Topical NSAIDs, intravitreal dexamethasone and peribulbar triamcinolone for pseudophakic macular edema.

BACKGROUND: The purpose of this study is to assess the effectiveness of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids (intravitreal dexamethasone and peribulbar triamcinolone) in treating pseudophakic macular edema (PME). METHODS: Retrospective study of 33 eyes. Variables included best corrected visual acuity (BCVA; logMAR scale) and central retinal thickness (CRT) and central choroidal thickness (CCT) assessed with swept-source OCT. All patients were initially prescribed topical NSAIDs and reevaluated after 2 months. If improvement in BCVA or CRT was noted, topical NSAIDs were continued until resolution. If no improvement was observed at 2 months or subsequent visits, intravitreal dexamethasone implant was performed. Patients who refused intravitreal treatment were offered peribulbar triamcinolone. RESULTS: After treatment with topical NSAIDs for a median of 2 months, BCVA increased significantly from 0.5 to 0.3 while CRT decreased significantly from 435 to 316 µm. PME resolved in 19 of the 33 eyes (57.6%). Of the 14 recalcitrant cases, 13 were treated with corticosteroids. Of these 13 cases, 9 (69.2%) resolved. BCVA increased non-significantly from 0.7 to 0.4. CRT and CCT decreased significantly from 492 to 317 µm and from 204 to 182 µm respectively. CONCLUSIONS: The overall success rate of the treatment algorithm was greater than 80%, a remarkable finding considering that no randomized study has yet been conducted to determine the optimal therapeutic protocol for PME. This is the first study to evaluate choroidal thickness in PME using SS-OCT, which could play a key role in its pathophysiology and provide useful information to improve the management of PME.

Retinal findings in pediatric patients with Usher syndrome Type 1 due to mutations in MYO7A gene.

PURPOSE: To describe retinal alterations detected by swept-source optical coherence tomography (SS-OCT) in paediatric patients with Usher syndrome type 1 (USH1) and to compare these findings to previously published reports. METHODS: Thirty-two eyes from 16 patients (11 males and 5 females) with a genetic diagnosis of USH1 because of MYO7A mutations underwent SS-OCT. Patients ranged in age from 4 to 17 years (mean, 11,13 ± 4,29). The subfoveal and macular area were analysed with SS-OCT at 1050 nm using 12 radial scans of 12.0 mm. Structural abnormalities were evaluated and correlated with best-corrected visual acuity (BCVA). RESULTS: The most common qualitative retinal abnormality was external layer damage in macular area. Specific alterations included external limiting membrane loss/disruption (27 eyes; 84.4%), disruption of the Myoid zone (27 eyes; 84.4%); Ellipsoid zone disruption (28 eyes; 87.5%), and loss of the outer segments (29 eyes; 90.6%). The damage of the retinal pigment epithelium was divided according to the loss of the different layers: phagosome zone (30 eyes; 93.8%), melanosome zone (29 eyes; 90.6%) and mitochondria zone (0 eyes; 0%). The presence of cystoid macular oedema (CMO) was significantly correlated with alterations in photoreceptors. Disruption or absence of the myoid and ellipsoid zones of the photoreceptors were the only variables independently associated with decreased BCVA. CONCLUSIONS: The findings of this study suggest that the physiopathologic basis of early-stage Usher syndrome (USH) may be changes in the outer retinal layer, particularly the photoreceptors, which in turn may cause alterations-such as CMO-in the inner retinal layers. Accordingly, monitoring the condition of photoreceptors during follow-up may be advisable for the early detection of pathologic changes.

INTERNAL LIMITING MEMBRANE PEELING VERSUS NONPEELING TO PREVENT EPIRETINAL MEMBRANE DEVELOPMENT IN PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT: A Swept-Source Optical Coherence Tomography Study With a New Postoperative Classification System.

PURPOSE: To determine whether internal limiting membrane peeling in primary rhegmatogenous retinal detachment prevents epiretinal membrane (ERM) development. Secondarily, we propose a classification system for postoperative ERMs. METHODS: Retrospective, interventional, comparative case series. Consecutive eyes with primary rhegmatogenous retinal detachment (n = 140) treated by a single surgeon. The presence of postoperative ERMs was assessed with swept-source optical coherence tomography. RESULTS: An ERM was detected in 26 eyes (46.4%) in the nonpeeling group and in one eye (1.8%) in the internal limiting membrane peeling group (P ≤ 0.001). The median visual acuity significantly improved in both groups (P ≤ 0.001). Inner retinal dimples were observed in 41.1% of eyes in the internal limiting membrane peeling group versus 0% in the nonpeeling group (P ≤ 0.001), and they were not correlated with visual acuity (r = 0.011; P = 0.941). Based on swept-source optical coherence tomography findings, we identified three different types of ERMs: 7 (26.9%) were classified as Type 1, 12 (46.1%) as Type 2, and 7 (26.9%) as Type 3. Superficial retinal plexus deformations observed on optical coherence tomography angiography and en face images were detected in 100% of Type 3 ERMs, 41.6% of Type 2, and 0% of Type 1 (χ = 14.3; P = 0.001). Interestingly, all of the patients who presented these alterations also had metamorphopsia. CONCLUSION: Internal limiting membrane peeling in primary rhegmatogenous retinal detachment seems to prevent postoperative ERM development. Swept-source optical coherence tomography analysis is helpful to define and classify different types of ERMs and to establish the surgical indication for their removal.

Clinical predictors of survival in metastatic uveal melanoma.

PURPOSE: To determine the clinical factors that influence survival in patients with metastatic uveal melanoma. STUDY DESIGN: Single-center, retrospective review of patients' medical records. METHODS: The following data of ninety-nine consecutive patients (49 men, 50 women) with metastatic uveal melanoma were registered: patient demographics; primary tumor characteristics; features of first melanoma-related metastasis; symptoms and patient status at distant disease debut and metastasis treatment. Overall survival was analyzed by Kaplan-Meier estimates. A Cox proportional hazards regression model was applied to identify independent predictors associated with survival. RESULTS: Mean patient age at metastatic diagnosis was 60.7 years (standard deviation, 12.8). The liver was the first metastatic site in most (92.9%) cases. The median disease-free interval was 26 months (interquartile range, 34). Median overall survival after detection of the first metastasis was 8 months (interquartile range, 14). The baseline characteristics of the primary uveal melanoma were not associated with survival in patients with stage IV disease. In the multivariate analysis, the following factors at first metastatic diagnosis were associated with improved overall survival: disease-free interval > 36 months; better performance status; and normal serum lactate dehydrogenase and gamma glutamyl transpeptidase levels. Overall survival was not influenced by specific metastatic treatment. CONCLUSION: Although metastatic uveal melanoma has a poor prognosis, this study reveals the existence of several independent prognostic factors for prolonged overall survival. These findings may help improve survival estimates in patients with advanced disease.

Changes in Choroidal Thickness After Intravitreal Injection of Anti-Vascular Endothelial Growth Factor in Pachychoroid Neovasculopathy.

Purpose: We evaluate changes in choroidal thickness after intravitreal injection (IVI) therapy for pachychoroid neovasculopathy (PNV). Methods: An observational, retrospective, consecutive case series was studied of 18 patients (18 eyes) who underwent anti-vascular endothelial growth factor (VEGF) therapy for PNV. The 18 fellow eyes in these patients were used as controls. All eyes were evaluated with swept-source optical coherence tomography (SS-OCT) and optical coherence tomography angiography (OCTA). Results: Mean patient age was 68.3 ± 7.0 years. Mean follow-up was 16.4 ± 2.0 months. No differences in the best-corrected visual acuity (BCVA) of the affected eyes were observed between baseline and 12-month follow-up (median Early Treatment of Diabetic Retinopathy Study [ETDRS] score, 77.5 vs. 76 letters, P = 0.074; median logMAR, 0.22 vs. 0.22, P = 0.453). However, subfoveal choroidal thickness (SFCT) decreased significantly from a mean of 317.7 ± 39.9 µm at baseline to 266.9 ± 56.3 µm at 12 months (P ≤ 0.001). Median change in SFCT at 12 months was 44.0 µm (range, 17-133 µm). SFCT decreased by 16% from baseline to month 12. The change in SFCT at 12 months was highly correlated with the number of IVI (rs = 0.762, P ≤ 0.001). No significant changes in SFCT were observed in the fellow eyes over the 12-month study period (median, 267.5 vs. 267.0 µm; P = 0.930). Conclusions: Choroidal thickness decreased significantly from baseline to month 12 in eyes with PNV treated with anti-VEGF injections. This reduction might be attributable to a reduction in choroidal vascular permeability and, thus, with a decrease in PNV activity. Prospective studies are needed to confirm these findings.

Prognostic Factors and Decision Tree for Long-Term Survival in Metastatic Uveal Melanoma.

PURPOSE: The purpose of this study was to demonstrate the existence of a bimodal survival pattern in metastatic uveal melanoma. Secondary aims were to identify the characteristics and prognostic factors associated with long-term survival and to develop a clinical decision tree. MATERIALS AND METHODS: The medical records of 99 metastatic uveal melanoma patients were retrospectively reviewed. Patients were classified as either short (≤ 12 months) or long-term survivors (> 12 months) based on a graphical interpretation of the survival curve after diagnosis of the first metastatic lesion. Ophthalmic and oncological characteristicswere assessed in both groups. RESULTS: Of the 99 patients, 62 (62.6%) were classified as short-term survivors, and 37 (37.4%) as long-term survivors. The multivariate analysis identified the following predictors of long-term survival: age ≤ 65 years (p=0.012) and unaltered serum lactate dehydrogenase levels (p=0.018); additionally, the size (smaller vs. larger) of the largest liver metastasis showed a trend towards significance (p=0.063). Based on the variables significantly associated with long-term survival, we developed a decision tree to facilitate clinical decision-making. CONCLUSION: The findings of this study demonstrate the existence of a bimodal survival pattern in patients with metastatic uveal melanoma. The presence of certain clinical characteristics at diagnosis of distant disease is associated with long-term survival. A decision tree was developed to facilitate clinical decision-making and to counsel patients about the expected course of disease.

Pigmented free-floating vitreous cyst.

A 45-year-old man presented with a mobile shadow in the central visual field of his left eye for the preceding 4 months. His visual acuity was not affected. Funduscopy showed a brownish, oval-shaped structure floating in the vitreous cavity of the left eye. B-scan ultrasound demonstrated an oval-spherical hypoechogenic structure floating at the posterior pole. The absence of pertinent medical history and normal results from systemic exploration suggested a congenital etiology. The condition was observed regularly without any evidence of change. Differential diagnosis of vitreous cysts is important in order to establish an adequate therapeutic approach.

Sequential bilateral retinal artery occlusion.

An 86 year old woman experienced a sequential bilateral loss of vision over a period of less than 24 hours. Clinical findings and complementary studies suggested a bilateral atherogenic embolic event. Initially, she presented a superior branch retinal artery occlusion in her right eye followed by a central retinal artery occlusion with cilioretinal artery sparing in her left eye. Some conservative maneuvers performed did not improve visual acuity in the left eye. Supra-aortic Doppler ultrasonography revealed mild right internal carotid artery stenosis and moderate left internal carotid artery stenosis with a small, smooth, and homogeneous plaque. The transthoracic echocardiography showed a severe calcification of the mitral valve with a mild-moderate rim of stenosis. Central retinal artery occlusion and branch retinal artery occlusion are characterized by painless monocular loss of vision. Clinical approach and management attempt to treat the acute event, find the source of the vascular occlusion, and prevent further vascular events from occurring. Giant cell arteritis is a potentially treatable cause of central retinal artery occlusion and should be excluded in every single patient over 50 years old.

Correlation between spectral-domain optical coherence tomography and autofluorescence findings in sclerochoroidal calcification.

OBJECTIVE: The purpose of this article is to report the correlation between spectral domain-optical coherence tomography and autofluorescence findings in 3 consecutive cases with sclerochoroidal calcification. DESIGN: Observational case series. PARTICIPANTS: The study involved 3 patients with bilateral sclerochoroidal calcification. METHODS: B-scan ultrasonography, spectral domain-optical coherence tomography, and autofluorescence were performed in each eye. The choroidal vascular thickness and autofluorescence patterns of the calcified plaques were evaluated with spectral domain-optical coherence tomography and autofluorescence, respectively. RESULTS: An important variation of choroidal vascular thickness overlying sclerochoroidal calcification was observed in spectral domain-optical coherence tomography. Autofluorescence showed 2 patterns of autofluorescence closely correlated with changes in choroidal vascular thickness. In those zones where the thicknesses of choriocapillaris complex were reduced, a hyperautofluorescence pattern was observed in autofluorescence. The hypoautofluorescence pattern was observed in outpouching zone of retinal pigment epithelium-choriocapillaris complex seen in spectral domain-optical coherence tomography. The hypoautofluorescence pattern was closely correlated with remarkable reduction of the choriocapillaris complex. There were no significant differences between the patterns of autofluorescence except the extension. CONCLUSIONS: Spectral domain-optical coherence tomography and autofluorescence are noninvasive complementary imaging studies that may help to improve our knowledge about sclerochoroidal calcification. Characteristic patterns of autofluorescence were closely correlated with spectral domain-optical coherence tomography findings. More patients need to be evaluated with both complementary studies to establish conclusions related with these findings.

Infecciones en el paciente neutropénico con cáncer / Infections in neutropenic patient with cancer

Los procesos sépticos en los pacientes inmunocomprometidos y con enfermedades malignas asociadas causan una elevada morbimortalidad. El riesgo de desarrollar una infección está directamente relacionado con la intensidad y duración de la neutropenia, evaluado este último aspecto mediante el conteo absoluto de neutrófilos. Es importante determinar el gérmen causal, así se logra administrar una terapia más racional y evita la aparición de cepas resistentes por el empleo de un tratamiento antimicrobiano empírico de amplio espectro. Debe realizarse una evaluación cuidadosa de los pacientes, lo que permite ubicarlos en las categorías de bajo o de alto riesgo de desarrollar infecciones. De esta manera se recoge la información necesaria para elegir un tratamiento empírico inicial por vía oral o intravenoso, y un manejo extra o intrahospitalario de acuerdo a las características de cada paciente. La profilaxis antibacteriana con fluoroquinolonas constituye un aspecto controversial en los pacientes neutropénicos con cáncer, aunque algunos estudios recientes han proporcionado evidencia clara de su eficacia.

Péptido beta amiloide, proteína Tau y enfermedad de Alzheimer / Amyloid-beta peptide, Tau protein and Alzheimers disease

Se realizó una actualización sobre la enfermedad de Alzheimer, que constituye la causa más frecuente de demencia. Se establecieron aspectos relacionados con los cromosomas 21 y 17. Mutaciones en el gen de la proteína precursora amiloidea, localizado en el cromosoma 21, son responsables de 5 a 20 porciento de los casos de enfermedad de Alzheimer familiar precoz. La proteína precursora amiloidea al ser procesada por una vía amiloidogénica origina el beta amiloide, el cual se deposita en las placas seniles y causa efectos tóxicos directos sobre las neuronas. En el cromosoma 17 se encuentra el gen que codifica la síntesis de la proteína Tau. Mutaciones en este gen provocan una fosforilación irreversible de la proteína que impiden su función normal y facilitan su autoagregación, formando los ovillos neurofibrilares. Aunque aún en estudio, se acepta que el depósito de beta amiloide constituye una de las primeras causas de la enfermedad, sin embargo, la única correlación establecida entre la intensidad de la enfermedad y las lesiones patológicas se da con los ovillos neurofibrilares(AU)

Péptido beta amiloide, proteína Tau y enfermedad de Alzheimer / Amyloid-beta peptide, Tau protein and AlzheimerÆs disease

Se realizó una actualización sobre la enfermedad de Alzheimer, que constituye la causa más frecuente de demencia. Se establecieron aspectos relacionados con los cromosomas 21 y 17. Mutaciones en el gen de la proteína precursora amiloidea, localizado en el cromosoma 21, son responsables de 5 a 20 porciento de los casos de enfermedad de Alzheimer familiar precoz. La proteína precursora amiloidea al ser procesada por una vía amiloidogénica origina el beta amiloide, el cual se deposita en las placas seniles y causa efectos tóxicos directos sobre las neuronas. En el cromosoma 17 se encuentra el gen que codifica la síntesis de la proteína Tau. Mutaciones en este gen provocan una fosforilación irreversible de la proteína que impiden su función normal y facilitan su autoagregación, formando los ovillos neurofibrilares. Aunque aún en estudio, se acepta que el depósito de beta amiloide constituye una de las primeras causas de la enfermedad, sin embargo, la única correlación establecida entre la intensidad de la enfermedad y las lesiones patológicas se da con los ovillos neurofibrilares

Tratamiento de la infección por Helicobacter pylori: comentario al respecto / Treatment of infection caused by Helicobacter pylori: a comment on this regard

Se realizó una revisión bibliográfica sobre las pautas de tratamiento recomendadas en la infección causada por Helicobacter pylori. Las altas tasas de erradicación logradas por los esquemas triple y cuádruple, hacen que éstos sean utilizados como primera y segunda línea de tratamiento respectivamente. Se relacionan las afecciones asociadas con la infección, en las que se debe utilizar el tratamiento erradicador. El uso de antimicrobianos, en zonas donde la resistencia era elevada, redujo la eficacia del esquema utilizado. La vacuna anti-H. pylori constituyó una novedosa opción de tratamiento. La utilización de diferentes sitios mucosos de vacunación con adyuvantes de baja toxicidad, también se trataron en este trabajo. La efectividad terapéutica de la vacuna, según los autores, resultó alta en modelos experimentales y alcanzó 100 porciento de protección frente a la infección por esta bacteria gramnegativa(AU)