Síndrome de Horner: revision de la literatura / Horner´s Syndrome: literature review

Resumen El Síndrome de Horner (SH) es una condición provocada por un grupo heterogéneo de patologías. Estas tienen en común el daño de la vía simpática. La localización más común de la lesión es a nivel preganglionar, por trauma o cirugías en región cervical, torácica o ápex pulmonar. El diagnóstico es primordialmente clínico mediante la identificación de la triada de miosis, ptosis y anhidrosis. Se confirma con las pruebas para cocaína e hidroximetanfetamina. El tratamiento se lleva a cabo primero con agentes farmacológicos. Los que tienen disminución del campo visual por la ptosis o por razones cosméticas se llevan a tratamiento quirúrgico. En ese caso los abordajes operatorios recomendados para ptosis leve son el procedimiento de Fasanella-Servat, el avance de aponeurosis del elevador y en casos severos el cabestrillo frontal. El objetivo es hacer una revisión de los algoritmos diagnósticos y terapéuticos del SH para lograr un abordaje sistemático debido a las múltiples etiologías que posee.

Abstract Horner Syndrome is a condition caused by a heterogeneous group of pathologies. These have in common the damage of the sympathetic pathway. The most common location of the lesion is at the preganglional level, due to trauma or surgeries in the cervical, thoracic or pulmonary apex region. The diagnosis is primarily clinical by identifying the triad of myosis, ptosis and anhidrosis. It is confirmed with the cocaine and hydroxymethamphetamine tests. Treatment is first carried out with pharmacological agents. Those with diminished visual field due to ptosis or cosmetic reasons are undergoing surgical treatment. In this case, the recommended operative approaches for mild ptosis are the Fasanella-Servat procedure, the elevator aponeurosis advance and, in severe cases, the frontalis sling. The objective is to review the diagnostic and therapeutic algorithms of SH in order to achieve a systematic approach due to the multiple aetiologies it possesses.

Malposiciones palpebrales y su influencia en la topografía corneal previa y posterior a su corrección quirúrgica / Palpebral malpositions and their influence on corneal topography before and after surgical correction

Introducción: las malposiciones palpebrales (ptosis, dermatochalasis superior y ectropión) son de los principales motivos de consulta en el área de cirugía plástica ocular. Aún no hay información concluyente en la literatura sobre los cambios corneales topográficos que se generan con las malposiciones palpebrales y si hay cambios en la topografía corneal posterior a la corrección quirúrgica de estas. Objetivo: determinar los cambios corneales topográficos de los pacientes con malposiciones palpebrales sometidos a corrección quirúrgica. Diseño del estudio: estudio observacional prospectivo longitudinal. Método: pacientes seleccionados por conveniencia a quienes se les realizó corrección quirúrgica de afecciones palpebrales (ptosis, ectropión y dermatochalasis superior) en el Hospital Militar Central de Bogotá entre abril y septiembre de 2019. Se describieron los datos de la topografía corneal previa a la corrección y al mes y tres meses después de esta y la agudeza visual mejor corregida preoperatoria y en la última evaluación postoperatoria realizada. Resultados: se realizó corrección quirúrgica de malposiciones palpebrales a 106 ojos de 54 pacientes. El cilindro medio tuvo un cambio de 0,13 D y el desplazamiento de su eje de 1, 49º. El cambio global en la queratometría media fue de 0,01 D y el grosor corneal central disminuyó 1,5 mcs. En cuanto la agudeza visual mejor corregida hubo un aumento de 0,0415 por escala LogMAR. Conclusión: la cirugía de las malposiciones palpebrales genera cambios topográficos corneales, donde la corrección de ptosis es la que más cambios ocasiona, con persistencia de los cambios a los 3 meses postoperatorio.

Background: palpebral malpositions (ptosis, upper dermatochalasis and ectropion) are the main reasons for consultation in the area of eye plastic surgery. There is still no conclusive information in the literature on the topographic corneal changes that are generated with palpebral malpositions and if there are changes in the corneal topography after surgical correction. Objective: to determine the topographic corneal changes of patients with palpebral malpositions submitted to surgical correction. Study design: longitudinal prospective observational study. Method: patients selected for convenience who underwent surgical correction of palpebral conditions (ptosis, ectropion and upper dermatochalasis) at the Central Militar Hospital of Bogotá between April and September 2019. Corneal topography data prior to correction were described and one month and three months after this and the visual acuity better corrected preoperatively and in the last postoperative evaluation performed. Results: surgical correction of palpebral malpositions was performed in 106 eyes of 54 patients. The middle cylinder had a change of 0,13 D and the displacement of the cylinder axis of 1,49 °. The average global change in mean keratometry was 0,01 D and the central corneal thickness decreased 1,5 mcs. With the best corrected visual acuity there was an increase of 0,0415 per LogMAR scale. Conclusion: palpebral malpositions surgery generates corneal topographic changes, where the correction of ptosis is the one that causes the most changes, with persistence of the changes at 3 months postoperatively.

Eficacia de la técnica Supramáxima en la corrección de la ptosis palpebral superior moderada y grave / Efficacy of the Supramaximal technique for correction of moderate and severe upper eyelid ptosis

RESUMEN Objetivo: Evaluar la eficacia de la técnica quirúrgica Supramáxima en la corrección de la ptosis palpebral superior moderada y grave. Métodos: Se realizó un ensayo clínico aleatorizado a simple ciega, en 95 pacientes (119 ojos), provenientes de la Consulta de Oftalmología del Hospital Hermanos Ameijeiras, desde febrero del año 2016 a noviembre de 2017, los cuales recibieron tratamiento quirúrgico con la técnica Supramáxima o la técnica Suspensión al frontal. La eficacia del tratamiento se evaluó en cuanto a: caída del párpado, altura del pliegue palpebral, distancia margen reflejo y satisfacción del paciente. Resultados: El promedio de edad fue de 59,35 años, con leve predominio del sexo femenino (56,8 por ciento) y de la ptosis palpebral grave (51,6 por ciento). La diabetes mellitus fue la enfermedad sistémica más frecuente (56,8 por ciento). La eficacia terapéutica de la TSM fue superior (96,7 por ciento) a la TSF (86,2 por ciento). Se constató una mayor satisfacción del paciente con la TSM (97,9 por ciento). Conclusiones: La técnica quirúrgica Supramáxima es más eficaz que la suspensión al frontal en la corrección de la ptosis palpebral superior moderada y grave(AU)

ABSTRACT Objective: Evaluate the efficacy of the Supramaximal surgical technique for correction of moderate and severe upper eyelid ptosis. Methods: A randomized single-blind trial was conducted with 95 patients (119 eyes) from the Ophthalmology Service of Hermanos Ameijeiras Hospital from February 2016 to November 2017. These patients had undergone surgery by either Supramaximal technique or frontal suspension technique. Efficacy of the treatment was evaluated in terms of eyelid ptosis, eyelid crease height, margin-reflex distance and patient satisfaction. Results: Mean age was 59.35 years, with a slight predominance of the female sex (56.8 percent) and of severe eyelid ptosis (51.6 percent). Diabetes mellitus was the most common systemic condition (56.8 percent). The therapeutic efficacy of SMT was higher (96.7 percent) than that of FST (86.2 percent). Patient satisfaction was higher with SMT (97.9 percent). Conclusions: The Supramaximal surgical technique is more effective than frontal suspension for correction of moderate and severe upper eyelid ptosis(AU)

Técnica de fijación frontal en cirugía de ptosis palpebral mediante banda de silicona / Silicone band brow fixation in ptosis surgery

RESUMEN Se presentó un caso operado de ptosis palpebral severa del ojo izquierdo, en un paciente de 83 años de edad, chofer profesional. el mismo fue corregido mediante la técnica de Fox, fijando el párpado superior al músculo frontal con una banda de silicona de 1 mm de ancho. Se presentaron los buenos resultados de esta cirugía correctiva en el trans-operatorio y post-operatorio de 7 días y al mes. Se mostraron resultados satisfactorios visual y estético con el uso de la misma. No se reportó reacción adversa a la banda de silicona. Se recomienda extender el uso de esta técnica a todos los servicios de la provincia. Continuar el perfeccionamiento de la misma en el servicio (AU).

ABSTRACT An 83 years old patient, professional driver, operated of a severe ptosis in the left eye, is corrected by Fox procedure, fixating the upper eyelid to the frontal muscle with a silicone band of 1 mm. The good corrective results, during surgery, after that, at 7 days and at a month, are showed as a great achievement in visual and aesthetic fields. There was not allergic reaction to the silicone material. We recommend to extend the use of this procedure to all provinces services and to continue the improvement of the procedure in our service (AU).

Retracción palpebral en ojo contralateral: poscirugía de ptosis palpebral / Eyelid retraction in contralateral eye: eyelid ptosis postsurgery

Se presenta a una paciente con antecedentes de tratamiento quirúrgico hace dos años para la elevación del párpado superior por ptosis palpebral derecha, quien exhibía retracción palpebral izquierda, aparentemente secundaria a la cirugía de ptosis, que dejaba expuesta ampolla de filtración por trabeculectomía previa, la cual le causaba molestias permanentes y la limitaba a realizar sus actividades diarias, cuadro clínico que se constató a las 24 horas en el posoperatorio. Se remitió a nuestro Centro y se discutió en colectivo. Se decidió realizar nueva cirugía de la ptosis derecha y tarsorrafia izquierda, con lo que se logró corrección de la ptosis derecha y recubrimiento de la bula de filtración del ojo izquierdo. Se mantuvo asintomática hasta los 3 meses del posoperatorio en que apareció con retracción palpebral izquierda recurrente. Se evaluó nuevamente y se decidió, por la edad de la paciente y los antecedentes de reintervenciones en ambos ojos así como el riesgo de complicación de cirugía filtrante, aplicar toxina botulínica en el párpado superior, 3 cc equivalente a 7 U. Con la aplicación de la toxina botulínica se logró la caída del párpado superior izquierdo, lo que permitió cubrir la bula de filtración, y desapareció la sintomatología. La toxina botulínica, a pesar de tener un efecto transitorio, constituye una buena opción en los pacientes con retracción palpebral en quienes otros tratamientos no han sido satisfactorios(AU)

A female patient with a history of surgical treatment for eyelid ptosis is reported. Two years before, she was operated on for correction of upper eyelid due to right eyelid ptosis, but now she presented left eyelid retraction, apparently secondary to ptosis surgery, which exposed a filtering bleb caused by previous traveculectomy. This condition caused permanent disturbances and restricted her daily activities, a clinical picture that was confirmed 24 hours after the surgery. She was sent to our center and the case was collectively discussed. It was decided to perform a new surgery to correct right ptosis and left tarsoraphy. The result was correction of right ptosis and coating of the filtering bleb in the left eye. She remained asymptomatic for three months in the postoperative period, but recurrent left eyelid retraction occurred. She was re-evaluated and it was decided, due to the patient´s age and the history of resurgeries in both eyes in addition to the risk of filtering surgery complications, to apply botulinum toxin in the upper eyelid at a dose of 3cc equal to 7 U. The administration of botulinum toxin allows fall of the left upper eyelid and covering of the filtering bleb, thus symptoms disappeared. Despite its transient effect, botulinum toxic is a good option for patients with eyelid retraction who had not achieved satisfactory results with other types of treatment(AU)

Presentación de un caso: síndrome de claude bernard-horner post resección de higroma quístico / Presentation of a case: claude bernard-horner's syndrome post resection of cystic hygroma

El Higroma quístico es una malformación congénita que consiste en uno o más espacios linfáticos llenos de líquido, suelen reconocerse en recién nacidos, pero típicamente pueden ser visibles cuando aumentan de tamaño conforme al crecimiento del paciente. El Síndrome de Claude Bernard-Horner se caracteriza por una miosis, ptosis palpebral y anhidrosis en pacientes con afectación de la vía oculosimpatica, se considera una complicación neurológica iatrogénica infrecuente. Se presenta una paciente femenina de 4 años con diagnostico posnatal de higroma quístico cervical tras estudio patológico realizado, el cual fue extraído quirúrgicamente. Tres días después la paciente presenta ptosis del parpado superior izquierdo con presencia de miosis y disminución de la sudoración del mismo lado, sin alteraciones en la fuerza y movimiento del miembro superior Izquierdo.

Cystic hygroma is a congenital malformation consisting of one or more lymphatic spaces filled with fluid, usually recognized in newborns, but typically can be visible when they increase in size according to the patient's growth. The Claude Bernard-Horner Syndrome is characterized by miosis, palpebral ptosis and anhidrosis in patients with oculosympathetic pathway involvement, it is considered an infrequent iatrogenic neurological complication. We present a 4-year-old female patient with postnatal diagnosis of cervical cystic hygroma after a pathological study, which was surgically removed. Three days later, the patient presented ptosis of the left upper eyelid with the presence of miosis and decreased sweating on the same side, without alterations in the strength and movement of the left upper limb.

Myotonic dystrophy type 1: frequency of ophthalmologic findings / Distrofia miotônica tipo 1: frequência dos achados oftalmológicos

ABSTRACT The purpose of the study was to evaluate the frequency of ophthalmologic abnormalities in a cohort of myotonic dystrophy type 1 (DM1) patients and to correlate them with motor function. We reviewed the pathophysiology of cataract and low intraocular pressure (IOP). Method Patients were included after clinical and laboratory diagnosis and after signed informed consent. They were evaluated by Motor Function Measure scale, Portuguese version (MFM-P) and ophthalmic protocol. Results We evaluated 42 patients aged 17 to 64 years (mean 40.7 ± 12.5), 22 of which were men. IOP (n = 41) was reduced in all but one. We found cataract or positivity for surgery in 38 (90.48%) and ptosis in 23 (54.76%). These signs but not IOP were significantly correlated with severity of motor dysfunction. Abnormalities in ocular motility and stereopsis were observed. Conclusion Cataract and ptosis are frequent in DM1 and associated to motor dysfunction. Reduced IOP is also common, but appears not to be related with motor impairment.

RESUMO O objetivo do estudo foi avaliar a frequência das anormalidades oftalmológicas em uma coorte de pacientes com distrofia miotônica tipo 1 (DM1) correlacionando-as à função motora. Revisamos a fisiopatogenia da catarata e baixa pressão intraocular (PIO). Método Os pacientes foram incluídos após diagnóstico clínico-laboratorial de DM1. Aqueles que assinaram o termo de participação foram avaliados pela escala medida da função motora, versão em português (MFM-P) e protocolo oftalmológico. Resultados Avaliamos 42 pacientes de 17 a 64 anos (média 40,7 ± 12,5), 22 do sexo masculino. Encontramos catarata ou positividade de cirurgia em 38 (90,48%) e blefaroptose em 23 (54,76%) e esses sinais foram correlacionados significativamente à maior gravidade da disfunção motora. Baixa PIO também foi comum e não correlacionada à gravidade motora. Alterações da motilidade ocular e de estereopsia ocorreram. Conclusão Catarata e ptose palpebral são frequentes na DM1 e associadas à gravidade motora. Baixa PIO é comum e parece ser independente da evolução motora.

Plicatura e reinserção da aponeurose do músculo levantador da pálpebra superior com sutura contínua na correção cirúrgica da ptose palpebral leve e moderada-experiência pessoal / Plication and reinsertion of the aponeurosis of the lifting muscle of the upper eyelid with continuous suture in the surgical correction of light and moderate eyelid ptosis - personal experience

Introdução: A blefaroptose ou ptose palpebral caracteriza-se pelo posicionamento anômalo da pálpebra superior em relação à sua posição normal, que é de 1 a 2 mm abaixo do limbo superior da íris; pode variar, apresentando desde uma queda discreta, até a oclusão total da fenda palpebral. Em geral, trata-se de deficiência muscular ou nervosa, de etiologia congênita ou adquirida, que resulta na impossibilidade de elevação completa da pálpebra superior, podendo também ocorrer por desinserção aponeurótica. Apresenta-se neste trabalho a tática da sutura contínua da aponeurose do músculo levantador ao tarso, ou mesmo na sua plicatura, para o tratamento da ptose leve ou moderada. Métodos: No período de 2006 a 2012, foram realizadas 26 cirurgias, abordando a aponeurose do músculo levantador com encurtamento na relação 4:1, usando sutura contínua em duplo sentido, finalizando-a com ponto em formato de oito. Resultados: Em 88,32% dos casos, os resultados foram bons e, em 11,68%, regulares. Apenas um caso evoluiu com retração na pálpebra superior, elevando o sulco palpebral. Observou-se correção incompleta, com ptose residual de 2 a 4 mm em 2 casos, os quais foram submetidos a revisão cirúrgica após 6 meses.

Introduction: Blefaroptose or eyelid ptosis is characterized by the anomalous positioning of the upper eyelid in relation to its normal position, which is 1 to 2 mm below the upper margin of the iris. It can vary from a slight descent to a total occlusion of the eyelid slit. In general, whether caused by a muscular or nerve deficiency, congenital or acquired, it results in the impossibility to use the muscle to raise the eyelid. It can also occur due to the detachment of the aponeurosis. Presented in this study is the tactic of continuous suture of the aponeurosis of the lifting muscle at the tarsus or at its foldings, for the treatment of light or moderate ptosis. Methods: In the period from 2006 to 2012, we analyzed 26 eyelids submitted to surgical treatment. 24 were operated upon, addressing the aponeurosis of the raising muscle with a shortening in the relation of 4:1 and, in 2 cases, with the reinsertion of the aponeurosis in the raising muscle of the eyelid, using continuous two-way suture completing the same with a stitch in a figure eight. Results: In 88.32% of the cases, the results were considered good, and in 11.68% satisfactory.

Técnica de crawford en el tratamiento de la ptosis palpebral congénita / Crawford´s technique in the treatment of congenital palpebral ptosis

OBJETIVO: evaluar los resultados quirúrgicos de la técnica de Crawford mediante el empleo de silastic y polipropileno 4.0 y las complicaciones presentadas. MÉTODOS: se realizó un estudio descriptivo y prospectivo de 12 pacientes (16 párpados) con ptosis palpebral congénita desde enero 2009 a diciembre 2010 en la consulta de Oculoplastia del Instituto Cubano de Oftalmología "Ramón Pando Ferrer". Fueron excluidos los que tenían cirugía anterior de dicha enfermedad. RESULTADOS: el 83,3 % fueron del sexo masculino y el 91,6 % menores de 9 años de edad; de ellos, 4 casos de 0 a 2 y de 6 a 8, respectivamente; 3 casos en el grupo de 3 a 5 y solo 1 caso mayor de 9 años. El 75 % fueron ptosis congénita simple y el 56 % severas. La ptosis resultó corregida en 13 párpados para el 81 %. Con el uso desutura polipropileno 4.0, dos párpados se encontraron hipocorregidos (12,6 %) y seis corregidos (37,5 %); con silastic, un párpado quedó hipocorregido, (6,3 %) y siete corregidos (43,7 %). Se presentó el 25 % de complicaciones, 3 párpados hipocorregidos y un granuloma supraciliar. CONCLUSIONES: la ptosis resultó más frecuente en menores de 8 años del sexo masculino. Predominó la ptosis congénita simple, unilateral y severa. La técnica de Crawford resultó efectiva en la mayoría de los casos y similar con los dos materiales empleados.

OBJECTIVE: to evaluate the surgical outcomes of the Crawford technique through the use of silastic and polypropylene 4.0 materials and the identified complications. METHODS: a prospective and descriptive study of 12 patients (16 eyelids) with congenital ptosis conducted from January 2009 to December 2010 in the oculoplasty surgery in "Ramón Pando Ferrer" Cuban Institute of Ophthalmology. Those patients with prior surgery to treat this disease were excluded. RESULTS: in the study group, 83,3 % were males and 91,6 % were younger than 9 years old, 4 cases aged 0-2 and 6 8 years, respectively, 3 cases aged 3 to 5 and only one case older than 9 years. Seventy five percent of treated cases had simple congenital ptosis and 56 % suffered the severe form. Ptosis was corrected in 13 eyelids for 81 %. Using polypropylene sutures 4.0, two eyelids were undercorrected (12,6 % ) and 6 corrected (37,5 %) whereas the use of silastic resulted in one undercorrected eyelid (6,3 %) and 7 corrected ( 43,7 %). There was a 25 % complication rate, three undercorrected eyelids and one superciliary granuloma. CONCLUSIONS: ptosis was more frequent in male children younger than 8 years. Simple congenital ptosis predominated, either unilateral or severe. Crawford technique was effective in most cases and with similar results using both materials.

Bilateral ptosis and supranuclear downgaze paralysis

The purpose of this article is to highlight an uncommon combination of supranuclear downward gaze paralysis with bilateral eyelid ptosis in a 53-years-old man with a radiation induced midbrain tumor and to discuss the aspects regarding the centers and pathways that mediate supranuclear vertical gaze movements.

O objetivo deste artigo é ressaltar uma rara condição caracterizada por paralisia supranuclear do olhar conjugado para baixo associada a ptose palpebral bilateral em um homem de 53 anos, causada por tumor mesencefálico radio-induzido, e discutir os aspectos relacionados ao controle supranuclear dos movimentos oculares verticais.

Frontalis muscle transfer for the treatment of upper eyelid ptosis.

The management of severe blepharoptosis is problematic. A variety of surgical approaches do not yield good results especially in the presence of poor levator function. In this report, direct frontalis muscle transfer was used for the treatment of severe blepharoptosis with poor levator function. Twenty-one patients with severe blepharoptosis and poor levator function were operated during the period from 1995 to 1998 using this technique. Excellent and good results were achieved in 8 and 13 patients (38.1% and 61.9%), respectively. Two patients (9.5%) had complications. One was entropion and the other was hematoma, both of which were improved by reoperations. All patients had lagophthalmos postoperatively which subsided one month after surgery without complication. The patients were all satisfied.