Paediatric Horner syndrome. A case series of 14 patients in a tertiary hospital.

BACKGROUND: Horner syndrome (HS) is characterised by the triad of upper eyelid ptosis, miosis, and facial anhidrosis. Due to its wide variety of causes, it can occur at any age, and is uncommon in paediatrics. The aetiology and diagnostic approach of paediatric HS (PHS) is controversial. OBJECTIVE: The purpose of this study is to describe the clinical characteristics of a 14 case series, focusing on the aetiology of HS and the clinical evolution the patients presented. METHODS: A retrospective observational study was conducted on patients under 14 years-old (enrolled between 1st January 2009 and 30th April 2020). Depending on the age at diagnosis (before or after the first 5 months of life), the study cases were divided into two groups: congenital or acquired. RESULTS: Fourteen patients, with a mean age of 8.5 months, were enrolled. The most frequent cause of PHS were tumours (6/14), with the most representative neoplasm being neuroblastoma (4/14). Of the acquired cases (8/14), the most frequent cause was iatrogenic (5/8), mainly secondary to cervical or thoracic surgery. The main origin of congenital HS (6/14) was neuroblastoma (4/6), being the first manifestation of the disease in 50% of patients (2/4). CONCLUSION: HS may be the first sign of a major underlying disease, such as neuroblastoma. For this reason, children presenting with HS of unknown origin require imaging studies to exclude a life threatening disease. A thorough examination is essential for early diagnosis of these patients.

Chronic cytomegalovirus necrotizing retinitis in a patient with scleroderma and mixed connective tissue disease.

The case is presented of a 52-year-old woman with scleroderma, mixed connective tissue disease, and interstitial lung disease, who developed chronic cytomegalovirus necrotizing retinitis while on treatment with prednisone, mycophenolate, and hydroxychloroquine. Initially diagnosed as macular hole, the patient underwent a pars plana vitrectomy. Two months after surgery, due to progressive worsening, the diagnosis was made and treatment started (intravenous and intravitreal ganciclovir). The patient developed severe macular atrophy with final visual acuity of counting fingers. A chronic retinal necrosis can be caused by cytomegalovirus infection in non-HIV patients with partial immune dysfunction from other causes, characterized by a slowly progressive granular retinitis with occlusive vasculitis.

Síndrome de Horner pediátrico. A propósito de una serie de 14 casos en un hospital terciario / Paediatric Horner syndrome. A case series of 14 patients in a tertiary hospital

Antecedentes El síndrome de Horner (SH) se caracteriza por la triada de ptosis palpebral, miosis y anhidrosis facial. Debido a su amplia variedad de causas puede ocurrir en cualquier edad, siendo infrecuente en pediatría. La etiología y estudio diagnóstico del SH pediátrico (SHP) es motivo de controversia. ObjetivoDescribir las características clínicas de una serie de 14 niños diagnosticados de SH, incidiendo en la etiología del SH y en la evolución clínica que presentaron. Métodos Estudio observacional retrospectivo de pacientes menores de 14 años diagnosticados de SHP en nuestro centro entre el 01 de enero del 2009 y el 30 de abril del 2020. En función de la edad al diagnóstico, los casos se dividieron en congénitos (antes de los cinco meses) y adquiridos. Resultados Se reclutaron 14 pacientes, con una mediana de edad al diagnóstico de 8,5 meses. La causa más frecuente de SHP fue tumoral (6/14), siendo la neoplasia más representativa el neuroblastoma (4/14). De los casos adquiridos (8/14), la causa más frecuente fue iatrogénica (5/8), secundario a cirugía cérvico-torácica. La etiología principal del SH congénito (6/14) fue el neuroblastoma (4/6), siendo la primera manifestación clínica de la enfermedad en el 50% de los pacientes (2/4). Conclusiones El SH puede ser el primer signo de una enfermedad subyacente grave, como es el neuroblastoma. Por este motivo, es necesario realizar un adecuado estudio de extensión en todos los pacientes pediátricos diagnosticados de SH sin una causa clara atribuible. Es fundamental un examen riguroso para un diagnóstico precoz de estos pacientes (AU)

Background Horner syndrome (HS) is characterised by the triad of upper eyelid ptosis, miosis, and facial anhidrosis. Due to its wide variety of causes, it can occur at any age, and is uncommon in paediatrics. The aetiology and diagnostic approach of paediatric HS (PHS) is controversial. ObjectiveThe purpose of this study is to describe the clinical characteristics of a 14 case series, focusing on the aetiology of HS and the clinical evolution the patients presented. Methods A retrospective observational study was conducted on patients under 14 years-old (enrolled between 1 st January 2009 and 30th April 2020). Depending on the age at diagnosis (before or after the first 5 months of life), the study cases were divided into two groups: congenital or acquired. Results Fourteen patients, with a mean age of 8.5 months, were enrolled. The most frequent cause of PHS were tumours (6/14), with the most representative neoplasm being neuroblastoma (4/14). Of the acquired cases (8/14), the most frequent cause was iatrogenic (5/8), mainly secondary to cervical or thoracic surgery. The main origin of congenital HS (6/14) was neuroblastoma (4/6), being the first manifestation of the disease in 50% of patients (2/4). Conclusion HS may be the first sign of a major underlying disease, such as neuroblastoma. For this reason, children presenting with HS of unknown origin require imaging studies to exclude a life threatening disease. A thorough examination is essential for early diagnosis of these patients. (AU)

Retinitis necrosante crónica por citomegalovirus en una paciente con esclerodermia y enfermedad mixta del tejido conectivo / Chronic cytomegalovirus necrotising retinitis in a patient with scleroderma and mixed connective tissue disease

Mujer de 52 años de edad con esclerodermia, enfermedad mixta del tejido conectivo, enfermedad pulmonar intersticial y malnutrición severa a causa de la afectación esofágica de su enfermedad, en tratamiento con prednisona, micofenolato e hidroxicloroquina, que desarrolló una necrosis retiniana crónica por citomegalovirus. Inicialmente diagnosticada de agujero macular, se realizó una vitrectomía para su corrección. No fue hasta 2meses después de la intervención, como consecuencia del empeoramiento progresivo, cuando se realizó el diagnóstico y el comienzo del tratamiento con ganciclovir por vía intravenosa e intravítrea. La agudeza visual final fue de contar dedos, como consecuencia de una grave atrofia macular. En pacientes VIH negativos con inmunodeficiencia parcial por otras causas, puede desarrollarse una necrosis retiniana crónica por citomegalovirus, caracterizada por una necrosis granular lentamente progresiva acompañada de una vasculitis retiniana oclusiva (AU)

The case is presented of a 52-year-old woman with scleroderma, mixed connective tissue disease, and interstitial lung disease, who developed chronic cytomegalovirus necrotising retinitis while on treatment with prednisone, mycophenolate, and hydroxychloroquine. Initially diagnosed as macular hole, the patient underwent a pars plana vitrectomy. Two months after surgery, due to progressive worsening, the diagnosis was made and treatment started (intravenous and intravitreal ganciclovir). The patient developed severe macular atrophy with final visual acuity of counting fingers. A chronic retinal necrosis can be caused by cytomegalovirus infection in non-HIV patients with partial immune dysfunction from other causes, characterised by a slowly progressive granular retinitis with occlusive vasculitis (AU)

Peripapillary pachychoroidopathy. / Paquicoroidopatía peripapilar.

A study was made on 8 eyes of 5 patients between 47 and 65 years of age with peripapillary pachychoroidopathy. They all presented with a serous detachment of the neuroepithelium or retinal pigment epithelium in the nasal macular region that extended to the optic disc, with an increase in choroidal thickness at that level. An analysis was made of the choroidal thickness using high penetration optical coherence tomography, as well as their outcome in a period between 12 and 48 months. Peripapillary pachychoroidopathy is a distinct variant of the pachychoroid disease spectrum. It must be distinguished from other disorders, such as inflammatory or neuro-ophthalmological conditions, that may manifest in the vicinity of the optic disc. When faced with a patient with suspected pachychoroidopathy, a specific study of the papillary area should be considered using high penetration optical coherence tomography.

Características fundoscópicas en tres casos de hiperquilomicronemia familiar / Fundoscopic characteristics in three cases of familial hyperchylomicronaemia

CASO CLÍNICO: Presentamos tres casos de pacientes con hiperquilomicronemia familiar y lipemia retinalis, y analizamos de forma comparada las características fundoscópicas de cada uno de ellos. DISCUSIÓN: El aspecto característico del fondo retiniano en color salmón-pálido corresponde con grados severos de lipemia retinalis. Los hallazgos relativos a la tonalidad del árbol vascular en segmentos distales constituyen probablemente el dato exploratorio que mejor orienta el diagnóstico oftalmológico en niveles inferiores de hipertrigliceridemia

CASES REPORT: Three cases are presented of patients with familial hyperchylomicronaemia and lipaemia retinalis, in whom an analysis is made of the fundoscopic characteristics of each of them. DISCUSSION: The typical appearance of the retinal fundus is pale salmon coloured and corresponds to levels of severe lipaemia retinalis. As regards the findings, the vascular tree tonality is probably the best exploratory evidence to help in the ophthalmological diagnosis

Arteritis de Takayasu: obstrucción arterial retiniana isquémica como posible presentación inicial / Takayasu's arteritis: Ischaemic retinal arterial occlusion as a possible initial presentation

El 25% de los pacientes con arteritis de Takayasu presentan manifestaciones oculares siendo el modo de presentación variable. Presentamos una mujer de 41 años de edad con pérdida progresiva de la visión en un ojo secundaria a una oclusión arterial retiniana isquémica. Habiendo descartado otras causas y con test derivado proteico purificado (PPD, por sus siglas en inglés) sospechosa de tuberculosis, se consideró diagnóstico presuntivo de tuberculosis. Se inició tratamiento antiinfeccioso y anti-inflamatorio sistémico, sin respuesta terapéutica. A los 18 meses, se produjo un fallo renal agudo secundario a la estenosis de la arteria renal derecha. El angio-TC reveló un engrosamiento del arco aórtico y de sus ramas, diagnosticándose finalmente arteritis de Takayasu. Por lo tanto, se enfatiza la importancia del médico oftalmólogo en el diagnóstico de la enfermedad cuya manifestación oftalmológica potencialmente asociada, se puede presentar de forma inicial y tempranamente

Ocular manifestations are observed in 25% of patients with Takayasu's arteritis. Its signs and symptoms can be very variable. The case is presented of a 41-year-old woman with progressive vision loss in her right eye secondary to ischaemic retinal arterial occlusion. After a systematic study, a protein purified derivative (PPD) skin test compatible with tuberculosis was found to be the only alteration. After ruling out other causes, and based on the initial suspicion of tuberculous retinal vasculitis, treatment was started with antimicrobial agents and systemic corticosteroids, without any therapeutic response. Eighteen months later, the patient developed acute kidney failure, secondary to right renal artery stenosis. The CT-angiography revealed a thickening of the aortic arch and its branches, and Takayasús arteritis was finally diagnosed. Therefore, emphasis is made on the importance of the ophthalmologist in the diagnosis of Takayasús arteritis, in which its ophthalmological manifestations can be an early sign of the disease

Fundoscopic characteristics in three cases of familial hyperchylomicronaemia. / Características fundoscópicas en tres casos de hiperquilomicronemia familiar.

CASES REPORT: Three cases are presented of patients with familial hyperchylomicronaemia and lipaemia retinalis, in whom an analysis is made of the fundoscopic characteristics of each of them. DISCUSSION: The typical appearance of the retinal fundus is pale salmon coloured and corresponds to levels of severe lipaemia retinalis. As regards the findings, the vascular tree tonality is probably the best exploratory evidence to help in the ophthalmological diagnosis.

Takayasu's arteritis: Ischaemic retinal arterial occlusion as a possible initial presentation. / Arteritis de Takayasu: obstrucción arterial retiniana isquémica como posible presentación inicial.

Ocular manifestations are observed in 25% of patients with Takayasu's arteritis. Its signs and symptoms can be very variable. The case is presented of a 41-year-old woman with progressive vision loss in her right eye secondary to ischaemic retinal arterial occlusion. After a systematic study, a protein purified derivative (PPD) skin test compatible with tuberculosis was found to be the only alteration. After ruling out other causes, and based on the initial suspicion of tuberculous retinal vasculitis, treatment was started with antimicrobial agents and systemic corticosteroids, without any therapeutic response. Eighteen months later, the patient developed acute kidney failure, secondary to right renal artery stenosis. The CT-angiography revealed a thickening of the aortic arch and its branches, and Takayasús arteritis was finally diagnosed. Therefore, emphasis is made on the importance of the ophthalmologist in the diagnosis of Takayasús arteritis, in which its ophthalmological manifestations can be an early sign of the disease.

Desprendimiento de retina neurosensorial macular asociado al uso de topiramato / Macular neurosensory retinal detachment associated with topiramate use

Mujer de 36 años diagnosticada de hipertensión intracraneal idiopática tratada con acetazolamida y topiramato, que presenta desprendimientos neurosensoriales retinianos. La paciente fue seguida durante 2 años estableciéndose una relación entre los desprendimientos neurosensoriales y el topiramato, con recurrencias tras la introducción del topiramato y mejoría tras la retirada del mismo. Estos hechos señalan al topiramato como posible responsable del cuadro. El topiramato podría ser responsable de la aparición de desprendimientos neurosensoriales de la retina y mácula. Aunque los casos de efusión cilio coroidea producidos por este fármaco son bien conocidos, sus efectos secundarios sobre la retina son menos frecuentes. Ya que se trata de un fármaco de amplio uso, tanto neurólogos como oftalmólogos deberían ser conscientes de sus posibles efectos secundarios

A 36 year-old woman with idiopathic intracranial hypertension was treated with topiramate and acetazolamide. The patient was followed-up for 2 years, with a relationship between neurosensory detachments and topiramate being established, with recurrences after the introduction of topiramato and improvement after its withdrawal. These findings point topiramate as a possible cause of the clinical picture. Topiramate may cause retinal and macular neurosensory detachments. Although the ciliochoroidal effusion cases caused by this drug are well-known, its retinal side effects are less common. As it is a widely used drug, neurologists and ophthalmologists should be aware of its possible ocular side effects

Macular neurosensory retinal detachment associated with topiramate use. / Desprendimiento de retina neurosensorial macular asociado al uso de topiramato.

A 36 year-old woman with idiopathic intracranial hypertension was treated with topiramate and acetazolamide. The patient was followed-up for 2 years, with a relationship between neurosensory detachments and topiramate being established, with recurrences after the introduction of topiramato and improvement after its withdrawal. These findings point topiramate as a possible cause of the clinical picture. Topiramate may cause retinal and macular neurosensory detachments. Although the ciliochoroidal effusion cases caused by this drug are well-known, its retinal side effects are less common. As it is a widely used drug, neurologists and ophthalmologists should be aware of its possible ocular side effects.