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.

[Intermediate-term outcome of glaucoma drainage devices]. / Resultados a medio plazo de los dispositivos de drenaje para glaucoma.

OBJECTIVE: To study the intermediate-term results of glaucoma drainage devices (DDG) with respect to control of intraocular pressure (IOP), control of glaucoma, and maintenance of pre-operative visual acuity. METHODS: This was a retrospective cohort study of 86 eyes in 77 patients in whom a DDG was implanted, using descriptive statistics and survival analysis. RESULTS: Success was achieved in 53 eyes (61.6%), complete (without treatment) in 34 eyes (39.5%) and qualified (needing treatment) in 19 eyes (22.1%). In the 33 eyes where the DDG treatment was unsuccessful, poor IOP control occurred in 13 eyes - (15.1%), and complications occurred in 20 eyes (23.2%) resulting in a severe reduction or loss of visual acuity (plate exposure, suprachoroidal hemorrhage, retinal detachment). IOP control was obtained in 66 eyes (76.7%), 47 of them without treatment (54.6%), although on 13 occasions the overall treatment failed due to complications occurring. Despite IOP control, glaucoma progression occurred in 7 eyes (8.1%). Preoperative vision was maintained in 46 eyes (53.5%), but decreased by 3 or more lines in 20 eyes (46.5%); bullous kerathopathy was the most frequent cause of the worsening. Loss of light perception occurred in 21 eyes (24.4%) and 4 eyes (4.6%) were eviscerated. CONCLUSIONS: DDG are an effective surgical option for control of IOP when conventional surgery has a poor prognosis, but they are associated with an increased risk of serious complications and loss of visual acuity in a significant proportion of cases.

[Malignant exophtalmos in hyperthyroidism with a hypothyroid crisis]. / Exoftalmos maligno en hipertiroidismo con crisis hipotiroidea.

CASE REPORT: We present the case of a 56-year-old male with a malignant exophthalmos in the context of Graves' disease. He suffered a significant worsening coincident with a hypothyroid crisis, and various therapeutic approaches were required for reduction of the proptosis. DISCUSSION: When managing this condition, both the severity of the exophthalmos and the activity of the thyroid must be considered when choosing which of the different therapeutic approaches should be employed.

[An unusual presentation of a pilomatrixoma in the eyelid]. / Presentación inusual en el párpado de pilomatricoma.

CASE REPORT: A 32-year-old man developed a lesion, over a period of 1 year, at the margin of the right upper eyelid. The presumed diagnosis was a pyogenic granuloma. An excision biopsy was performed and the histopathologic diagnosis was a pilomatrixoma. DISCUSSION: Eyelid pilomatrixoma is commonly misdiagnosed preoperatively and is extremely rare in middle-aged patients.

[Acute pancreatitis presenting as sudden blindness]. / Pérdida de visión como diagnóstico de pancreatitis aguda.

CASE REPORT: A 36-year-old man with a history of alcohol abuse presented with sudden blindness. The ophthalmologic examination showed Purtscher-like retinopathy. The presumed diagnosis was acute pancreatitis, which was confirmed by complementary laboratory studies. DISCUSSION: Sudden acute visual loss with Purstcher-like retinopathy may be present in acute pancreatitis, although it is a very rare as a presenting symptom. Early diagnosis based on ophthalmic symptoms may help in the recognition and treatment of the disease and prevent later complications.

[Needle revision of late failing filtering blebs after glaucoma surgery]. / Repermeabilización mediante revisión con aguja de ampollas de filtración con fracaso tardío tras cirugía de glaucoma.

PURPOSE: To evaluate the results of bleb needling in eyes subjected to filtering surgery six months or more previously. METHODS: A retrospective study of 23 eyes in 21 patients subjected to bleb needling performed by means of a 25G needle, 6 months to 23 years after failed filtering surgery (mean 67.3 months). The mean number of bleb needlings was 1.2 and the mean number of 5-fluorouracil subconjunctival injections was 3.9. RESULTS: The mean intraocular pressure (IOP) before needling was 26 mmHg and the mean anti-glaucoma medications was 1.3 per eye. The mean postoperative IOP was 16.3 mmHg and mean anti-glaucoma medications 0.7. A diffuse filtering bleb was evident in 12 eyes (54.5%). The results of needling were worse in eyes subjected to previous surgery for glaucoma or other failed bleb needling procedures (75% failure). CONCLUSION: Needle revision of the filtering bleb is a simple and safe technique that offers good results even years after a filtering surgery had been performed. It should be considered before other medical or surgical treatments in patients with a previously functioning bleb and a permeable sclerectomy site at gonioscopy.

Long-term persistence of fascia lata patch graft in glaucoma drainage device surgery.

PURPOSE: Conjunctival erosion in glaucoma drainage device surgery can be prevented by the use of patch grafts to cover the extraocular portion of the tube. Several materials can be used, among them human preserved fascia lata. METHODS: The authors present a case of a failed Ahmed glaucoma valve due to encapsulation of the bleb, in which the fascia lata patch placed to cover the tube was removed 32 months later, during the implantation of a second glaucoma drainage device. RESULTS: Histopathologic examination of the fascia lata patch demonstrated its persistence, without degradation or cellular infiltration. CONCLUSIONS: Human preserved fascia lata is a suitable material for tube covering in glaucoma drainage device surgery, with long-term survival.

[Results and complications of expanded polytetrafluoroethylene in frontalis suspension ptosis surgery. Study of 59 cases]. / Resultados y complicaciones del politetrafluoroetileno expandido en la cirugía de ptosis palpebral por suspensión al frontal. Estudio de 59 casos.

PURPOSE: To evaluate the functional results and complications of the use of expanded polytetrafluoroethylene (ePTFE) in frontalis suspension surgery for the treatment of moderate-severe palpebral ptosis (> 3 mm) with poor or absent levator muscle function. METHODS: Retrospective study of 59 frontalis suspension procedures performed between 1992 and 2003 on 38 patients with palpebral ptosis (21 bilateral). Seventeen (44.7%) cases were women and 21 (55.3%) men. The mean age was 51.7 S.D. 27.6 years (range, 2 to 87). The surgical techniques used were performed by a Wright fascia needle. The etiology, ptosis grade, levator function, Bell's phenomenon and frontalis compensation were studied. RESULTS: After a median follow-up time of 35.9 S.D. 18.5 months (range, 6 to 72), we observed that the functional results were good in 55 cases (93.2%). Infection with preseptal cellulitis appeared in 1 case (1.7%) and required removal of the material, and in 2 cases (3.4%) there were foreign body granulomas that were resolved by excision. Two cases (3.4%) had to be reoperated due to recurrence. CONCLUSIONS: The ePTFE, in our experience, is a good material with excellent functional results and relatively few complications in the surgical treatment of eyelid ptosis for frontalis suspension. Other synthetic materials or fascia lata may be used, but all carry the risk of potential infection, extrusion, granuloma formation or recurrence.

Primary cutaneous adenoid cystic carcinoma of the eyelid.

PURPOSE: To report a case of primary cutaneous adenoid cystic carcinoma involving the eyelid. METHODS: We examined a 70-year-old woman with an 18-month history of a gradually enlarging, blue-colored mass in the medial third of the right upper eyelid. Excisional biopsy and additional resection of the medially infiltrated margin resulted in tumor-free edges. Superior cervical and orbital evaluations were performed. RESULTS: Histopathologic evaluation revealed a primary cutaneous adenoid cystic carcinoma. No gland pathology was documented. No tumor recurrence has been noted. CONCLUSION: Primary cutaneous adenoid cystic carcinoma, an uncommon tumor of the skin, should be added to the differential diagnosis of eyelid tumors.

Eyelid verrucous carcinoma.

PURPOSE: To report a case of verrucous carcinoma (VC) that presented as an eyelid mass on the right eye. CASE REPORT: A 66-year-old man developed a slow-growing eyelid lesion on the lateral canthus of the right eye. The tumor was firm, well-defined, sessile, acuminate, and exuded foul-smelling fluid. RESULTS: Excisional biopsy revealed a VC. The patient remains asymptomatic. CONCLUSIONS: VCs are extremely rare eyelid tumors. This clinicopathological entity is a low-grade variant of squamous cell carcinoma that occurs mainly in the intraoral, genitogluteal, and plantar areas. A role of human papillomavirus (HPV) in these tumors has been recently identified. VCs characteristically show locally aggresive growth. This is the second case reported in the literature on the eyelid. VC should be considered in the differential diagnosis of eyelid tumors.

Propionibacterium acnes endophthalmitis in Ahmed glaucoma valve.

PURPOSE: To report a case of Propionibacterium acnes endophthalmitis in a patient with an Ahmed glaucoma valve. CASE REPORT: A nine-year-old boy with bilateral congenital glaucoma, with an Ahmed glaucoma valve implanted in the left eye, had recurrent conjunctival dehiscence and endophthalmitis. RESULTS: Vitreous cultures demonstrated the presence of Propionibacterium acnes. CONCLUSIONS: This is the first reported case of Propionibacterium acnes endophthalmitis in an Ahmed glaucoma valve and the second one in a glaucoma drainage device. We strongly recommend using a patch graft to prevent and treat tube exposure. Conjunctival grafts may be useful to close the conjunctiva when there is marked scarring to prevent patch exposure and melting or extrusion.

Chondroid syringomas of the eyelid: two cases.

PURPOSE: We report two new cases of chondroid syringoma (CS) of the eyelid. Until 1961, this entity was known as pleomorphic adenoma or benign mixed tumour of the skin of salivary glands type. This tumour occurs most commonly in the head and neck regions. CASE REPORTS: We describe two cases of CS with rapid growth, in the upper right eyelid, with no relation with the palpebral lobe of the lacrimal gland. RESULTS. Treatment consists of wide local surgical excision with its capsule, in its entirety. CONCLUSIONS: These tumours of the ocular adnexa are exceedingly rare. Malignant transformation is possible.

Eyelid phakomatous choristoma.

PURPOSE: To report a case of congenital phakomatous choristoma (PC) of the eyelid, a rare tumor of lenticular anlage in the subcutaneous tissue and dermis. CASE: A boy had a mass in the right lower eyelid near the inner canthus at birth. At age 10 months, the tumor was excised. RESULTS: The tumor cells showed intense immunoreactivity positive for S-100 protein, vimentin, and periodic acid-Schiff. Keratin markers, epithelial membrane antigen, glial fibrillary acidic protein, muscle specific actin, and epithelial membrane antigen were negative. The histopathologic features were consistent with those of a PC. CONCLUSIONS: This histopathologic and immunoreactivity study supports the proposal that PC is a rare entity of lenticular anlage origin. Only 18 such cases have been described previously.

[Neoplasms of the caruncle. Clinicopathologic study of 40 cases]. / Tumores de carúncula. Estudio clínico-patológico de 40 casos.

PURPOSE: To determine the type and frequency of the neoplasms on the lachrymal caruncle and to compare the results with other published case series. METHODS: Retrospective study of forty cases of lesions of the lachrymal caruncle, surgically treated during a 13-year period (1991-2003) are presented. There were 19 females and 21 males. The mean age was 42.1, SD 19.5 years. RESULTS: Ten different histopathologic types of lesions were found. The most frequent lesion was the nevus (40%), and the second, the papilloma (30%). Thirty-seven neoplasms (92.5%) were benign, 2 (5%) premalignant and 1 (2.5%) malignant. The clinical diagnosis was accurate in 87.5% of the cases. CONCLUSION: In this case series, we confirm the low frequency of caruncular neoplasms as well as the wide variety of histopathologic types found in this location. There was a wide range of ages and we did not find any evident sex predominance. Malignant lesions were uncommon, with only one case of basal cell carcinoma. Our results are similar to those of other case series.

[Eyelid and cutaneous lesions as the sole indicators of tuberous sclerosis]. / Lesiones palpebrales y cutáneas como única manifestación de esclerosis tuberosa.

CASE REPORT: A 53-year old woman presented a tuberous sclerosis complex (Bourneville's disease) characterised by facial cutaneous angiofibromas, periungual fibromas and cutaneous leaf-shaped macules in the thorax. She also presented two neoplasms in the left lower eyelid which were histopathologically diagnosed as angiofibromas. There were no other ophthalmologic or systemic findings. DISCUSSION: Tuberous sclerosis complex is an autosomical dominant neurocutaneous phakomatosis in which up to 80% of cases represent new mutations, characterized by mental retardation, epilepsy and angiofibromas. Incidence is very low and ophthalmic presentation with isolated cutaneous angiofibromas is most unusual.

[Basal cell and squamous cell carcinomas of the eyelid in adults under 50 years of age: 13 cases]. / Carcinomas palpebrales de células basales y escamosas en adultos menores de 50 años: 13 casos.

PURPOSE: It is widely accepted that exposure to UV light may cause malignant lesions in the eyelid of elderly people. Its occurrence in young adults is much less frequent and requires an early diagnosis and accurate treatment as well. MATERIAL AND METHOD: We have retrospectively reviewed a series of 13 patients younger that 50 years of age who had been surgically treated in our hospital between 1990 and 1997. RESULTS: The pathologic examination revealed 12 basal cell carcinomas and one squamous cell carcinoma. Lesions were small nodular tumors with a previous mean evolution of 34 months (2.6 years). CONCLUSION: Although the periocular area may develop several kinds of malignancies due to the presence of various types of tissues, most of the lesions found in the eyelid are carcinomas. With an early diagnosis and correct treatment, prognosis is good. The purpose of the surgical treatment is not only the excision of the lesion, but also to maintain shape and function of the eyelid and preserve the eye as well.

[Incidence of encapsulated bleb after filtering surgery]. / Incidencia de ampolla encapsulada tras cirugía filtrante.

OBJECTIVE: To determine the incidence of encapsulated bleb (EB) after filtering surgery, and the risk factors for the development of this complication, especially those related with the surgical procedure. METHODS: Ninety eyes that were submitted to trabeculectomy were prospectively studied. Lens extraction was associated in 56 eyes (62.9%). All patients were followed up for at least 3 months. RESULTS: There were clinical characteristics of encapsulation in 29 eyes (32.3%) and EB with a peak IOP of 25 mmHg or higher in 14 eyes (15.7%). The incidence of EB formation was 20.5% in men and 11.8% in women (p.044). The incidence of EB was higher in the trabeculectomy group alone (24.2%) than in the group in which it was associated to cataract surgery (10.5%) (p.003). There were clinical characteristics of encapsulation in 40.7% of primary open angle glaucoma (p.041). EB was significantly associated with an increased failure rate (21.4%) when compared to normal blebs (5.55% failure rate) (p<.001). CONCLUSIONS: The encapsulated bleb is significantly more frequent in the male gender and thick conjunctivas and in trabeculectomy alone versus trabeculectomy associated to cataract surgery. It means a significantly greater risk of failure after surgery in the short term.

[Glaucoma drainage device obstruction]. / Obstrucción del tubo de los dispositivos de drenaje.

PURPOSE: To determine the pathophysiology and to discuss possible solutions for tube obstruction since this is a frequent complication in glaucoma drainage device surgery. MATERIAL AND METHODS: 81 eyes with a glaucoma drainage device (GDD) fitted by our Department during the last twelve years (1991-2002) were retrospectively reviewed and eleven cases of tube obstruction were detected. The treatments included Nd-Yag laser, anterior vitrectomy, blood clot removal and intracamerular rTPA. RESULTS: The obstruction was proximal in ten cases and distal in one. Of the former, the obstruction was caused by a blood clot in six cases, by vitreous in three cases and by a fibrinous membrane in one case. The nature of the distal obstruction was not determined. One case of vitreous obstruction occurred after a posterior capsulotomy with Nd-Yag laser two years after positioning the GDD. Complete success was achieved in five cases, and partial success in three where antiglaucoma therapy had to be maintained postoperatively. Complete failure was found in the other three cases. CONCLUSIONS: The material which most frequently caused the tube obstruction was blood and although in some cases this may resolve spontaneously, clot removal with forceps or rTPA intracameral injection may be helpful. In vitreous obstruction, Nd-Yag laser may temporariril clear the tube, but extensive anterior vitrectomy is required to maintain long-term permeability. We suggest carrying out a small posterior capsulotomy in pseudophakic patients with a GDD.

[Benign hair-follicle derived eyelids tumors in adults]. / Tumores palpebrales benignos derivados de los folículos pilosos en adultos.

PURPOSE: Benign eyelid neoplasms derived from hair follicles are frequently misdiagnosed, including pilomatricoma, trichoepithelioma, trichilemmoma, trichoblastoma and inverted follicular keratosis. METHODS: We reviewed 17 tumors seen in the last 9 years, between 1992 and 2002. Excisional biopsy constituted the treatment in all cases. RESULTS: The mean age was 44.5 years (range 13-80 years). Ten were women and 7 men. Pilomatricoma and trichoepithelioma accounted for 76.5% of all neoplasms. All trichoepitheliomas were found as solitary tumors and no patient had a history of familial trichoepithelioma. The remaining neoplasms (23.5%) were trichilemmomas, trichoblastoma and inverted follicular keratosis. No patient recurred locally and there were no malignant transformations after a mean follow-up of 3.1 years. The most frequent hair follicle neoplasms in our series was pilomatricoma (9 cases). CONCLUSIONS: Benign hair follicle neoplasms are rare in the eyelid. Most can simulate a basal cell carcinoma when evaluation is based on clinical evidence alone, and only the pilomatricoma may resemble a benign neoplasm. Thereby they must be excised with free surgical margins. All excised eyelid lesions should be sumitted for histopathologic examination because it is not possible to obtain 100% accuracy in diagnosing eyelid tumors.

[Squamous cell carcinomas of the eyelids: 18 cases]. / Epiteliomas espinocelulares palpebrales: 18 casos.

PURPOSE: Squamous cell carcinoma (SCC) is relatively uncommon in eyelid (1 to 2% of all eyelid lesions). The true frequency of this tumor has been difficult to estimate because of a tendency for overdiagnosis (basal cell carcinoma and sebaceous carcinoma) in published reports of eyelids lesions. METHODS: We present a retrospective review of a series of 18 patients, surgically treated in our hospital between 1990 and 1998, analysing their characteristics. RESULTS: The pathologic examination revealed 18 SCC. Tumors developed most frequently in males, lower eyelid and right eye. The mean age and highest incidence decade were 71 years old and 71-80 years old (45%). CONCLUSIONS: SCC is the second common malignant eyelid tumor. Male are most affected. Recurrence after surgical excision is uncommon, but three of our patients developed orbital invasion (16.6%). SCC are much more likely to metastasise than basal cell carcinomas. They arise from pre-existing actinic keratoses, however, they possess less metastasic risk than other presentations. Unfortunately, our culture values the well-tanned look. At-risk patients may pay the ultimate price for this vanity.