Afectación iatrogénica de la motilidad ocular por fármacos antitumorales inhibidores de los puntos de control / Iatrogenic impairment of ocular motility by immune checkpoint inhibitors

Se encontraron 4 revisiones sistemáticas que incluían este tipo de iatrogenia ocular, así como numerosos reportes de casos aislados. Los efectos adversos reportados comprenden: paresias oculomotoras, neuropatía óptica, atrofia óptica, síndromes miasteniformes, pseudo-orbitopatía tiroidea, síndrome del ápex orbitario e hipofisitis. La mayoría se manejaron sin interrupción o con interrupción parcial del tratamiento oncológico. Se requirieron tratamientos sistémicos agresivos para el manejo adecuado de la iatrogenia ocular.Es imprescindible que el oftalmólogo se familiarice con los nuevos tratamientos oncológicos ICI, capaces de provocar iatrogenia sobre la motilidad ocular grave e incapacitante para el paciente. La comunicación de efectos adversos con los tratamientos empleados puede ayudar al manejo más adecuado de estos pacientes. La investigación debe ir orientada al diagnóstico diferencial complejo y a optimizar las decisiones sobre los tratamientos oncológicos. (AU)

Cancer therapy relies on new antitumoral drugs called immune checkpoint inhibitors (ICI), which produce long-lasting anti-tumor responses and lengthen survival, but cause autoimmune-type toxicity. The clinical characteristics induced by ICI are not well characterized to date and careful collection of clinical data is required to accurately define its safety profile.We conducted a literature search in the main clinical search engines to identify pharmacological ocular iatrogenic events of ICIs related to ocular motility. Four systematic reviews were found that included this type of ocular iatrogenesis as well as numerous isolated case reports. Reported adverse effects include: oculomotor paresis, optic neuropathy, optic atrophy, myastheniform syndromes, thyroid pseudo-orbitopathy, orbital apex syndrome, and hypophysitis. Most were managed without interruption or with partial interruption of cancer treatment. Aggressive systemic treatments were required for adequate management of ocular iatrogenic events.It is essential that the ophthalmologist become familiar with the new ICI oncological treatments, capable of causing severe and disabling motilidad ocular iatrogenesis for the patient. The communication of adverse effects and the report of the treatments used can help the most appropriate management of these patients. Research should be oriented towards complex differential diagnosis and to optimize decisions on cancer treatments. (AU)

Iatrogenic affectation of ocular motility by immune checkpoint inhibitors.

Cancer therapy relies on new antitumoral drugs called immune checkpoint inhibitors (ICI), which produce long-lasting anti-tumor responses and lengthen survival, but cause autoimmune-type toxicity. The clinical characteristics induced by ICI are not well characterized to date and careful collection of clinical data is required to accurately define its safety profile. We conducted a literature search in the main clinical search engines to identify pharmacological ocular iatrogenic events of ICIs related to ocular motility. Four systematic reviews were found that included this type of ocular iatrogenesis as well as numerous isolated case reports. Reported adverse effects include: oculomotor paresis, optic neuropathy, optic atrophy, myastheniform syndromes, thyroid pseudo-orbitopathy, orbital apex syndrome, and hypophysitis. Most were managed without interruption or with partial interruption of cancer treatment. Aggressive systemic treatments were required for adequate management of ocular iatrogenic events. It is essential that the ophthalmologist become familiar with the new ICI oncological treatments, capable of causing severe and disabling motilidad ocular iatrogenesis for the patient. The communication of adverse effects and the report of the treatments used can help the most appropriate management of these patients. Research should be oriented towards complex differential diagnosis and to optimize decisions on cancer treatments.

Entrenamiento quirúrgico con fantomas en cirugía de estrabismo / Surgical training with phantoms in strabismus surgery

Antecedentes y objetivo La simulación en el aprendizaje quirúrgico responde a necesidades éticas y pragmáticas. Nuestro propósito es describir los efectos sobre las habilidades quirúrgicas de la realización de un taller de entrenamiento quirúrgico en cirugía de estrabismo con fantomas. La preocupación por la seguridad del paciente obliga a plantearse el empleo de simuladores (virtuales y físicos tridimensionales) y modelos animales permite al aspirante practicar sin riesgos los procedimientos antes de enfrentarse a un caso real. Material y métodos Realización de un taller con contenido teórico previo y práctica real con fantomas diseñados para simular cirugía de estrabismo (globo ocular, 6 músculos, conjuntiva, párpado y cápsula de Tenon insertados en cráneo) de dimensiones anatómicas reales. Encuesta de satisfacción y evaluación subjetiva de aprendizaje por parte del alumno y del tutor experto según el modelo de evaluación de Kirkpatrick. Resultados Completaron la encuesta 100% de los 26 alumnos asistentes a dos cursos (15 alumnos en un curso y 11 alumnos en otro curso) y 100% de los tres tutores que participaron en ambos cursos; 20 eran médicos residentes y 20 especialistas en oftalmología. La satisfacción global de los alumnos fue de 8,2 (± 0,68). Conclusiones Según los resultados de la encuesta de evaluación de acciones formativas de Kirkpatrick, la percepción de alumnos y tutores es que el entrenamiento con fantomas en cirugía de estrabismo puede ayudar a mejorar las habilidades necesarias para una práctica segura e independiente. Siendo el objetivo último mejorar la seguridad del paciente (AU)

Background and purpose Simulation in surgical learning responds to ethical and pragmatic needs. Our purpose is to describe the effects on surgical skills of conducting a surgical training workshop on strabismus surgery with phantoms. Concern for patient safety makes it necessary to consider the use of simulators (virtual and three-dimensional physical) and animal models that allow the applicant to safely practice the procedures before facing a real case. Material and methods Realization of a workshop with previous theoretical content and real practice with phantoms designed to simulate strabismus surgery (eyeball, six muscles, conjunctiva, eyelid and Tenon capsule inserted in the skull) of real anatomical dimensions. Satisfaction survey and subjective evaluation of learning by the student and the expert tutor according to the Kirkpatrick evaluation model. Results 100% of the 26 students attending two courses (15 students in one course and 11 students in another course) and 100% of the three tutors who participated in both courses completed the survey. Twenty were resident doctors and 20 specialists in ophthalmology. The overall satisfaction of the students was 8.2 (± 0.68). Conclusions According to the results of the Kirkpatrick training actions evaluation survey, the perception of students and tutors is that training with phantoms in strabismus surgery can help improve the skills necessary for safe and independent practice. The ultimate goal being to improve patient safety (AU)

Surgical training with phantoms in strabismus surgery.

BACKGROUND AND PURPOSE: Simulation in surgical learning responds to ethical and pragmatic needs. Our purpose is to describe the effects on surgical skills of conducting a surgical training workshop on strabismus surgery with phantoms. Concern for patient safety makes it necessary to consider the use of simulators (virtual and three-dimensional physical) and animal models that allow the applicant to safely practice the procedures before facing a real case. MATERIAL AND METHODS: Realization of a workshop with previous theoretical content and real practice with phantoms designed to simulate strabismus surgery (eyeball, 6 muscles, conjunctiva, eyelid and tenon capsule inserted in the skull) of real anatomical dimensions. Satisfaction survey and subjective evaluation of learning by the student and the expert tutor according to the Kirkpatrick evaluation model. RESULTS: Total, 100% of the 26 students attending two courses (15 students in one course and 11 students in another course) and 100% of the 3 tutors who participated in both courses completed the survey. 20 were resident doctors and 20 specialists in ophthalmology. The overall satisfaction of the students was 8.2 (±0.68). CONCLUSIONS: According to the results of the Kirkpatrick training actions evaluation survey, the perception of students and tutors is that training with phantoms in strabismus surgery can help improve the skills necessary for safe and independent practice. The ultimate goal being to improve patient safety.

Corticodependent bilateral trochleitis.

Trochleitis is usually a transient and non-disabling inflammation of the trochlea of superior oblique. The case is presented of a difficult to manage bilateral trochleitis in a 29-year-old woman. After an exhaustive aetiological study with neuro-imaging tests, as well as an analysis of autoimmunity and infection, no underlying cause was found. Multiple injections of corticosteroids were required in both eyes, with a partial effect. Surgical intervention was finally decided in order to visually examine the trochlea, take biopsies, and inject methylprednisolone. These were effective in relieving the symptoms. This case is exceptional due to it involving both eyes and its severity, and represented a therapeutic challenge for the clinical team.

Trocleítis bilateral corticodependiente / Corticodependent bilateral trochleitis

La trocleítis es habitualmente una inflamación transitoria, unilateral y no incapacitante de la tróclea del oblicuo superior. Presentamos el caso de una trocleítis bilateral en mujer de 29 años de evolución tórpida. Tras estudio etiológico exhaustivo con pruebas de neuroimagen, análisis de autoinmunidad e infeccioso no se encontró ninguna causa subyacente. Precisó múltiples infiltraciones en ambos ojos con efecto parcial. Finalmente se decidió intervención quirúrgica para exploración visual de la tróclea, toma de biopsias e infiltración de metilprednisolona que resultaron eficaces en el alivio sintomático. Este caso es excepcional por su bilateralidad y severidad, suponiendo un desafío terapéutico para el equipo clínico (AU)

Trochleitis is usually a transient and non-disabling inflammation of the trochlea of superior oblique. The case is presented of a difficult to manage bilateral trochleitis in a 29-year-old woman. After an exhaustive aetiological study with neuro-imaging tests, as well as an analysis of autoimmunity and infection, no underlying cause was found. Multiple injections of corticosteroids were required in both eyes, with a partial effect. Surgical intervention was finally decided in order to visually examine the trochlea, take biopsies, and inject methylprednisolone. These were effective in relieving the symptoms. This case is exceptional due to it involving both eyes and its severity, and represented a therapeutic challenge for the clinical team (AU)