Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery.

INTRODUCTION: Anti-thrombotic drugs (antiplatelets and anticoagulants) are widely used for different clinical reasons. This means that there are an increasing number of patients undergoing elective ophthalmic surgery that are being treated with these drugs. A better knowledge of their implications and their peri-operative use may help to prevent surgical and secondary adverse events. There is often no firm recommendation on how to manage certain drugs in certain surgeries. OBJECTIVE: To review the recommendations in the scientific literature as regards managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. MATERIAL AND METHODS: A review was made of the relevant guidelines and studies using an antiplatelet and anticoagulant drugs approach for cataract, vitreo-retinal, glaucoma, oculoplastic, and strabismus surgeries. RESULTS: Recommendations about whether to continue or discontinue anti-thrombotic drugs in the peri-operative period of different ophthalmic surgical fields are presented. CONCLUSIONS: There are only firm recommendations of maintaining anti-thrombotic drugs as regards cataract surgery using phacoemulsification with topical anaesthesia. In other surgical fields, ophthalmologists should balance the risk of thromboembolic events and risks of haemorrhagic complications in order to carry out a proper management. A multi-disciplinary approach is recommended for complex cases. Additional studies should be performed to better characterise the peri-operative use of anti-thrombotic agents in order to prepare clinical guidelines for ophthalmic surgery.

Purtscher-like retinopathy after a stent implant for the treatment of carotid aneurysm.

Purtscher retinopathy is an occlusive microangiopathy associated with traumatic causes and usually causes visual impairment. For non-traumatic origins, it is called Purtscher-like retinopathy (PLR). A 26-year-old man reported loss of vision in his left eye after the implantation of a telescoping stent for the treatment of an intracranial carotid aneurysm. The fundus of the eye showed numerous cotton-wool spots and superficial haemorrhages. The spontaneous evolution was favourable, with almost complete resolution, except for an inferior residual scotoma. The appearance of PLR may be associated with the implantation of an endovascular stent for the treatment of intracranial aneurysms.

Evaluation of the insertion distance of the medial rectus in consecutive exotropia by means of intraoperative measure and optical coherence tomography.

PURPOSE: To assess the agreement between the measurements of the distance from the medial rectus muscles insertion to the limbus measured by intra-operative spectral-domain optical coherence tomography (SD-OCT) in consecutive exotropia (cXT). METHODS: An analysis was performed on total of 14 medial rectus (MR) muscles of 14 patients who underwent surgery for the treatment of cXT. The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper. The intraclass correlation coefficient (ICC) and Bland Altman plots were calculated to determine the agreement between the two methods, as well as the correlation. RESULTS: Mean age was 36.3 ± 16.0 years (range 13-60), with 60% being women. Mean preoperative deviation was 38.7 ± 16.9 prismatic dioptres (PD) (range 16-65), being +1.3 ± 6.3 PD (range -12 to +10 PD) after surgery. Intraoperatively the MR insertion was found at 8.7 ± 2.1 mm (range 5.5-12.0) and by OCT at 7.7 ± 1.2 mm (range 5.3-10.0). The ICC showed a moderate to good agreement (0.659; 95% confidence interval: 0.157-0.885; p < 0.001), with a correlation of R = 0.792 (p = 0.011). A better agreement was observed in those MR that were less retro-inserted. CONCLUSIONS: SD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on, showing moderate to good agreement with intraoperative measurements. However, the agreement was poor in muscles with a large retro-insertion.

A variant Nishida's technique for surgical correction of monocular elevation deficiency syndrome.

Monocular elevation deficiency (MED) is characterized by unilateral limitation of supraductions, similar in adduction and abduction, in addition to hypotropia and ptosis. We describe a case of a 62-year-old woman with long-standing left ptosis who was initially operated with a frontal suspension technique. On subsequent examinations, a MED of that eye was found. The passive duction test was positive, so the inferior rectus was recessed. In addition, a modified Nishida technique was performed, consisting of the scleral anchorage of the superior edges of the rectus, medial and lateral, 12mm from the corneal limbus in the superonasal and superotemporal quadrants, respectively. Postoperatively, the left eye presented a minimal hypotropia of 3 PD. This modified technnique used here on the horizontal rectus muscles, turned out to be effective and safe for the correction of MED.

Orbital apex syndrome secondary to herpes zoster ophthalmicus.

Herpes zoster ophthalmicus usually presents with ocular manifestations, but neurological complications are much more infrequent. An 84-year-old woman with herpes zoster of the left first trigeminal branch developed herpetic keratouveitis in her left eye despite treatment with oral valaciclovir. Seven days later, a progressive and total left ophthalmoplegia appeared, requiring hospital admission and intravenous treatment with acyclovir and corticosteroids. The neuroimaging was suggestive of an orbital apex syndrome. The evolution of the ophthalmoplegia was favourable, with complete resolution at 5 months, but with decreased visual acuity due to the optic nerve involvement.

«Do Not Do¼ recommendations for retinopathies: A mixed consensus study.

PURPOSE: Among the main causes of blindness and severe vision loss are age-related macular degeneration, diabetic macular oedema, and retinal vein occlusion. The «Do Not Do¼ recommendations are strategies to improve quality of care and optimise healthcare costs. The aim of this study was to establish, by consensus, practices of low value in the above-mentioned pathologies, in addition to estimating their occurrence. MATERIALS AND METHODS: Mixed methods study including a first phase of consensus of a multidisciplinary panel of experts using the Nominal Group technique. In the second phase, a retrospective observational study was conducted, by conducting a review of medical records. RESULTS: A total of 7 recommendations were established for age-related macular degeneration, 4 for diabetic macular oedema, and 5 for retinal vein occlusion. A total of 1,012 medical records were reviewed by the 4 participating hospitals. The review of medical records revealed that agreed «Do Not Do's¼ occurred in a range between 0.6% and 31.4% of the cases included in the study. CONCLUSIONS: This study identified «Do Not Do¼ recommendations in these pathologies that occur relatively often in clinical practice. It is necessary to review the healthcare processes that will enable these practices to be eradicated, and the quality of care to be improved.

«Do Not Do¼ recommendations for retinopathies: A mixed consensus study. / Recomendaciones «no hacer¼ para retinopatías: estudio mixto de consenso.

BACKGROUND AND OBJECTIVE: Among the main causes of blindness and severe vision loss are age-related macular degeneration, diabetic macular oedema, and retinal vein occlusion. The «Do Not Do¼ recommendations are strategies to improve quality of care and optimise healthcare costs. The aim of this study was to establish, by consensus, practices of low value in the above-mentioned pathologies, in addition to estimating their occurrence. MATERIALS AND METHODS: Mixed methods study including a first phase of consensus of a multidisciplinary panel of experts using the Nominal Group technique. In the second phase, a retrospective observational study was conducted, by conducting a review of medical records. RESULTS: A total of 7 recommendations were established for age-related macular degeneration, 4 for diabetic macular oedema, and 5 for retinal vein occlusion. A total of 1,012 medical records were reviewed by the 4 participating hospitals. The review of medical records revealed that agreed «Do Not Do's¼ occurred in a range between 0.6% and 31.4% of the cases included in the study. CONCLUSIONS: This study identified «Do Not Do¼ recommendations in these pathologies that occur relatively often in clinical practice. It is necessary to review the healthcare processes that will enable these practices to be eradicated, and the quality of care to be improved.

Diagnosis by multimodal imaging in peripapillary pachychoroid syndrome: A case report. / Diagnóstico mediante imagen multimodal en síndrome paquicoroideo peripapilar: a propósito de un caso.

The case is reported of a 73-year-old male presenting with the recently described peripapillary pachychoroid syndrome. This syndrome is included in the pachychoroid diseases, which is a relatively new condition characterised by increased choroidal thickness with attenuation of the choriocapillary layer located above dilated choroidal vessels. It is associated with progressive malfunction of the retinal pigment epithelium and neovascularisation. The case is presented with a multimodal image, in which some tests show signs not previously described. In addition, a description is presented of the asymmetric outcome of both eyes after multiple treatments, since the left eye has a very severe affectation, and is refractory to the treatment.

Evaluation of the insertion distance of the medial rectus in consecutive exotropia by means of intraoperative measure and optical coherence tomography. / Evaluación de la distancia al recto medio en la exotropía consecutiva mediante tomografía de coherencia óptica y medida intraoperatoria.

PURPOSE: To assess the agreement between the intraoperative measurements of the distance from the medial rectus muscles insertion to the limbus and preoperative spectral-domain optical coherence tomography (SD-OCT) in consecutive exotropia (cXT). METHODS: An analysis was performed on total of 14 medial rectus (MR) muscles of 14 patients who underwent surgery for the treatment of cXT. The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper. The intraclass correlation coefficient (ICC) and Bland Altman plots were calculated to determine the agreement between the two methods, as well as the correlation. RESULTS: Mean age was 36.3±16.0 years (range 13-60), with 60% being women. Mean preoperative deviation was 38.7±16.9 prismatic dioptres (PD) (range 16 to 65), being +1.3±6.3 PD (range -12 to +10 PD) after surgery. Intraoperatively the MR insertion was found at 8.7±2.1mm (range 5.5 - 12.0) and by OCT at 7.7±1.2mm (range 5.3 - 10.0). The ICC showed a moderate to good agreement (0.659; 95% confidence interval: 0.157-0.885; P<.001), with a correlation of R=0.792 (P=.011). A better agreement was observed in those MR that were less retro-inserted. CONCLUSIONS: SD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on, showing moderate to good agreement with intraoperative measurements. However, the agreement was poor in muscles with a large retro-insertion.

A variant Nishida's technique for surgical correction of monocular elevation deficiency syndrome. / Variante de la técnica de Nishida para la corrección quirúrgica del síndrome de déficit monocular de la elevación.

Monocular elevation deficiency (MED) is characterized by unilateral limitation of supraductions, similar in adduction and abduction, in addition to hypotropia and ptosis. We describe a case of a 62-year-old woman with long-standing left ptosis who was initially operated with a frontal suspension technique. On subsequent examinations, a MED of that eye was found. The passive duction test was positive, so the inferior rectus was recessed. In addition, a modified Nishida technique was performed, consisting of the scleral anchorage of the superior edges of the rectus, medial and lateral, 12mm from the corneal limbus in the superonasal and superotemporal quadrants, respectively. Postoperatively, the left eye presented a minimal hypotropia of 3 PD. This modified technnique used here on the horizontal rectus muscles, turned out to be effective and safe for the correction of MED.

Perforating ocular wounds in occupational accidents.

We review 77 patients with perforating ocular wounds due to occupational accidents seen in our hospital over a period of 5 years. Industrial accidents were the most frequent cause (61.04%), followed by agricultural (25.97%) and services trade (12.98%). Seventy-five patients were males (97.40%), with a mean age of 32.88 years. The cornea was statistically the most frequent location (p less than 0.001). The nasal quadrants were more frequently affected than the temporal ones (p less than 0.001) and the upper quadrants were also more affected than the lower ones, especially in the cornea (p less than 0.001). Fifty-two percent had intraocular foreign bodies; industrial accidents were responsible of 65% of these injuries. They were significantly more frequent in summer than in autumn (p less than 0.001) and spring (p less than 0.01). We discuss the prognosis of these injuries and the circumstances that may influence in their occurrence, stressing the importance of prevention programs.