COVID-19 and the eye: how much do we really know? A best evidence review / COVID-19 e o olho: quanto sabemos realmente? Uma revisão das melhores evidências

ABSTRACT To identify and classify available information regarding COVID-19 and eye care according to the level of evidence, within four main topics of interest: evidence of the virus in tears and the ocular surface, infection via the conjunctival route, ocular manifestations, and best practice recommendations. A structured review was conducted in PubMed, ScienceDirect, LILACS, SciELO, the Cochrane Library and Google Scholar on COVID-19 and ophthalmology. The Oxford Centre for Evidence Based Medicine 2011 Levels of Evidence worksheet was used for quality assessments. 1018 items were identified in the search; 26 records were included in the qualitative synthesis, which encompassed 6 literature reviews, 10 case series or cross-sectional studies, 4 case reports, and 6 intervention descriptions. Seventeen out of 26 records (65%) were categorized as level 5 within the Oxford CBME methodology grading system, the rest were level 4. The evidence generated on COVID-19 and ophthalmology to date is limited, although this is understandable given the circumstances. Both the possible presence of viral particles in tears and conjunctiva, and the potential for conjunctival transmission remain controversial. Ocular manifestations are not frequent and could resemble viral infection of the ocular surface. Most recommendations are based on the strategies implemented by Asian countries during previous coronavirus outbreaks. There is a need for substantive studies evaluating these strategies in the setting of SARS-CoV-2. In the meantime, plans for applying these measures must be implemented with caution, taking into account the context of each individual country, and undergo regular evaluation.

RESUMO Identificar e classificar as informações disponíveis sobre o COVID-19 e o tratamento oftalmológico de acordo com o nível de evidência, dentro de quatro tópicos principais de interesse: evidência do vírus nas lágrimas e na superfície ocular, infecção pela via conjuntival, manifestações oculares e recomendações de melhores práticas. Foi realizada uma revisão estruturada no PubMed, ScienceDirect, LILACS, SciELO, Biblioteca Cochrane e Google Scholar no COVID-19 e oftalmologia. A planilha de Níveis de Evidência 2011 do Oxford Centre for Evidence Based Medicine 2011 foi usada para avaliações de qualidade. Mil e dezoito itens foram identificados na busca; Foram incluídos 26 registros na síntese qualitativa, que incluiu 6 revisões de literatura, 10 séries de casos ou estudos transversais, 4 relatos de casos e 6 descrições de intervenções. Dezessete dos 26 registros (65%) foram classificados como nível 5 no sistema de classificação da metodologia Oxford CBME, o restante foi no nível 4. As evidências geradas no COVID-19 e na oftalmologia até o momento são limitadas, embora isso seja compreensível dadas as circunstâncias. Tanto a possível presença de partículas virais em lágrimas e conjuntiva quanto o potencial de transmissão conjuntival permanecem controversos. As manifestações oculares não são frequentes e podem se assemelhar a infecção viral da superfície ocular. A maioria das recomendações baseia-se nas estratégias implementadas pelos países asiáticos durante surtos anteriores de coronavírus. Há necessidade de estudos aprofundados avaliando essas estratégias no cenário da SARS-CoV-2. Enquanto isso, os planos para a aplicação dessas medidas devem ser implementados com cautela, levando em consideração o contexto de cada país e submetidos a auditorias periódicas.

Infección por el complejo Mycobacterium avium-intracellulare en pacientes con VIH/SIDA en un hospital peruano: Una serie de casos / Infection by the Mycobacterium avium-intracellulare complex in patients with HIV/AIDS in a Peruvian hospital: A series of cases

RESUMEN Existe poca información sobre la presencia del complejo Mycobacterium avium-intracellulare (MAC) en el Perú. Se describen cinco casos de infección por MAC en pacientes con VIH/SIDA del Hospital Nacional Dos de Mayo, Lima-Perú. Los pacientes presentaron, principalmente, fiebre persistente, diarrea crónica, síndrome consuntivo, pancitopenia y citofagocitosis. En todos ellos se identificó bacilos acido-alcohol resistentes en heces, por lo que recibieron tratamiento antituberculoso. El cultivo de heces fue negativo para Mycobacterium tuberculosis y, posteriormente, en todos se identificó a MAC mediante una prueba molecular (Genotype) en el cultivo de heces. Tres pacientes recibieron tratamiento para MAC luego de la identificación; sin embargo, todos fallecieron. Ante presentaciones similares a lo reportado, se sugiere el uso de métodos de mayor rendimiento (hemocultivo, mielocultivo, pruebas moleculares), así como asociar tempranamente drogas con actividad para MAC al esquema antituberculoso con la intención de mejorar el pronóstico de este grupo de pacientes.

ABSTRACT There is little information on the presence of the Mycobacterium avium-Intracellulare (MAC) complex in Peru. Five cases of MAC infection are described in patients with HIV/AIDS at the National Hospital Dos de Mayo, Lima - Peru. The patients presented, mainly, persistent fever, chronic diarrhea, consumptive syndrome, pancytopenia and citofagocitosis. In all of them, resistant acid-alcohol bacilli were identified in feces, so they received antituberculous treatment. The culture of feces was negative for Mycobacterium tuberculosis and, later, in all cases MAC was identified using a molecular test (genotype) in the culture of feces. Three patients received treatment for MAC right after identification; however, they all died. Before presentations similar to the reported, we suggest the use of higher performance methods (blood culture, myeloculture, molecular tests), as well as early associating drugs with activity for MAC to antitubercular scheme with the intention of improving the prognosis of this group of patients.

Elevada frecuencia de dislipidemia en pacientes infectados por VIH en un hospital público peruano / High frequency of dyslipidemia in HIV-infected patients in a peruvian public hospital

El objetivo del estudio fue determinar la frecuencia y características de la dislipidemia en pacientes con VIH en terapia antirretroviral de gran actividad (TARGA) en un hospital público peruano. Se realizó un estudio transversal en pacientes que tuvieran un perfil lipídico completo luego de recibir al menos seis meses de TARGA. La dislipidemia se definió según los criterios NCEP-ATP III. Se revisaron 2975 historias clínicas, 538 (18.1%) fueron incluidas en el análisis. La frecuencia de dislipidemia fue 74.7%. Los esquemas de TARGA que incluían inhibidores de la proteasa (IP) (OR 1.22; IC95% 1,11-1,34) y la edad mayor de 40 años (OR 1.17; IC95% 1,06-1,29) mostraron asociación con dislipidemia, ajustado por carga viral, nivel de células CD4 y sexo. En conclusión, la dislipidemia fue muy frecuente en la muestra estudiada y estuvo asociada principalmente al uso de IP. Es necesario promover el control de la dislipidemia como parte de la atención integral del paciente con infección por VIH.

The objective of the study was to determine the frequency and characteristics of dyslipidemia in patients with HIV in highly active antiretroviral therapy (HAART) in a Peruvian public hospital. A cross-sectional study was carried out in patients with complete lipid profile after receiving at least six months of HAART. Dyslipidemia was defined according to the criteria of the NCEP-ATP III. We reviewed 2 975 clinical histories, and included 538 (18.1%) in the analysis. The frequency of dyslipidemia was 74.7%. HAART regimens which include protease inhibitors (PI) (odds ratio [OR]: 1.22; confidence interval at 95% [CI 95%]: 1.11-1.33) and to be older than 40 years (OR: 1.17; CI 95%: 1.05-1.28) were associated with dyslipidemia, adjusted by viral load, CD4 lymphocyte level and gender. In conclusion, dyslipidemia was very common in our sample and was mainly associated with the use of PI. It is necessary to promote the dyslipidemia control as part of the comprehensive care of the patient with HIV.

Diarrea recurrente por Cystoisopora belli en pacientes con infección por VIH con TARGA / Recurrent diarrhea due to Cystoisopora belli in HIV/AIDS patients receiving HAART

La Cystoisospora belli, antes denominada Isospora belli, es el agente etiológico de la cystoisosporiasis, una infección oportunista que afecta a pacientes inmunodeprimidos, caracterizada por diarrea crónica y pérdida ponderal. La incidencia de diarrea crónica por este agente, en pacientes infectados por el VIH, ha disminuido considerablemente. Ello gracias al advenimiento de la terapia antirretroviral de gran actividad (TARGA), con la que se ha logrado mejorar la respuesta inmunológica del paciente y disminuir su carga viral. Se presentan seis casos de cystoisosporiasis recurrente y refractaria en pacientes con infección por VIH, en quienes se diagnosticó cystoisosporiasis pese a que previamente se encontraban recibiendo profilaxis con trimetropin/sulfametoxazol (TMP/SMX). Cinco de ellos evolucionaron de manera tórpida y fallecieron, a pesar de una buena respuesta al TARGA (adecuado incremento de CD4 y disminución de la carga viral hasta rangos indetectables), y de tratamiento con TMP/SMX por vía oral y otros medicamentos de segunda línea.

The Cystoisospora belli, before denominated as Isospora belli, is the etiologic agent of cystoisosoporiasis, an opportunistic infection affecting immunocompromised patients, characterized by chronic diarrhea and weight loss. The incidence of chronic diarrhea for this agent, in HIV patients, has decreased considerably. This thanks to the advent of highly active antiretroviral therapy (HAART), which has improved the patient’s immune response and decrease viral load. We present six cases of cystoisosoporiasis recurrent and refractory to treatment in HIV patients, who was being treated with with trimethoprim / sulfamethoxazole (TMP / SMX) orally as a prophylaxis. Five of these patients passed away due to the infection, despite of the fact that they had a good response to HAART (adequate increase in CD4 and viral load undetectable) and they had been treated with second line drugs.

Eficacia y seguridad de la ciclofotocoagulación transescleral de contacto de 360° en glaucoma refractario avanzado / Efficacy and safety of 360° contact transscleral cyclophotocoagulation for advanced refractory glaucoma

Trasfondo: la ciclofotocoagulación transescleral de contacto se ha convertido en una opción válida para pacientes con glaucoma refractario avanzado. Objetivo: determinar la eficacia y seguridad de este procedimiento con un protocolo de aplicación de 360°. Material y método: un estudio cohorte prospectivo en un lapso de 8 meses, con una muestra de 12 ojos en 12 pacientes, donde se realizó un seguimiento por 30 días, para analizar cambios en la presión intraocular, el dolor y el uso de fármacos antiglaucomatosos. Resultados: la media de edad fue 61 ± 14 años; la presión intraocular media antes de la ciclofotocoagulación transescleral fue de 52 ± 10, 30 días después se redujo a 20.5 ± 5.9mmHg (p<0,001); la estimación del dolor antes del procedimiento tuvo una media de 4 sobre 5, 30 días después se redujo a 1 sobre 5 (p<0,001); la media de fármacos antiglaucomatosos usados antes del procedimiento fue de 3 y se redujo a 0 al mes del procedimiento(p<0,001). Conclusión: la ciclofotocoagulación transescleral de contaco de 360º si reduce la presión intraocular en pacientes con glaucoma refractario avanzado o absoluto de forma eficaz y segura, además de disminuir el dolor y reducir la necesidad de fármacos.

Background: contact transscleral cyclophotocoagulation has become a valid option for patients with advanced refractory glaucoma. Objective: to determine the efficacy and safety of this procedure with a 360 ° application protocol. Materials and Methods: a cohort prospective study within an 8-month period, with a sample of 12 eyes in 12 patients, who were followed for 30 days, in order to analyze changes in intraocular pressure, pain and usage of antiglaucoma medications. Results: the mean age was 61 ± 14, the intraocular pressure mean before transscleral cyclophotocoagulation was 52 ± 10, 30 days later it was reduced to 20.5 ± 5.9mmHg (p <0.001), the pre-procedure pain estimation had an average of 4 out of 5, 30 days later it was reduced to 1 out of 5 (p <0.001), the mean of the antiglaucoma drugs used was 3 before the procedure and it was reduced to 0 after a month (p <0.001). Conclusion: the 360 ° Contac transscleral cyclophotocoagulation does reduce or nullify intraocular pressure in advanced refractory glaucoma patients efficiently and securely; it also reduces pain and the need for drugs.

Guía para el manejo de pacientes con la nueva influenza A (H1N1) / Guidelines for management of patients with novel influenza a (h1n1)

Para afrontar la pandemia por la nueva Influenza A (H1N1) se requiere de un adecuado manejo de los casos, en esesentido, la Sociedad Peruana de Enfermedades Infecciosas y Tropicales ha desarrollado una guía que se resumeen este artículo. Se detalla el diagnóstico clínico y flujos para la toma de decisiones, el manejo terapéutico y las consideraciones a tener en cuenta para casos graves y situaciones especiales, como es el caso de las gestantes.

To fight the pandemic of novel influenza A (H1N1) virus an appropriate management of cases is required, in that sense, the Peruvian Society of Infectious and Tropical Diseases has developed a guide which is summarized in this article. We detail clinical diagnosis and flows for decision making, therapeutic considerations and elements to take in account for severe cases and special situations, such as pregnant women.

Parámetros del espesor retiniano en 32 voluntarios sanos trabajadores del hospital Doctor Teodoro Maldonado Carbo, de Guayaquil – Ecuador, mediante tomografía de coherencia óptica / Parameters of retinal thickness in 32 healthy volunteers working at Doctor Teodoro Maldonado Carbo” hospital of Guayaquil – Ecuador, through optical coherence tomography

Propósito: Realizar un primer acercamiento para conocer las medidas del grosor retiniano en la población ecuatoriana y determinar la influencia de las variables demográficas y antropométricas. Metodología: Mediante un estudio transversal se incluyó a las personas luego de valoración oftalmológica. Se determinaron características demográficas, antropométricas y se midió con tomografía de coherencia óptica el área del anillo, el volumen macular total y la capa de fibras nerviosas de la retina con sus cuadrantes. Se realizó Test de Student, Correlación de Pearson, Regresión lineal y se compararon los datos con la bibliografía. Resultados: Se estudiaron 32 voluntarios sanos trabajadores del hospital “Dr. Teodoro Maldonado Carbo”. En la tabla 1 se reportan sus características demográficas, antropométricas y valores del Tomógrafo de Coherencia Óptica. La edad presentó una correlación negativa con los valores del OCT, siendo más significativa en el cuadrante superior r=0.5 (p= <0.01). El cuadrante nasal del ojo derecho presentó un grosor de 21.56 micras mayor que el del ojo izquierdo (p= <0.001). No se encontró asociación con las demás variables estudiadas. En la cuarta tabla se presenta el 95 del intervalo de confianza y se lo compara con otras poblaciones. Discusión: La correlación negativa de la edad en el grosor retiniano y las diferencias en el cuadrante nasal entre el ojo derecho e izquierdo también se han reportado en otros estudios. La muestra pequeña podría ser la causa por la que no se encontró asociación con otras variables. Aunque se observan diferencias con los parámetros del el grosor retiniano de otras poblaciones, todavía es necesario validar estos resultados.

Purpose: To carry out a first approach to know the measurement of retinal thickness of Ecuadorians and determine the influence of demographic and anthropometric variables. Methodology: Through a cross sectional study people were included after ophthalmologic valuation. Demographic, and anthropometric characteristics were determined and the ring surface, the total macular volume and the nerve fiber layers of the retina with its quadrant were measured with optical coherence tomography. The Student’s test, Pearson’s correlation, lineal regression were carried out and the data was compared to the bibliography. Results: 32 healthy volunteers working at “Dr, Tedodro Maldonado Carbo”. In Chart #1 demographic and anthropometric characteristics, and Optical Coherence Scanner validities are reported. The age showed a negative correlation with OCT (Optical Coherence Tomography) validities, being more significant in the top quadrant r=0.5 (p= <0.01). Right eye nasal quadrant showed a thickness of 21.56 microns bigger than the one of the left eye (p= <0.001). No association with the other variables studied was found. In the fourth chart we can see 95 of confidence interval and it’s compared to other populations. Discussion: The negative correlation of age in the retinal thickness and the differences in the nasal quadrant between right eye and left eye have also been reported in other studies. The small sample might be the cause for not finding the association with other variables. Although we can observe differences with parameters in the retinal thickness in other populations, it is still necessary to validate these results.