Characteristics and type of strabismus associated to macular diplopia. Treatment outcomes.

OBJECTIVE: To study the clinical characteristics of macular diplopia, treatment, and outcome. METHODS: Retrospective descriptive study of cases referred to the ocular motility section of a tertiary hospital with diplopia, diagnosed with macular diplopia between 2022-23. The etiology of the macular pathology and the type of associated strabismus were recorded. The result was considered good if the diplopia improved or was eliminated with the medical or surgical treatment. Follow-up time from the onset of diplopia until data collection was recorded. RESULTS: a total of 19 cases comprised the sample (63.2% women), mean age: 67.16 years. Amblyopia (21.1%), high myopia (47.4%), epirretinal membrane (ERM) (36.8%), neovascular membrane (26.3%), macular hole (10.5%), and lamellar (15.8%), and age macular degeneration (5.3%) were registered. The 47.4% had vertical diplopia, horizontal: 5.3 and 47.4% mixed. The mean horizontal deviation was: 7.3 PD (prism diopters) and vertical: 6.22 PD. Ocular extorsion was observed in 26.3%, and intorsion: 5.3%. Torticollis was present in 15.8%. The treatment consisted of strabismus surgery + Botox (15.8%), strabismus surgery (47.4%), medical treatment with Fresnel prims or Scotch cellophane (36.8%). A 68.4% presented a good result at the end of the study. The mean follow-up was 55.58 months. CONCLUSIONS: Misregistration of macular photoreceptors is the most common cause of binocular diplopia in patients with ERM or other macular pathologies. Most complains of vertical or mixed diplopia. Sensorimotor evaluation of these patients should be thorough. Early diagnosis prevents unnecessary prescription of prism glasses. Surgical and/or medical treatment achieves good results in most cases.

Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye.

PURPOSE: To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy. METHODS: A retrospective study of 9 cases between 2017-2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD). RESULTS: The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology). CONCLUSION: Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

Convergence insufficiency with diplopia: Surgical treatment in adults.

OBJECTIVE: To study the outcomes of treatment with central mini-plication of the medial rectus (MR) muscles in adult convergence insufficiency with diplopia. METHODS: The study sample comprised 9 cases (7 women). The length of MR plication was collected. Other variables reported were postsurgical deviation, overcorrections in the early postoperative period and at the end of follow-up, final horizontal deviation at near and at distance vision, diplopia, and mean follow-up from surgery. Surgical outcome was considered to be favorable when diplopia and symptoms were resolved and final exotropia at near was ≤8 pd at the end of follow-up. RESULTS: A central mini-plication of the MR was performed in 9 patients (8 unilateral). Mean (±SD) age was 58.66 (21.39) years. Mean near preoperative deviation: 16.22 (±2.9) pd and distance preoperative deviation: 6.88 (±4) pd Overcorrection at distance vision was recorded in 5 cases; this resolved by 3 months postoperatively. There was not overcorrection at near vision except one case. None of the cases operated on had overcorrection at the end of follow-up. The final horizontal deviation was ≤8 pd at near vision, except for 3 cases (mean: 6.22). Symptoms and diplopia resolved in 8 cases. The mean follow-up was 10.33 months. CONCLUSION: Central mini-plication of 1 or 2 medial rectus muscles can improve the symptoms and signs of exotropia associated with convergence insufficiency when exercises and the prisms are rejected by the patients and when these approaches have not solved the problem.

Transposition of the inferior oblique muscle belly without disinsertion for overshoot in adduction treatment.

PURPOSE: To evaluate the efficacy and safety of inferior oblique muscle transposition and myopexy in patients with mild/moderate inferior oblique muscle overaction, with or without diplopia. METHOD: We retrospectively analysed data for the 12 patients who underwent the technique. Data were collected from October 2018 to September 2021. Surgery was performed by suturing the inferior oblique belly to the sclera at 5 mm posterior to the temporal end of the inferior rectus. All 12 patients had mild hypertropia (≤6 prism diopters [pd]) in primary position and mild/moderate inferior oblique overaction. Mean preoperative hypertropia was 4.42 pd ±â€¯1.62. Diplopia was recorded in 10 cases. The diagnoses were fourth nerve paresis (9), unilateral primary inferior oblique overaction (2) and dissociated vertical deviation (1). Torticollis was observed in 7 cases, 2 had subjective torsion and 2 objective torsion. RESULTS: Mean age was 46.86 ±â€¯25.1 years (50%: men). Diplopia resolved in 9 of the 10 cases. The mean final vertical deviation was 1.5 ±â€¯2.93 (p = 0.001) pd in straight gaze. Of 7 mild overshoot in adduction, it disappeared in 3 and 4 remained the same. Of 5 moderate overshoot in adduction, 2 improved to mild and 3 disappeared. Torticollis was eliminated in 5 patients and improved in another 2. Mean time from surgery was 14.08 ±â€¯8.05 months. There were no overcorrections. CONCLUSIONS: Inferior oblique muscle transposition with myopexy is a safe and effective procedure in patients with mild-to-moderate inferior oblique muscle overaction and small-angle hypertropia, with or without diplopia.

Surgical outcomes of acquired acute comitant esotropia. Causes and classification.

PURPOSE: To study the results of surgical treatment of acquired concomitant esotropia and its posible causes. METHODS: Retrospective study of the patients with acute acquired esotropia that were operated on since 2017. Distance and near horizontal deviation, spherical equivalent and the excessive use of the tablets and smartphones were analyzed. A good sensorial outcome was considered when stereopsis was recovered and good motor outcome if horizontal deviation was ≤10 prism diopters at the end of the follow-up. RESULTS: A total of 15 cases were included (60% women), mean age: 29.07 years (86.66% ≥16 years). Mean time since the beginning of the symptoms to the surgery was 23.3 months. Mean horizontal preoperative deviation was 19.73 ± 7.2 pd at near and 22.93 ± 7.3 dp at distance decreasing to 3.33 ± 3.8 pd at near and 3.86 ± 3.9 pd at distance (P < .001). The 66.6% had diplopía. The 46.66% had decompensated esophoria or microesotropia, 86,66 % myopia and the 33.33% referred excesive use of the tablets and smartphones. The medial rectus recession were done in 10 cases. A good motor outcome was obtained in the 93.33% of the cases and sensorial outcome in the 53.3% without diplopía. CONCLUSION: Surgery was an excellent treatment to resolve the deviation and diplopia. The esophorias and microesotropias represented near the half of the cases and the excesive use of the tablets and smartphones were the third part of the sample. Most of the patients had myopia.

Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia: A Post Hoc Analysis of Three Cohort Studies.

BACKGROUND: There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection. METHODS: This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (2007-2016). The impact of ED and factors associated with mortality were assessed. RESULTS: Of 1023 candidemia episodes, 235 met inclusion criteria. Of these, 54 (23%) were classified as the ED group and 181 (77%) were classified as the non-ED group. ED was more common in catheter-related candidemia (51.9% vs 31.5%; P = .006) and episodes caused by Candida parapsilosis, yet it was less frequent in patients in the intensive care unit (24.1% vs 39.2%; P = .043), infections caused by Nakaseomyces glabrata (0% vs 9.9%; P = .016), and candidemia from an unknown source (24.1% vs 47%; P = .003). In the ED and non-ED groups, 30-day mortality was 11.1% and 29.8% (P = .006), respectively. Chronic obstructive pulmonary disease (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.48-10.61), Pitt score > 2 (OR, 4.39; 95% CI, 1.94-9.20), unknown source of candidemia (OR, 2.59; 95% CI, 1.14-5.86), candidemia caused by Candida albicans (OR, 3.92; 95% CI, 1.48-10.61), and prior surgery (OR, 0.29; 95% CI, 0.08-0.97) were independent predictors of mortality. Similar results were found when a propensity score for receiving ED was incorporated into the model. ED had no significant impact on mortality (OR, 0.50; 95% CI, 0.16-1.53). CONCLUSIONS: Early de-escalation is a safe strategy in patients with candidemia caused by fluconazole-susceptible strains with controlled source of bloodstream infection and hemodynamic stability. These results are important to apply antifungal stewardship strategies.

Changes in ocular motility in Kabuki syndrome. / Alteraciones de la motilidad ocular en el síndrome de Kabuki.

Kabuki syndrome is a rare genetic disorder, caused by mutation in the KMT2D or KDM6A genes, which affects several organs in the majority of patients, among which are the eyes. The most typical clinical characteristics are mental retardation, postnatal growth retardation, skeletal anomalies, and characteristic facial features. As the eyes are affected in most of the cases, ophthalmological examination is recommended for the early detection of ocular anomalies, in order to prevent visual impairment. The most frequent ocular signs are strabismus, ptosis, and refractive anomalies. A series of cases of Kabuki syndrome is described in five children, four of whom exhibited strabismus with esotropia, over action of inferior oblique muscles, and under action of superior oblique muscles associated with a V pattern. Most published papers do not report or might underestimate the ocular problems. It may be appropriate to perform orbital magnetic resonances in order to detect changes in the muscle paths that are related to the pathology of the eye movements found.

Can nonalcoholic beer, silicon and hops reduce the brain damage and behavioral changes induced by aluminum nitrate in young male Wistar rats?

Aluminum consumption has been associated with various neurodegenerative diseases. Previous studies suggest that regular beer intake reverses the pro-oxidant and inflammatory statuses induced by aluminum nitrate intoxication. This paper aims to evaluate the in vitro antioxidant capacity and acetylcholinesterase inhibitory activity of non-alcoholic beer (NABeer), silicon or hops, as well as their effect on animal behavior (e.g. curiosity, immobilization, rearing, grooming, swimming) and brain antioxidant enzyme (activity and gene expression) and anti-inflammatory status in aluminum nitrate intoxicated rats. Male Wistar rats were divided into five groups: 1) Control, 2) Aluminum nitrate (450 µg/kg/day), 3) Aluminum nitrate plus NABeer, 4) Aluminum nitrate plus hops, and 5) Aluminum nitrate plus silicon. Hops showed the highest in vitro antioxidant capacity and silicon the highest anticholinesterase activity. In the Aluminum group the brain aluminum/silicon ratio increased with impairment of brain antioxidant and inflammatory statuses. NABeer, silicon and hops block the negative effect on the in vivo antioxidant and inflammatory statuses induced by Aluminum nitrate and improve swimming and rearing behavioral tests. The various positive results suggest that NABeer is useful as a functional multi-target drink in the prevention of some neurodegenerative events caused by aluminum intoxication. More studies are required to conclude present results.

Self-Regeneration of Chirality with l-Cysteine through 1,3-Dipolar Cycloadditions between Diazoalkanes and Enantiomerically Pure Thiazolines: Experimental and Computational Studies.

Enantiopure 2-thia-4-azabicyclo[3.1.0]hexanes, which can be considered constrained cysteines, have been obtained from l-cysteine by application of the "self-regeneration of chirality" concept. The key intermediates are homochiral thiazolines that can be prepared in multigram scale and react smoothly with a series of diazoalkanes providing Δ1-pyrazolines except for phenyldiazomethane that yield the isomeric Δ2-pyrazolines. Nitrogen extrusion in Δ1-pyrazolines and further reduction of the sulfinyl group yielded the target compounds in good overall yield. Computational studies of the cycloaddition reaction were used for determining the polarity of the process and explaining the observed stereoselectivity. Additional topological studies were employed for determining the influence of noncovalent interactions in the stereochemical course of the reaction, which showed to be a highly asynchronous concerted process.

Full 3-D OCT-based pseudophakic custom computer eye model.

We compared measured wave aberrations in pseudophakic eyes implanted with aspheric intraocular lenses (IOLs) with simulated aberrations from numerical ray tracing on customized computer eye models, built using quantitative 3-D OCT-based patient-specific ocular geometry. Experimental and simulated aberrations show high correlation (R = 0.93; p<0.0001) and similarity (RMS for high order aberrations discrepancies within 23.58%). This study shows that full OCT-based pseudophakic custom computer eye models allow understanding the relative contribution of optical geometrical and surgically-related factors to image quality, and are an excellent tool for characterizing and improving cataract surgery.

Comparison of the characteristics in hen and quail corneas as experimental models of refractive surgery. / Comparación de las características corneales en gallina y codorniz como modelos experimentales de cirugía refractiva.

AIM: To compare the histological, morphological and the biophysical measurements between hen and quail corneas, in order to determine which of them were better suited for use as an animal model for research into corneal refractive surgery. MATERIAL AND METHODS: A study was performed using the biophysical measurements of the cornea (curvature, thickness, refraction, and axial length) of 20 animals (10 hens and 10 quails). The corneas were then prepared for histological analysis under microscopy light. RESULTS: The analysis showed that both groups have the same number of corneal layers as the human cornea and with an evident Bowman's layer. The thickness of the hen cornea and axial length of the eye, 225.3±18.4µm and 12.8±0.25mm, respectively, were larger than that of the quail (P<.01 and P<.001, respectively). The radius of curvature for the hen central cornea, 3.65±0.08mm, was greater than that for the quail (P<.001), but the refractive power of each cornea was similar. The proportion of total corneal thickness of the hen stroma, 82.6%, was more similar to that of the human than was the quail stroma, 72.5%. Within the hen stroma, the density of keratocytes, 8.57±1.49 per 5,000µm(2), was about half that in the quail stroma (P<.005). CONCLUSIONS: Because of the large size of the hen cornea, the stromal thickness and proportional similarity of the corneal layers with human cornea, the hen maybe better than the quail as an alternative species suitable for use in studies of corneal refractive surgery.

Oestrogen activity of the serum in adolescents with Type 1 diabetes.

AIMS: To assess serum oestrogen levels and oestrogenic activity in adolescents with Type 1 diabetes compared with a healthy control group. METHODS: We conducted a cross-sectional study that evaluated adolescents with Type 1 diabetes (n = 38) and healthy adolescents (control group; n = 32). Serum oestrogens, urinary oestrogen metabolites and serum oestrogenic activity were assessed. Oestrogenic activity was evaluated in an in vitro cell proliferation assay using a modified E-screen assay with MCF-7/BUS cells. RESULTS: Adolescents with Type 1 diabetes had lower oestrogenic activity levels in both phases of the menstrual cycle compared with the control group (follicular phase: 76 vs 94%; luteal phase: 97 vs 131%; P < 0.01), even after adjusting for BMI, oestradiol and oestrone levels. Postmenarcheal adolescents with Type 1 diabetes had lower oestradiol levels compared with control subjects in the follicular phase (63.3 pmol/l vs 89.4 pmol/l; P < 0.01) and higher oestrone levels compared with controls in the luteal phase (196 vs 151.9 pmol/l; P < 0.05). CONCLUSIONS: Adolescents with Type 1 diabetes had lower levels of serum oestrogenic activity, and these were lower than expected based on their serum oestradiol levels. We postulate that changes in the serum milieu of oestrogens in patients with Type 1 diabetes may explain their decreased oestrogenic activity and may play a role in their adverse metabolic profile.

Outcomes of minimally invasive strabismus surgery for horizontal deviation.

OBJECTIVE: To study the outcomes of minimally invasive strabismus surgery (MISS) for treating horizontal deviation METHOD: Case Series of the first 26 consecutive patients operated on using the MISS technique in our hospital from February 2010 to March 2014. RESULTS: A total of 40 eyes were included: 26 patients (mean age: 7.7 years old ± 4.9); 34.61%: male. A total of 43 muscles were operated on: 20 medial, and 23 lateral recti; 28 recessions (range: 3-7.5mm), 6 resections (6-7 mm), and 9 plications (6.5-7.5 mm) were performed. No significant difference was found (P>0.05) for visual acuity at postoperative day 1, and 6 months after surgery. A mild hyperaemia was observed in 29.27%, moderate in 48.78%, and severe in 21.95% at postoperative day 1 and in 63.41%, 31.70% and 4.87%, respectively, at 4 days after surgery. The complications observed were 4 intraoperative conjunctival haemorrhages, 1 scleral perforation, and 2 Tenon's prolapses. A conversion from MISS to a fornix approach was necessary in 1 patient because of bad visualization. The operating time range decreased from 30 to 15 minutes. CONCLUSIONS: The MISS technique has obtained good results in horizontal strabismus surgery. The conjunctival inflammation was mild in most of the cases at postoperative day 4. The visual acuity was stable during follow-up, and operating time decreased after a 4-year learning curve.

[Clostridium difficile, are all our patients diagnosed?]. / Clostridium difficile, ¿están todos los que son?

BACKGROUND: A close correlation between clinical and microbiological diagnosis in Clostridium difficile infection (CDI) is very important to identify how severe is this health problem, and to approach its correct management of it, individually and as a population problem. OBJETIVES: a) To evaluate if there is an adequate correlation between the microbiological and clinical diagnosis in CDI patients; b) to determine if the discordance between the microbiological and clinical diagnosis could be associated with different clinical patient characteristics, therapeutic attitudes, and outcomes. PATIENTS AND METHODS: A retrospective study was conducted, using clinical and epidemiologic data, on inpatients with a microbiological diagnosis of CDI in 2013 in the Hospital Clínico San Carlos in Madrid (Spain), depending on whether their clinical ICD diagnosis was included. RESULTS: From a total of 33,317 discharged patients, 204 patients had a CDI diagnosis. Only 51.5% patients had this diagnosis stated in their discharge report. Patients on whom the clinical diagnosis was included, were older, had higher level of dependence (P<.05), and received treatment for CDI more frequently (P<.001) than patients who did not have the clinical diagnosis included. A lower treatment rate was associated with a higher mortality (P=.032) CONCLUSIONS: Nearly half of patients with a microbiological diagnosis of CDI did not have the clinical diagnosis included in their clinical report. Patients without the clinical diagnosis were younger, had less disability, and received specific antibiotics for CDI less frequently. Not receiving specific antibiotics for CDI was associated with higher mortality.

Epidemiology and outcome of candidaemia in patients with oncological and haematological malignancies: results from a population-based surveillance in Spain.

A prospective, population-based surveillance on candidaemia was implemented in five metropolitan areas of Spain from May 2010 to April 2011. We aimed to describe the distribution and susceptibility pattern of Candida species, and to evaluate risk factors for mortality in patients with oncological (solid tumours) and haematological malignancies. Adults (≥ 16 years) with cancer were included in the present report. Impact of therapeutic strategies on 7- and 30-day mortality were analysed by logistic regression, adjusting for propensity score by inverse weighting probability of receiving early antifungal treatment and catheter removal. We included 238 (32.6%) patients (195 oncological, 43 haematological). Compared with oncological patients, haematological patients were more likely to have received chemotherapy (53.5% versus 17.4%, p < 0.001) or corticosteroids (41.9% versus 21%, p < 0.001), and have neutropenia (44.2% versus 1.5%, p < 0.001). Overall, 14.8% of patients developed breakthrough candidaemia. Non-albicans Candida species (71.1% versus 55.6%, p 0.056) and Candida tropicalis (22.2% versus 7.6%, p 0.011) were more frequent in haematological patients. Based on EUCAST breakpoints, 27.6% of Candida isolates were non-susceptible to fluconazole. Resistance to echinocandins was negligible. Mortality at 7 and 30 days was 12.2% and 31.5%, respectively, and did not differ significantly between the patient groups. Prompt antifungal therapy together with catheter removal (≤ 48 hours) was associated with lower mortality at 7 days (adjusted OR 0.05; 95% CI 0.01-0.42) and 30 days (adjusted OR 0.27; 95% CI 0.16-0.46). In conclusion, non-albicans species are emerging as the predominant isolates, particularly in haematological patients. Prompt, adequate antifungal treatment plus catheter removal may lead to a reduction in mortality.

[Spasm of the near reflex. Treatment with botulinum toxin]. / Espasmo del reflejo de cerca. Tratamiento con toxina botulínica.

CLINICAL CASE: A 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DISCUSSION: Near reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

[Duane vertical surgical treatment]. / Tratamiento del síndrome de Duane vertical.

CASE REPORT: We report 3 cases with a vertical incomitance in upgaze, narrowing of palpebral fissure, and pseudo-overaction of both inferior oblique muscles. Surgery consisted of an elevation of both lateral rectus muscles with an asymmetrical weakening. A satisfactory result was achieved in 2 cases, whereas a Lambda syndrome appeared in the other case. DISCUSSION: The surgical technique of upper-insertion with a recession of both lateral rectus muscles improved vertical incomitance in 2 of the 3 patients; however, a residual deviation remains in the majority of cases.

Female reproduction and type 1 diabetes: from mechanisms to clinical findings.

BACKGROUND: The functional reproductive alterations seen in women with type 1 diabetes (T1D) have changed as therapy has improved. Historically, patients with T1D and insufficient metabolic control exhibited a high prevalence of amenorrhea, hypogonadism and infertility. This paper reviews the impact of diabetes on the reproductive axis of female T1D patients treated with modern insulin therapy, with special attention to the mechanisms by which diabetes disrupts hypothalamic-pituitary-ovarian function, as documented mainly by animal model studies. METHODS: A comprehensive MEDLINE search of articles published from 1966 to 2012 was performed. Animal model studies on experimental diabetes and human studies on T1D were examined and cross-referenced with terms that referred to different aspects of the gonadotropic axis, gonadotrophins and gonadal steroids. RESULTS: Recent studies have shown that women with T1D still display delayed puberty and menarche, menstrual irregularities (especially oligomenorrhoea), mild hyperandrogenism, polycystic ovarian syndrome, fewer live born children and possibly earlier menopause. Animal models have helped us to decipher the underlying basis of these conditions and have highlighted the variable contributions of defective leptin, insulin and kisspeptin signalling to the mechanisms of perturbed reproduction in T1D. CONCLUSIONS: Despite improvements in insulin therapy, T1D patients still suffer many reproductive problems that warrant specific diagnoses and therapeutic management. Similar to other states of metabolic stress, T1D represents a challenge to the correct functioning of the reproductive axis.