorragia vítrea, sendo indicado vitrectomia posterior e endofotocoagulação difusa. Descrevemos pela primeira vez na literatura uma associação entre drusas de nervo óptico com oclusão combinada de artéria e veia central da retina. Acreditamos que a presença das drusas foi o principal fator na patogênese do processo obstrutivo vascular causado por efeitos compressivos na cabeça do nervo óptico, visto que nenhum outro fator foi encontrado.

O uso do laser de argônio no tratamento da triquíase / Argon laser in the treatment of trichiasis

OBJETIVO: Avaliar a eficácia da técnica de termoablação dos folículos pilosos dos cílios em triquíase com laser de argônio e observar a preferência dos pacientes submetidos a este tratamento, pela anestesia tópica com colírio anestésico ou pela anestesia local injetável. MÉTODOS: Estudo prospectivo de 55 pálpebras de 39 pacientes com triquíase, tratados com fotocoagulação dos folículos pilosos com Argon green laser (Alcon® - EUA). Neste estudo avaliou-se a idade e o sexo dos pacientes, o número de sessões realizadas, a evolução após as aplicações e a preferência pelo tipo de anestesia. Os parâmetros utilizados foram: (1) Mira - 150 µm; (2) Potência- 750 mW; (3) Tempo de exposição- 0,2 s. Cada cílio recebeu, no máximo, 9 disparos por sessão. RESULTADOS: Dentre os 39 participantes do estudo, 58,9 por cento eram do sexo feminino e 41 por cento do sexo masculino. A idade média foi de 71 anos. Houve cura em 69 por cento (38 pálpebras), sendo 29 por cento (16 pálpebras) com apenas uma sessão de laser. Houve preferência estatisticamente significativa pelo procedimento realizado sob anestesia local injetável. CONCLUSAO: Os resultados sugerem que a anestesia local no tratamento da triquíase com laser de argônio é a preferência da maioria dos pacientes e que a termoablação dos folículos pilosos com laser de argônio é tratamento efetivo para a triquíase.

Oclusão de ramo da veia central da retina / Retinal vein branch occlusion

As oclusões venosas retinianas são a segunda causa mais comum de doenças vasculares da retina, atrás apenas da retinopatia diabética. A obstrução venosa de ramo é definida como a oclusão focal de uma veia retiniana em nível de um cruzamento arteriovenoso, no qual a artéria passa anteriormente à veia. Serão revisto o estudo multicêntrico sobre o tratamento com fotocoagulação a "laser" para esta doença, bem como abordadas as novas terapêuticas cirúrgicas propostas.