Absceso epidural espinal: caso clínico pediátrico / Pediatric case report: Spinal epidural abscess

El absceso epidural espinal, una patología poco frecuente, presenta una incidencia de un caso cada 100 000 individuos, y se observa un aumento debido al incremento de factores de riesgo, tales como diabetes mellitus, anomalías espinales, tatuajes, acupuntura, analgesia epidural, sumado a una mayor disponibilidad de métodos de imágenes. Es una colección purulenta localizada entre la duramadre y el canal medular. Los gérmenes más comunes son Staphylococcus aureus y bacterias Gram-negativas. Sin tratamiento oportuno, evoluciona a la compresión medular y secuelas neurológicas permanentes. Una niña de 11 años se presentó con fiebre de 48 horas de evolución, dolor lumbar izquierdo, marcha antálgica con envaramiento lumbar. El examen neurológico era normal. Sobre los miembros inferiores, se observaban lesiones ampollares destechadas. La resonancia nuclear magnética mostró una imagen compatible con absceso epidural espinal. Evolucionó favorablemente. El tratamiento consistió en drenaje quirúrgico y antibióticos por 6 semanas. Del cultivo del material obtenido, creció Staphylococcus aureus meticilino sensible.

Spinal epidural abscess is an uncommon pathology. It has an incidence of one case per 100 000 individuals. An increase is observed due to the raise of risk factors such as diabetes mellitus, spinal abnormalities, tattoos, acupuncture, epidural analgesia, and a greater availability of imaging methods. It is a purulent collection located between the dura and the medullary canal. The most common germs are Staphylococcus aureus and Gram-negative bacteria. Without timely treatment, it evolves to medullary compression and permanent neurological sequelae. An 11-year-old girl was admitted with fever of 48 hs evolution, left lower back pain, antalgic gait with lumbar stiffness. Neurological examination was normal. Blunt blistering lesions were observed on lower limbs. Magnetic resonance imaging showed an image compatible with spinal epidural abscess. The evolutionwas favorable. Treatment consisted of surgical drainage and antibiotics for 6 weeks. From the culture of the material obtained, methidllin-sensitive Staphylococcus aureus was isolated.

Macular hole formation, progression, and surgical repair: case series of serial optical coherence tomography and time lapse morphing video study.

BACKGROUND: To use a new medium to dynamically visualize serial optical coherence tomography (OCT) scans in order to illustrate and elucidate the pathogenesis of idiopathic macular hole formation, progression, and surgical closure. CASE PRESENTATIONS: Two patients at the onset of symptoms with early stage macular holes and one patient following repair were followed with serial OCTs. Images centered at the fovea and at the same orientation were digitally exported and morphed into an Audiovisual Interleaving (avi) movie format. Morphing videos from serial OCTs allowed the OCTs to be viewed dynamically. The videos supported anterior-posterior vitreofoveal traction as the initial event in macular hole formation. Progression of the macular hole occurred with increased cystic thickening of the fovea without evidence of further vitreofoveal traction. During cyst formation, the macular hole enlarged as the edges of the hole became elevated from the retinal pigment epithelium (RPE) with an increase in subretinal fluid. Surgical repair of a macular hole revealed initial closure of the macular hole with subsequent reabsorption of the sub-retinal fluid and restoration of the foveal contour. CONCLUSIONS: Morphing videos from serial OCTs are a useful tool and helped illustrate and support anterior-posterior vitreofoveal traction with subsequent retinal hydration as the pathogenesis of idiopathic macular holes.

Assessment of central corneal thickness using optical coherence tomography.

PURPOSE: To demonstrate the capability of model OCT3 optical coherence tomographer to evaluate central corneal thickness (CCT) in normal human corneas in vivo and compare the results with the those of standard ultrasound (US) pachymetry and Orbscan. SETTING: New York Eye & Ear Infirmary Resident Clinic, New York, New York, USA. METHODS: The CCT in 22 eyes of 11 subjects was determined with the OCT3 (Carl Zeiss Meditec), Orbscan (Bausch & Lomb, Inc.), and US pachymetry (DGH Technology, Inc.). Three central corneal scans of each eye were obtained using the OCT3. First, OCT3 data were processed using the standard OCT software program (OCT3(std)). Second, OCT3 raw data were exported and measurements were repeated using Scion Image for Windows program (OCT3(sci)). The OCT3 and Orbscan results were compared with the mean of 5 US pachymetry measurements in each eye. RESULTS: The OCT3(std), OCT3(sci), and Orbscan CCT measurements showed high correlations with US pachymetry (r=0.981, r=0.984, and r=0.942, respectively; P<.0001). Bland-Altman analysis showed a high level of agreement between US pachymetry and OCT3 techniques but not Orbscan. High repeatability for OCT3(std) (r(2)=0.05) and OCT3(sci) (r(2)=0.01) was also seen. CONCLUSION: Results show the OCT3 is an accurate, noninvasive, and reproducible technique for evaluation of CCT.

Redefining the limit of the outer retina in optical coherence tomography scans.

OBJECTIVE: A highly reflective layer seen in retinal optical coherence tomography (OCT) has been believed to correspond to the choriocapillaris (CHC) and retinal pigment epithelium (RPE). On gray-scale scans of OCT-2000, and on Stratus OCT, this layer by the outer retinal limit can be resolved into 2 distinct laminae. We analyzed these 2 laminae in normal and abnormal maculae to infer their anatomic correlate. DESIGN: Retrospective study. METHODS: Analysis of macular OCT scans was performed in 44 patients using OCT-2000, and in 39 patients using Stratus OCT. Thirty of these patients had no ocular disease, and their OCT was normal. The other 53 patients had several macular diseases of different etiologies. Both color and gray-scale images were analyzed. RESULTS: Macular OCT scans showed a double laminae at the level where the retina interfaces the RPE in normal subjects using both OCT-2000 and Stratus OCT. In 2-dimensional scans, this laminar structure appears as a double line. It is best distinguished on the Stratus OCT and gray-scale images of OCT-2000. This double line consisted of a thin inner line and a thicker outer line. Similar analysis in patients with macular pathology showed a discernible double line at the retina/RPE interface in at least part of the scan. However, in patients with macular hole, the area corresponding to the absent retina showed only a single line. The inner line component appeared to follow the contour of the retina. This phenomenon was also seen in eyes with neurosensory detachment secondary to central serous chorioretinopathy and other etiologies. In contrast, in macular pathologies where the outer retina did not lose contiguity with the RPE, such as in lamellar macular hole and in cystoid macular edema, the double line persisted. Software for retinal thickness measurements regularly place the outer limit of the retina at the internal aspect of the inner line, probably underestimating the retinal thickness by about 24 to 34 mum. CONCLUSIONS: A double laminar structure at the outer retina/RPE/CHC interface can be consistently distinguished on commercially available OCT of normal eyes. In eyes with macular pathology, OCT analysis of the inner lamina leads us to conclude it is most likely part of the neurosensory retina and not part of the RPE/CHC complex as previously thought.

Reduced need for corneal epithelial debridement during vitreo-retinal surgery using two different viscous surface lubricants.

PURPOSE: Corneal clarity is frequently reduced during vitrectomy and scleral buckling surgery secondary to epithelial edema, requiring epithelial debridement to improve visibility. The presence of toxic preservatives in the corneal lubricant solutions is hypothesized to be a contributing factor to epithelial edema during vitreo-retinal surgery. DESIGN: Interventional study. METHODS: We compared prospectively the corneal clarity and epithelial debridement frequency in 71 patients within a single institution in whom either Goniosol (2.5% methylcellulose, boric acid, edetate disodium, sodium borate, potassium chloride, water, and 0.01% benzalkonium chloride) or GenTeal gel (0.3% hydoxypropyl-methylcellulose, carbopol 980, phosphonic acid, sorbitol, water, and 0.028% sodium perborate) was used as a corneal lubricant during the course of vitrectomy surgery using sutured contact lenses. Corneal clarity was subjectively graded in a scale of I to IV during surgery. Statistical analysis was made between these two groups for parametric and categorical data. RESULTS: All eyes started with a corneal clarity grade of I (best possible). Corneal clarity decreased significantly faster in eyes where Goniosol was used to a median grade of III at 1 hour of surgical time. In eyes where GenTeal gel was used, corneal clarity decreased much slower, to a median grade of I at 1 hour of surgical time. The difference in frequency of epithelial debridement was also statistically significant: 54% and 14% for Goniosol and GenTeal eyes, respectively. Other factors that may cause corneal epithelial edema and affect corneal clarity were not statistically different between the Goniosol and the GenTeal groups, including median operative time, estimated intraocular pressure, pre- and intraoperative topical solutions and medications, and number of prior ocular procedures. CONCLUSIONS: The use of GenTeal gel as a corneal lubricant maintains corneal clarity longer than Goniosol during the course of vitrectomy surgery using a contact lens viewing system, limiting the need for epithelial debridement.

Lupus erimatoso sistémico y síndrome antifosfolipídico / Systemic lupus erymatosus and antipholipid syndrome

presentamos un paciente con diagnóstico de lupus eritemado sistémico que ingresó a nuestro hospital con un cuadro de fiebre,artromialgias y decaimiento.Fue asumido como portador de una enfermedad infecciosa o con una reactivación de su enfermedad de base.Posteriormente desarrolló un síndrome antifsofolipídico caracterizado por livedo reticularis,necrosis epidérmica en el primer dedo del pie derecho,ataque isquémico transitorio,plaquetopenia y positividad en las pruebas para detectar anticuerpos anticardiolipina