Childhood-Onset Non-Infectious Uveitis in the "Biologic Era". Results From Spanish Multicenter Multidisciplinary Real-World Clinical Settings.

OBJECTIVE: To characterize and describe clinical experience with childhood-onset non-infectious uveitis. STUDY DESIGN: A multicenter retrospective multidisciplinary national web-based registry of 507 patients from 21 hospitals was analyzed. Cases were grouped as immune disease-associated (IMDu), idiopathic (IDIu) or ophthalmologically distinct. Characteristics of juvenile idiopathic arthritis-associated (non-HLA-B27-related) uveitis (JIAu), IDIu, and pars planitis (PP) were compared. RESULTS: IMDu (62.3%) and JIAu (51.9%) predominated in young females; and IDIu (22.7%) and PP (13.6%) in older children, without sex imbalance. Ocular complications occurred in 45.3% of cases (posterior synechiae [28%], cataracts [16%], band keratopathy [14%], ocular hypertension [11%] and cystoid macular edema [10%]) and were associated with synthetic (86%) and biologic (65%) disease-modifying antirheumatic drug (DMARD) use. Subgroups were significantly associated (p < 0.05) with different characteristics. JIAu was typically anterior (98%), insidious (75%), in ANA-positive (69%), young females (82%) with fewer complications (31%), better visual outcomes, and later use of uveitis-effective biologics. In contrast, IDIu was characteristically anterior (87%) or panuveitic (12.1%), with acute onset (60%) and more complications at onset (59%: synechiae [31%] and cataracts [9.6%]) and less DMARD use, while PP is intermediate, and was mostly bilateral (72.5%), persistent (86.5%) and chronic (86.8%), with more complications (70%; mainly posterior segment and cataracts at last visit), impaired visual acuity at onset, and greater systemic (81.2%), subtenon (29.1%) and intravitreal (10.1%) steroid use. CONCLUSION: Prognosis of childhood uveitis has improved in the "biologic era," particularly in JIAu. Early referral and DMARD therapy may reduce steroid use and improve outcomes, especially in PP and IDIu.

Branch retinal artery occlusion in a patient with one eye. Laser Nd:YAG approach. / Oclusión de rama arterial retiniana en un paciente con ojo único. Abordaje mediante láser Nd:YAG.

CLINICAL CASE: An 82-year-old man was admitted to the emergency department complaining of a sudden painless visual loss in his left eye (OS). He was diagnosed with branch retinal artery occlusion (BRAO) with a visible embolus. In 2012, he had a central artery occlusion (CRAO) in his right eye (OD). An embolysis with Nd:YAG laser was attempted, the retinal arterial blood flow was restored completely and the visual field was improved, with no secondary complications. CONCLUSIONS: Nd:YAG laser embolysis is a treatment to be considered in patients with BRAO with a visible embolus. The risks and benefits of the procedure should be evaluated, comparing it with possible permanent loss of visual acuity and other vascular complications caused by BRAO.

Study of association of CTLA4 gene variants to non-anterior uveitis.

This study was undertaken to investigate the possible genetic association of functional CTLA4 polymorphisms with susceptibility to non-anterior uveitis. Four hundred and seventeen patients with endogenous non-anterior uveitis and 1517 healthy controls of Spanish Caucasian origin were genotyped for the CTLA4 polymorphisms rs733618, rs5742909 and rs231775, using predesigned TaqMan(©) allele discrimination assays. PLINK software was used for the statistical analyses. No significant associations between the CTLA4 polymorphisms and susceptibility to global non-anterior uveitis were found. It was also the case when the potential association of these genetic variants with the anatomical localization of the disease, such as intermediate, posterior or panuveitis, was assessed. Our results do not support a relevant role of these CTLA4 polymorphisms in the non-anterior uveitis genetic predisposition.

Genetic and Environmental Influences on Retinopathy of Prematurity.

OBJECTIVE: The goals were to isolate and study the genetic susceptibility to retinopathy of prematurity (ROP), as well as the gene-environment interaction established in this disease. METHODS: A retrospective study (2000-2014) was performed about the heritability of retinopathy of prematurity in 257 infants who were born at a gestational age of ≤ 32 weeks. The ROP was studied and treated by a single pediatric ophthalmologist. A binary logistic regression analysis was completed between the presence or absence of ROP and the predictor variables. RESULTS: Data obtained from 38 monozygotic twins, 66 dizygotic twins, and 153 of simple birth were analyzed. The clinical features of the cohorts of monozygotic and dizygotic twins were not significantly different. Genetic factors represented 72.8% of the variability in the stage of ROP, environmental factors 23.08%, and random factors 4.12%. The environmental variables representing the highest risk of ROP were the number of days of tracheal intubation (p < 0.001), postnatal weight gain (p = 0.001), and development of sepsis (p = 0.0014). CONCLUSION: The heritability of ROP was found to be 0.73. The environmental factors regulate and modify the expression of the genetic code.

[A protocol for the treatment of retinopathy of prematurity in Spain]. / Protocolo de tratamiento de la retinopatía del prematuro en España.

OBJECTIVE: To prepare a protocol for the treatment of retinopathy of prematurity (ROP) agreed by the majority of Spanish ophthalmologists dedicated to this topic. MATERIAL AND METHOD: A draft of the protocol was produced taking into account the experience of the participants and up to date publications. This draft was corrected by all the ophthalmologists participating in the project, and the final document was agreed by all of them. RESULTS: We present general guidelines as an aid for the treatment of ROP, including treatment criteria, treatment methods, a calendar of action, and follow-up. CONCLUSIONS: It is important to have a common working protocol for the treatment of ROP to improve care and to avoid mistakes. Although individual Hospitals may adapt the protocol to their daily activity, it is recommended that there is a minimal working protocol agreed by most of professionals dedicated to pediatric ophthalmology in Spain.

Screening program for retinopathy of prematurity in Spain.

OBJECTIVE: To prepare a retinopathy of prematurity (ROP) screening program as agreed by most of Spanish ophthalmologists dedicated to this topic. MATERIALS AND METHODS: A draft of the protocol was produced taking into account the experience of the participants and current publications. This draft was corrected by all the ophthalmologists participating in the project and the final document produced was agreed by all of them. RESULTS: We present general guidelines to help in the screening of ROP, including treatment criteria, treatment methods, and a calendar of action. CONCLUSIONS: It is important to have a common working protocol in the screening of ROP to improve the action and to avoid mistakes. Although individual Hospitals may adapt the protocol to their daily activity, it is recommended that there is a minimal working protocol agreed by most of professionals dedicated to pediatric ophthalmology in Spain.

[Immunohistochemical markers in the diagnosis of pigmented conjunctival lesions]. / Utilidad de marcadores inmunohistoquímicos para el diagnóstico de lesiones pigmentadas conjuntivales.

OBJECTIVE/METHOD: The aim of this study was to assess the importance of immunohistochemical markers in the diagnosis of pigmented conjunctival lesions. Due to the difficulty of making an exact clinical diagnosis, the suspicion of malignancy requires the removal of the lesion and performing a histopathology study in which immunohistochemical markers may help to determine the nature of the lesion. CASES REPORT/DISCUSSION: A case is presented of a 25 year-old woman with a pigmented lesion in the caruncle. It appeared recently and was growing fast with increasing pigmentation. Due to a suspicion of malignancy, the total lesion was removed. The microscopic study revealed cellular alterations which suggested malignancy. However, after carrying out immunohistochemical markers the diagnosis was conjunctival compound nevus.

Utilidad de marcadores inmunohistoquímicos para el diagnóstico de lesiones pigmentadas conjuntivales / Immunohistochemical markers in the diagnosis of pigmented conjunctival lesions

Objetivo/Método: Valorar la importancia de los marcadores inmunohistoquímicos para el diagnóstico de certeza de lesiones pigmentadas de la conjuntiva. Debido a la dificultad del diagnóstico clínico exacto, la sospecha de malignidad obliga a realizar una extirpación de la lesión y estudio anatomopatológico en el cual los marcadores inmunohistoquímicos ayudan a determinar la naturaleza de la lesión. Caso clínico/Discusión: Mujer de 25 años que presenta una lesión pigmentada en carúncula de aparición reciente y crecimiento rápido con aumento de la pigmentación. Se sospecha malignidad por lo que se realiza extirpación total de la lesión. El estudio microscópico muestra alteraciones celulares sugerentes de malignidad pero tras realizar marcadores inmunohistoquímicos el diagnóstico es nevus conjuntival compuesto(AU)

Objective/Method: The aim of this study was to assess the importance of immunohistochemical markers in the diagnosis of pigmented conjunctival lesions. Due to the difficulty of making an exact clinical diagnosis, the suspicion of malignancy requires the removal of the lesion and performing a histopathology study in which immunohistochemical markers may help to determine the nature of the lesion. Cases Report/Discussion: A case is presented of a 25 year-old woman with a pigmented lesion in the caruncle. It appeared recently and was growing fast with increasing pigmentation. Due to a suspicion of malignancy, the total lesion was removed. The microscopic study revealed cellular alterations which suggested malignancy. However, after carrying out immunohistochemical markers the diagnosis was conjunctival compound nevus(AU)

[Repair of a leaking bleb filtration with conjunctival and amniotic membrane transplantation]. / Comunicación corta. Reparación de ampolla filtrante postrabeculectomía con injerto de conjuntiva y membrana amniótica.

CLINICAL CASE: A 71-year-old woman presented with a leaking bleb after a combined phacotrabeculectomy performed 13 years ago. To construct a new filtering bleb, the necrotic area was fully excised. The amniotic membrane was inserted over the scleral flap underneath healthy conjunctiva edges. A conjunctiva-Tenon autograft from the contralateral eye was sutured and was sealed with fibrin adhesive. DISCUSSION: We propose a new surgical technique to repair late leak failures after trabeculectomy with mitomycin C in blebs with a large avascular area. Transplantation of amniotic membrane and conjunctival autograft may be used to repair late leak failures with inadequate conjunctiva to advance.

Comunicación corta. Reparación de ampolla filtrante postrabeculectomía con injerto de conjuntiva y membrana amniótica / Repair of a leaking bleb filtration with conjunctival and amniotic membrane transplantation

Caso clínico: Mujer de 71 años que presenta punto de fuga en la ampolla de una facotrabeculectomíarealizada 13 años antes. Se reseca área necrótica y se sutura trasplante demembrana amniótica sobre el tapete escleral hiperfiltrante. Sobre esta se sutura injerto deconjuntiva y Tenon del ojo contralateral.Discusión: Se propone nueva técnica quirúrgica para el tratamiento de fístula de filtracióntardía tras trabeculectomía con mitomicina C y área avascular extensa. Se aplica adhesivo defibrina para el sellado de incisiones. El doble trasplante de membrana amniótica y conjuntivacontralateral puede utilizarse para reparar puntos de fuga tardíos postrabeculectomía conconjuntiva insuficiente(AU)

Clinical Case: A 71-year-old woman presented with a leaking bleb after a combined phacotrabeculectomyperformed 13 years ago. To construct a new filtering bleb, the necrotic areawas fully excised. The amniotic membrane was inserted over the scleral flap underneathhealthy conjunctiva edges. A conjunctiva-Tenon autograft from the contralateral eye wassutured and was sealed with fibrin adhesive.Discussion: We propose a new surgical technique to repair late leak failures after trabeculectomywith mitomycin C in blebs with a large avascular area. Transplantation of amniotic membrane and conjunctival autograft may be used to repair late leak failureswith inadequate conjunctiva to advance(AU)

[Retinopathy of prematurity in multiple births: risk analysis for plus disease]. / Enfermedad plus en la retinopatía del prematuro de gestación múltiple. Análisis de riesgo.

PURPOSE: To analyze the risk factors associated with plus disease in retinopathy of prematurity (ROP). METHOD: Over a period of 8.5 years we carried out a prospective study of ROP in twins and triplets. Fifty-four multiple-birth infants with low birth weight (< or =1500 g) and low gestational age (32< or = weeks) were admitted to the University Hospital of Granada. RESULTS: Logistic regression analyses showed the following variables to be associated with an increased risk of plus disease: severe ROP, large area of avascular retina, low gestational age, low birth weight, a patent ductus arteriosus, length of mechanical ventilation, adverse events increase, low 5 min Apgar scores and poor postnatal weight gain (in the first 4 to 6 weeks of life). Using multiple logistic regression, only the grade of ROP (OR: 5.5; p < 0.009) and poor postnatal weight gain (OR: 0.58; p < 0.04) were predictive factors of development of plus disease. Infants with <> disease gained an average 3.9 +/- 3.1 g/day in the first 6 weeks of life, compared to a mean of 11.84 +/- 8.3 g/day for those without plus disease (p < 0.0001). CONCLUSION: Advanced ROP stages and poor weight gain were the most significant factors associated with plus disease. Twins who gained weight at more than 7 g/day in the first 4-6 weeks of life had a significantly reduced risk of plus disease. A good weight gain is an effective strategy against avoidable blindness due to ROP.

Enfermedad plus en la retinopatía del prematuro de gestación múltiple. Análisis de riesgo / Retinopathy of prematurity in multiple births: risk analysis for plus disease

Objetivo: Determinar los factores de riesgo asociadoscon la enfermedad plus en la retinopatía delprematuro (ROP).Método: En los últimos 8,5 años, realizamos unestudio prospectivo sobre la ROP en gemelos y trillizos.Cincuenticuatro prematuros nacidos de partomúltiple con peso (≤ 1500 gr) y edad gestacional(≤ 32 semanas).Resultados: Los factores que presentaron asociadoun mayor riesgo de enfermedad plus fueron: gradoavanzado de ROP, mayor área sin vascularizar,menor edad gestacional, menor peso al nacer, existenciade ductus arteriovenoso persistente, mayornúmero de días intubado, mayor número de eventosadversos, menor puntaje en el test Apgar 2 y unamenor ganancia de peso postnatal. Con regresiónlogística binaria, sólo el grado más avanzado deROP (OR: 5,5; p < 0,009) y la menor ganancia depeso posnatal (OR: 0,58; p < 0,04) resultaron factorespredictivos del desarrollo de la enfermedad plus.En las 4-6 primeras semanas de vida, los niños conenfermedad plus obtenían una pobre gananciamedia de peso de 3,9 ± 3,1 gr/día frente a los11,84 ± 8,3 gr/día que alcanzaban aquellos sinenfermedad plus (p < 0,0001).Conclusiones: Los factores más significativamenteasociados con la enfermedad plus eran el estadioavanzado de ROP y la pobre ganancia de peso. Losgemelos que ganan más de 7 gr/día de peso, en lasprimeras 4-6 semanas de vida, significativamentereducen el riesgo de enfermedad plus. Una buenaganancia de peso postnatal es una estrategia efectivacontra la ceguera evitable de la ROP(AU)

Purpose: To analyze the risk factors associated withplus disease in retinopathy of prematurity (ROP).Method: Over a period of 8.5 years we carried outa prospective study of ROP in twins and triplets.Fifty-four multiple-birth infants with low birthweight (≤ 1500 g) and low gestational age (32≤weeks) were admitted to the University Hospital ofGranada.Results: Logistic regression analyses showed thefollowing variables to be associated with an increasedrisk of plus disease: severe ROP, large area ofavascular retina, low gestational age, low birthweight, a patent ductus arteriosus, length of mechanicalventilation, adverse events increase, low 5 minApgar scores and poor postnatal weight gain (in thefirst 4 to 6 weeks of life).Using multiple logistic regression, only the grade ofROP (OR: 5.5; p < 0.009) and poor postnatal weightgain (OR: 0.58; p < 0.04) were predictive factors ofdevelopment of plus disease. Infants with ®plus»disease gained an average 3.9 ± 3.1 g/day in the first6 weeks of life, compared to a mean of 11.84 ± 8.3g/day for those without plus disease (p < 0.0001).Conclusion: Advanced ROP stages and poorweight gain were the most significant factors associated with plus disease. Twins who gained weightat more than 7 g/day in the first 4-6 weeks of lifehad a significantly reduced risk of plus disease. Agood weight gain is an effective strategy againstavoidable blindness due to ROP(AU)

[The Granada Diabetic Retinopathy Study. Direct screening of 8,244 patients. I]. / Estudio Granada sobre Retinopatía Diabética. Cribado de 8.244 pacientes diabéticos. I.

OBJECTIVES: To evaluate the results of regular screening for diabetic retinopathy in the geographic area assigned to the San Cecilio University Hospital of Granada. MATERIAL AND METHODS: A multicenter prospective cohort study was carried out over a 2-year follow-up period. Retinal examinations were performed in 8244 diabetics in 14 health centres. 11,924 retinal examinations using an indirect ophthalmoscope, following pupil dilatation, were carried out. The classification of the lesions was as recommended by the simplified international scale of diabetic retinopathy and macular edema. The intervals between fundus examinations followed those recommended by the ETDRS. RESULTS: The crude prevalence of diabetes in the health area concerned was 2.77%. The average screening compliance of the program was 84.1%, and in only 0.3% of the patients was the fundus ophthalmoscopy ungradable. 91.3% of the known diabetic population attended for at least one fundus examination, with only 3.4% of the patients being referred for hospital treatment. The annual cost of the program was set at 53,173 Euros, with the average cost of each examination (6000 per year) being 8.87 Euros. CONCLUSIONS: The Diabetic Retinopathy Screening Program (through dilated pupils) carried out with indirect ophthalmoscopy is cost-effective. It provides coverage to the whole known diabetic population with a high level of compliance. The percentage of patients whose fundus can be considered ungradable is minimal.

[Filtering bleb after surgical cyclodialysis]. / Ampolla filtrante secundaria a cirugía de ciclodiálisis.

CASE REPORT: A 35-year-old man with degenerative myopia suffered blunt ocular trauma due to being hit in the face by a ball. The injury caused four cyclodialysis clefts in his left eye which resulted in hypotony and chorioretinal folds. DISCUSSION: The persisting hypotony was unsuccessfully treated with topical therapy and with laser photocoagulation. Therefore, a surgical treatment with direct cyclopexy was performed. In one of the cyclodialysis clefts, incarcerated vitreous was found, and this was considered to be the reason for its incomplete closure. In the postoperative period complete closure of the cyclodialysis cleft was observed; however an unexpected filtering bleb appeared, which could have affected good control of intraocular pressure.

[Recurrence of bacterial endophthalmitis after penetrating keratoplasty]. / Endoftalmitis recurrente en queratoplastia penetrante, por flora mixta.

OBJECTIVE/METHODS: One month after penetrating keratoplasty, a male patient suffered recurrent abscess and endophthalmitis caused by mixed bacteria (Staphylococcus aureus and Candida Albicans). RESULTS: Two samples of vitreous and aqueous were taken, and a combination of systemic Vancomycin and Amphotericin B were injected intravitreally. The patient was asymptomatic for a month, but the abscess reactivated and was treated with Vancomycin and Ciprofloxacin administered intravenously. Fifteen days after withdrawing the treatment endophthalmitis returned and was treated with vitrectomy and additional systemic/intravitreal antibiotics and antifungal therapy. The final visual acuity was 20/40. CONCLUSIONS: The delayed vitrectomy proved to be necessary to remove established germs and to eliminate recurrent infections.

[Variables related to the first presbyopia correction]. / Edad de la primera compensación de la presbicia, factores asociados.

PURPOSE: We carried out a prospective study based on variables related to the age of appearance of presbyopia (AAP): refraction defect, sex, iris color, profession and pupil diameter. METHOD: Our sample population was made up of 179 persons who present consecutively for the first optical correction of presbyopia as sole reason, having a refractive defect equal to 1 diopter or less. RESULTS: In our series the AAP was not influenced by the small refraction defect, neither by sex or iris color. Different professions showed a significant AAP difference later in life (farmers, x = 51.76 D.E. 5.47 years) or earlier (services workers, x = 46.15 D.E. 3.55 years) (p<0.000003, ANOVA), than other professions such as housewife (48.42 D.E. 4.71 years) and construction workers (47.54 D.E. 3.93 years). We found significant differences in AAP among subjects with intense miosis (<2,5 mm, x = 51 D.E. 5.39 years) and without miosis (3 to 7 mm, x = 47.47 D.E. 4.71 years) (p<0.02 t Student). CONCLUSIONS: The variables which determine a significant delay in the AAP are: profession (farmer and housewife) and miosis, a 1 mm pupilar diameter reduction, in near vision, could contribute to a delay of 1.53 years in AAP.

Edad de la primera compensación de la presbicia, factores asociados / Variables related to the first presbyopia correction

Objetivo: Hemos realizado un estudio prospectivo sobre aquellas variables relacionadas con la edad de aparición de la presbicia (AAP): defecto de refracción, sexo, color del iris, profesión y diámetro pupilar. Métodos: Nuestra muestra poblacional consta de 179 personas que acudían consecutivamente demandando su primera corrección óptica de presbicia, como único motivo, presentando un defecto de refracción igual o inferior a 1 dioptría. Resultados: En nuestra serie la AAP no estaba influenciada por el pequeño defecto de refracción, ni por el sexo, ni por el color del iris. Las diferentes profesiones demostraban una diferencia significativa en la media de AAP, más tardía (agricultores, x= 51,76 D.E. 5,47 años), o más temprana (trabajadores del sector Servicios, x= 46,15 D.E. 3,55 años) (p<0,000003, ANOVA), que otras profesiones tales como amas de casa (48,42 D.E. 4,71 años) y trabajadores de la construcción (47,54 D.E. 3,93 años).Nosotros hemos encontrado diferencias significativas en la AAP entre personas con intensa miosis (<2,5 mm, x=51 D.E. 5,39 años) y pacientes sin miosis (3 a 7 mm, x= 47,47 D.E. 4,71 años) (p<0,02, t a Student 0,05).Conclusiones: Las variables que determinan un retraso significativo en la AAP son: la profesión (agricultores y amas de casa) y la miosis, 1 mm de reducción del diámetro pupilar, en la visión de cerca, podía contribuir en un retraso en la AAP de 1,53 años (AU)