Hemangioma de coroide e o desafio do diagnóstico diferencial / Choroidal hemangioma and the challenge of differential diagnosis

Resumo O hemangioma de coroide é um tumor benigno relativamente raro, que se apresenta de forma circunscrita ou difusa, sendo esta última normalmente associada à Síndrome de Sturge-Weber. Os tumores circunscritos manifestam-se de forma insidiosa, com o diagnóstico realizado comumente após o aparecimento de sintomas secundários. Apresentam como diagnóstico diferencial lesões graves e potencialmente letais, como melanoma de coroide e doença metastática. Neste relato descrevemos o caso de um hemangioma intraocular nodular avançado associado a descolamento hemorrágico da retina, evidenciando o desafio do diagnóstico diferencial devido às semelhanças clínicas e radiológicas compartilhadas pelos tumores.

Abstract Choroidal hemangioma is a fairly rare benign vascular tumor that can manifest in either circumscribed or diffuse type; the latter one is usually related to Sturge-Weber Syndrome. The circumscribed tumors have an insidious presentation and diagnosis is commonly made after the onset of secondary symptoms. Serious and potentially lethal lesions, such as choroidal melanoma and metastatic disease, may represent a differential diagnosis. In this report, we describe an advanced case of nodular hemangioma associated with hemorrhagic retinal detachment. This case highlights the challenge of differential diagnosis in intraocular tumors, due to their similar clinical and radiologic features.

Glaucoma neovascular y atrofia esencial de iris / Neovascular glaucoma and essential iris atrophy

Los glaucomas secundarios son de difícil manejo, independientemente de las causas. Entre ellos, el glaucoma neovascular representa un reto para los oftalmólogos por las causas que lo producen y la gran pérdida visual que provoca. De igual manera, el síndrome iridocorneoendotelial es una enfermedad poco frecuente. El glaucoma ocurre aproximadamente en el 50 por ciento de los casos en dependencia del síndrome que predomine, mucho más grave en la atrofia esencial del iris. Presentamos un caso clínico de una paciente femenina de 58 años de edad en quien aparecen en cada ojo, de manera independiente, estos dos tipos de glaucomas secundarios(AU)

Secondary glaucomas are always difficult to manage, no matter what their causes might be. Among them, neovascular glaucomas pose a challenge to ophthalmologists, due to the factors bringing them about and the great visual loss they produce. On the other hand, iridocorneal endothelial syndrome is an uncommon condition. Glaucoma develops in about 50 percent of the cases, depending on the prevailing syndrome, and is much more severe in essential iris atrophy. A clinical case is presented of a 58-year-old female patient with these two types of secondary glaucoma, one type in each eye(AU)

Glaucoma neovascular, complicación de la isquemia retiniana / Neovascular glaucoma, a retinal ischemia complication

Introducción: el glaucoma neovascular es un tipo de glaucoma secundario frecuente en los pacientes diabéticos, se produce por la formación de una membrana fibrovascular a nivel del ángulo camerular, como consecuencia de un estímulo angiogénico producido por enfermedades que generan isquemia ocular. Los pacientes con retinopatía diabética proliferativa pueden sufrir esta enfermedad de difícil tratamiento para el oftalmólogo, y que constituye una amenaza para la visión del paciente. Objetivo: revisar aspectos clínicos, patogenia, métodos para el diagnóstico y tratamiento terapéutico del glaucoma neovascular con vistas a prevenir o reducir la pérdida visual. Desarrollo: el glaucoma neovascular es una complicación de la diabetes mellitus y de otras enfermedades generales, que provoca una disminución importante de la visión, y en muchas ocasiones, ceguera. Las enfermedades oculares que con más frecuencia lo producen son la oclusión de la vena central de la retina, la retinopatía diabética proliferativa y el síndrome isquémico ocular, generando isquemia retiniana y coroidea con la consecuente formación de neovasos. Conclusiones: la educación al paciente diabético y el adecuado tratamiento terapéutico de la retinopatía diabética es importante para prevenir la aparición del glaucoma neovascular(AU)

Introduction: neovascular glaucoma is the type of secondary glaucoma common in diabetic patients; it is caused by the formation of fibrovascular membrane at the camerular angle as a result of angiogenic stimulus due to ocular ischemia-generating diseases. The proliferative diabetic retinopathy patients may suffer this difficult-to-treat disease that represents a threat to the vision of a patient. Objective: to review clinical aspects, pathogenenesis, diagnosis methods and treatment of the neovascular glaucoma with a view to preventing or reducing the vision loss. Development: neovascular glaucoma is a complication of diabetes mellitus and of other general diseases, which brings about significant reduction of vision and often blindness. The most frequent eye diseases responsible for this are central retinal vein occlusion, proliferative diabetic retinopathy and ocular ischemic syndrome, leading to retinal and choroid ischemia with resulting formation of neovessels. Conclusions: education aimed at diabetic patient and the adequate therapeutic treatment of the diabetic retinopathy is important to prevent the occurrence of neovascular glaucoma(AU)

Manejo de las complicaciones oftalmológicas de la Diabetes Mellitus / Management of ophthalmological complications of Diabetes Mellitus

Esta guìa contiene datos generales relacionados con la ceguera la edad en pacientes diabeticos no controlada. hay un incremento de casos por ceguera a nivel mundial que son de alta prevalencia y severidad. algunas clsificaciones de la diabetes mellitus oftalmopatìas; retinopatìa, opacidades del cristalino o cataratas, glaucoma, lesiones de la cornea, paresia o paralisis de musculos extraoculares secundario a neuropatìa. aunque existen alguna medidas de estricto control metabolico.

Neovascular Glaucoma Due to Branch Retinal Vein Occlusion Combined with Branch Retinal Artery Occlusion

Branch retinal artery occlusion (BRAO) and branch retinal vein occlusion (BRVO) rarely cause neovascular glaucoma (NVG). A 58-year-old woman with hypertension and type 2 diabetic mellitus complained of progressive visual loss in her right eye for the previous 3 months. At initial examination, visual acuity was 20 / 63 in the right eye. Angle neovascularization was observed and the intraocular pressure (IOP) was 30 mmHg in her right eye. Fundus examination and fluorescein angiography showed BRAO combined with BRVO. We immediately injected intravitreal and intracameral bevacizumab in her right eye. The next day, we performed scatter photocoagulation in the nonperfusion area. One month later, visual acuity was 20 / 20 in her right eye and the IOP was 17 mmHg with one topical antiglaucoma agent. The neovascularization had regressed completely. We report a case of unilateral NVG which was caused by BRAO with concomitant BRVO and advise close ophthalmic examination of the iris and angle in BRVO with BRAO.

Árboles de decisiones para el diagnóstico y tratamiento de pacientes con glaucoma neovascular / Decision trees for the diagnosis and treatment of patients with neovascular glaucoma

Mundialmente los estudios epidemiológicos relacionados con los glaucomas secundarios, como es el caso del neovascular, son escasos si se comparan con el glaucoma crónico simple.Desarrollo: se realizó una revisión bibliográfica sobre el diagnóstico y tratamiento del glaucoma neovascular. Se utilizó la técnica de árboles de decisiones, basada en las historias clínicas de los pacientes, así como en el resultado obtenido del análisis estadístico multivariado del estudio. Se expusieron desde la perspectiva de investigación de desarrollo tecnológico, los resultados alcanzados del análisis teórico y estadístico, que facilitaron el logro de árboles de decisiones como expresión de uniformidad del diagnóstico y tratamiento

Epidemiological studies related to secondary glaucoma all over the world, as it is the case of neovascular one, they are rare when compared with simple chronic glaucoma.Development: a literature review on diagnosis and treatment of neovascular glaucoma was carried out. Decision trees technique, based on medical histories of patients as well as the results of the multivariate statistical analysis of the study was used. The results of the statistical and theoretical analysis were presented which facilitated the achievement of decision trees as an expression of diagnosis and treatment uniformity

Intravitreal cysticercosis presenting as neovascular glaucoma.

We report two cases of intraocular cysticercosis which showed a peculiar presentation of neovascular glaucoma which is hitherto unreported. Two young adults presented with symptoms of raised intraocular pressure due to neovascular glaucoma. On dilated fundus examination both were found to have dead intravitreal cysticercosis. The cysts were removed by a three-port vitrectomy and intracameral injection of bevacizumab was given to help in the regression of rubeosis. Trabeculectomy had to be combined in one case. The intraocular pressure returned to normal. No recurrence of rubeosis was seen even after one year.

Neovascular Glaucoma Following Stereotactic Radiosurgery for an Optic Nerve Glioma: A Case Report

A 13-year-old girl with a right intraorbital optic nerve glioma (ONG) was referred to our glaucoma clinic because of uncontrolled intraocular pressure (IOP) in her right eye. The IOP reached as high as 80 mmHg. Several months earlier, she had undergone stereotactic image-guided robotic radiosurgery using the CyberKnife for her ONG; the mass had become smaller after treatment. Her visual acuity was no light perception. Slit lamp examination revealed rubeosis iridis, a swollen pale optic disc, and vitreous hemorrhage. After medical treatment, the IOP decreased to 34 mmHg, and no pain was reported. Although the mass effect of an ONG can cause neovascular glaucoma (NVG), this case shows that stereotactic radiosurgery may also cause NVG, even after reducing the mass of the tumor. Patients who undergo radiosurgery targeting the periocular area should be followed carefully for complications.

Comportamiento clínico epidemiológico del glaucoma neovascular en un servicio de glaucoma / Clinical epidemic behavior of the neovascular glaucoma in a glaucoma service

Entre las enfermedades oculares, el glaucoma, está contemplado entre aquellas que más cambios han sufrido en muchos de sus variados aspectos con el decursar de los años. Objetivo: Describir el comportamiento clínico epidemiológico del glaucoma neovascular en el Servicio de Glaucoma del Centro Oftalmológico Carlos J Finlay de la provincia de Camagüey. Método: Se realizó un estudio descriptivo, longitudinal y retrospectivo para determinar el comportamiento clínico epidemiológico del glaucoma neovascular en pacientes atendidos en dicho centro durante el período del 1 de enero del 2006 al 31 de octubre del 2007. El universo estuvo constituido por sesenta pacientes y la muestra quedó constituida por cincuenta y dos de ellos. Las variables estudiadas fueron: grupos de edades, sexo, color de la piel, antecedentes patológicos personales generales, antecedentes patológicos personales oculares, síntomas, signos, agudeza visual y variantes de tratamiento en cada paciente. Resultados: Se encontraron un total de cincuenta y dos pacientes con glaucoma neovascular. Predominaron el grupo de edades de más de 60 años, el sexo masculino y la raza blanca. Primó la Diabetes Mellitus como antecedente patológico personal general y la Retinopatía Diabética como antecedente patológico ocular. Conclusiones: El glaucoma neovascular ocupa un lugar importante dentro de la oftalmología, si se tiene en cuenta sus fatales consecuencias oculares, se expone la descripción de sus características.

Among the ocular diseases, glaucoma is considered among those that more changes have suffered in many of its varied aspects with the course of the years. Objective: To describe the clinical epidemic behavior of the neovascular glaucoma in the Glaucoma Service at the Ophthalmologic Center Carlos J Finlay" of Camagüey province. Method: A descriptive, longitudinal and retrospective study was conducted to determine the clinical epidemic behavior of the neovascular glaucoma in patients attended in the Glaucoma Service at the Ophthalmologic Center Carlos J. Finlay of Camagüey province from January 1st, 2006 to October 31st, 2007. The universe was constituted by sixty patients and the sample was conformed by fifty-two of them. The studied variables were: age groups, sex, skin color, general personal pathological antecedents, ocular personal pathological antecedents, symptoms, signs and visual acuity and treatment variants in each patient. Results: A total of fifty-two patients with neovascular glaucoma were found. The age group of more than 60 years, the masculine sex and the white race prevailed. Diabetes mellitus as general personal pathological antecedent and diabetic retinopathy as ocular pathological antecedent predominated. Conclusions: The neovascular glaucoma occupies an important place in ophthalmology, if it is take into account its ocular fatal consequences; the description of its characteristics is exposed.

Intravitreal Bevacizumab (Avastin) Treatment of Neovascular Glaucoma in Ocular Ischemic Syndrome

We report a case of ocular ischemic syndrome accompanied by neovascular glaucoma that was successfully treated with Bevacizumab. A 70-year-old male patient diagnosed with neovascular glaucoma of the left eye 3-4 years prior complained of continuous left eye pain and declining visual acuity despite receiving the latest treatment methods. At the time of admission the patient had no light perception in the left eye and his intraocular pressure was 30 mmHg. Anterior segment and fundus examinations revealed neovascularization of the iris and stenosis of the retinal vessel. Hypofluorescence of the choroid and retinal vessels was observed on fluorescence fundus angiography. Left internal carotid artery stenosis was observed on a brain MRI. Despite being treated with eye solution and oral medication, intraocular pressure was not controlled. After 7 days, we performed an intravitreal Bevacizumab 1.25 mg/0.05mL injection. One day after the intravitreal Bevacizumab injection, the neovascularization had nearly regressed and intraocular pressure was 30 mmHg. Intravitreal Bevacizumab injection produced regression of neovascularization and proved effective for treatment of neovascular glaucoma in this case of ocular ischemic syndrome.

Intravitreal Bevacizumab (Avastin) Treatment of Neovascular Glaucoma in Ocular Ischemic Syndrome

We report a case of ocular ischemic syndrome accompanied by neovascular glaucoma that was successfully treated with Bevacizumab. A 70-year-old male patient diagnosed with neovascular glaucoma of the left eye 3-4 years prior complained of continuous left eye pain and declining visual acuity despite receiving the latest treatment methods. At the time of admission the patient had no light perception in the left eye and his intraocular pressure was 30 mmHg. Anterior segment and fundus examinations revealed neovascularization of the iris and stenosis of the retinal vessel. Hypofluorescence of the choroid and retinal vessels was observed on fluorescence fundus angiography. Left internal carotid artery stenosis was observed on a brain MRI. Despite being treated with eye solution and oral medication, intraocular pressure was not controlled. After 7 days, we performed an intravitreal Bevacizumab 1.25 mg/0.05mL injection. One day after the intravitreal Bevacizumab injection, the neovascularization had nearly regressed and intraocular pressure was 30 mmHg. Intravitreal Bevacizumab injection produced regression of neovascularization and proved effective for treatment of neovascular glaucoma in this case of ocular ischemic syndrome.

Glaucoma neovascular: reporte de un caso / Neovascular glaucoma: a case report

El glaucoma neovascular es una forma de glaucoma secundario, de difícil tratamiento y pronóstico, como consecuencia de una isquemia retiniana. Puede ser identificado con un mejor conocimiento de las características de la enfermedad. Se presenta un caso típico secundario probablemente a una retinopatía diabética, con manifestaciones clínicas y de medios diagnósticos evidentes, se expone su evolución, tratamiento y pronóstico.

The neovascular glaucoma is a form of secondary glaucoma, of difficult treatment and prognosis, as a result of an ischemia retinae. It can be identified with a better knowledge of the characteristics of the disease. A typical secondary case probably to a diabetic retinopathy is presented, with clinical manifestations and diagnostic evident means, it is exposed its evolution, treatment and prognosis.

Glaucoma neovascular: estudo descritivo dos aspectos epidemiológicos. Proposta de um fluxograma na abordagem terapêutica / Neovascular glaucoma: epidemiology and prognostic factors. Proposal of a flow chart to quideguide the treatment

Objetivo: Avaliar as causas de glaucoma neovascular (GNV), bem como os fatores que influenciam prognóstico e o resultado do tratamento efetuado. Métodos: Estudou-se retrospectivamente um grupo de 38 pacientes com diagnóstcos de GNV atendidos consecutivamentes no setor de Glaucoma da UNICAMP entre setembro de 1996 e março de 1997. Resultados: A principal causa de GNV encontrada foi retinopatia diabética proliferativa (RDP)em 18 pacientes (47,4 por cento), seguida de oclusäo da veia central de retina (OVCR) em 14 (36,8 por cento). O único fator progóstico positivamente correlacionado à acuidade visual final foi a acuidade visual inicial (p=0,004). Näo houve associaçäo entre pressäo intraocular (PIO) inicial e acuidade visual final, nem tampouco entre extensäo de goniossinéquias e acuidade visual final(p>0,05). Entre os 38 pacientes, 8(21,1por cento) foram submetidos a cirurgia, onde observamos uma diminuiçäo significativa da PIO de 39,75ñ10,99mmHg para 21,88ñ12,14mmHg(p=0,01,)5(13,1por5 cento)obtiveram reduçäo da PIO de 31,4ñ7,4mmHg para 16,0ñ4,6 mmHg graças a tratamento clínico da PIO( medicaçäo anti-glaumatosa + ablaçäo retiniana) (p=0,01).Os demais 25 pacientes (65,8 por cento) näo apresentavam prognóstico visual suficiente que justificasse cirurgia (acuidade visual menor ou igual a percepçäo luminosa). Ao final do período de seguimento, 71,1 por cento dos pacientes apresentaram acuidade visual pior ou igual à percepçäo de luminosa. Conclusäo: O GNV mostrou ser moléstia de difícil controle terapêutico e com prognóstico visual ruim. Na tentativa de minimizar esta evoluçäo desfavorável, propusemos um fluxograma de abordagem do paciente com GNV.

Glaucoma neovascular. Ciclofotocoagulación diascleral con LASER semiconductor de diodos. Informe preliminar de 12 casos / Neovascular glaucoma: ciclo-photo-coagulation by diod semi-conductive LASER

Se efectuó ciclofotocoagulación diascleral (CFCD) con LASER semiconductor de diodos en 14 ojos de 12 pacientes con glaucoma neovascular avanzado, los parámetros que utilizamos fueron: 1750 a 2000 mW de poder, 2 segundo de duración, 20 a 30 aplicaciones 1 mm posterior al limbo córneo-esclerar, con una sonda ®G¼ de iris Medical Instruments, la TIO peroperatoria promedio fue de 47 ñ 13 mm Hg; a los 6 meses se registró una TIO promedio de 30 ñ 18 mm Hg y al año 30 ñ 15 mm Hg en 7 de los ojos en estudio (prueba t de Student pareada p= 0.03). El promedio de medicamentos antiglaucomatosos utilizados preoperatoriamente fue 2.5 ñ 0.62 a los 6 meses y al año se emplearon 1.57 ñ 0.72. Todos los ojos tratados con CFCD presentaron inflamación conjuntival leve y fenómeno de Tyndall+ que se resolvió en el transcurso de una a dos semanas. Estos resultados sugieren que la CFCD con LASER semiconductor de diodos pueden ser de utilidad en el tratamiento de glaucoma neovascular