Análisis de un programa de teleoftalmología para el cribado de retinopatía diabética en área rural tras cinco años / Five-year experience of tele-ophthalmology for diabetic retinopathy screening in a rural population

OBJETIVO: Estudiar la prevalencia de retinopatía diabética (RD) y los factores de riesgo asociados en la población incluida en un programa de teleoftalmología en área rural. Evaluar la capacidad diagnóstica de RD de los médicos de atención primaria (MAP) y su correcta coordinación con los oftalmólogos, cuantificando el ahorro generado. MATERIAL Y MÉTODOS: Estudio observacional transversal de una muestra aleatoria de 394 pacientes incluidos en el programa de teleoftalmología desde enero de 2010 a enero de 2015. Analizamos características clínicas, hallazgos de RD en las retinografías y la correcta derivación de imágenes por los MAP al servicio de oftalmología según los criterios establecidos: RD moderada o severa, baja agudeza visual (AV), mala calidad de imagen y presión intraocular (PIO) > 22 mmHg. Análisis estadístico con SPSS. Pruebas t de Student y χ 2. RESULTADOS: La prevalencia de RD fue del 12,1%. Los pacientes con hemoglobina glucosilada > 7,68% o tratados con combinación de antidiabéticos orales e insulina presentaron mayor riesgo de RD (p < 0,05). El 43,3% de los pacientes derivados correctamente a oftalmología presentaban retinopatía moderada o severa. Los pacientes no derivados a oftalmología de forma correcta pasaron de un 91,7% en 2010 a un 98,6% en 2014. Estimamos un ahorro global de 152.550,45€. CONCLUSIONES: El programa de teleoftalmología resulta útil como cribado de RD. Los MAP son capaces de discriminar los pacientes que requieren valoración oftalmológica, evitando consultas presenciales y generando ahorro

OBJECTIVE: To identify the prevalence and risk factors of diabetic retinopathy (DR) among rural inhabitants included in a tele-ophthalmology program. To analyse diagnostic accuracy among primary care physicians, concordance with ophthalmologists, and financial savings. MATERIAL AND METHODS: An observational randomised study was conducted on 394 patients included in a tele-ophthalmology program (from January 2010 to January 2015). An analysis was performed on the clinical characteristics, DR findings in retinography images, and correspondence between the request for a second interpretation by an ophthalmologist, and previously established criteria for it: presence of moderate to severe DR, vision loss, poor image quality and/or intraocular pressure > 22 mmHg. Statistical analysis was performed using the SPSS program (Student t and χ 2 tests). RESULTS: DR prevalence was 12.1%. Patients with glycosylated haemoglobin values > 7.68% or those treated with a combination of insulin and oral antidiabetic drugs showed a higher risk of DR (P < .05). 43.3% of patients correctly referred to ophthalmologists showed moderate to severe DR. Unnecessary referrals to specialists were improved from 91.7% in 2010 to 98.6% in 2014. It is estimated that the program has made a total saving of €152,550.45. CONCLUSIONS: Tele-ophthalmology programs are a useful tool in DR screening. Primary care physicians are able to distinguish patients who need specialist care, avoiding unnecessary referrals to ophthalmologists, and saving costs

Utilidad del índice de complejidad quirúrgica en el proceso de cirugía de catarata / Usefulness of surgical complexity classification index in cataract surgery process

OBJETIVO: Evaluar la utilidad del índice de complejidad quirúrgica (ICQ) como indicador de la dificultad técnica esperable en la cirugía de catarata. MATERIAL Y MÉTODOS: Estudio retrospectivo de intervenciones de catarata realizadas entre enero de 2013 y diciembre de 2014. Se realizó muestreo aleatorizado simple y se obtuvo un tamaño muestral representativo de 159 pacientes (p = 0,5, precisión 10%, seguridad 95%). Se analizó el registro y valor del ICQ en la historia clínica electrónica (HCE), la presencia de pseudoexfoliación (PSX), el cumplimiento de criterios de inclusión en lista de espera quirúrgica (LEQ) y los resultados funcionales. Se clasificó el ICQ en 7 categorías (rango: 1-4) según factores predictivos de dificultad técnica, que se estimó de forma indirecta a través del tiempo quirúrgico (TQ). Se utilizó el programa SPSS aplicando t de Student y chi-cuadrado para la comparación de grupos. RESULTADOS: La prevalencia de PSX fue del 18,2% (IC 95%: 11,9-24,5). El 96,8% de los pacientes cumplía alguno de los criterios para su inclusión en LEQ y el 98,1% experimentaron una ganancia visual final ≥2 líneas, considerados ambos indicadores de calidad del proceso de catarata. El ICQ se había registrado en la HCE del 98,1% de los pacientes, y se agrupó para el estudio en 2 categorías: alta y baja complejidad quirúrgica. Se encontraron diferencias estadísticamente significativas en la distribución del TQ en función del ICQ asignado (p < 0,005) y la presencia de PSX (p < 0,005). CONCLUSIONES: El ICQ permite estimar la complejidad técnica de la cirugía de catarata en términos de duración de la intervención, lo que facilita la programación quirúrgica, especialmente en aquellas áreas con alta prevalencia de PSX, en las que el riesgo teórico de complicaciones es mayor

OBJECTIVE: To evaluate the usefulness of surgical complexity classification index (SCCI) to predict the degree of surgical difficulty in cataract surgery. MATERIAL AND METHODS: This retrospective study includes data collected between January 2013 and December 2014 from patients who underwent cataract extraction by phacoemulsification at our hospital. A sample size of 159 patients was obtained by simple random sampling (P=.5, 10% accuracy, 95% confidence). The main variables were: recording and value of SCCI in electronic medical record (EMR), presence of exfoliation syndrome (XFS), criteria for inclusion in surgical waiting list (SWL), and functional results. SCCI was classified into 7 categories (range: 1-4) according to predictors of technical difficulty, which was indirectly estimated in terms of surgical time (ST). All statistical analyses were performed using SPSS v15.0 statistical software. RESULTS: Prevalence of XFS was 18.2% (95%CI: 11.9-24.5). In terms of quality indicators in the cataract surgery process, 96.8% of patients met at least one of the criteria to be included in SWL, and 98.1% gained ≥2 Snellen lines. The SCCI was recorded in EMR of 98.1% patients, and it was grouped for study into 2 categories: High and low surgical complexity. Statistically significant differences in the distribution of ST were found depending on the assigned SCCI (P<.005) and the presence of XFS (P<.005). CONCLUSIONS: The SCCI enables to estimate the degree of surgical complexity in terms of ST in cataract surgery, which is especially useful in those areas with high prevalence of XFS, because of the higher theoretical risk of surgical complications

Usefulness of surgical complexity classification index in cataract surgery process. / Utilidad del índice de complejidad quirúrgica en el proceso de cirugía de catarata.

OBJECTIVE: To evaluate the usefulness of surgical complexity classification index (SCCI) to predict the degree of surgical difficulty in cataract surgery. MATERIAL AND METHODS: This retrospective study includes data collected between January 2013 and December 2014 from patients who underwent cataract extraction by phacoemulsification at our hospital. A sample size of 159 patients was obtained by simple random sampling (P=.5, 10% accuracy, 95% confidence). The main variables were: recording and value of SCCI in electronic medical record (EMR), presence of exfoliation syndrome (XFS), criteria for inclusion in surgical waiting list (SWL), and functional results. SCCI was classified into 7 categories (range: 1-4) according to predictors of technical difficulty, which was indirectly estimated in terms of surgical time (ST). All statistical analyses were performed using SPSS v15.0 statistical software. RESULTS: Prevalence of XFS was 18.2% (95%CI: 11.9-24.5). In terms of quality indicators in the cataract surgery process, 96.8% of patients met at least one of the criteria to be included in SWL, and 98.1% gained ≥2 Snellen lines. The SCCI was recorded in EMR of 98.1% patients, and it was grouped for study into 2 categories: High and low surgical complexity. Statistically significant differences in the distribution of ST were found depending on the assigned SCCI (P<.005) and the presence of XFS (P<.005). CONCLUSIONS: The SCCI enables to estimate the degree of surgical complexity in terms of ST in cataract surgery, which is especially useful in those areas with high prevalence of XFS, because of the higher theoretical risk of surgical complications.

Five-year experience of tele-ophthalmology for diabetic retinopathy screening in a rural population. / Análisis de un programa de teleoftalmología para el cribado de retinopatía diabética en área rural tras cinco años.

OBJECTIVE: To identify the prevalence and risk factors of diabetic retinopathy (DR) among rural inhabitants included in a tele-ophthalmology program. To analyse diagnostic accuracy among primary care physicians, concordance with ophthalmologists, and financial savings. MATERIAL AND METHODS: An observational randomised study was conducted on 394 patients included in a tele-ophthalmology program (from January 2010 to January 2015). An analysis was performed on the clinical characteristics, DR findings in retinography images, and correspondence between the request for a second interpretation by an ophthalmologist, and previously established criteria for it: presence of moderate to severe DR, vision loss, poor image quality and/or intraocular pressure >22mmHg. Statistical analysis was performed using the SPSS program (Student t and χ(2) tests). RESULTS: DR prevalence was 12.1%. Patients with glycosylated haemoglobin values >7.68% or those treated with a combination of insulin and oral antidiabetic drugs showed a higher risk of DR (P<.05). 43.3% of patients correctly referred to ophthalmologists showed moderate to severe DR. Unnecessary referrals to specialists were improved from 91.7% in 2010 to 98.6% in 2014. It is estimated that the program has made a total saving of €152,550.45. CONCLUSIONS: Tele-ophthalmology programs are a useful tool in DR screening. Primary care physicians are able to distinguish patients who need specialist care, avoiding unnecessary referrals to ophthalmologists, and saving costs.

Oclusión de arteria central retiniana tras facoemulsificación con anestesia peribulbar: hipótesis patogénicas / Central retinal artery occlusion after phacoemulsification under peribulbar anaesthesia: Pathogenic hypothesis

CASO CLÍNICO: Paciente de 77 años, intervenido de catarata en ojo derecho bajo anestesia peribulbar, sin complicaciones. Al día siguiente presenta edema palpebral severo con empeoramiento progresivo, secundario a reacción alérgica no conocida a la povidona yodada. A los 5 días presenta una resolución del cuadro alérgico, detectándose amaurosis y mancha rojo cereza. El eco-Doppler de troncos supraaórticos y el angio-TAC confirman una estenosis del 80% de la arteria carótida interna ipsilateral. DISCUSIÓN: Las oclusiones vasculares retinianas constituyen una complicación infrecuente de la anestesia loco-regional orbitaria. Su aparición obliga a descartar causas subyacentes, como enfermedad carotídea, así como a reflexionar sobre los factores locales o sistémicos que han colaborado en su aparición

CLINICAL CASE: A 77-year-old patient had uneventful cataract surgery in the right eye under peribulbar anaesthesia. The next day, a severe and progressive eyelid swelling was noted, caused by an unknown allergic reaction to povidone-iodine. The allergic signs dissapeared by the fifth day, but amaurosis and a cherry-red spot were detected. Doppler ultrasound and CT angiography confirmed an 80% ipsilateral internal carotid artery stenosis. DISCUSSION: Retinal vascular occlusion after orbital loco-regional anaesthesia is rare. When this complication occurs, carotid disease, and local or systemic factors, should be evaluated

Central retinal artery occlusion after phacoemulsification under peribulbar anaesthesia: Pathogenic hypothesis.

CLINICAL CASE: A 77-year-old patient had uneventful cataract surgery in the right eye under peribulbar anaesthesia. The next day, a severe and progressive eyelid swelling was noted, caused by an unknown allergic reaction to povidone-iodine. The allergic signs dissapeared by the fifth day, but amaurosis and a cherry-red spot were detected. Doppler ultrasound and CT angiography confirmed an 80% ipsilateral internal carotid artery stenosis. DISCUSSION: Retinal vascular occlusion after orbital loco-regional anaesthesia is rare. When this complication occurs, carotid disease, and local or systemic factors, should be evaluated.

[A case of triamcinolone-induced pseudo-endophthalmitis after vitrectomy]. / Un caso de pseudoendoftalmitis por triamcinolona tras vitrectomía.

CASE REPORT: Vitrectomy with vitreous injection of triamcinolone in a patient suffering cystoid macular edema, secondary to a lens fragment luxation after subluxated cataract phacoemulsification, was performed. Four days after the surgery she presented because of discomfort and visual loss in the operated eye, and was found to have a 3.4 mm hypopyon. DISCUSSION: We describe the differences between infectious endophthalmitis, toxic endophthalmitis and pseudo-endophthalmitis.

Un caso de pseudoendoftalmitis por triamcinolona tras vitrectomía / A case of triamcinolone-induced pseudo-endophthalmitis after vitrectomy

Caso clínico: Se realizó una vitrectomía con inyección de triamcinolona a una paciente que padecía un edema macular quístico secundario a la luxación de un fragmento de cristalino tras facoemulsificación de una catarata subluxada. A los cuatro días tras la cirugía acudió a la consulta con pérdida de agudeza visual y sensación de cuerpo extraño en el ojo operado. La paciente presentaba un hipopión de 3,4 mm.Discusión: Se discutieron las diferencias entre la endoftalmitis infecciosa, tóxica y la pseudoendoftalmitis

Case report: Vitrectomy with vitreous injection of triamcinolone in a patient suffering cystoid macular edema, secondary to a lens fragment luxation after subluxated cataract phacoemulsification, was performed. Four days after the surgery she presented because of discomfort and visual loss in the operated eye, and was found to have a 3.4 mm hypopyon. Discussion: We describe the differences between infectious endophthalmitis, toxic endophthalmitis and pseudo-endophthalmitis

[Congenital factor VII deficiency (author's transl)]. / Déficit de factor VII.

A new case of factor VII congenital deficiency is presented in a four year old girl, with a factor VII level of 3.9%. The patient had no history of bleeding and her coagulation disorder was a casual finding. Clinical features of the disease and its therapeutic guidelines are discussed. It seemed appropriate to continue the study in order to evaluate the factor VII capacity of inhibiting an specific antibody, to confirm heterozygosity of partents and to prove that this case is a genetic variant of factor VII deficiency with good prognosis.