Amiloidose de conjuntivas palpebrais inferiores: um relato de caso / Lower eyelid conjunctival amyloidosis: a case report

RESUMO A amiloidose é caracterizada pela deposição extracelular de fibrilas amiloides proteicas nos tecidos, incluindo conjuntiva, motivada por sua insolubilidade em proteínas proteolíticas. A amiloidose conjuntival, afetando especificamente a conjuntiva palpebral, é um achado raro na prática clínica. Os autores descrevem um caso de um paciente do sexo masculino, caucasiano, de 71 anos, apresentando lesões bilaterais localizadas na conjuntiva da pálpebra inferior, elevadas, bem delimitadas, amareladas, aliadas a pálpebras desestabilizadas. Foi realizada excisão cirúrgica das lesões, e o exame histológico confirmou se tratar de amiloidose conjuntival. Não houve recorrência após o procedimento. A amiloidose conjuntival afetando ambas as pálpebras inferiores é um achado raro na literatura. O manejo da amiloidose conjuntival depende da extensão do envolvimento local e do status sistêmico do paciente, variando de sintomático, com o uso de lubrificantes, até cirúrgico, com a remoção das lesões.

ABSTRACT Amyloidosis is characterized by extracellular deposition of protein amyloid fibrils in tissues, including conjunctiva, which are insoluble in proteolytic proteins. Conjunctival amyloidosis specifically in the palpebral conjunctiva is a rare finding in clinical practice. The authors described the case of a 71-year-old caucasian male patient, with bilateral lesions located in the lower eyelid conjunctiva, elevated, well-defined, yellowish, combined with destabilized eyelids. Surgical excision of the lesions was performed, and the histological examination confirmed conjunctival amyloidosis. There was no recurrence after the procedure. Conjunctival amyloidosis in both lower eyelids is a rare finding in the literature. The management of conjunctival amyloidosis depends on the extent of local involvement and patient's general health status, varying from symptomatic, with use of ocular lubricants, to surgical, by removing the lesions.

Retalho zigomático-palpebral: uma técnica opcional para a reconstrução da pálpebra inferior / Zygomatic-palpebral flap: an optional technique for lower eyelid reconstruction

Introdução: A reconstrução de pálpebra inferior representa um desafio peculiar ao cirurgião plástico, uma vez que traduz uma região facial de importância estética e funcional. O objetivo é apresentar uma técnica opcional para a reconstrução de defeitos da pálpebra inferior com o retalho cutâneo zigomáticopalpebral. Esta técnica mostra uma alternativa nos casos de pele escleroatrófica de pessoas idosas, bem como para pessoas jovens, que não apresentam redundância da pele palpebral superior, impossibilitando por exemplo o uso de enxertos de pálpebra superior ou retalhos como o de Fricke ou Tripier. Métodos: Os autores mostram a indicação do retalho em casos de ectrópio cicatricial, reconstrução após ressecção de neoplasias, associação com outros retalhos como de Hughes ou para cobertura de enxertos cartilaginosos. É um retalho de transposição composto por pele e subcutâneo, randomizado. A técnica baseia-se no uso de retalho local, de características muito semelhantes à área do defeito, o que permite mimetização, segurança e exequibilidade. Resultados: Os resultados imediatos e tardios são satisfatórios e bem aceitos pelos pacientes e pela equipe cirúrgica em termos estéticos e funcionais, com oclusão palpebral adequada e lubrificação ocular preservada. Conclusão: O retalho zigomático-palpebral apresenta como vantagens a simplicidade de execução, sangramento mínimo, baixa morbidade de área doadora e feito sob anestesia local. O objetivo de reconstruir defeitos da pálpebra é restaurar a anatomia e função. Esta pode ser uma tarefa desafiadora, especialmente em defeitos maiores que podem estar presentes nos procedimentos oncológicos em jovens e em idosos com pele escleroatrófica e mínima frouxidão.

Introduction: Lower eyelid reconstruction represents a unique challenge to plastic surgeons, since it involves a facial region of aesthetic and functional importance. The objective is to present an optional technique for the reconstruction of lower eyelid defects using zygomatic-palpebral skin flap. This technique represents an alternative in cases of scleroatrophic skin in older patients, and for young people who do not have an upper eyelid skin redundancy, which prevents, for example, the use of upper eyelid grafts or flaps such as those of Fricke or Tripier. Methods: The authors describe the flap used in cases of cicatricial ectropion and reconstruction after resection of neoplasms and association with other flaps, such as those of Hughes, or for coverage of cartilage grafts. The flap consisted of a transposition flap made up of skin and underlying subcutaneous tissues, randomized . The technique was based on the use of a local flap with highly similar characteristics to the defect area, which allowed it to mimic functions, while being safe and feasible. Results: The immediate and late results in terms of aesthetics and function were satisfactory and well accepted by patients and the surgical team, with adequate eyelid occlusion and preserved ocular lubrication. Conclusion: The advantages of the zygomatic-palpebral flap are its ease of execution, minimal bleeding, low morbidity of the donor area, and the use of local anesthesia. The reconstruction of eyelid defects aims to restore anatomy and function. This can be a challenging task, especially in cases with larger defects that may be present after oncologic procedures both in young and old patients presenting with scleroatrophic skin and minimal tissue laxity.

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).

Unilateral floppy eyelid syndrome with ipsilateral intolerance to brimonidine / Síndrome da palpebral flácida unilateral com intolerância a brimonidina ipsilateral

Abstract The authors report a case of unilateral floppy eyelid syndrome with ipsilateral intolerance to brimonidine in a 65-year-old man. The singularity of this case is the combination of two rare illnesses of great phlogistic potentiality in the same eye. The purpose of this article is to report a case of unilateral floppy eyelid syndrome with ipsilateral intolerance to brimonidine, emphasizing a possible relation between them. The result was a unilateral keratopathy that emulated an intraepithelial neoplasia. The key to solving the problem was an unexplained anterior uveitis that raised the suspicion of drug toxicity.The upper eyelid eversion of the affected eye during sleep seemed to be the common denominator of both ailments. The bizarre aspect of the epitheliopathy most likely resulted from the combination of trauma, insufficient lubrication, and drug intolerance.

Resumo Os autores relatam um caso de síndrome da pálpebra flácida unilateral com intolerância ipsilateral à brimonidina em um homem de 65 anos de idade. A singularidade deste caso é a combinação de duas doenças raras de grande potencialidade inflamatória no mesmo olho. O objetivo deste artigo é relatar um caso de síndrome da pálpebra flácida com intolerância ipsilateral à brimonidina, enfatizando uma possível relação entre eles. O resultado foi uma ceratopatia unilateral que simulou uma neoplasia intra-epitelial. A chave para resolver o problema foi uma uveíte anterior inexplicável que levantou a suspeita de toxicidade medicamentosa. A eversão da pálpebra superior do olho afetado durante o sono parece ser o denominador comum de ambas as doenças. O aspecto bizarro da epiteliopatia provavelmente resultou da combinação de trauma, lubrificação insuficiente e intolerância ao medicamento.

Eficacia del sondaje intraductal en la disfunción de las glándulas de Meibomio / Efficacy of intraductal probing in Meibonian gland dysfunction

Objetivo: determinar la efectividad del sondaje intraductal en el tratamiento de la disfunción de las glándulas de Meibomio. Métodos: se realizó un estudio descriptivo, longitudinal, prospectivo, en el Instituto Cubano de Oftalmología Ramón Pando Ferrer, en el período de marzo del año 2014 al mismo mes del año 2015 en 50 ojos (25 pacientes) con diagnóstico de disfunción de las glándulas de Meibomio, a los que se les realizó el sondaje intraductal. Resultados: el tiempo de ruptura de la película lagrimal preoperatorio mínimo fue de 1 segundo y el máximo de 9; al mes y a los seis meses el tiempo de ruptura de la película lagrimal mínimo era de 9 segundos y el máximo de 13. En el preoperatorio los 50 ojos tuvieron tiempo de ruptura de la película lagrimal ˂ 10 segundos; en cambio, al mes y a los seis meses el 50 por ciento tenían tiempo de ruptura de la película lagrimal de ≥ 10 segundos. El índice de enfermedad de la superficie ocular preoperatorio fue 87,80 ± 9,48; a la semana 64,00 ± 10,20; al mes 35,30 ± 9,55 y a los seis meses 36,10 ± 10,37, con diferencia significativa con respecto al preoperatorio ( p= 0,000); no entre el posoperatorio de uno y seis meses (p= 0,6135). Los lubricantes fueron necesarios en todos antes y después del procedimiento; pero al mes y a los seis meses todos los usaban con menor frecuencia. No hubo complicaciones; 5 ojos (10 por ciento) necesitaron un segundo tratamiento y el tiempo promedio fue de 4,4 meses. Conclusiones: el sondaje intraductal de las glándulas de Meibomio es un procedimiento único, seguro, con baja necesidad de retratamiento, que reduce la necesidad del uso de lubricantes, por lo que es un tratamiento efectivo en la disfunción de estas(AU)

Objective: to determine the effectiveness of intraductal probing in treatment of Meibonian gland dysfunction. Methods: a prospective, longitudinal and descriptive study was conducted in 50 eyes (25 patients), who had been diagnosed as Meibonian gland dysfunction and performed the intraductal probing at Ramon Pando Ferrer Cuban Institute of Ophthalmology in the period March 2014 to March 2015. Results: the minimal length of time of rupture of the lachrymal film before surgery was one second and the maximum 9 seconds; after one month and six months the minimal value was 9 seconds and the maximum value was 13. In the preoperative period, 50 eyes showed length of time of rupture of the lachrymal film below 10 seconds; however, one month and six months later, 50 percent of patients had length of time of rupture of the lachrymal film equal or over 10 seconds. The preoperative index of disease of the ocular surface was 87.80 ± 9.48; after one week was 64.00 ± 10.20; after one month 35.30 ± 9.55 and after six months 36.10 ± 10.37, with significant difference in the preoperative (p= 0.000); but it was non-significant between the postoperative term at one month and at six months (p= 0.6135). Oils were necessary in all the eyes before and after the surgical procedure; however, one month and six months later, all the patients used them less frequently. There were no complications, five eyes (10 percent) required a second treatment and the average time elapsed was 4.4 months(AU) Conclusions: the intraductal Meibonian gland probing is a safe, single procedure with almost no requirement for retreatment, which reduces the need for the use of oils and is and effective therapy for Meibonian gland dysfunction.

Retracción palpebral de causa neurológica: presentación de tres pacientes, interpretación patogénica / Eyelid retraction of neurologic origin: report of three cases

Eyelid retraction, has received limited attention and it has passively been interpreted as the result of an overactive levator palpebrae superioris muscle secondary to midbrain injury. However, eyelid retractions can occur in other neurological diseases, not directly related with the midbrain. We report three patients who developed eyelid retraction. One patient had a bilateral eyelid retraction, related with Creutzfeldt-Jakob disease (CJD). Another patient had a unilateral right eyelid retraction associated with a thalamic-mesencephalic infarct. The third patient had a bilateral pontine infarction on magnetic resonance imaging. In the patient with CJD, eyelid retraction did not subside. Among patients with infarctions, the retraction persisted after focal symptoms had subsided, showing an evolution that was apparently independent of the basic process. The analysis of these patients allows us to conclude that the pathogenesis of eyelid retraction includes supranuclear mechanisms in both the development and maintenance of the phenomenon. Unilateral or bilateral eyelid retraction does not alter the normal function of eyelid, which ever had normal close eye blink. In these reported cases, a hyperactivity of levator palpebrae superioris muscle was clinically ruled out.

Ptosis palpebral y diplopia como forma de presentación clínica de sarcoidosis, reporte de un caso / Right ptosis and diplopia as the primary presentation of sarcoidosis: a case report

Introducción: La sarcoidosis es una enfermedad granulomatosa sistémica de causa desconocida que compromete primariamente al pulmón. Si afecta al sistema nervioso, se denomina neurosarcoidosis. El objetivo del presente artículo es dar a conocer dicha patología y entregar elementos clínicos que permitan diagnosticarla tempranamente. Presentación del caso: Se presenta el caso de un paciente de género masculino de 24 años de edad, previamente sano, que consulta por ptosis palpebral derecha y diplopía intermitente de 3 meses de evolución, con estudio posterior mediante resonancia nuclear magnética de cerebro que corrobora la afección del sistema nervioso central y una biopsia estereotáxica cerebral que confirma la presencia de tejido cerebral con lesiones granulomatosas no caseificantes compatible con el diagnóstico de neurosarcoidosis. Discusión: La sarcoidosis se presentará en un 95% de los casos con síntomas y signos derivados de la afección pulmonar, afectándose el sistema nervioso sólo en un 5 a un 10% de los casos. El diagnóstico se basa en la existencia de manifestaciones clínico-radiológicas compatibles, la confirmación histológica de granulomas no caseificantes y la exclusión de otras enfermedades granulomatosas.Si bien el manejo de la sarcoidosis es sintomático, en el caso de la neurosarcoidosis existe consenso en que los pacientes deben ser tratados con corticoterapia

Orbital Sarcoidosis Presenting as Diffuse Swelling of the Lower Eyelid

The author reports a case of orbital Sarcoidosis in a 70-year-old female that initially presented as diffuse swelling of the lower eyelid. The patient complained of painless swelling of the left lower lid without palpable mass, and a computerized tomography (CT) scan of the orbit was unremarkable. A serum angiotensin converting enzyme level was elevated, and hilar lymphadenopathy was noted on the chest CT. The patient underwent surgical debulking for histologic confirmation, which led to a final diagnosis of sarcoidosis involving the orbital fat. Unexplained chronic eyelid swelling without a mass should be considered a possible ophthalmic manifestation of orbital sarcoidosis.

Solitary giant molluscum contagiosum presenting as lid tumor in an immunocompetent child.

We report the case of a three-year-old male child who presented with a single painless subcutaneously located upper lid mass of 1.2 × 1.5 cm with a central depression. The mass could be easily separated from overlying skin on complete excision biopsy and showed a never described before whitish brain like appearance consisting of multiple lobes and gyri, which histopathologically proved to be molluscum contagiosum (MC). Tests to investigate underlying immunodeficiency did not show any evidence of immunocompromised state.

Application of tele-ophthalmology in remote diagnosis and management of adnexal and orbital diseases.

Purpose: To assess the feasibility of making a diagnosis of adnexal and orbital diseases by Tele-ophthalmological means. Materials and Methods: Tele-consultation for eye diseases was done for 3497 patients from remote areas of Tamilnadu as part of the rural tele-ophthalmology project of a tertiary eye care hospital during a period of nine months from October 2004 to June 2005. These patients were comprehensively examined on-site by optometrists. Using digitized images sent by store and forward technique and videoconferencing, the ophthalmologist made a diagnosis and advised treatment. Results: Adnexal or orbital diseases were detected in 101 out of 3497 patients (2.88%). Medical treatment was advised to 13 of 101 patients (12.8%). Surgery was advised in 62 of 101 patients (61.28%) whereas 18 of 101 patients (17.8%) required further investigations at a tertiary center. Conclusion: It was feasible to apply the satellite based tele-ophthalmology set-up for making a presumptive diagnosis and planning further management of adnexal and orbital diseases based on live interaction and digital still images of the patients.

Lúpus discóide em pálpebras: relato de caso / Discoid lupus on the eyelids: case report

O lúpus discóide caracteriza-se por lesões limitadas à pele, eritematosas e recobertas por escamas brancas aderentes, que aparecem mais nas áreas expostas ao sol. Relatamos um caso de uma paciente feminina de 26 anos, com ardência e hiperemia dos olhos há meses, em tratamento de blefarite sem melhora. Apresentava ao exame lesões palpebrais ulceradas, que através do exame de imunofluorescência direta foram diagnosticadas como lúpus discóide. Diante de lesões palpebrais crônicas refratárias a tratamento clínico, mesmo na ausência de alterações nos exames complementares, deve-se realizar a biópsia incisional para elucidação do caso, e se necessário, o exame de imunofluorescência direta.

Discoid lupus is characterized by erythematosus lesions limited to the skin, covered by adherent white scales, which rise at places more exposed to the sun. A case of a 26 year-old woman, who was suffering for months from redness and burning of the eyes, and was been treated for blepharitis without resolution is reported. On the eyelids exam, ulcerated lesions were found, that were diagnosed as discoid lupus by immunofluorescence. When faced with chronic lesions on the eyelids that do not respond to medical treatment, even if the ancillary exams are normal, the incisional biopsy must be performed to elucidate the diagnosis and, if necessary, immunofluorescence should be done as well.

Fascitis necrosante palpebral y shock tóxico por Streptococcus pyogenes / Necrotizing fasciitis of the eyelids and toxic shock syndrome due to Streptococcus pyogenes

Necrotizing fasciitis (NF) is a serious infection that compromises subcutaneous tissue, fascia, and adipose tissue, with high mortality rate and sequelae. Extremities, trunk and pelvis are the most common body sites affected. Periorbital celullitis with necrotizing fasciitis of the eyelid is rare. We report the case of a three years old child with bilateral NF of the eyelids and toxic shock syndrome secondary to Streptococcus pyogenes infection ocurring after a minor skin trauma. Early recognition leading to intensive care treatment and prompt surgical debridement were critical in the favourable outcome of the child.

La fascitis necrosante (FN) es una infección grave de los tejidos subcutáneos, localizada más frecuentemente en extremidades, tronco y pelvis. El compromiso de la cara y la región palpebral es inusual. Reportamos el curso clínico de un niño de tres años, previamente sano, que presentó una FN palpebral bilateral asociado a shock tóxico por Streptococcus pyogenes, secundaria a un trauma localizado. El paciente requirió tratamiento en cuidado intensivo con resucitación enérgica, antimicrobianos, inmunoglobulina intravenosa y desbridamiento quirúrgico precoz, lo que permitió su evolución favorable.

case report of primary localized amyloidosis of eyelid with extensive calcification and ossification, clinically presenting as a bone tumor

Primary localized amyloidosis of eyelid is a localized type of amyloidosis without evidence of systemic involvement. We report a 75-year-old man suffering of unilateral [left] ptosis due to upper eyelid mass with bony consistency. Eye examination revealed upper lid mass attached to tarsus. No ocular infection or inflammation was found. Pathologist reported diffuse distribution of eosinophilic homogenous deposits of stroma that show apple green birefringence by polarized light compatible with amyloidosis. Primary localized amyloidosis may appear as a bony tumoral mass. It is important to consider secondary localized and systemic amyloidosis in differential diagnosis of the disease

Síndrome de Urbach-Wiethe: relato de caso / Urbach-Wiethe syndrome: a case report

Apresentação de um caso de síndrome de Urbach-Wiethe com manifestações típicas, inclusive oculares. Paciente do sexo feminino, 15 anos, com quadro de prurido ocular relacionado à presença de lesões papuliformes em margens palpebrais (blefarose moniliforme), em associação com outras alterações sistêmicas. O diagnóstico foi confirmado por meio de biópsia cutânea e foi instituído uso de lágrimas artificiais, com alívio parcial do sintoma. O objetivo do trabalho é relatar um caso com manifestações características da doença atendido no Setor de Oftalmologia da Faculdade de Medicina de Marília.

We present a case of Urbach-Wiethe syndrome with typical findings, including ocular lesions. A 15-year-old girl was referred to our department complaining of itchy eyelid lesions (moniliform blepharosis) associated with other systemic manifestations. Diagnosis was confirmed by performing skin biopsy. Artificial tears were prescribed, with partial relief of the symptom. The objective of the present study is to describe a typical case of Urbach-Wiethe syndrome attended at the Ophthalmologic Sector of the Medical School of Marília.

Leishmania mexicana infection of the eyelid in a traveler to Belize

A 50 year-old man, a United States resident, presented in Texas with a violaceous non-ulcerating lesion, involving the entire lower eyelid. The patient had traveled to a jungle area of Belize several hours drive from the capital city. Leishmania mexicana was isolated. The lesion only partially resolved after an initial course of sodium stibogluconate, requiring retreatment. At two years of follow-up, there was no relapse. The parasite isolated from the patient caused a progressive, non-ulcerating lesion in an experimental mouse footpad infection. This is an unusual case of cutaneous leishmaniasis in a traveler. Travelers must be educated about personal protective measures to prevent exotic infections acquired during travel.