Angiografía mediante tomografía de coherencia óptica en patología macular vascular / Optical coherence tomography angiography in macular vascular pathology

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Retraso en el tratamiento de la degeneración macular asociada a la edad en España / Delay in age-related macular degeneration treatment in Spain

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Incidencia de los tipos de neovascularización asociada a la edad en práctica clínica habitual en España / The incidence of subtypes of age-related choroidal neovascularisation in clinical practice in Spain

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Teleoftalmología para el cribado de la retinopatía diabética: experiencia de 8 años / Tele-ophthalmology for diabetic retinopathy screening: 8 years of experience

OBJETIVO: Mostrar los resultados de un programa de cribado de la retinopatía diabética desde el ámbito de la atención primaria. MÉTODOS: Se realizó un estudio retrospectivo de los datos recogidos mediante registro informático automatizado desde el 1 de enero de 2007, hasta el 31 de diciembre de 2015. RESULTADOS: El número de pacientes cribados aumentó progresivamente desde 7.173 en 2007 hasta 42.339 en 2015. Asimismo, la habilidad de los médicos de familia en la interpretación de retinografías mejoró progresivamente, clasificando como normales un 55% de las retinografías en 2007, llegando a un 68% en 2015. El número de retinografías consideradas no valorables disminuyó a lo largo del programa, registrándose picos de hasta el 15% y situándose en un 7% en 2015, en parte gracias a un cambio en la normativa, que permitió dilatar la pupila. Se detectaron cada vez menos casos graves, pasándose de un 14% de retinopatías diabéticas no proliferativas severas y proliferativas al inicio del programa a un 3% en 2015. CONCLUSIONES: El cribado de la oftalmopatía diabética mediante teleoftalmología se reveló como un método muy valioso en una población en crecimiento como es la diabética, facilitando las revisiones al usuario, ayudando a descongestionar los servicios de atención especializada y detectando los casos tratables con mayor precocidad. Sin embargo, los efectos de la implantación no fueron inmediatos, obteniéndose unos resultados modestos en los primeros años del proyecto, que mejoraron en los años subsiguienteS

PURPOSE: To describe the results of a diabetic retinopathy screening program implemented in a primary care area. METHODS: A retrospective study was conducted using data automatically collected since the program began on 1 January 2007 until 31 December 2015. RESULTS: The number of screened diabetic patients has progressively increased, from 7,173 patients in 2007 to 42,339 diabetic patients in 2015. Furthermore, the ability of family doctors to correctly interpret retinographies has improved, with the proportion of retinal images classified as normal having increased from 55% in 2007 to 68% at the end of the study period. The proportion of non-evaluable retinographies decreased to 7% in 2015, having peaked at 15% during the program. This was partly due to a change in the screening program policy that allowed the use of tropicamide. The number of severe cases detected has declined, from 14% with severe non-proliferative and proliferativediabetic retinopathy in the initial phase of the program to 3% in 2015. CONCLUSIONS: Diabetic eye disease screening by tele-ophthalmology has shown to be a valuable method in a growing population of diabetics. It leads to a regular medical examination of patients, helps ease the workload of specialised care services and favours the early detection of treatable cases. However, the results of implementing a program of this type are not immediate, achieving only modest results in the early years of the project that have improved over subsequent years

Tele-ophthalmology for diabetic retinopathy screening: 8 years of experience. / Teleoftalmología para el cribado de la retinopatía diabética: experiencia de 8 años.

PURPOSE: To describe the results of a diabetic retinopathy screening program implemented in a primary care area. METHODS: A retrospective study was conducted using data automatically collected since the program began on 1 January 2007 until 31 December 2015. RESULTS: The number of screened diabetic patients has progressively increased, from 7,173 patients in 2007 to 42,339 diabetic patients in 2015. Furthermore, the ability of family doctors to correctly interpret retinographies has improved, with the proportion of retinal images classified as normal having increased from 55% in 2007 to 68% at the end of the study period. The proportion of non-evaluable retinographies decreased to 7% in 2015, having peaked at 15% during the program. This was partly due to a change in the screening program policy that allowed the use of tropicamide. The number of severe cases detected has declined, from 14% with severe non-proliferative and proliferativediabetic retinopathy in the initial phase of the program to 3% in 2015. CONCLUSIONS: Diabetic eye disease screening by tele-ophthalmology has shown to be a valuable method in a growing population of diabetics. It leads to a regular medical examination of patients, helps ease the workload of specialised care services and favours the early detection of treatable cases. However, the results of implementing a program of this type are not immediate, achieving only modest results in the early years of the project that have improved over subsequent years.

Espesor y volumen macular normal, mediante tomografía de coherencia óptica de dominio espectral, en nuestra población de referencia / Normal macular thickness and volume using spectral domain optical coherence tomography in a reference population

Objetivo: Establecer los valores de normalidad de espesor y volumen macular obtenidos mediante SD-OCT Cirrus (Carl ZeissMeditec, Dublín, CA, EE. UU.). Secundariamente, evaluar la asociación entre espesor y volumen macular, sexo y edad. Material y método: Estudio prospectivo, con pacientes que fueron visitados en la unidad de retina del HUNSC y solo presentaban enfermedad retiniana en uno de los ojos. Todos los protocolos Macular Cube 512 × 128 fueron realizados por un mismo operador. De cada paciente, solo se analizó el ojo sano. Resultados: Se analizaron 100 ojos de 100 pacientes. El espesor foveal central medio fue 261,31 ± 17,67 μm, siendo significativamente (p < 0,05) mayor en hombres (267,74 ± 16,98 μm) que en mujeres (255,60 ± 16,40 μm). La media obtenida para el volumen del cubo fue de 10,09 ± 0,37 mm3 y para el espesor medio del cubo de 280,33 ± 10,34 μm; no encontrando diferencias estadísticamente significativas entre sexos (p < 0,05). El espesor macular medio es menor a nivel central, aumenta en el anillo perifoveal interno y disminuye a continuación en el anillo perifoveal externo. Asimismo, de todos los cuadrantes el de mayor espesor es el nasal (328,27 ± 12,96 μm), seguido del superior (326,27 ± 11,89 μm), inferior (322,53 ± 12,37 μm) y por último, el de menor espesor es el temporal (313,35 ± 14,20 μm). La edad media de los pacientes incluidos es de 60,86 ± 14 años. Conclusión: El espesor foveal central medio y el espesor del anillo perifoveal interno son significativamente mayores en hombres que en mujeres. Tanto el volumen como el espesor medio del cubo, así como los sectores nasales y el sector supero interno, decrecen con la edad, únicamente de forma significativa en las mujeres (AU)

Objective: To establish normal values of macular thickness and volume obtained by the Cirrus SD-OCT (Carl ZeissMeditec, Dublin, CA, U.S.A.). Secondly, to assess the association between macular thickness and volume, sex and age. Material and methods: A prospective study was conducted on patients who were seen in a hospital Retina Unit, and who only had retinal disease in one eye. All the Macular Cube 512 × 128 scan protocols were performed by the same operator. Only the healthy eye was scanned in each patient. Results: A total of 100 eyes of 100 patients were analysed. The mean central foveal thickness was 261.31 ± 17.67 microns, and was significantly (P<0.05) higher in males (267.74 ± 16.98 microns) than in females (255.60 ± 16.40 microns). The mean obtained for the volume of the cube was 10.09 ± 0.37 mm 3, and the mean thickness of 280.33 ± 10.34 cube um, with no statistically significant differences between gender being found (P<0.05). The mean macular thickness is less at central level, increases in the inner perifoveal ring, and then decreases in the outer perifoveal ring. Furthermore, of all quadrants the greatest thickness was the nasal (328.27 ± 12.96 microns), followed by the upper (326.27 ± 11.89 microns), lower (322.53 ± 12.37 mm) sectors, with the temporal sector being the thinnest (313.35 ± 14.20 microns). The mean age of the patients was 60.86 ± 14 years. Conclusion: The mean central foveal thickness and the thickness of the inner perifoveal ring are significantly higher in men than in women. Both the mean volume and thickness of the cube, as well as nasal and inner superior sectors decrease with age, being significantly only in women (AU)

[Normal macular thickness and volume using spectral domain optical coherence tomography in a reference population]. / Espesor y volumen macular normal, mediante tomografía de coherencia óptica de dominio espectral, en nuestra población de referencia.

OBJECTIVE: To establish normal values of macular thickness and volume obtained by the Cirrus SD-OCT (Carl ZeissMeditec, Dublin, CA, U.S.A.). Secondly, to assess the association between macular thickness and volume, sex and age. MATERIAL AND METHODS: A prospective study was conducted on patients who were seen in a hospital Retina Unit, and who only had retinal disease in one eye. All the Macular Cube 512 × 128 scan protocols were performed by the same operator. Only the healthy eye was scanned in each patient. RESULTS: A total of 100 eyes of 100 patients were analysed. The mean central foveal thickness was 261.31 ± 17.67 microns, and was significantly (P<.05) higher in males (267.74 ± 16.98 microns) than in females (255.60 ± 16.40 microns). The mean obtained for the volume of the cube was 10.09 ± 0.37mm 3, and the mean thickness of 280.33 ± 10.34 cube um, with no statistically significant differences between gender being found (P<.05). The mean macular thickness is less at central level, increases in the inner perifoveal ring, and then decreases in the outer perifoveal ring. Furthermore, of all quadrants the greatest thickness was the nasal (328.27 ± 12.96 microns), followed by the upper (326.27 ± 11.89 microns), lower (322.53 ± 12.37mm) sectors, with the temporal sector being the thinnest (313.35 ± 14.20 microns). The mean age of the patients was 60.86 ± 14 years. CONCLUSION: The mean central foveal thickness and the thickness of the inner perifoveal ring are significantly higher in men than in women. Both the mean volume and thickness of the cube, as well as nasal and inner superior sectors decrease with age, being significantly only in women.

[Guidelines of clinical practice of the SERV (Spanish Retina and Vitreous Society): management of ocular complications of diabetes. Diabetic retinopathy and macular oedema]. / Guías de práctica clínica de la SERV: manejo de las complicaciones oculares de la diabetes. Retinopatía diabética y edema macular.

OBJECTIVE: Diabetes mellitus is considered the most common cause of blindness in the working population of industrialized countries, with diabetic macular edema being the most common cause of decreased visual acuity and proliferative diabetic retinopathy (PDR) being responsible for the most severe visual deficits. We have therefore tried to establish a guide for clinical intervention whose purpose is to provide orientation on the treatment of diabetic retinopathy and its complications. This is necessary at a time when many treatment options have emerged whose role is not yet fully defined. METHOD: A group of expert retina specialists selected by the SERV (Vitreous-Retina Spanish Society) assessed the published results of different treatment options currently available, suggesting lines of action according to the degree of diabetic retinopathy present and the presence or absence of macular edema. RESULTS: PDR is primarily treated with pan-retinal photocoagulation. For clinically significant diabetic macular edema without signs of vitreomacular traction, the treatment of choice continues to be focal/grid photocoagulation. Similarly, retinovitreal surgery is indicated for both conditions. The use of antiangiogenic drugs was also analyzed but remains inconclusive. CONCLUSION: Laser therapy is effective in the management of diabetic retinopathy and diabetic macular edema. The role of antiangiogenics is not yet sufficiently defined.

Guías de Práctica Clínica de la SERV: Manejo de las complicaciones oculares de la diabetes. Retinopatía diabética y edema macular / Guidelines of Clinical Practice of the SERV: Management of ocular complications of diabetes. Diabetic retinopathy and macular oedema

Objetivo: La diabetes mellitus está considerada como la causa más frecuente de ceguera en lapoblación activa en los países industrializados,siendo el edema macular diabético la causa más frecuentede disminución de la agudeza visual y laretinopatía diabética proliferante la responsable delos déficit visuales más severos. Por ello hemosintentado establecer una guía de actuación clínicacuyo propósito es proporcionar unas directrices quesirvan de orientación para el tratamiento de la retinopatía diabética y sus complicaciones. Esto sehace necesario en un momento en el que han aparecidonumerosas alternativas terapéuticas cuyo papelaún no está completamente definido.Método: Un grupo de expertos retinólogos seleccionadospor la SERV han evaluado los resultadospublicados sobre las distintas opciones terapéuticasque existen en la actualidad, en base a lo cual sesugieren líneas de actuación según el grado de retinopatíadiabética que presenta el paciente y la presenciao no de edema macular.Resultados: El tratamiento princeps de la RDP esla panretinofotocoagulación (PFC). El tratamientode elección en el edema macular diabético clínicamentesignificativo sin signos de tracción vítreomacular continúa siendo la fotocoagulaciónfocal/rejilla. La cirugía retinovítrea tiene así mismosus indicaciones en ambas afecciones. Se discute eluso de fármacos antiangiogénicos.Conclusión: La laserterapia es efectiva en el manejode la RD y del EMD. El papel de los antiangiogénicosaún no está suficientemente definido (AU)

Objective: Diabetes mellitus is considered the most common cause of blindness in the working populationof industrialized countries, with diabetic macularedema being the most common cause of decreasedvisual acuity and proliferative diabetic retinopathy(PDR) being responsible for the most severevisual deficits. We have therefore tried to establisha guide for clinical intervention whose purpose is toprovide orientation on the treatment of diabetic retinopathyand its complications. This is necessary at a time when many treatment options have emergedwhose role is not yet fully defined.Method: A group of expert retina specialists selectedby the SERV (Vitreous-Retina Spanish Society)assessed the published results of different treatmentoptions currently available, suggesting lines ofaction according to the degree of diabetic retinopathypresent and the presence or absence of macularedema.Results: PDR is primarily treated with pan-retinalphotocoagulation. For clinically significant diabeticmacular edema without signs of vitreomacular traction,the treatment of choice continues to befocal/grid photocoagulation. Similarly, retinovitrealsurgery is indicated for both conditions. The use ofantiangiogenic drugs was also analyzed but remainsinconclusive.Conclusion: Laser therapy is effective in the managementof diabetic retinopathy and diabetic macularedema. The role of antiangiogenics is not yet sufficiently defined (AU)

[Review of the protocol for the treatment of diabetic retinopathy]. / Revisión del protocolo para el tratamiento de la retinopatía diabética.

We present general guidelines to help us with the treatment of diabetic retinopathy (DR) at a time when numerous therapeutic alternatives have been developed although their role has not yet been adequately defined. This protocol is not directed at experienced retinologists but rather at general ophthalmologists who require a practical and up to date guide of a pathology as prevalent as RD. The different therapeutic options available, and their most accepted indications depending on the degree of diabetic retinopathy that patients have, are reviewed. We propose what to do in cases of mild, moderate and severe non-proliferative diabetic retinopathy as well as in cases of proliferative diabetic retinopathy (panphotocoagulation/antiangiogenic drugs/vitreorretinal surgery). The treatment of diabetic macular edema depending on its angiographic and topographic characteristics is also discussed. The importance of metabolic control of the patient is stressed (tight glycemic control, control of arterial hypertension and dyslipemia) in aiding the treatment of diabetic retinopathy. This therapeutic proposal has been discussed widely by retinologists from the four largest hospitals in the Canary Islands, and is therefore an agreed text based on recent scientific literature.

Revisión del protocolo para el tratamiento de la retinopatía diabética / Revision of the protocol for the treatment of diabetic retinopathy

Se presentan unas directrices generales con el objetivode proporcionar una orientación en el manejo dela retinopatía diabética (RD) en un momento en elque han aparecido numerosas alternativas terapéuticascuyo papel aún no está suficientemente definido.Este protocolo está dirigido no a retinólogos expertossino a oftalmólogos generales que precisen una guíapráctica y actualizada de una patología tan prevalentecomo la RD.En este documento se revisan las distintas opcionesterapéuticas disponibles y su indicación más aceptadasegún el grado de retinopatía diabética que presenteel paciente. Se plantea así que hacer con unaretinopatía diabética no proliferativa (RDNP) leve,moderada (ambas control por su oftalmólogo dezona) y severa (en casos muy seleccionados puedeconsiderarse la realización de una panfotocoagulación–PFC–). Los pacientes con retinopatía diabéticaproliferativa (RDP) serán tratados en los centroshospitalarios (PFC/fármacos antiangiogénicos/cirugía vítreorretiniana –CVR–) hasta que sea controladosu proceso. Se discute asimismo el tratamientodel edema macular (EM) diabético según sus característicasangiográficas y topográficas.Se hace hincapié en la importancia del control metabólicodel paciente (optimizar el control glucémico,de su hipertensión arterial y de la dislipemia) comotratamiento necesario y coadyuvante de su RD.Esta propuesta terapéutica ha sido ampliamente discutidapor retinólogos de los cuatro grandes hospitalesde Canarias por lo que se trata de un texto consensuadobasado en la bibliografía científica actual(AU)

We present general guidelines to help us with thetreatment of diabetic retinopathy (DR) at a timewhen numerous therapeutic alternatives have beendeveloped although their role has not yet been adequatelydefined. This protocol is not directed atexperienced retinologists but rather at general ophthalmologistswho require a practical and up to dateguide of a pathology as prevalent as RD.The different therapeutic options available, andtheir most accepted indications depending on thedegree of diabetic retinopathy that patients have, arereviewed. We propose what to do in cases of mild,moderate and severe non-proliferative diabetic retinopathyas well as in cases of proliferative diabeticretinopathy (panphotocoagulation/antiangiogenicdrugs/vitreorretinal surgery). The treatment of diabeticmacular edema depending on its angiographicand topographic characteristics is also discussed.The importance of metabolic control of thepatient is stressed (tight glycemic control, control of arterial hypertension and dyslipemia) in aidingthe treatment of diabetic retinopathy.This therapeutic proposal has been discussedwidely by retinologists from the four largest hospitalsin the Canary Islands, and is therefore an agreedtext based on recent scientific literature(AU)

[Ischemic anterior syndrome and intraocular calcification]. / Síndrome de isquemia anterior y calcificación intraocular

OBJECTIVE/METHODS: We report the case of a sixty-year-old female that following retinal detachment surgery in her left eye, presented with a clinical picture that initially was misdiagnosed as endophthalmitis. RESULTS/CONCLUSIONS: The patient suffered an anterior ischemic syndrome secondary to the retinal surgery, and accidentally, the presence of an intraocular calcification was discovered. We study the influence of the osteoblastic neoformation in the ischemic process.

Síndrome de isquemia anterior y calcificación intraocular / Isquemic anterior syndrome and intraocular calcification

Objetivo/Métodos: Presentamos el caso de una mujer de 60 años que tras ser intervenida por desprendimiento de retina, en su ojo izquierdo, presenta cuadro clínico que inicialmente se confunde con endoftalmitis. Resultados/Conclusiones: La paciente presentó un síndrome de isquemia anterior posterior a la intervención quirúrgica, descubriéndose, de forma casual, la presencia de una calcificación intraocular. Valoramos si en el proceso isquémico influyó la neoformación osteoblástica (AU)

Objective/Methods: We report the case of a sixty-year-old female that following retinal detachment surgery in her left eye, presented with a clinical picture that initially was misdiagnosed as endophthalmitis. Results/Conclusions: The patient suffered an anterior ischemic syndrome secondary to the retinal surgery, and accidentally, the presence of an intraocular calcification was discovered. We study the influence of the osteoblastic neoformation in the ischemic process (AU)

[Technique of inverse scleral flap in the treatment of peripheral corneal defects (Abreu and Delgado technique)]. / Técnica de recubrimiento escleral inverso en el tratamiento de defectos corneales periféricos (Técnica de Abreu y Delgado).

PURPOSE: To present a new easy-to-perform technique for the treatment of peripheral corneal defects (perforation or significant thinning), which has had good results. METHODS: This technique, which consists in sliding and suturing a limbal based inverted scleral flap (similar to the scleral flap used in glaucoma surgery) over the affected peripheral cornea, is described. We present 7 cases: one dellen, two marginal ulcers, two perforating traumatisms, one descematocele and one case of corneal thinning after pterygium surgery. RESULTS: All 7 cases were satisfactorily resolved without modifying either the astigmatism or visual acuity. CONCLUSIONS: This is an easy-to-perform technique which offers good results and although it has some limitations, it can be recommended for the treatment of many peripheral corneal defects (perforations and significant thinning).

[Doppler ultrasound in type I diabetes: preliminary results]. / Ecografía Doppler en diabetes tipo I: primeros resultados.

PURPOSE: To study the differences of blood flow in type I diabetes patients using a color Doppler ultrasound. MATERIAL AND METHODS: We measured the systolic peak velocity (Vmax), diastolic velocity (Vmin) as well as the resistance index in the central retinal artery (CRA) and in the ophthalmic artery (OA) using a color Doppler ultrasound in 40 diabetic patients. We classified the patients according to the duration of diabetes, which ranged from 1 to 28 years. and whether retinopathy was present. We compared the results against those obtained in the 40 control subjects without vascular pathology. RESULTS: When the results of the two groups were compared, we found that no decrease was observed in the CRA flow rate in diabetics without retinopathy, however there was a significant decrease in flow velocity in patients with initial (p<0.05), moderate (p<0.001) or proliferative retinopathy (p<0.05). The ophthalmic artery presents an increase in the vascular resistance in diabetics with proliferative retinopathy. As the time of diabetes increases, there is a decrease in the blood flow in CRA and an increase in resistance in the OA. CONCLUSIONS: The Doppler ultrasound is a non-invasive technique which allows us to perform a hemodynamic study of the orbital vessels. It is essential to understand the correlation between blood flow velocity and the severity of retinopathy in diabetes patients as it manifests the relationship between the velocity of the blood flow with the severity of the retinopathy and that there is a direct relationship with the evolution of the diabetes and the flood flow velocity.

Técnica de recubrimiento escleral inverso en el tratamiento de defectos corneales periféricos (técnica de Abreu y Delgado) / Technique of inverse scleral flap in the treatment of peripheral corneal defects (Abreu and Delgado technique)

Objetivo: Presentamos una nueva técnica para el tratamiento de las lesiones corneales periféricas (perforaciones o adelgazamientos importantes) de fácil realización y con buenos resultados finales. Material y métodos: Describimos la técnica, que consiste en el deslizamiento de un tapete escleral invertido con base en limbo (similar al colgajo escleral que se hace en la cirugía de glaucoma) que sobreponemos y suturamos sobre la córnea periférica afectada. Presentamos siete casos (un Dellen, dos úlceras marginales, dos traumatismos perforantes, un descemetocele y un adelgazamiento corneal tras cirugía de pterigión). Resultados: En los siete casos presentados, se consiguió la resolución ad integrum, sin modificación del astigmatismo ni de la agudeza visual. Conclusiones: Se trata de una técnica sencilla en su realización y con buenos resultados finales, que si bien tiene sus limitaciones, se puede aplicar a un buen número de defectos corneales periféricos (perforaciones o adelgazamientos importantes). (AU)

Ecografía doppler en diabetes tipo I: Primeros resultados / Doppler ultrasound in type I Diabetes: First results

Objetivos: Estudiar mediante ecografía doppler color las características del flujo sanguíneo en pacientes con diabetes tipo 1.Material y métodos: Medimos, mediante un ecógrafo doppler color, la velocidad de flujo del pico sistólico (Vmax), diastólico (Vmin) y el índice de resistencia (IR) en la arteria central de la retina (ACR) y en la arteria oftálmica (AOFT) en 40 pacientes diabéticos. Clasificamos a los pacientes según la duración de la diabetes, estando entre 1 y 28 años, y la presencia o no de retinopatía. Comparamos los resultados obtenidos con 40 sujetos control sin patología vascular. Resultados: Al comparar los pacientes diabéticos con el grupo control observamos que no se aprecia una disminución de la velocidad del flujo de la ACR en los diabéticos sin retinopatía, pero si hay una disminución significativa en diabéticos con retinopatía leve (p<0,05), moderada-severa (p<0,001) y proliferante (p<0,05). La arteria oftálmica presenta un aumento en la resistencia vascular en los diabéticos con retinopatía proliferante. A medida que aumenta el tiempo de evolución de la diabetes, apreciamos una disminución del flujo sanguíneo en la ACR y un aumento de la resistencia vascular en la AOFT. Conclusiones: La ecografía doppler es una técnica no invasiva que nos permite realizar un estudio hemodinámico de los vasos orbitarios. Siendo fundamental el conocimiento del flujo sanguíneo y su correlación con la severidad de la retinopatía, nos pone de manifiesto el empeoramiento del flujo sanguíneo con el avance de la retinopatía y con el tiempo de evolución de la diabetes (AU)