Clinical evidence of intravitreal triamcinolone acetonide in the management of age-related macular degeneration.

Triamcinolone acetonide (TA) is one of the first pharmacologic compounds evaluated for the treatment of choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). The most important effects of TA consist in the stabilisation of the blood-retinal barrier and the down-regulation of inflammation. TA also has anti-angiogenic and anti-fibrotic properties. The peculiar characteristic of being well tolerated by ocular tissues and the capability to remain active for many months after a single intravitreal injection, make this drug a safe and effective alternative. In the past decade, intravitreal injection of TA (IVTA) has emerged as a useful treatment of several ocular diseases such as uveitis, macular edema secondary to retinal vasculature disease, neovascularisation and vitreoretinopathy. In this paper, we review all the available evidence of its use in AMD as mono-therapy or in combination with other treatments, and we discuss which role TA will play in the treatment of AMD in the future. The first experiences with IVTA as monotherapy for the treatment of exudative AMD reported a positive outcome in transiently reducing the leakage from CNV. However, in the long-term follow-up, IVTA as monotherapy had no effect on the risk of severe visual acuity loss, despite a significant anti-angiogenic effect found 3 months after the treatment. Consequently, studies using the combination of IVTA and photodynamic therapy (PDT), which acts synergistically, were performed. They reported to improve vision and to reduce the number of re-treatments with PDT. A large number of publications confirmed the positive synergic role of combining TA and PDT (therapies) for the treatment of all types of CNV: classic or predominantly classic, occult or minimally classic and RAP (Retinal Angiomatous Proliferation) lesions. The advantages registered with the use of IVTA plus PDT compared to PDT alone were partially limited by the side effects, such as the rapid evolution of cataract. Nevertheless, cataract surgery may stimulate the development of CNV (result in stimulating CNV). However, in large, randomized, clinical trials on combination therapy of TA and PDT, visual acuity failed to show an improvement, even though the lesion size and subretinal fluid had decreased, compared to controls treated with PDT alone. Some authors reported an increased risk of developing macular atrophy after the combination therapy with IVTA and PDT. Reduction of the PDT fluence rate in association with the use of steroids resulted in reducing the risk of macular atrophy and in a better visual acuity outcome. The introduction of anti-VEGF-based drugs has revolutionized the treatment of AMD and has replaced all the previous therapies used for CNV. Visual improvement becomes an expectation in a higher proportion of patients, previously limited to minimizing vision loss. Anti-VEGF therapy also resulted in superior visual improvement compared to all types of combination therapy with IVT and PDT. Nevertheless, anti-VEGF monotherapy also has many limitations due to the need of repetitive treatments, increased costs and tachyphylaxis. Treatment regimens involving TA in combination therapy with anti-VEGF and PDT may preserve benefits for substantially longer periods. A question remains open on whether a combination treatment with anti-VEGF, triamcinolone and/or PDT may be a treatment option in patients with exudative AMD, by offering, with one cycle of therapy, functional VA benefits comparable to those observed with continued monthly anti-VEGF therapy. Further trials, of higher scientific significance, are needed to study the potential of these treatment options.

[Surgical treatment of acquired myogenic eyelid ptosis]. / Tratamiento quirúrgico de ptosis palpebral miogénica adquirida.

OBJECTIVE: To report the surgical outcome of aponeurosis surgery in patients with acquired myogenic eyelid ptosis and describe surgical guidelines for their correction. METHODS: The clinical records of two patients with acquired myogenic eyelid ptosis after surgical correction were reviewed. RESULTS: In two patients with acquired myogenic eyelid ptosis and barely good levator function, levator resection surgery was performed. Corneal complications appeared in both cases. CONCLUSION: Patients with acquired myogenic eyelid ptosis are at risk of post-operative surgical complications from corneal exposure. Surgical correction should be conservative and performed only when the visual axis is compromised.

Tratamiento quirúrgico de ptosis palpebral miogénica adquirida / Surgical treatment of acquired myogenic eyelid ptosis

Objetivo: Reportar el resultado de la cirugía de la aponeurosis del elevador en dos pacientes con ptosis palpebral miogénica adquirida y describir pautas quirúrgicas para su corrección.Métodos: Se revisaron las historias clínicas de dos pacientes con ptosis palpebral miogénica posterior a la corrección quirúrgica.Resultados: En dos pacientes con ptosis palpebral miogénica adquirida con escasa función del elevador se realizó cirugía de resección del elevador. Aparecieron complicaciones corneales en ambos casos.Conclusión: Los pacientes con ptosis palpebral miogénica tienen riesgo de complicaciones post-quirúrgicas por exposición corneal. La corrección quirúrgica debe ser conservadora y realizarse solamente cuando el eje visual está comprometido

Objective: To report the surgical outcome of aponeurosis surgery in patients with acquired myogenic eyelid ptosis and describe surgical guidelines for their correction. Methods: The clinical records of two patients with acquired myogenic eyelid ptosis after surgical correction were reviewed. Results: In two patients with acquired myogenic eyelid ptosis and barely good levator function, levator resection surgery was performed. Corneal complications appeared in both cases. Conclusion: Patients with acquired myogenic eyelid ptosis are at risk of post-operative surgical complications from corneal exposure. Surgical correction should be conservative and performed only when the visual axis is compromised

[Criss-cross heart: anesthetic considerations for total cavopulmonary shunt (Fontan procedure)]. / Corazón en criss-cross. Consideraciones anestésicas para derivación cavopulmonar total (Fontan).

We report the anesthetic technique used for interatrial septal defect a 2-year-old girl weighing 11 Kg who presented with crossed atrioventricular connection (criss-cross heart), transposition of the great vessels, interatrial and interventricular septal defects, and subpulmonary and pulmonary valve stenoses. The patient was proposed for total cavopulmonary anastomosis with basal arterial oxygen saturation (SapO2) at 65%. Anesthesia was induced with inhaled agents and after intubation, hyperventilation was induced to achieve an end-tidal carbon dioxide pressure around 27 mm Hg. General anesthesia was provided in combination with spinal infusion of morphine chloride (100 microg Kg(-1)) for pain control. A Fontan procedure was carried out uneventfully with cardiopulmonary bypass. Milrinone was used at the extracorporeal circuit pump outlet. The patient was transferred to the pediatric intensive care unit where she was extubated without complications 90 minutes after admission. Anesthetic management is based on maintaining adequate preloading doses by administering volume, inhaled and/or intravenous agents, or use of vasoconstrictors and adjustment of ventilator parameters to modify pulmonary or systemic vascular resistance. We were able to maintain normal arterial pressure in our patient and provide adequate preloading through hyperventilation to reduce pulmonary vascular resistance.

Corazón en criss-cross. Consideraciones anestésicas para derivación cavopulmonar total (Fontan) / Criss-cross heart: anesthetic considerations for total cavopulmonary shunt (Fontan procedure)

Presentamos la técnica anestésica realizada en una paciente de 2 años de edad y 11 Kg de peso que presenta corazón con conexión atrioventricular cruzada o corazon en criss-cross, transposición de los grandes vasos, comunicación interauricular, comunicación interventricular, y estenosis subpulmonar y valvular pulmonar. Propuesta para anastomosis cavopulmonar total, presentaba SapO2 basal de 65%. Se realizó inducción inhalatoria y tras la intubación se inició hiperventilación para conseguir ETCO2 en torno a 27 mmHg. Se realizó una anestesia combinada general y caudal con cloruro mórfico (100 μg Kg-1) para control del dolor. Se practicó una intervención tipo Fontan, bajo circulación extracorpórea sin incidentes, empleándose milrinona a la salida de bomba. Se trasladó a la Unidad de Cuidados Intensivos pediátricos donde se extubó 90 minutos después de su ingreso, sin complicaciones. El manejo anestésico se basa en mantener precargas adecuadas mediante administración de volumen, uso de agentes inhalados y/o intravenosos, o uso de vasoconstrictores y variación parámetros ventilatorios para modificar resistencias vasculares pulmonares y/o sistémicas. En nuestro caso se procuró mantener una presión arte-rial normal y precarga adecuada, con hiperventilación para disminuir las resistencias vasculares pulmonares

We report the anesthetic technique used for interatrial septal defect a 2-year-old girl weighing 11 Kg who presented with crossed atrioventricular connection (criss-cross heart), transposition of the great vessels, interatrial and interventricular septal defects, and subpulmonary and pulmonary valve stenoses. The patient was proposed for total cavopulmonary anastomosis with basal arterial oxygen saturation (SapO2 ) at 65%. Anesthesia was induced with inhaled agents and after intubation, hyperventilation was induced to achieve an end-tidal carbon dioxide pressure around 27 mm Hg. General anesthesia was provided in combination with spinal infusion of morphine chloride (100 µg Kg–1) for pain control. A Fontan procedure was carried out uneventfully with cardiopulmonary bypass. Milrinone was used at the extra-corporeal circuit pump outlet. The patient was transferred to the pediatric intensive care unit where she was extubated without complications 90 minutes after admission. Anesthetic management is based on maintaining ad-equate preloading doses by administering volume, inhaled and/or intravenous agents, or use of vasoconstrictors and adjustment of ventilator parameters to modify pulmonary or systemic vascular resistance