Analysis of the Recurrence of Plus Disease after Intravitreal Ranibizumab as a Primary Monotherapy for Severe Retinopathy of Prematurity.

PURPOSE: To assess the outcomes of severe retinopathy of prematurity (ROP) in zone I or posterior zone II, and of aggressive posterior ROP treated with a single dose of intravitreal ranibizumab (IVR) as monotherapy. DESIGN: Retrospective study. PARTICIPANTS: The study included premature babies diagnosed with aggressive posterior ROP or ROP 3+ in zone I or posterior zone II. METHODS: Intravitreal injection of 0.25 mg (0.025 mL) ranibizumab was performed in the operating room. A disposable 1-mL syringe with a 30-gauge needle was used. MAIN OUTCOME MEASURES: Favorable outcome was considered regression of ROP after treatment (meaning regression of the retinal neovascularization and plus disease). Unfavorable outcome was progression to stages 4 and 5 of ROP. RESULTS: The study included 43 infants (85 eyes). The mean birth weight and gestational age were 1276±302 g and 29.7±2.0 weeks, respectively. The mean postmenstrual age at ROP diagnosis was 36±2.7 weeks and at treatment was 37.2±2.2 weeks. All 85 eyes demonstrated total regression of plus disease after a single dose of IVR. Twelve infants (29.2%) developed full vascularization of the peripheral retina in both eyes. Twenty-two infants (43 eyes [53.6%]) developed ROP reactivation at a mean interval of 7.1±3 weeks (range, 3-15 weeks) after IVR and needed rescue laser treatment of the peripheral avascular retina. The mean postmenstrual age at rescue laser was 43±3.2 weeks (range, 35.5-54.5 weeks). Six patients (11.6%) had persistent peripheral avascular retina in zone II for >6 months (or 24 weeks) after IVR treatment. CONCLUSIONS: Although there was complete regression of plus disease in all treated eyes, only 29.2% of the patients reached complete peripheral retinal vascularization. There was a disease reactivation in 53.6% of the patients and they needed additional laser therapy. The results of IVR treatment in severe ROP, even when initial control of the disease was achieved, did not eliminate the risk of late reactivation of the disease by retinal neovascularization. Some of the treated patients may achieve a permanent interruption in the development of the peripheral retinal vascularization.

Intravitreal ranibizumab as a primary or a combined treatment for severe retinopathy of prematurity.

PURPOSE: The aim of the study was to assess the outcomes of severe retinopathy of prematurity (ROP) in zone I or posterior zone II treated with intravitreal ranibizumab (IVR) as monotherapy or combined treatment with laser photocoagulation. METHODS: This is a retrospective study analyzing clinical records of the included patients. Patients were divided into two groups: group 1 included patients who received only IVR treatment; and group 2 was subdivided into group 2A - including patients with IVR as initial treatment and complementary laser photocoagulation if retinal neovascularization or plus disease did not regress, and group 2B - including patients with initial laser photocoagulation and IVR as rescue therapy. Favorable outcomes were regression of the retinal neovascularization and plus disease, meaning control of the disease. Unfavorable outcomes were progression to stages 4 and 5 of ROP. RESULTS: Fifty-seven eyes were included in the study. Mean birth weight and gestational age were 1,281±254 g and 29.5±2.1 weeks, respectively. Group 1 comprised of 16 eyes, with favorable outcomes in 14 eyes (87.5%). Group 2 comprised of 41 eyes, with favorable outcomes in 29 eyes (70.7%), in a mean follow-up period of 12.8 months. CONCLUSION: IVR was effective to treat severe cases of ROP as a primary or a combined treatment. Forty-three of the 57 treated eyes (75.4%) achieved regression of ROP and favorable outcomes.

Intravitreal bevacizumab at 4-month intervals for prevention of macular edema after plaque radiotherapy of uveal melanoma.

PURPOSE: To evaluate the efficacy of intravitreal bevacizumab for prevention of macular edema after plaque radiotherapy of uveal melanoma. DESIGN: Retrospective, single-center, nonrandomized, interventional comparative study. PARTICIPANTS: Patients with uveal melanoma treated with plaque radiotherapy were divided into 2 groups: a bevacizumab group and a control group. INTERVENTION: The bevacizumab group received intravitreal bevacizumab injection at the time of plaque removal and every 4 months thereafter for 2 years (total, 7 injections). The control group had no intravitreal bevacizumab injection. Both groups had periodic follow-up with ophthalmoscopy and optical coherence tomography (OCT). MAIN OUTCOME MEASURES: Development of OCT-evident macular edema. RESULTS: There were 292 patients in the bevacizumab group and 126 in the control group. The median foveolar radiation dose was 4292 cGy (bevacizumab) and 4038 cGy (control; P = 0.327). The cumulative incidence of OCT-evident macular edema over 2 years (bevacizumab group vs. control group) was 26% versus 40% (P = 0.004), respectively; that for clinically evident radiation maculopathy was 16% versus 31% (P = 0.001), respectively; that for moderate vision loss was 33% versus 57% (P < 0.001), respectively; and that for poor visual acuity was 15% versus 28% (P = 0.004), respectively. There was no statistically significant difference in clinically evident radiation papillopathy (P = 0.422). Kaplan-Meier estimates at 2 years showed statistically significantly reduced rates of OCT-evident macular edema (P = 0.045) and clinically evident radiation maculopathy (P = 0.040) in the bevacizumab group compared with controls. CONCLUSIONS: Patients receiving intravitreal bevacizumab injection every 4 months after plaque radiotherapy for uveal melanoma demonstrated OCT-evident macular edema, clinically evident radiation maculopathy, moderate vision loss, and poor visual acuity less frequently over a period of 2 years than patients not receiving the injections.

Intravenous chemoreduction or intra-arterial chemotherapy for cavitary retinoblastoma: long-term results.

OBJECTIVE: To assess the long-term results of chemotherapy for cavitary retinoblastoma. METHODS: Retrospective, nonrandomized, interventional case series of 26 cavitary retinoblastomas in 25 eyes of 24 patients. Retinoblastomas were treated with intravenous chemoreduction and/or intra-arterial chemotherapy. Main outcome measures included tumor control, globe salvage, and metastasis. RESULTS: Of 24 patients with cavitary retinoblastoma, the mean age at diagnosis was 16 months. The mean number of cavitary tumors per eye was 1 (median, 1; range, 1-2), with a mean tumor basal diameter of 13 (median, 13; range, 7-24) mm and mean tumor thickness of 7 (median, 6; range, 3-17) mm. The mean number of cavities per tumor was 2 (median, 2; range, 1-5), with a mean cavity diameter of 3 (median, 2; range, 1-10) mm. Related features included vitreous seeds in 7 tumors (27%), subretinal seeds in 6 (23%), and subretinal fluid in 13 (50%). Intravenous chemoreduction was used in 23 tumors (88%); intra-arterial chemotherapy, in 2 (8%); and both, in 1 (4%). After treatment, the mean reduction in tumor base was 22% and mean reduction in tumor thickness was 29%. Despite minimal reduction, tumor recurrence was noted in only 1 eye (4%), globe salvage was achieved in 22 (88%), and there were no cases of metastasis or death during 49 (range, 6-189) months of follow-up. CONCLUSION: Despite minimal visible tumor response to chemotherapy, cavitary retinoblastoma displays relatively stable long-term results.

Fluorescein angiographic findings after intra-arterial chemotherapy for retinoblastoma.

PURPOSE: To evaluate fluorescein angiography (FA) findings after intra-arterial chemotherapy (IAC) for retinoblastoma. DESIGN: Retrospective case series. PARTICIPANTS: Twenty-four eyes of 24 patients. INTERVENTION: Fifty-five IAC procedures for delivery of melphalan 5 mg and possible carboplatin 30 mg. MAIN OUTCOME MEASURES: Vascular flow of iris, retina, and choroid after IAC. RESULTS: All patients received melphalan 5 mg, whereas the first 6 patients also were treated with additional carboplatin 30 mg. The IAC was performed as primary treatment in 17 eyes and as secondary treatment (after systemic chemotherapy) in 7 eyes. Two patients also received external-beam radiotherapy before IAC. At presentation, FA revealed neovascularization of the iris (NVI) in 8 eyes, and after IAC, complete NVI regression was noted in 5 eyes (63%). After a mean follow-up of 13 months after IAC, FA depicted the main tumor with decreased fluorescence in 22 eyes (92%). After 55 ophthalmic artery catheterizations, retinal vascular abnormalities by FA were detected in 7 eyes (13%) and choroidal vascular abnormalities were detected in 6 eyes (11%). The retinal abnormalities included ophthalmic artery obstruction (n = 1), transient ophthalmic artery spasm (n = 1), central retinal artery obstruction (n = 1), branch retinal artery obstruction (n = 2), and peripheral retinal ischemia (n = 2). Additional retinal neovascularization was found in 1 patient. The choroidal abnormalities included sector (n = 5) or diffuse (n = 1) choroidal nonperfusion. New-onset iris neovascularization was found in 2 patients. Retinal vascular abnormalities were diagnosed after median of 1 month after the first IAC, whereas choroidal vascular abnormalities were found after median of 5 months after the first IAC. CONCLUSIONS: Fluorescein angiography suggests that vascular perfusion to the retina and the choroid can be compromised after IAC for retinoblastoma. The most common vascular abnormality was choroidal sector or diffuse nonperfusion.

Phacomatosis pigmentovascularis of cesioflammea type in 7 patients: combination of ocular pigmentation (melanocytosis or melanosis) and nevus flammeus with risk for melanoma.

OBJECTIVE: To describe the features of phacomatosis pigmentovascularis (cesioflammea type). DESIGN: Noninterventional retrospective case series composed of 7 patients. RESULTS: Nevus flammeus combined with ipsilateral ocular melanocytosis or melanosis was seen in all 7 patients. Additional contralateral nevus flammeus was observed in 3 patients. Nevus flammeus (unilateral in 4 patients and bilateral in 3 patients) was distributed in trigeminal nerves V1 (n = 3), V2 (n = 7), and V3 (n = 5). Related findings included diffuse choroidal hemangioma (n = 1) and glaucoma (n = 1), with no patients having brain hemangioma or seizures. Ocular pigmentary abnormalities (unilateral in all 7 patients) included congenital ocular melanocytosis (n = 6) and conjunctival acquired melanosis (n = 1). Pigmentation was sectorial (partial) in 5 patients and complete in 2 patients. Melanocytosis involved the periocular skin in 1 patient, sclera in 2 patients, iris in 2 patients, and choroid in 4 patients. In 3 of 6 patients, melanocytosis was visible in the choroid only on dilated fundus evaluation. Related tumors included choroidal melanoma (n = 3), optic disc melanocytoma (n = 1), and conjunctival melanoma in situ (primary acquired melanosis) (n = 1). Melanoma metastasis developed in 1 patient. CONCLUSIONS: Phacomatosis pigmentovascularis shows features of nevus flammeus and more serious ocular pigmentary abnormalities (uveoscleral melanocytosis and conjunctival melanosis). Melanocytosis may be detected only by dilated ocular fundus examination, as found in 3 of 6 patients. Furthermore, choroidal melanoma can develop from melanocytosis, as noted in 3 of our 6 patients (50%). All patients with nevus flammeus should be examined for phacomatosis pigmentovascularis by an ophthalmologist because ocular melanocytosis and uveal melanoma may remain hidden within the eye.

Malformaciones congénitas genitourinarias como factor etiopatogénico en la infección de vías urinarias del lactante / Congenital defects of genito-urinary system as a factor that causes urinary tract infection in newborns

Estudio multicéntrico, retro-prospectivo, longitudinal realizado en los hospitales de niños “León Becerra” y “Dr. Francisco de Ycaza Bustamante”, en lactantes de 0–30 meses de edad, con infección de vías urinarias (IVU) comprobada por urocultivo, a los cuales se les realizó pruebas de orina, sanguíneas y radiológicas, para lograr un estudio completo del paciente y determinar si existían malformaciones congénitas del tracto urinario.Objetivos: Detectar malformaciones génito-urinarias congénitas en lactantes de 0-30 meses de edad.Prevención del daño renal progresivo y sus consecuencias.Contribuir con alternativas prácticas y oportunas a la solución de las complicaciones médico-quirúrgicas de la IVU en lactantes.Resultados: De 78 pacientes, el 58% fueron del sexo masculino. En el 65% del universo se encontró como causante de la infección a la E. coli. La fiebre por encima de 38°C se presentó en el 98% de los casos. El 22% de los pacientes presentaron malformaciones congénitas de las vías urinarias. La malformación congénita genitourinaria más común fue el reflujo vésicoureteral que se presentó en 9 pacientes. En lo que a recurrencias de infección se refiere, de los 78 casos estudiados, el 67% presentaron recurrencias. De los 17 (100%) pacientes que presentaron malformaciones, 15 (88%) presentaron como antecedente I.V.U. recurrentes.Conclusiones: La IVU sigue siendo una enfermedad de alta prevalencia en los lactantes, afectando más al sexo masculino en esta edad. La Escherichia coli, fue el agente etiológico más frecuente. El síntoma más común fue la fiebre >38° C. Las malformaciones congénitas del tracto urinario son un factor etiopatogénico importante en la IVU ya que tienen una prevalencia del 22%.

A multicentric, retro-prospective, longitudinal study was done at the “Leon Becerra” Children Hospital and “Dr. Francisco of Ycaza Bustamante” Children Hospital, in newborns of 0–30 months of age with urinary tract infection (UTI) checked by urine culture. Urine, blood, and radiological exams were done to determine if congenital defect of the genito-urinary tract existed. Objectives: Detector genito-urinary defect congenital in newborns to 0-30 months.Prevention of the progressive renal damage and their consequences. To contribute with practical and opportune alternatives to the solution of this clinical-surgical problem. Results: Of 78 patients, 58% were male babies. In 65% of the universe E. Coli was the agent causing infection. The fever above 38°C was presented in 98% of the cases. 22% of the patients presented congenital defects of the urinary tract. The most common congenital defect in our study was vesicoureteral reflux that 9 patients in our study had. In what refers to recurring infections, of the 78 studied cases; 67% presented recurrences. Of the 17 (100%) patient that had congenital defect, 15 (88%) had history of recurring U.T.I. Conclusions: The UTI continues being an illness of high prevalence in the newborns, affecting male babies at this age. The Escherichia coli was the agent most frequently produces infection. The most common symptom was fever >38°C. The congenital defects of the urinary tract are an important factor in the UTI with a prevalence of 22%.

Anatomía quirúrgica del transplante renal / Surgical anatomy of the renal transplant

Este trabajo se basa en la experiencia adquirida en transplantes de riñón, por un mismo equipo quirúrgico, a través de 19 años de actuación, en una misma institución CEMIC. Desde el inicio, en 1970, se estudió exahustivamente la antomía del dador, del receptor y del aparato urinario, en relación con el injerto renal, lo que se expresa en los correspondientes capítulos de este trabajo. El objeto es disminuir la agresión al máximo aprovechando las vías de abordaje anatomicamente más simples de evolución más satisfactoria y con mejor recuperación del paciente. También describimos en detalle y así lo referimos, la celda renal y sus relaciones, la estructura del riñon y la arquitectura intrarrenal, tanto canicular como vascular. La primera por la posibilidad de derivaciones urinarias tradicionales y desde 1985 de la cirugía endourológica pos-trasplante. La segunda por la relación de los elementos vasculares del pedículo renal entre sí, con los órganos vecinos y con los grandes vasos. Importan y se describen también las malformaciones que se pueden diagnosticar previamente y que hacen a la selección del dador vivo relacionado, o que durante el acto operatorio, obliguen a cirugías complementarias inmediatas. Expuestas en otro capítulo, la estructura anatómica y funcional de la vía excretora así como su irrigación y las oportunidades que esta brinda en la reconstrucción canicular urinaria. Se estudian también las técnicas posibles en la anastomosis vasculares y en la vía excretora así como sus variaciones. Se describen los recaudos quirúrgicos, basados en la antomía del aparato urinario, que permite prevenir ciertas complicaciones, como por ejemplo, el reflujo y las intervenciones complementarias, si a pesar de todo aquellas ocurren. Finalmente se hace mención a la posibilidad del uso de segmentos entéricos, en reemplazo de sectores urinarios.

Anatomía quirúrgica del transplante renal / Surgical anatomy of the renal transplant

Este trabajo se basa en la experiencia adquirida en transplantes de riñón, por un mismo equipo quirúrgico, a través de 19 años de actuación, en una misma institución CEMIC. Desde el inicio, en 1970, se estudió exahustivamente la antomía del dador, del receptor y del aparato urinario, en relación con el injerto renal, lo que se expresa en los correspondientes capítulos de este trabajo. El objeto es disminuir la agresión al máximo aprovechando las vías de abordaje anatomicamente más simples de evolución más satisfactoria y con mejor recuperación del paciente. También describimos en detalle y así lo referimos, la celda renal y sus relaciones, la estructura del riñon y la arquitectura intrarrenal, tanto canicular como vascular. La primera por la posibilidad de derivaciones urinarias tradicionales y desde 1985 de la cirugía endourológica pos-trasplante. La segunda por la relación de los elementos vasculares del pedículo renal entre sí, con los órganos vecinos y con los grandes vasos. Importan y se describen también las malformaciones que se pueden diagnosticar previamente y que hacen a la selección del dador vivo relacionado, o que durante el acto operatorio, obliguen a cirugías complementarias inmediatas. Expuestas en otro capítulo, la estructura anatómica y funcional de la vía excretora así como su irrigación y las oportunidades que esta brinda en la reconstrucción canicular urinaria. Se estudian también las técnicas posibles en la anastomosis vasculares y en la vía excretora así como sus variaciones. Se describen los recaudos quirúrgicos, basados en la antomía del aparato urinario, que permite prevenir ciertas complicaciones, como por ejemplo, el reflujo y las intervenciones complementarias, si a pesar de todo aquellas ocurren. Finalmente se hace mención a la posibilidad del uso de segmentos entéricos, en reemplazo de sectores urinarios. (AU)

Actualización, fisiopatología y terapéutica en la tuberculosis urinaria / Update, physiopathology and therapeutic in urinary tuberculosis

1- La tuberculosis urinaria es hematógena, bilateral, post-primaria y alejada en su evolución, debe investigársela en todo tuberculoso, pues es oligo, mono o asintomática durante largos períodos. 2- La vía excretora tiene particular signifación en la evolución de la tuberculosis y en el compromiso de la función renal, su participación constituye la denominada "segunda enfermedad tuberculosa" de Puigvert. 3- El tratamiento médico localiza focos parenquimatosos, controla la inflamación aguda canalicular o provoca su cicatrización por esclerosis retráctil, lo que intensifica la uroectasia. 4- El tratamiento quirúrgico es complementario del médico. Por ser las lesiones frecuentemente bilaterales, deberán tratarse en lo posible con cirugía conservadora, reparadora y sustitutiva, en una secuencia quirúrgica sin reglas fijas en el orden de ejecución, sólo por necesidad se practicará cirugía radical. 5- La bilateralidad de las lesiones alcanza al 80 por ciento de las observaciones y puede ser contemporánea o extemporánea, únicas o múltiples, altas o bajas. 6- La mayoría de los enfermos tuberculosos urinarios fallecen por insuficiencia renal, condicionada por trastornos urodinámicos, pionefrosis o exclusión renal, procesos que pueden y deben evitarse con un adecuado y oportuno tratamiento médico-quirúrgico.

Actualización, fisiopatología y terapéutica en la tuberculosis urinaria / Update, physiopathology and therapeutic in urinary tuberculosis

1- La tuberculosis urinaria es hematógena, bilateral, post-primaria y alejada en su evolución, debe investigársela en todo tuberculoso, pues es oligo, mono o asintomática durante largos períodos. 2- La vía excretora tiene particular signifación en la evolución de la tuberculosis y en el compromiso de la función renal, su participación constituye la denominada "segunda enfermedad tuberculosa" de Puigvert. 3- El tratamiento médico localiza focos parenquimatosos, controla la inflamación aguda canalicular o provoca su cicatrización por esclerosis retráctil, lo que intensifica la uroectasia. 4- El tratamiento quirúrgico es complementario del médico. Por ser las lesiones frecuentemente bilaterales, deberán tratarse en lo posible con cirugía conservadora, reparadora y sustitutiva, en una secuencia quirúrgica sin reglas fijas en el orden de ejecución, sólo por necesidad se practicará cirugía radical. 5- La bilateralidad de las lesiones alcanza al 80 por ciento de las observaciones y puede ser contemporánea o extemporánea, únicas o múltiples, altas o bajas. 6- La mayoría de los enfermos tuberculosos urinarios fallecen por insuficiencia renal, condicionada por trastornos urodinámicos, pionefrosis o exclusión renal, procesos que pueden y deben evitarse con un adecuado y oportuno tratamiento médico-quirúrgico. (AU)