Patch endothelial keratoplasty for corneal perforations secondary to ocular surface disease: case series.

BACKGROUND: Corneal perforation is an ophthalmic emergency. The conventional management of corneal perforation can be associated with severe complications especially in patients with ocular surface disease. Endothelial keratoplasty has been suggested as an alternative surgical technique for the management of corneal perforations. We present a case series of nine patients with corneal perforation and ocular surface disease managed with secondary patch endothelial keratoplasty. METHODS: This is a retrospective case series of nine patch endothelial keratoplasties performed between 2016 and 2022 at a quaternary eye hospital in Australia. The surgical technique is similar to conventional endothelial keratoplasty except descemetorhexis was not performed. RESULTS: A total of 9 cases were treated during the review period. Eight of the nine cases had an improvement in visual acuity. One case failed to achieve corneal tectonic objective. CONCLUSION: Patch endothelial keratoplasty is a safe secondary procedure for the management of corneal perforations in patients with ocular surface disease.

Sleeve gastrectomy as a surgical technique in bariatric surgery: Results of safety and effectiveness.

INTRODUCTION: The aim of this study is to evaluate the safety and effectiveness results of sleeve gastrectomy as a bariatric technique. METHODS: Observational follow-up study of a cohort of patients who underwent sleeve gastrectomy in our center between 2008 and 2017. A total of 223 patients were included: 166 as a primary technique (group 1) and 57 as a hypothetical first stage (group 2). RESULTS: In group 1, the postoperative morbidity is 12.6%, with a fistula rate of 4.2%; 5.4% required reoperation and mortality was 0.6%. In group 2, postoperative morbidity is 14%, with a fistula rate of 5.3%; 10.5% required reoperation and mortality was 5.3%. In group 1, 79.6% and 62.5% of patients at 2 and 5 years respectively managed to achieve a % EBMIL > 50%. In group 2, the second stage was completed only in 8 patients (14.0%). Of the patients who did not complete the second stage, 32.2% and 5.9% achieved a % EEBMIL > 100% at 2 and 5 years. Analyzing those who completed the second stage, the mean EEBMIL% was 90.5% and 93.4% at 2 and 5 years. CONCLUSIONS: Sleeve gastrectomy is a safe technique in patients with BMI < 45 and effective in terms of weight loss in the short-medium term. In patients with BMI > 55, a preoperative optimization aimed at reducing morbidity and mortality is necessary, as well as adequately planning the second stage, without which it is clearly insufficient.

High rate of de novo esophagitis 5 years after sleeve gastrectomy: a prospective multicenter study in Spain.

BACKGROUND: Major concerns years after the sleeve gastrectomy (SG) include weight regain, development of hiatal hernia (HH) and gastroesophageal reflux disease, with esophagitis and Barrett's esophagus (BE). Both problems could be related, and the incidence of asymptomatic patients is troubling. OBJECTIVE: To study the incidence of reflux symptoms, esophagitis, BE, HH, and asymptomatic pathology and their relationship with weight regain in patients 5 years after undergoing SG at different bariatric centers in Spain. SETTING: Public and private hospitals with bariatric surgery units. METHODS: Prospective, multicenter, nonrandomized study involving 13 Spanish hospitals with a cumulative experience of 4,500 patients having undergone the SG procedure and patients who had been subjected to the procedure at least 5 years previously along with preoperative gastroscopy. The clinical history, preoperative gastroscopy, and technical details of the SG were recorded. A specific clinical questionnaire was given that recorded the intake volume, perception of satiety, and gastroesophageal reflux (GER) symptoms. Gastroscopy, pH-metry, and manometry studies were carried out, and the data were analyzed statistically. The study has been authorized by the official Spanish ethics committee CEI/CEIm Hospital Universitario Gran Canaria Dr Negrín (code 2019-216-1). RESULTS: One hundred and five patients who underwent SG and who had with at least 5 years of follow-up were included. All procedures were performed laparoscopically. The mean age of patients was 51.1 years, and 70.5% were women. The mean characteristics of the SG procedure were a 37.2F probe, at 4.6 cm from the pylorus, and a crura closure was performed in 5 cases. There were no major complications (Clavien-Dindo grade >3) or deaths. The average preoperative body mass index was 46.3 kg/m2, the minimum reached was 20.6 kg/m2, whereas the average after 5 years was of 34.5 kg/m2. GER, HH, and esophagitis symptoms went from 17.1%, 28.6%, and 5.7%, respectively, before the SG to 76%, 30.5%, and 31.4%, respectively, 5 years after the procedure. Symptoms persisted over the years in 37.1% of cases and presented de novo in 52.8% of cases. Fifty-three percent of manometries (n = 27, total 51) and 64% of pH-metries (n = 32, total 53; DeMeester average score was 65) were pathologic 5 years after the procedure. Concerning gastroscopies, 5 years after the procedure, HH was found in 33 patients (30.5% of total) and esophagitis in 32 patients (31.4% of total). Eighty patients (76%) had GER symptoms, and 25 patients (24%) were asymptomatic. Only 1 patient (.9%) developed BE. CONCLUSIONS: Our study has confirmed a high rate of both persistent and de novo esophagitis and hiatal hernia, many of which were asymptomatic, 5 years after SG had been performed. Weight regain and a striking increase in gastric capacity are risk factors indicative of esophagitis, even when patients are asymptomatic. We consider a control gastroscopy and the preventive use of proton pump inhibitors necessary in these cases regardless of symptoms. We recommend that a control gastroscopy should be performed in all cases regardless of symptoms 5 years after SG. Further studies are needed to validate these recommendations.

Evolución del grado de control de una cohorte de pacientes anticoagulados de Atención Primaria / Evolution of the degree of control in a cohort of anticoagulated patients in Primary Care

Introducción: Solo el 60 por ciento de los pacientes en tratamiento con antagonistas de la vitamina K (AVK) están controlados. Objetivos: A nalizar una cohorte de pacientes anticoagulados para valorar su grado de control y su evolución a los 2 años, tras una intervención formativa breve. Métodos: Estudio longitudinal, observacional, retrospectivo de 157 anticoagulados con AVK. Se recogieron datos sociodemográficos, comorbilidades, motivo de prescripción del AVK y grado de control basal y tras 2 años de seguimiento. Utilizamos 2 métodos de valoración diferentes: Rosendaal y método directo (porcentaje de INR-Razón Normalizada Internacional- en rango). Asimismo, establecimos correlaciones temporales intramétodo. Resultados: El grado de control pasó del 47,3 por ciento al 53,5 por ciento a los 2 años, según Rosendaal (p= 0,52), y del 39,5 por ciento al 53,5 por ciento según el método directo (p< 0,05). El tiempo en rango terapéutico fue del 63,1 ±19,9 por ciento al inicio y 65 ±19,2 por ciento al final del seguimiento. La correlación entre los 2 controles fue positiva para ambos métodos (Rosendaal: 0,23; método directo: 0,33). El análisis multivariante fue significativo para el sexo masculino y para un objetivo diferente de 2,5-3,5 (odds ratio: 2,22 y 2,73, respectivamente). Conclusiones: El control del INR mejoró a los 2 años de seguimiento tras la actividad formativa. La evolución del grado de control de cada paciente es parcialmente predecible. El peor control se asoció al sexo femenino y al objetivo de INR de 2,5-3,5. El control mejora 2,22 veces en los varones y 2,73 veces en quienes no tienen un INR objetivo de 2,5-3,5(AU)

Introduction: Only 60 percent of patients on treatment with vitamin K antagonists (AVK) are controlled. Objectives: We proposed to analyze a cohort of anticoagulated patients to assess their degree of control and their evolution at 2 years, after a brief training intervention. Methods: Longitudinal, observational, retrospective study of 157 anticoagulated with AVK. Sociodemographic data, comorbidities, reason for VKA prescription and degree of baseline control were collected and after 2 years of follow-up. We use 2 different valuation methods: Rosendaal and direct method (INR percentage -International Normalized Ratio- in range). Likewise, we established intra-method temporal correlations. Results: The degree of control went from 47.3 percent to 53.5 percent at 2 years, according to Rosendaal (p = 0.52), and from 39.5 percent to 53.5 percent according to the direct method (p<0.05). The time in the therapeutic range was 63.1±19.9 percent at the start and 65±19.2 percent at the end of the follow-up. The correlation between the 2 controls was positive for both methods (Rosendaal: 0.23; direct method:0.33). The multivariate analysis was significant for males and for a target other than 2.5-3.5(odds ratio: 2.22 and 2.73, respectively). Conclusions: INR control improved after 2 years of follow-up after training activity. The evolution of the degree of control of each patient is partially predictable. The worst control was associated with female sex and the INR goal of 2.5-3.5. Control improves 2.22 times in males and 2.73 times in those without a target INR of 2.5-3.5(AU)

Visual Acuity and Number of Amniotic Membrane Layers as Indicators of Efficacy in Amniotic Membrane Transplantation for Corneal Ulcers: A Multicenter Study.

BACKGROUND: To evaluate new indicators in the efficacy of amniotic membrane transplantation (AMT) for non-healing corneal ulcers (NHCUs). METHODS: Retrospective, multicenter study. In total, 223 AMTs for NHCU in 191 patients were assessed. The main outcomes studied were the success rate of AMT (complete re-epithelization), postoperative visual acuity (VA) gain, and number of AM layers transplanted. RESULTS: The overall AMT success rate was 74.4%. In 92% of our patients VA stability or improvement. Postoperative VA was significantly higher than preoperative VA in the entire cohort (p < 0.001) and in all etiological groups of ulcers (post-bacterial, p ≤ 0.001; post-herpetic, p ≤ 0.0038; neurotrophic ulcers, p ≤ 0.014; non-rheumatic peripheral, p ≤ 0.001; and ulcers secondary to lagophthalmos and eyelid malposition or trauma, p ≤ 0.004). Most participants (56.5%) presented a preoperative VA equal to or less than counting fingers (≤0.01). Of these, 13.5% reached a postoperative VA equal to or better than legal blindness (≥0.05) after AMT. A higher success rate was observed in the monolayer than in the multilayer AMT (79.5% and 64.9%, respectively; p = 0.018). No statistically significant values were found between the number of layers transplanted and VA gain (p = 0.509). CONCLUSION: AMT is not only beneficial in achieving complete re-epithelialization in NHCUs but also in improving postoperative VA; these improvements are independent of etiologies of ulcers. Furthermore, the use of monolayer AMT seems to be a more appropriate option than multilayer AMT for NHCU since the multilayer AMT did not present better outcomes (success rate and VA gain) compared to monolayer AMT in the different types of ulcers studied.

Severe visual loss by inhalation of methanol.

Purpose: To describe a clinical case of toxic optic neuropathy with severe visual loss caused by inhalation abuse of methanol products. Method: A 25-year-old male student was admitted to the emergency department with an acute bilateral visual loss and headaches, nausea, and cold sweats. A complete clinical and ophthalmologic examination was performed. Results: On ophthalmic examination, visual acuity (VA) was light perception in the right eye (RE) and no light perception in the left eye (LE). Pupillary examinations demonstrated dilated, non-reactive pupils. An arterial blood gas analysis showed systemic metabolic acidosis with a pH of 7.23 and Gap anion elevated. Consequently, these results were enough to provide a substantial suspicion of methanol toxicity and start the treatment. 72 hours after, he confessed that he had been inhaling methanol-based solvent for eight years. Conclusions: Methanol-induced toxicity can cause a non-reversible toxic optic neuropathy. Blood acidemia with Gap anion elevated and a suspicious fundus ophthalmic examination allows a fast diagnosis. A quick treatment based on dialysis, intravenous ethanol, sodium bicarbonate, vitamin B12, and intravenous methylprednisolone slows the secondary intoxication damages. We presented herein a procedure to identify and manage toxic optic neuropathy caused by methanol inhalation. Abbreviations: VA = Visual Acuity, RE = right eye, LE = left eye, OCT = Optical Coherence Tomography, RNFL = Retinal Nerve Fiber Layer, CT = computed tomography, MRI = magnetic resonance imaging, VEPs = visual evoked potentials.

A tricky case of unilateral orbital inflammation: carotid cavernous fistula in Graves-Basedow disease.

Purpose: To describe a rare clinical case of Carotid Cavernous Fistula (CCF) in Graves-Basedow disease (GBD). Method: A 62-year-old female with history of GBD and inactive Graves' ophthalmopathy (GO) was admitted with progressive exophthalmos in her right eye (RE) and diagnosed with GO reactivation the previous month. Results: On examination, dilated and tortuous conjunctival blood vessels, chemosis and exophthalmos were observed in the RE. There was an asymmetry in the intraocular pressures of 20 mmHg in the RE and 10 mmHg in the LE. Laboratory results showed normal thyroid function and positivity of some of the antibodies related to immune thyroid disorders. Neuroimaging showed an early and abnormal filling of the cavernous sinus (CS) and an enlarged superior ophthalmic vein. Consequently, the diagnosis of CCF was established. Interventional treatment was performed with good clinical outcome and no recurrence after 6 months of follow-up. Conclusions: CCFs are abnormal arteriovenous connections between the carotid arteries and CS. CCF picture can mimic the GO's manifestations. Thus, CCF should be considered in the differential diagnosis of GO, especially in unilateral, asymmetric, and atypical cases. We reported herein a case of CCF in a patient diagnosed with GBD, having a previous history of inactive GO, a diagnostic challenge, since the first presumed diagnosis in patients with GBD is always GO. To the best of our knowledge, there are only three previous reports in the medical literature in which the CCF was diagnosed in a GBD patient with a history of GO. Abbreviations: CCF = Carotid Cavernous Fistula, GBD = Graves-Basedow disease, GO = Graves' ophthalmopathy, CS = cavernous sinus, SOV = superior ophthalmic vein, ICA = internal carotid artery, IOP = intraocular pressure.

Intraocular pressure responses to walking with surgical and FFP2/N95 face masks in primary open-angle glaucoma patients.

PURPOSE: The use of face mask is globally recommended as a preventive measure against COVID-19. However, the intraocular pressure (IOP) changes caused by face masks remain unknown. The objective of this study was to assess the impact of wearing surgical and FFP2/N95 face masks during a 400-m walking protocol on IOP in primary open-angle glaucoma (POAG) patients. METHODS: Thirteen subjects diagnosed of POAG (21 eyes) were enrolled in this study. IOP was measured at baseline, during the 400-m walking protocol and after 5 min of passive recovery while POAG patients wore a surgical mask, FFP2/N95 mask and no mask in randomized order. From the 21 POAG eyes, we analyzed the IOP changes caused by physical exercise with two face masks and without wearing any face mask. RESULTS: At rest (baseline and recovery measurements), the use of the different face masks did not affect IOP levels (mean differences ranging from 0.1 to 0.6 mmHg). During physical activity, wearing an FFP2/N95 mask caused a small (mean differences ranging from 1 to 2 mmHg), but statistically significant, IOP rise in comparison to both the surgical mask and control conditions (Cohen's d = 0.63 and 0.83, respectively). CONCLUSION: Face masks must be used to minimize the risk of SARS-CoV-2 transmission, and POAG patients can safely use FFP2/N95 and surgical masks at rest. However, due to the IOP rise observed while walking with the FFP2/N95 mask, when possible, POAG patients should prioritized the use of surgical masks during physical activity.

Sleeve gastrectomy as a surgical technique in bariatric surgery: Results of safety and effectiveness. / Gastrectomía vertical como técnica quirúrgica en cirugía bariátrica: análisis de resultados de seguridad y efectividad.

INTRODUCTION: The aim of this study is to evaluate the safety and effectiveness results of sleeve gastrectomy as a bariatric technique. METHODS: Observational follow-up study of a cohort of patients who underwent sleeve gastrectomy in our center between 2008 and 2017. A total of 223 patients were included: 166 as a primary technique (group 1) and 57 as a hypothetical first stage (group 2). RESULTS: In group 1, the postoperative morbidity is 12.6%, with a fistula rate of 4.2%; 5.4% required reoperation and mortality was 0.6%. In group 2, postoperative morbidity is 14%, with a fistula rate of 5.3%; 10.5% required reoperation and mortality was 5.3%. In group 1, 79.6% and 62.5% of patients at 2 and 5 years respectively managed to achieve a % EBMIL>50%. In group 2, the second stage was completed only in 8 patients (14.0%). Of the patients who did not complete the second stage, 32.2% and 5.9% achieved a % EEBMIL>100% at 2 and 5 years. Analyzing those who completed the second stage, the mean EEBMIL% was 90.5% and 93.4% at 2 and 5 years. CONCLUSIONS: Sleeve gastrectomy is a safe technique in patients with BMI<45 and effective in terms of weight loss in the short-medium term. In patients with BMI>55, a preoperative optimization aimed at reducing morbidity and mortality is necessary, as well as adequately planning the second stage, without which it is clearly insufficient.

Minimally invasive and robotic surgery in the surgical treatment of esophagogastric junction cancer. / Cirugía mínimamente invasiva y robótica en el tratamiento quirúrgico de las neoplasias de la unión esofagogástrica.

Minimally invasive surgery provides for the treatment of esophagogastric junction tumors under safe conditions, reducing respiratory and abdominal wall complications. Recovery is improved, while maintaining the oncological principles of surgery to obtain an optimal long-term outcome. It is important to have a sufficient volume of activity to progress along the learning curve with close expert supervision in order to guarantee R0 resection and adequate lymphadenectomy. Minimal invasiveness ought not become an objective in itself. Should total gastrectomy be performed, the risk of a positive proximal margin makes intraoperative biopsy compulsory, without ruling out a primary open approach. Meanwhile, minimally invasive esophagectomy has been gaining ground. Its main difficulty, the intrathoracic anastomosis, can be safely carried out either with a mechanical side-to-side suture or a robot-assisted manual suture, thanks to the 3-D vision and versatility of the instruments.