Evolución de la técnica «avance de colgajo frontal» en la ptosis congénita / Evolution of the «frontal flap advancement» in congenital ptosis

El tratamiento de la ptosis congénita con mala función del elevador se basa habitualmente en una suspensión del párpado superior al músculo frontal mediante diversos tipos de materiales autógenos o aloplásticos. Sin embargo, el empleo de dichos materiales conlleva una serie de complicaciones, lo cual dio lugar a la búsqueda de una técnica quirúrgica mediante la que, sin necesidad de ningún material adicional, se enlazaran músculo frontal y tarso; el avance de colgajo frontal. No obstante, es una técnica menos conocida y que todavía no está estandarizada, por lo que a lo largo del tiempo se han ido describiendo variaciones para mejorar los resultados estéticos y funcionales. El objetivo de esta revisión bibliográfica es repasar en detalle las distintas variaciones de la técnica quirúrgica y obtener la mejor opción con o sin la combinación de las diferentes versiones empleadas hasta el momento. Según los resultados observados, se podría deducir que la cirugía con mejores resultados estéticos y funcionales sería la siguiente; una única incisión en el surco palpebral para realizar una disección suborbicular hasta alcanzar reborde orbitario. Realización de lipectomía si lo precisa. A continuación, disección roma del músculo frontal y formación de colgajo en «U». Avance de la aponeurosis del elevador si se trata de una ptosis grave. Finalmente, sutura sin polea del colgajo frontal al tarso con tres puntos no reabsorbibles tratando de mantener el contorno simétrico al ojo contralateral y con una altura de 1,5mm por encima del limbo corneal (AU)

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improving the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determining which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a “U” shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5mm above the sclero-corneal limbus (AU)

Evolution of the «frontal flap advancement¼ in congenital ptosis.

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improve the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determine which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a "U" shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5 mm above the sclero-corneal limbus.

¿Melanoma o glaucoma? A propósito de un caso / Melanoma or glaucoma? A case report

CASO CLÍNICO: Presentamos a un paciente remitido con sospecha de melanoma de cuerpo ciliar debido a una lesión pigmentada en la raíz del iris del ojo izquierdo, asociada con presión intraocular alta a pesar de tratamiento máximo con medicación tópica y sistémica. El estudio sistemático reveló cambios unilaterales en el endotelio corneal, compatibles con el síndrome iridocorneal. Se implantó una válvula de Ahmed(R), logrando un control sostenido de la presión intraocular y de los defectos del campo visual. Discusión: Los síndromes iridocorneales son un amplio y heterogéneo grupo de enfermedades donde las células endoteliales crecen sobre el trabéculo, lo que lleva a un aumento en la presión intraocular. Debido a la naturaleza de la enfermedad, la cirugía de implante valvular puede ser la mejor opción terapéutica de entrada. El estudio clínico sistemático es crucial, ya que el diagnóstico diferencial puede incluir entidades potencialmente cegadoras e incluso mortales

CASE REPORT: The case is presented of a patient referred to us with suspicion of a ciliary body melanoma due to a pigmented lesion in iris root of left eye, associated with high intraocular pressure, despite maximal topical and systemic medication. The systematic workup revealed unilateral changes in the corneal endothelium, compatible with an iridocorneal syndrome. An Ahmed(R) valve was inserted, achieving sustained control of intraocular pressure and visual field defects. DISCUSSION: Iridocorneal syndromes are a wide and heterogeneous group of diseases, in which endothelial cells grow over the trabeculum, leading to an increase in intraocular pressure. Due to the nature of the disease, tube shunt surgery may be the best option in its treatment. Systematic workup is crucial, since the differential diagnosis may include potentially blinding and even life threatening conditions

Melanoma or glaucoma? A case report. / ¿Melanoma o glaucoma? A propósito de un caso.

CASE REPORT: The case is presented of a patient referred to us with suspicion of a ciliary body melanoma due to a pigmented lesion in iris root of left eye, associated with high intraocular pressure, despite maximal topical and systemic medication. The systematic workup revealed unilateral changes in the corneal endothelium, compatible with an iridocorneal syndrome. An Ahmed® valve was inserted, achieving sustained control of intraocular pressure and visual field defects. DISCUSSION: Iridocorneal syndromes are a wide and heterogeneous group of diseases, in which endothelial cells grow over the trabeculum, leading to an increase in intraocular pressure. Due to the nature of the disease, tube shunt surgery may be the best option in its treatment. Systematic workup is crucial, since the differential diagnosis may include potentially blinding and even life threatening conditions.

Casuística de 10 pacientes con queratitis por Acanthamoeba / A report of 10 patients with Acanthamoeba keratitis

CASOS CLÍNICOS: Presentamos 10 casos de queratitis por Acanthamoeba tratados en nuestro hospital entre 2008 y 2017. Todos eran portadores de lentes de contacto. Como tratamiento todos recibieron una biguanida junto a una diamidina. En 3 casos la infección no superaba el estroma superficial, respondiendo al tratamiento tópico. En 7 alcanzaba el estroma profundo, precisando 6 de ellos una queratoplastia penetrante, 3 «en caliente» por riesgo de perforación o extensión ocular. La agudeza visual mejoró en todos los casos. CONCLUSIÓN: La profundidad de la infección al diagnóstico aparece como el principal factor de riesgo para necesitar una queratoplastia penetrante

CLINICAL CASES: Cases are presented of 10 patients with Acanthamoeba keratitis treated between 2008 and 2017. All were contact lens wearers. All of them received treatment with a biguanide combined with a diamidine. In 3 cases the infestation did not exceed the superficial stroma, responding to topical treatment. In 7, the infection reached the deep stroma, with 6 of these cases requiring penetrating keratoplasty (PKP), 3 of them therapeutic PKP because of perforation risk or ocular spreading. The visual acuity improved in all the cases. CONCLUSION: The infestation depth at the time of diagnosis appears to be the main risk factor for requiring a PKP

A report of 10 patients with Acanthamoeba keratitis. / Casuística de 10 pacientes con queratitis por Acanthamoeba.

CLINICAL CASES: Cases are presented of 10 patients with Acanthamoeba keratitis treated between 2008 and 2017. All were contact lens wearers. All of them received treatment with a biguanide combined with a diamidine. In 3 cases the infestation did not exceed the superficial stroma, responding to topical treatment. In 7, the infection reached the deep stroma, with 6 of these cases requiring penetrating keratoplasty (PKP), 3 of them therapeutic PKP because of perforation risk or ocular spreading. The visual acuity improved in all the cases. CONCLUSION: The infestation depth at the time of diagnosis appears to be the main risk factor for requiring a PKP.