Evolución de la técnica «avance de colgajo frontal» en la ptosis congénita / Evolution of the «frontal flap advancement» in congenital ptosis

El tratamiento de la ptosis congénita con mala función del elevador se basa habitualmente en una suspensión del párpado superior al músculo frontal mediante diversos tipos de materiales autógenos o aloplásticos. Sin embargo, el empleo de dichos materiales conlleva una serie de complicaciones, lo cual dio lugar a la búsqueda de una técnica quirúrgica mediante la que, sin necesidad de ningún material adicional, se enlazaran músculo frontal y tarso; el avance de colgajo frontal. No obstante, es una técnica menos conocida y que todavía no está estandarizada, por lo que a lo largo del tiempo se han ido describiendo variaciones para mejorar los resultados estéticos y funcionales. El objetivo de esta revisión bibliográfica es repasar en detalle las distintas variaciones de la técnica quirúrgica y obtener la mejor opción con o sin la combinación de las diferentes versiones empleadas hasta el momento. Según los resultados observados, se podría deducir que la cirugía con mejores resultados estéticos y funcionales sería la siguiente; una única incisión en el surco palpebral para realizar una disección suborbicular hasta alcanzar reborde orbitario. Realización de lipectomía si lo precisa. A continuación, disección roma del músculo frontal y formación de colgajo en «U». Avance de la aponeurosis del elevador si se trata de una ptosis grave. Finalmente, sutura sin polea del colgajo frontal al tarso con tres puntos no reabsorbibles tratando de mantener el contorno simétrico al ojo contralateral y con una altura de 1,5mm por encima del limbo corneal (AU)

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improving the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determining which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a “U” shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5mm above the sclero-corneal limbus (AU)

Evolution of the «frontal flap advancement¼ in congenital ptosis.

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improve the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determine which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a "U" shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5 mm above the sclero-corneal limbus.

Casuística de 10 pacientes con queratitis por Acanthamoeba / A report of 10 patients with Acanthamoeba keratitis

CASOS CLÍNICOS: Presentamos 10 casos de queratitis por Acanthamoeba tratados en nuestro hospital entre 2008 y 2017. Todos eran portadores de lentes de contacto. Como tratamiento todos recibieron una biguanida junto a una diamidina. En 3 casos la infección no superaba el estroma superficial, respondiendo al tratamiento tópico. En 7 alcanzaba el estroma profundo, precisando 6 de ellos una queratoplastia penetrante, 3 «en caliente» por riesgo de perforación o extensión ocular. La agudeza visual mejoró en todos los casos. CONCLUSIÓN: La profundidad de la infección al diagnóstico aparece como el principal factor de riesgo para necesitar una queratoplastia penetrante

CLINICAL CASES: Cases are presented of 10 patients with Acanthamoeba keratitis treated between 2008 and 2017. All were contact lens wearers. All of them received treatment with a biguanide combined with a diamidine. In 3 cases the infestation did not exceed the superficial stroma, responding to topical treatment. In 7, the infection reached the deep stroma, with 6 of these cases requiring penetrating keratoplasty (PKP), 3 of them therapeutic PKP because of perforation risk or ocular spreading. The visual acuity improved in all the cases. CONCLUSION: The infestation depth at the time of diagnosis appears to be the main risk factor for requiring a PKP

A report of 10 patients with Acanthamoeba keratitis. / Casuística de 10 pacientes con queratitis por Acanthamoeba.

CLINICAL CASES: Cases are presented of 10 patients with Acanthamoeba keratitis treated between 2008 and 2017. All were contact lens wearers. All of them received treatment with a biguanide combined with a diamidine. In 3 cases the infestation did not exceed the superficial stroma, responding to topical treatment. In 7, the infection reached the deep stroma, with 6 of these cases requiring penetrating keratoplasty (PKP), 3 of them therapeutic PKP because of perforation risk or ocular spreading. The visual acuity improved in all the cases. CONCLUSION: The infestation depth at the time of diagnosis appears to be the main risk factor for requiring a PKP.

Patient-specific simulation of the intrastromal ring segment implantation in corneas with keratoconus.

PURPOSE: The purpose of this study was the simulation of the implantation of intrastromal corneal-ring segments for patients with keratoconus. The aim of the study was the prediction of the corneal curvature recovery after this intervention. METHODS: Seven patients with keratoconus diagnosed and treated by implantation of intrastromal corneal-ring segments were enrolled in the study. The 3D geometry of the cornea of each patient was obtained from its specific topography and a hyperelastic model was assumed to characterize its mechanical behavior. To simulate the intervention, the intrastromal corneal-ring segments were modeled and placed at the same location at which they were placed in the surgery. The finite element method was then used to obtain a simulation of the deformation of the cornea after the ring segment insertion. Finally, the predicted curvature was compared with the real curvature after the intervention. RESULTS: The simulation of the ring segment insertion was validated comparing the curvature change with the data after the surgery. Results showed a flattening of the cornea which was in consonance with the real improvement of the corneal curvature. The mean difference obtained was of 0.74 mm using properties of healthy corneas. CONCLUSIONS: For the first time, a patient-specific model of the cornea has been used to predict the outcomes of the surgery after the intrastromal corneal-ring segments implantation in real patients.

A new methodology for the in vivo estimation of the elastic constants that characterize the patient-specific biomechanical behavior of the human cornea.

This work presents a methodology for the in vivo characterization of the complete biomechanical behavior of the human cornea of each patient. Specifically, the elastic constants of a hyperelastic, second-order Ogden model were estimated for 24 corneas corresponding to 12 patients. The finite element method was applied to simulate the deformation of human corneas due to non-contact tonometry, and an iterative search controlled by a genetic heuristic was used to estimate the elastic parameters that most closely approximates the simulated deformation to the real one. The results from a synthetic experiment showed that these parameters can be estimated with an error of about 5%. The results of 24 in vivo corneas showed an overlap of about 90% between simulation and real deformed cornea and a modified Hausdorff distance of 25 µm, which indicates the great accuracy of the proposed methodology.

A new approach based on Machine Learning for predicting corneal curvature (K1) and astigmatism in patients with keratoconus after intracorneal ring implantation.

Keratoconus (KC) is the most common type of corneal ectasia. A corneal transplantation was the treatment of choice until the last decade. However, intra-corneal ring implantation has become more and more common, and it is commonly used to treat KC thus avoiding a corneal transplantation. This work proposes a new approach based on Machine Learning to predict the vision gain of KC patients after ring implantation. That vision gain is assessed by means of the corneal curvature and the astigmatism. Different models were proposed; the best results were achieved by an artificial neural network based on the Multilayer Perceptron. The error provided by the best model was 0.97D of corneal curvature and 0.93D of astigmatism.

[Atypical ophthalmic findings in Susac syndrome]. / Síndrome de Susac de presentación ocular atípica.

CASE REPORT: A 25-year-old woman with encephalopathy and sensorineural hearing loss was referred to us in order to confirm Susac syndrome, due to bilateral visual loss. Funduscopic examination revealed peripheral retinal microangiopathy. DISCUSSION: Susac syndrome is typically characterized by the clinical triad of encephalopathy, branch retinal artery occlusions, and hearing loss. In our case, ophthalmic findings were atypical. Interrupted vessels and microaneurisms accumulation in the peripheral retina of both eyes were observed.

Síndrome de Susac de presentación ocular atípica / Atypical Ophtalmic Findings in Susac Syndrome

Caso clínico: Mujer de 25 años de edad afecta de encefalopatía y pérdida auditiva neurosensorial, remitida a nuestro servicio para confirmar un síndrome de Susac por presentar una disminución de agudeza visual bilateral. En la exploración funduscópica se apreció una microangiopatía retiniana periférica. Discusión: El síndrome de Susac se caracteriza típicamente por la tríada encefalopatía, perdida auditiva neurosensorial, y oclusiones de ramas arteriales retinianas. En nuestro caso las alteraciones oculares eran atípicas, apreciándose amputación de vasos terminales con cúmulo de microaneurismas en retina periférica de ambos ojos (AU)

Case report: A 25-year-old woman with encephalopathy and sensorineural hearing loss was referred to us in order to confirm Susac syndrome, due to bilateral visual loss. Funduscopic examination revealed peripheral retinal microangiopathy. Discussion: Susac syndrome is typically characterized by the clinical triad of encephalopathy, branch retinal artery occlusions, and hearing loss. In our case, ophthalmic findings were atypical. Interrupted vessels and microaneurisms accumulation in the peripheral retina of both eyes were observed (AU)

Macular phototrauma after cataract extraction and multifocal lens implantation: case report.

PURPOSE: To report a patient who developed photic injury after cataract surgery and multifocal MF4 lens implantation METHODS: A 41-year-old caucasian woman without antecedents of interest was subjected to left catarct surgery involving phacoemulsification with capsular sac implantation of a new type of multifocal lens. A coaxial light microscope was used for surgery. The operation was filmed and anterior pole photographs were obtained. RESULTS: Two days after the operation, the patient noted a paracentral scotoma and hand movement visual acuity in the left eye. Indirect ophthalmoscopy revealed an oval, hyperpigmented macular lesion compatible with phototoxic maculopathy. CONCLUSIONS: Phototoxic injury to the macula may occur after cataract extraction. Implantation of an intraocular lens is an important factor in the producion of maculopathy, on account of its light-focusing effect on the retina. This effect was probably increased in our patient by the use of a new autofocus multifocal lens.

[Terson syndrome associated with a carotid-ophthalmic giant aneurysm]. / Síndrome de Terson asociado a aneurisma carótido-oftálmica gigante.

UNLABELLED: PURPOSE/MATERIAL AND METHOD: A case of a 42 year-old woman presenting headache, vomiting and loss of consciousness of sudden onset. Upon testing right eye presented amaurosis while left eye showed a visual acuity of 20/50. RESULTS/CONCLUSION: Brain angiography showed a right sided giant carotid aneurysm at the ophthalmic artery area. Globe fundus in left eye showed vitreal and intra-retinal hemorrhage appearing in retinal posterior pole and periphery of the retina. Subarachnoidal hemorrhage accompanied by intra-vitreal bleeding is known as Terson's Syndrome. Peculiarities of this clinical case are discussed in this paper.

Síndrome de terson asociado a aneurisma carótido-oftálmica gigante / Terson's syndrome referred from giant aneurysm in carotid and ophthalmic arteries

Objetivo/Métodos: Presentamos el caso de una paciente de 42 años con cefalea, vómitos y pérdida de conciencia de instauración súbita. Este cuadro fue debido a una hemorragia subaracnoidea secundaria a la ruptura espontánea de un aneurisma. Tras recuperar la conciencia, la agudeza visual de su ojo derecho era amaurosis mientras que la de su ojo izquierdo (OI) era de 20/50.Resultados/Conclusión: Mediante arteriografía cerebral se detectó un aneurisma carótido-oftálmico gigante derecho. Fundoscópicamente se observó en el OI una hemorragia intravítrea con hemorragias retinianas dispersas tanto en el polo posterior como en la periferia de la retina. La asociación de hemorragia subaracnoidea con intravítrea es conocida como síndrome de Terson. Se discuten las peculiaridades del caso con síndrome de Terson (AU)

Multilayer amniotic membrane transplantation in severe ocular graft versus host disease.

PURPOSE: To clarify the usefulness of multilayer amniotic membrane transplantation in an unusual case of calcareous corneal degeneration in a patient with graft-versus-host disease. METHODS: A 20-year-old Caucasian woman had bilateral calcareous corneal degeneration of one year of evolution, secondary to graft-versus-host disease. Treatment for both eyes with topical steroids and antibiotic ointment was not successful. Right eye had a spontaneous corneal perforation, and a three-layer circle amniotic membrane graft was applied to the whole cornea. RESULTS: During a follow-up period of 20 months we observed stability of the corneal epithelium and stroma. The amniotic membrane-covered area showed rapid epithelization, reduced inflammation and suppressed fibrosis formation. CONCLUSIONS: Multilayer amniotic membrane transplantation may be considered an alterantive for reconstructing the ocular surface in a patient with severe dry eyes and calcareous corneal degeneration, even with little perforation.

Posterior chamber phakic intraocular lenses to correct high myopia: a comparative study between Staar and Adatomed models.

PURPOSE: To determine the feasibility of using posterior chamber phakic intraocular lenses (PIOLs) to treat high myopia, comparing two different models, Staar and Adatomed. METHODS: Twenty-four eyes from 12 patients were studied prospectively. A phakic Staar IOL was implanted in one eye of each patient, and the other eye received a phakic Adatomed IOL. Patients with uveitis or ocular trauma prior to ocular surgery, diabetic retinopathy, or capsular pseudoexfoliation were excluded. The mean preoperative spherical equivalent refraction was -16.00 +/- 5.05 D for the Staar group and -15.39 +/- 2.83 D for the Adatomed group. Average follow-up was 32.4 months (range, 19 to 46 mo) for the Adatomed group and 18.3 months (range, 11 to 21 mo) for the Staar group and included evaluation of intraocular pressure, intraocular lens pigment deposits, lens decentration, anterior subcapsular cataract, and visual acuity. RESULTS: Spectacle-corrected and uncorrected visual acuity improved in all eyes in both groups. No statistically significant differences in visual acuity gain were observed with the two materials (Student t-test, P = .08 for the Staar group and P = .6 for the Adatomed group), although the gain in visual acuity was somewhat greater with the Staar PIOLs. The difference in mean intraocular pressure before surgery and at last follow-up was 1.5 mmHg for the Staar group and 2.3 mmHg for the Adatomed group (P = .36). The incidence of lens pigment deposits was the same in both groups (41.66%), with deposits in 5 of the 12 eyes in both groups. The incidence of lens decentration was higher in the Adatomed group (5/12; 41.66%) than in the Staar group (2/12; 16.7%). Anterior subcapsular cataract was higher in the Adatomed group (4/12; 33.3%) than in the Staar group (3/12; 25%). CONCLUSIONS: There was a higher incidence of lens decentration and anterior subcapsular cataract in the Adatomed group than in the Staar group.

Amaurosis fugax como manifestación precoz de schwanoma orbitario / Amaurosis fugax as the early manifestation of orbital schwannoma

Objetivo/método: Presentamos el caso de una mujer de 51 años que padecía desde hacía cuatro meses episodios de repetición de amaurosis fugax en su ojo izquierdo. Resultados/conclusiones: Mediante tomografía axial computerizada se diagnosticó una masa orbitaria circunscrita intraconal izquierda sospechosa de hemangioma cavernoso. Se le practicó una orbitotomía lateral izquierda resecándose una masa rojiza encapsulada, sugestiva de hemangioma cavernoso. Microscópicamente estaba compuesta por áreas de células fusiformes dispuestas en empalizada (Antoni tipo A), entremezcladas con áreas quísticas donde las células estaban rodeadas por una matriz mixoide (Antoni tipo B). En base a los hallazgos histopatológicos se estableció el diagnóstico de neurilemoma orbitario (AU)

Branch retinal vein occlusion associated with the 20210 G-to-A prothrombin variant.

PURPOSE: To describe a case of branch retinal vein occlusion (BRVO) in a patient who tested positive for the 20210 A allele of the prothrombin (PT) gene. METHODS: A 48-year-old man had visual loss in the right eye secondary to BRVO confirmed by ophthalmoscopy and fluorescein angiography. His medical history was not remarkable for common risk factors for retinal occlusive diseases. RESULTS: Laboratory tests for hypercoagulability were positive for PT 20210 A variant. The patient's family tested negative for the PT variant. CONCLUSIONS: Laboratory tests for coagulopathy, including the PT 20210 A variant, should be added to the examination of patients with central or BRVO, especially if most common risk factors for thrombosis have been excluded.