Biopsia del músculo recto lateral orbitario como diagnóstico de cáncer de mama metastásico no conocido / Lateral rectus muscle biopsy as diagnosis of unknown metastatic breast cancer

Mujer de 58 años sin antecedentes médicos de interés que consulta por diplopía binocular de una semana de evolución, asociada a dolor costal, disnea, astenia intensa y pérdida de peso de 2 meses de evolución. En la analítica de urgencia presenta hipercalcemia, insuficiencia renal y bicitopenia, y en la radiografía de tórax de urgencias se observan múltiples imágenes osteoclásticas que orientan inicialmente a mieloma múltiple con afectación extraósea. Además del estudio correspondiente, ante la diplopía horizontal se realiza TC craneal sin contraste, donde se observa una lesión adyacente a la pared lateral de la órbita izquierda, de densidad de partes blandas, que incluye el músculo recto externo y ejerce efecto masa sobre el nervio óptico desplazándolo medialmente. Además se observan múltiples lesiones líticas de distribución difusa en la calota, con patrón permeativo "en sal y pimienta". Se procede a la biopsia del músculo recto lateral y ósea de ala sacra, obteniendo como resultado metástasis de carcinoma compatible con origen mamario. Presentamos un caso atípico de diplopía horizontal en el contexto de una paciente con un cuadro constitucional severo sin diagnóstico establecido, en el que la biopsia del recto lateral, junto con la biopsia de médula ósea, son claves a la hora del diagnóstico de confirmación

The case concerns a 58 year-old female with no medical history of interest who consulted due to binocular diplopia of one week onset. It was associated with costal pain, dyspnoea, intense asthenia and weight loss of 2 months onset. In the blood analysis in the Emergency Department it showed hypercalcaemia, renal failure, and bicytopenia. The chest x-ray showed lytic bone lesions that initially lead to multiple myeloma with extra-osseous involvement. In addition to the corresponding study, in case of horizontal diplopia, a cranial CT scan without contrast was performed where an adjacent lesion to the lateral wall of the left orbit is observed. This was of soft tissue density, and included the external rectus muscle that exerts a mass effect on the optic nerve by displacing it medially. Many lytic bone diffuse lesions with salt and pepper pattern were found in the calotte. A rectus lateral muscle and bone biopsy of the sacral wing was performed, resulting in metastasis of carcinoma compatible with mammary origin. An atypical case is presented of horizontal diplopia in the context of a patient with a severe constitutional picture with no established diagnosis, in which the biopsy of the lateral rectum was key to the confirmation diagnosis

Lateral rectus muscle biopsy as diagnosis of unknown metastatic breast cancer. / Biopsia del músculo recto lateral orbitario como diagnóstico de cáncer de mama metastásico no conocido.

The case concerns a 58 year-old female with no medical history of interest who consulted due to binocular diplopia of one week onset. It was associated with costal pain, dyspnoea, intense asthenia and weight loss of 2 months onset. In the blood analysis in the Emergency Department it showed hypercalcaemia, renal failure, and bicytopenia. The chest x-ray showed lytic bone lesions that initially lead to multiple myeloma with extra-osseous involvement. In addition to the corresponding study, in case of horizontal diplopia, a cranial CT scan without contrast was performed where an adjacent lesion to the lateral wall of the left orbit is observed. This was of soft tissue density, and included the external rectus muscle that exerts a mass effect on the optic nerve by displacing it medially. Many lytic bone diffuse lesions with salt and pepper pattern were found in the calotte. A rectus lateral muscle and bone biopsy of the sacral wing was performed, resulting in metastasis of carcinoma compatible with mammary origin. An atypical case is presented of horizontal diplopia in the context of a patient with a severe constitutional picture with no established diagnosis, in which the biopsy of the lateral rectum was key to the confirmation diagnosis.

Síndrome de misdirección del humor acuoso tras cirugía filtrante de glaucoma en paciente con síndrome de transiluminación aguda iridiana bilateral (BAIT) / Aqueous humor misdirection syndrome after glaucoma filtering surgery in patient with bilateral acute iris transillumination (BAIT) syndrome

CASO CLÍNICO: El síndrome BAIT (Bilateral Acute Iris Transillumination (transiluminación iridiana aguda bilateral) es una enfermedad caracterizada por dispersión pigmentaria severa aguda bilateral del iris y parálisis del esfínter pupilar. Mujer de 51 años diagnosticada de síndrome BAIT con hipertensión ocular refractaria en ojo izquierdo (OI) que precisa realización de cirugía filtrante. Durante la primera semana del postoperatorio desarrolla un cuadro de misdirección del humor acuoso, por lo que se procede a vitrectomía posterior vía pars plana, con resolución del mismo. CONCLUSIÓN: Presentamos el primer caso descrito en la bibliografía de síndrome de misdirección acuosa secundaria a cirugía filtrante de glaucoma en una paciente con síndrome BAIT, patología de reciente definición y con pocos casos descritos actualmente

CASE REPORT: Bilateral Acute Iris Transillumination (BAIT) is a disease characterised by bilateral acute, severe pigment dispersion of the iris, and pupil sphincter paralysis. The case is reported of a 51-year-old female who was diagnosed with BAIT syndrome, with refractory ocular hypertension in the left eye, and who needed filtering surgery. Aqueous misdirection was developed a week after surgery, then pars plana vitrectomy was performed and the complication was solved. CONCLUSION: This is the first case described in literature of aqueous humor misdirection syndrome secondary to glaucoma filtering surgery in a patient diagnosed of BAIT syndrome. This is a recently defined disease with a few cases currently described

Aqueous humor misdirection syndrome after glaucoma filtering surgery in patient with bilateral acute iris transillumination (BAIT) syndrome. / Síndrome de misdirección del humor acuoso tras cirugía filtrante de glaucoma en paciente con síndrome de transiluminación aguda iridiana bilateral (BAIT).

CASE REPORT: Bilateral Acute Iris Transillumination (BAIT) is a disease characterised by bilateral acute, severe pigment dispersion of the iris, and pupil sphincter paralysis. The case is reported of a 51-year-old female who was diagnosed with BAIT syndrome, with refractory ocular hypertension in the left eye, and who needed filtering surgery. Aqueous misdirection was developed a week after surgery, then pars plana vitrectomy was performed and the complication was solved. CONCLUSION: This is the first case described in literature of aqueous humor misdirection syndrome secondary to glaucoma filtering surgery in a patient diagnosed of BAIT syndrome. This is a recently defined disease with a few cases currently described.

A propósito de un caso de hamartoma retiniano adyacente a cabeza de nervio óptico en un caso de esclerosis tuberosa / Peripapillar retinal hamartoma associated with tuberous sclerosis. Case report

Introducción: La esclerosis tuberosa es una enfermedad multisistémica rara, con un patrón de herencia autosómico dominante. Existen pocos casos documentados en la literatura de hamartomas retinales (astrocitomas) con progresión agresiva en el contexto de esta enfermedad. Caso clínico: Se presenta el caso de un varón de 31 años sin antecedentes de afecciones oftálmicas ni sistémicas conocidas, que refirió una historia de 6 meses de visión borrosa en el ojo derecho causada por un hamartoma unilateral de retina, en un caso no diagnosticado de esclerosis tuberosa. Discusión: Es necesario realizar un manejo multidisciplinario, con la colaboración del Departamento de Medicina Interna y de Oncología, así como ofrecer asesoramiento genético para los pacientes afectados. Las complicaciones están directamente relacionadas con el aumento del tamaño del tumor. El tratamiento no parece tener ninguna influencia en la historia natural de la enfermedad (AU)

Introduction: Tuberous sclerosis is a rare multisystemic disease with an autosomal dominant inheritance pattern. There are few documented cases in the literature of retinal hamartomas (astrocytomas) with aggressive progression in the context of this disease. Case report: A report is presented on a case of a 31 year-old male with unknown history of ophthalmic or systemic conditions, who referred to a history of 6 months of blurred vision in his right eye. This was caused by a unilateral retinal hamartoma due to an undiagnosed tuberous sclerosis. Discussion: Multidisciplinary management, with the cooperation of Internal Medicine and the Oncology Department, is needed in these cases, as well as genetic counselling for affected patients. Complications are directly related to increased tumour size. Treatment does not seem to have any influence on the natural history of the disease (AU)

Peripapillar retinal hamartoma associated with tuberous sclerosis. Case report. / A propósito de un caso de hamartoma retiniano adyacente a cabeza de nervio óptico en un caso de esclerosis tuberosa.

INTRODUCTION: Tuberous sclerosis is a rare multisystemic disease with an autosomal dominant inheritance pattern. There are few documented cases in the literature of retinal hamartomas (astrocytomas) with aggressive progression in the context of this disease. CASE REPORT: A report is presented on a case of a 31 year-old male with unknown history of ophthalmic or systemic conditions, who referred to a history of 6 months of blurred vision in his right eye. This was caused by a unilateral retinal hamartoma due to an undiagnosed tuberous sclerosis. DISCUSSION: Multidisciplinary management, with the cooperation of Internal Medicine and the Oncology Department, is needed in these cases, as well as genetic counselling for affected patients. Complications are directly related to increased tumour size. Treatment does not seem to have any influence on the natural history of the disease.

Metástasis de nervio óptico secundaria a adenocarcinoma de pulmón / Optic nerve metastasis caused by lung adenocarcinoma

Introducción: Las metástasis del nervio óptico aisladas son extremadamente infrecuentes. Muchos casos se asocian con afectación de otras localizaciones como la coroides, órbita o el sistema nervioso central. Caso clínico: Mujer de 57 años de edad con el diagnóstico de adenocarcinoma de pulmón con pérdida brusca de la visión del ojo derecho. Ante los hallazgos encontrados y los resultados de la RMN se realiza el diagnóstico de metástasis del nervio óptico. Discusión: Las metástasis de nervio óptico aisladas son un cuadro infrecuente, pero que tendremos que sospechar en todo paciente con antecedentes oncológicos que presenten un deterioro de la agudeza visual (AU)

Introduction: Isolated optic nerve metastases are extremely uncommon. Many cases are associated with involvement from locations such as the choroid, orbit, or central nervous system. Optic nerve metastases often have their origin in primary tumours of the breast, lung, and stomach, in adults. Case report: The case is presented of a 57 year-old woman with a diagnosis of lung adenocarcinoma. Her first complaint was a sudden loss of visual acuity in her right eye. The diagnosis of optic nerve metastases was made based on her history, and the results of the MRI scan. Discussion: Isolated optic nerve metastases are an uncommon condition, but should be suspected in any patient with a history of oncology who has deteriorated visual acuity (AU)

Optic nerve metastasis caused by lung adenocarcinoma. / Metástasis de nervio óptico secundaria a adenocarcinoma de pulmón.

INTRODUCTION: Isolated optic nerve metastases are extremely uncommon. Many cases are associated with involvement from locations such as the choroid, orbit, or central nervous system. Optic nerve metastases often have their origin in primary tumours of the breast, lung, and stomach, in adults. CASE REPORT: The case is presented of a 57 year-old woman with a diagnosis of lung adenocarcinoma. Her first complaint was a sudden loss of visual acuity in her right eye. The diagnosis of optic nerve metastases was made based on her history, and the results of the MRI scan. DISCUSSION: Isolated optic nerve metastases are an uncommon condition, but should be suspected in any patient with a history of oncology who has deteriorated visual acuity.

Desprendimiento coroideo seroso bilateral tras trabeculoplastia selectiva láser / Bilateral choroidal effusion after selective laser trabeculoplasty

La trabeculoplastia selectiva láser (TSL) es un medio eficaz para tratar el glaucoma de ángulo abierto con una baja tasa de complicaciones. Reportamos el caso de una mujer de 73 años con un glaucoma primario de ángulo abierto no controlado que tras someterse a una trabeculoplastia selectiva láser en ambos ojos desarrolló un desprendimiento coroideo bilateral (AU)

Selective laser trabeculoplasty (SLT) is an effective treatment to treat open-angle glaucoma with a low risk of complications. The case is presented of a 73 year-old woman with uncontrolled primary open-angle glaucoma who underwent selective laser trabeculoplasty in both eyes and developed bilateral choroidal effusion (AU)

Bilateral choroidal effusion after selective laser trabeculoplasty. / Desprendimiento coroideo seroso bilateral tras trabeculoplastia selectiva láser.

Selective laser trabeculoplasty (SLT) is an effective treatment to treat open-angle glaucoma with a low risk of complications. The case is presented of a 73 year-old woman with uncontrolled primary open-angle glaucoma who underwent selective laser trabeculoplasty in both eyes and developed bilateral choroidal effusion.

Tratamiento de un caso de toxicidad retiniana por aminoglucósidos con megadosis de corticoides más implante de dexametasona intravítreo (Ozurdex®) / A case of aminoglycosides induced retinal toxicity treated with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex®)

CASO CLÍNICO: Paciente que tras cirugía de glaucoma presenta pérdida súbita de visión, llegándose al diagnóstico de toxicidad retiniana por tobramicina, caracterizada por blanqueamiento retiniano con mancha rojo cereza, edema macular, y vasculitis con evolución a atrofia papilar y macular con esclerosis arteriolar. Ante la gravedad del cuadro ensayamos con megadosis de corticoides e implante intravítreo de dexametasona (Ozurdex®, Allergan S.A.) precozmente, sin buena respuesta. DISCUSIÓN: La toxicidad por aminoglucósidos es una complicación infrecuente, muy grave e idiosincrásica. Destacar que no existe tratamiento efectivo

CASE REPORT: The case is described of a patient who had a sudden loss of vision in her right eye after glaucoma surgery. A diagnosis of retinal toxicity due to tobramycin (an aminoglycoside) was reached, which was characterised by retinal whitening with a red cherry stain, macular oedema, and vasculitis that progressed to papillary and macular atrophy with arteriolar sclerosis. Given the severity of symptoms an early attempt was made with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex®, Allergan S.A.), without response. DISCUSSION: Aminoglycoside toxicity is a rare, idiosyncratic, very serious complication for which there is no effective treatment

A case of aminoglycosides induced retinal toxicity treated with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex(®)). / Tratamiento de un caso de toxicidad retiniana por aminoglucósidos con megadosis de corticoides más implante de dexametasona intravítreo (Ozurdex(®)).

CASE REPORT: The case is described of a patient who had a sudden loss of vision in her right eye after glaucoma surgery. A diagnosis of retinal toxicity due to tobramycin (an aminoglycoside) was reached, which was characterised by retinal whitening with a red cherry stain, macular oedema, and vasculitis that progressed to papillary and macular atrophy with arteriolar sclerosis. Given the severity of symptoms an early attempt was made with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex®, Allergan S.A.), without response. DISCUSSION: Aminoglycoside toxicity is a rare, idiosyncratic, very serious complication for which there is no effective treatment.

[An optic nerve tumor in von Hippel-Lindau disease, masquerading as a retinal hemangioma]. / Angioma retiniano como síndrome mascarada de tumor del nervio óptico en la enfermedad de von Hippel-Lindau.

CLINICAL CASE: A 35-year-old man with a family history of von Hippel-Lindau disease was diagnosed to have two retinal hemangiomas in the right eye and another in the left eye. The hemangiomas were treated with cryotherapy and laser photocoagulation respectively. Despite apparent good resolution of the retinal lesions, progressive visual loss was observed. An MRI was then performed and showed bilateral tumoral lesions of the optic nerve compatible with a glioma, meningioma or hemangioblastoma. Currently the visual acuity in his right eye is hand movement, and is 0.6 in the left eye. DISCUSSION: The presence of the retinal hemangiomas delayed the diagnosis of an optic nerve tumor in this patient.

Angioma retiniano como síndrome mascarada de tumor del nervio óptico en la enfermedad de von Hippel-Lindau / An optic nerve tumor in von Hippel-Lindau disease, masquerading as a retinal hemangioma

Caso clínico: Varón de 35 años con antecedentesfamiliares de enfermedad de von Hippel-Lindau(VHL) diagnosticado de dos hemangiomas retinianosen ojo derecho (OD) y uno en ojo izquierdo.Las lesiones se trataron con crioterapia en OD yláserterapia en OI. A pesar de una aparente buenaevolución de las lesiones retinianas hubo una progresivadisminución de la AV. Se realizó RM dondese evidenció lesiones tumorales del nervio óptico(NO) bilaterales compatibles con glioma, meningiomao hemangioblastoma. Actualmente: AV(OD): movimiento de manos y AV(OI): 0,6.Discusión: La presencia de los hemangiomas retinianosen este paciente hizo retrasar el diagnósticode un tumor en el NO, infrecuente en esta entidad

Clinical case: A 35-year-old man with a family history ;;of von Hippel-Lindau disease was diagnosed to ;;have two retinal hemangiomas in the right eye and ;;another in the left eye. The hemangiomas were treated ;;with cryotherapy and laser photocoagulation ;;respectively. Despite apparent good resolution of ;;the retinal lesions, progressive visual loss was ;;observed. An MRI was then performed and showed ;;bilateral tumoral lesions of the optic nerve compatible ;;with a glioma, meningioma or hemangioblastoma. ;;Currently the visual acuity in his right eye is ;;hand movement, and is 0.6 in the left eye. ;;Discussion: The presence of the retinal hemangiomas ;;delayed the diagnosis of an optic nerve tumor ;;in this patient