Neuropatía óptica compresiva. No todo lo que progresa es glaucoma / Compressive optic neuropathy. Not everything that progresses is glaucoma

Se presentan 3 casos clínicos de neuropatía óptica compresiva secundaria a meningiomas de diferente localización, diagnosticados inicialmente de glaucoma de tensión normal. Todas las pacientes eran mujeres de edad media, con excavación papilar, así como defectos en el campo visual asimétricos, rápidamente progresivos y deterioro de la agudeza visual, a pesar de presentar cifras de presión intraocular correctamente controladas con tratamiento hipotensor tópico. Debido a la evolución atípica de la enfermedad glaucomatosa, y sospechando una lesión compresiva del nervio óptico, se realizaron pruebas de neuroimagen, con las que se llegó al diagnóstico correcto. En casos de glaucoma de tensión normal hay que tener en cuenta como diagnóstico diferencial la neuropatía óptica compresiva. Diferenciar ambas afecciones constituye un reto diagnóstico que se debe sospechar ante la disminución atípica de la agudeza visual y deterioro de las pruebas, tanto funcionales como estructurales, de manera asimétrica y pese a las cifras de presión intraocular normales (AU)

Three clinical cases are presented of compressive optic neuropathy secondary to meningiomas of different locations, initially diagnosed with normal tension glaucoma (NTG). All patients were middle-aged women, with optic disc excavation, as well as asymmetric, rapidly progressive defects in the visual field (VF), and deterioration of the visual acuity (VA), despite presenting with intraocular pressure (IOP) correctly controlled with topical hypotensive therapy. Due to the atypical progression of the glaucoma disease, and suspecting a compressive lesion of the optic nerve, neuroimaging tests were performed, with which the correct diagnosis was reached. In cases of NTG, it is necessary to take into account compressive optic neuropathy as a differential diagnosis. Differentiating both pathologies is a diagnostic challenge that should be suspected due to the atypical decrease of the VA and deterioration of both functional and structural tests, and asymmetrically, despite the normal IOP (AU)

Compressive optic neuropathy. Not everything that progresses is glaucoma. / Neuropatía óptica compresiva. No todo lo que progresa es glaucoma.

Three clinical cases are presented of compressive optic neuropathy secondary to meningiomas of different locations, initially diagnosed with normal tension glaucoma (NTG). All patients were middle-aged women, with optic disc excavation, as well as asymmetric, rapidly progressive defects in the visual field (VF), and deterioration of the visual acuity (VA), despite presenting with intraocular pressure (IOP) correctly controlled with topical hypotensive therapy. Due to the atypical progression of the glaucoma disease, and suspecting a compressive lesion of the optic nerve, neuroimaging tests were performed, with which the correct diagnosis was reached. In cases of NTG, it is necessary to take into account compressive optic neuropathy as a differential diagnosis. Differentiating both pathologies is a diagnostic challenge that should be suspected due to the atypical decrease of the VA and deterioration of both functional and structural tests, and asymmetrically, despite the normal IOP.

Vitrectomía diagnóstica: serie de casos en un centro de referencia / Diagnostic vitrectomy: a case series in a single referral center

Objetivo: Estudiar la eficacia y perfil de seguridad de la vitretomía diagnóstica en pacientes con uveítis no filiada. Métodos: Estudio observacional descriptivo retrospectivo de 29 pacientes (37 ojos) con panuveítis no filiada en los que se realizó vitrectomía diagnóstica. Las características clínicas y demográficas fueron recogidas. Se estudiaron los métodos de extracción de muestras y las técnicas de procesado aplicadas para el diagnóstico. Resultados: De los 29 pacientes analizados 18 (62%) eran hombres. La media de edad fue de 63,11 años (desviación estándar: 14,55). El síntoma inicial más frecuente fue la disminución de agudeza visual, la agudeza visual media fue de 20/40 excluyendo 8 ojos en los que resultó inferior a 20/200. Veintiún pacientes presentaban alteración unilateral. Se realizó extracción de muestra en seco a todos los pacientes. Además, fueron empleadas las siguientes técnicas de toma de muestras: 5 biopsias retinianas, 5 muestras diluidas, 1 aspirado de absceso subretiniano, 1 aspirado de humor acuoso. Con respecto al procesado de las muestras la técnica más utilizada fue la citología en 25 ojos, seguida de la reacción en cadena de la polimerasa en 11 ojos, el cultivo en 10 ojos. El diagnóstico etiológico fue encontrado en 94,5% de los casos, siendo el principal linfoma, seguido de toxoplasmosis. Conclusión: La vitrectomía diagnóstica es útil para la identificación de la inflamación oftalmológica. Pueden utilizarse diferentes técnicas de obtención de muestras y procesado de las mismas

Objective: To study the results and safety of diagnostic vitrectomy in patients with unknown etiology panuveitis. Methods: A retrospective descriptive observational study was carried out in which a total of 29 patients (37 eyes) were included, who underwent a vitreous biopsy due to acute intraocular inflammatory processes. In all, demographic and clinical data were collected. We studied the specific samples extraction methods and their diagnosic processing. Results: Of the 29 patients analyzed, 18 were men. Mean of age was 63.11 years old (standard deviation: 14.55). The most frequent initial symptom was visual acuity decrease, with mean initial visual acuity being 20/40, excluding 8 eyes that had vision lower than 20/200. 21 presented unilateral ocular involvement. Vitrectomy was performed in all of them obtaining a dry sample. Vitrectomy was performed in all of the patients obtaining a dry sample. Moreover, the following techniques were done: 5 retinal biopsies, obtaining 5 muestras diluidas, 1 subretinal abscess aspirate and 1 aqueous humor aspirate. The most frequent processing technique that was used was cytology in 25 eyes, followed by PCR (polymerase chain reaction) in 11 eyes and culture in 10 eyes. Diagnosis was achieved in 94.5% of patients. Main diagnosis found was lymphoma, followed by toxoplasmosis. Conclusions: Diagnostic vitrectomy is very important in ophthalmic inflammation identification. Different techniques for obtaining and processing can be used

Réplica: Oclusión venosa central de la retina isquémica como posible diagnóstico diferencial de la retinopatía Purtscher-like / Reply: Ischemic central retinal venous occlusion as a possible differential diagnosis of Purtscher-like retinopathy

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Estudio de carcinomas agresivos a través de metástasis orbitarias / Study of aggressive carcinomas through orbital metástasis

Se presentan dos casos clínicos de metástasis orbitaria. El primero es el de un varón de 63 años con pérdida de agudeza visual reciente asociada a diplopía binocular. Las pruebas de neuroimagen revelan una tumoración de características agresivas con extensión intraconal e invasión ósea. El estudio sistémico nos lleva al diagnóstico de carcinoma broncogénico microcítico en estadio IV. El segundo caso corresponde a una mujer de 69 años con cáncer de mama en estadios precoces que presenta alteraciones de motilidad ocular y proptosis. Mediante tomografía computarizada se evidencia infiltración tumoral de musculatura extraocular. El estudio anatomopatológico confirma el diagnóstico de metástasis orbitaria. La enfermedad metastásica orbitaria es una entidad relativamente infrecuente, con presentación clínica variada y pronóstico desfavorable. Constituye un reto diagnóstico que se debe sospechar en pacientes con factores de riesgo para enfermedad tumoral y recurrir a las técnicas de imagen para definir la extensión y severidad del cuadro

Two clinical cases of orbital metastasis are presented. The first is a 63 year-old male with a recent loss of visual acuity associated with binocular diplopia. Neuroimaging tests revealed a tumour of aggressive features with intraconal extension and bone invasion. The systemic study led to the diagnosis of stage IV small cell bronchogenic carcinoma. The second case is a 69 year-old woman with breast cancer in early stages that showed alterations in ocular motility and proptosis. Computed tomography showed tumour infiltration of extraocular musculature. The anatomo-pathological study confirmed the diagnosis of orbital metastasis. Orbital metastatic disease is a relatively infrequent entity with varied clinical presentation and an unfavourable prognosis. It constitutes a diagnostic challenge that should be suspected in patients with risk factors for tumour disease and imaging techniques used to define the extent and severity of the condition

Retinopatía vasoproliferativa secundaria a enfermedad de Waldenström / Vasoproliferative retinopathy secondary to Waldenström's disease

Paciente de 66 años en seguimiento por retinopatía diabética refractaria a múltiples modalidades de tratamiento a pesar del buen control metabólico que refiere pérdida de peso progresiva. Por este motivo se decide realizar un estudio sistémico, detectándose anemia, elevación de la velocidad de sedimentación globular e hiperproteinemia a expensas de un pico monoclonal de IgM. Posteriormente, mediante la biopsia de médula ósea y el estudio genético, se llega al diagnóstico de macroglobulinemia de Waldenström. La macroglobulinemia de Waldenström es una patología linfoproliferativa de escasa frecuencia cuya principal manifestación es a través del síndrome de hiperviscosidad. Este puede producir signos oftalmológicos detectables mediante funduscopia y pruebas de imagen. El estudio multimodal es útil en el diagnóstico y seguimiento de la afectación retiniana. La incorporación de la angiografía por tomografía de coherencia óptica permite un estudio más preciso de los trastornos microvasculares que se pueden presentar a nivel del polo posterior

A 66 year-old patient, monitored for diabetic retinopathy refractory to multiple treatment methods despite a good metabolic control, referred to progressive weight loss. For this reason, a systemic study was performed, detecting anaemia, elevation of the erythrocyte sedimentation rate, and hyperproteinaemia due to elevated serum levels of monoclonal IgM. Subsequently, by performing a bone marrow biopsy and genetic study, the diagnosis of Waldenström macroglobulinaemia was made. Waldenström's macroglobulinaemia is a low frequency lymphoproliferative disease, for which the main manifestation is a hyperviscosity syndrome that can produce ophthalmological signs detectable by funduscopy and imaging tests. A multimodal study is useful in the diagnosis and monitoring of retinal involvement. The incorporation of angiography by optical coherence tomography allows a more precise study of the microvascular disorders that may occur at the posterior pole level

Estudio multimodal y tratamiento de la retinopatía tipo Purtscher / Response to anti-VEGF therapy in macular oedema secondary to acute retinal necrosis

Paciente de 52 años con múltiples factores de riesgo cardiovascular remitido por pérdida visual unilateral, aguda e indolora. En la fundoscopia destaca importante inflamación papilar con tortuosidad a este nivel y hemorragias. Las pruebas de imagen muestran edematización tanto del disco óptico como macular y afectación en capas internas retinianas. La angiografía con fluoresceína y la angiografía por tomografía de coherencia óptica de control muestran áreas de isquemia central y periférica. Dados los hallazgos clínicos y los antecedentes del paciente, se llega al diagnóstico de retinopatía de tipo Purtscher y se decide tratamiento con dexametasona intravítrea. La retinopatía de tipo Purtscher es una entidad de rara frecuencia que se presenta en pacientes con múltiples enfermedades sistémicas pero sin antecedentes traumáticos, lo que la diferencia de la retinopatía de Purtscher. En el pronóstico es importante el diagnóstico y la intervención precoz. No existen protocolos terapéuticos, pero con la terapia intravítrea con dexametasona se han obtenido buenos resultados

A 52-year-old patient with multiple cardiovascular risk factors referred for unilateral, acute, and painless visual loss. In the fundoscopic image there was significant papillary inflammation with tortuosity at this level and haemorrhages. Ophthalmological examination showed papillary inflammation, macular oedema, and involvement in retinal inner layers. The control fluorescein angiography and optical coherence tomography angiography showed areas of central and peripheral ischaemia. Given the clinical findings and background of the patient, the diagnosis of Purtscher-like retinopathy was reached and treatment with intravitreal dexamethasone was decided. Purtscher-like retinopathy is a rare entity that occurs in patients with multiple systemic pathologies, but without a traumatic background, which differentiates it from Purstcher's retinopathy. The diagnosis and early intervention are important in the prognosis. There are no therapeutic protocols, but good results have been obtained with intravitreal therapy with dexamethasone

Multimodal imaging and treatment of Purtscher-like retinopathy. / Estudio multimodal y tratamiento de la retinopatía tipo Purtscher.

A 52-year-old patient with multiple cardiovascular risk factors referred for unilateral, acute, and painless visual loss. In the fundoscopic image there was significant papillary inflammation with tortuosity at this level and haemorrhages. Ophthalmological examination showed papillary inflammation, macular oedema, and involvement in retinal inner layers. The control fluorescein angiography and optical coherence tomography angiography showed areas of central and peripheral ischaemia. Given the clinical findings and background of the patient, the diagnosis of Purtscher-like retinopathy was reached and treatment with intravitreal dexamethasone was decided. Purtscher-like retinopathy is a rare entity that occurs in patients with multiple systemic pathologies, but without a traumatic background, which differentiates it from Purstcher's retinopathy. The diagnosis and early intervention are important in the prognosis. There are no therapeutic protocols, but good results have been obtained with intravitreal therapy with dexamethasone.

Vasoproliferative retinopathy secondary to Waldenström's disease. / Retinopatía vasoproliferativa secundaria a enfermedad de Waldenström.

A 66 year-old patient, monitored for diabetic retinopathy refractory to multiple treatment methods despite a good metabolic control, referred to progressive weight loss. For this reason, a systemic study was performed, detecting anaemia, elevation of the erythrocyte sedimentation rate, and hyperproteinaemia due to elevated serum levels of monoclonal IgM. Subsequently, by performing a bone marrow biopsy and genetic study, the diagnosis of Waldenström macroglobulinaemia was made. Waldenström's macroglobulinaemia is a low frequency lymphoproliferative disease, for which the main manifestation is a hyperviscosity syndrome that can produce ophthalmological signs detectable by funduscopy and imaging tests. A multimodal study is useful in the diagnosis and monitoring of retinal involvement. The incorporation of angiography by optical coherence tomography allows a more precise study of the microvascular disorders that may occur at the posterior pole level.

Study of aggressive carcinomas through orbital metastasis. / Estudio de carcinomas agresivos a través de metástasis orbitarias.

Two clinical cases of orbital metastasis are presented. The first is a 63 year-old male with a recent loss of visual acuity associated with binocular diplopia. Neuroimaging tests revealed a tumour of aggressive features with intraconal extension and bone invasion. The systemic study led to the diagnosis of stage IV small cell bronchogenic carcinoma. The second case is a 69 year-old woman with breast cancer in early stages that showed alterations in ocular motility and proptosis. Computed tomography showed tumour infiltration of extraocular musculature. The anatomo-pathological study confirmed the diagnosis of orbital metastasis. Orbital metastatic disease is a relatively infrequent entity with varied clinical presentation and an unfavourable prognosis. It constitutes a diagnostic challenge that should be suspected in patients with risk factors for tumour disease and imaging techniques used to define the extent and severity of the condition.

Imagen multimodal en el estudio del fundus flavimaculatus / Multimodality imaging in the study of fundus flavimaculatus

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