Recomendaciones en el manejo de la retinocoroiditis de Birdshot / Recommendations for the management of Birdshot retinochoroiditis

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Desprendimiento neurosensorial macular recurrente en fístula carótido-cavernosa / Recurrent neurosensory macular detachment in carotid-cavernous fistula

CASO CLÍNICO: Varón de 46 años, acudió a Urgencias por disminución de agudeza visual y exoftalmos en ojo derecho. Aquejaba cefalea, diplopía de 4 meses de evolución e historia de desprendimiento neurosensorial (DNS) resuelto espontáneamente un mes antes. Presentaba tortuosidad de vasos conjuntivales y epiesclerales y nuevo DNS macular derecho. La sospecha de fístula carótido-cavernosa quedó confirmada mediante angiotomografía computarizada (angio-TC). Durante su ingreso la fístula se cerró espontáneamente. Al mes, el DNS había desaparecido. DISCUSIÓN: La fístula carótido-cavernosa debe incluirse en el diagnóstico diferencial de los DNS maculares. El DNS puede desaparecer espontáneamente al cerrarse la fístula

CASE REPORT: A 46 year-old man was seen in the emergency department complaining of vision loss and exophthalmos in his right eye. He also complained of headache, diplopia of 4 months onset, and neurosensory detachment that resolved spontaneously the month before. The study revealed tortuous conjunctival and episcleral vessels and neurosensory macular detachment in his right eye. A carotid-cavernous fistula was confirmed by computed tomography angiography. The fistula closed spontaneously during the hospitalization. One month later, the neurosensory detachment disappeared again. DISCUSSION: Carotid-cavernous fistula should be included in the differential diagnosis of neurosensory macular detachments. These neurosensory detachments can resolve spontaneously 11 the fistula is closed

[Recurrent neurosensory macular detachment in carotid-cavernous fistula]. / Desprendimiento neurosensorial macular recurrente en fístula carótido-cavernosa.

CASE REPORT: A 46 year-old man was seen in the emergency department complaining of vision loss and exophthalmos in his right eye. He also complained of headache, diplopia of 4 months onset, and neurosensory detachment that resolved spontaneously the month before. The study revealed tortuous conjunctival and episcleral vessels and neurosensory macular detachment in his right eye. A carotid-cavernous fistula was confirmed by computed tomography angiography. The fistula closed spontaneously during the hospitalization. One month later, the neurosensory detachment disappeared again. DISCUSSION: Carotid-cavernous fistula should be included in the differential diagnosis of neurosensory macular detachments. These neurosensory detachments can resolve spontaneously 11 the fistula is closed.

Serie pediátrica en una campaña oftalmológica en Turkana (Kenia) / Pediatric case series in an ophthalmic camp in Turkana (Kenya)

Introducción: Turkana es el distrito más grande de Kenia, situado en el extremo noroeste. Su población está en torno a 850.000 habitantes seminómadas dedicados principalmente al pastoreo. En torno al 60% de la población vive por debajo del umbral de la pobreza. La proporción de médicos por habitante es de 1:75.000.La última campaña realizada en Turkana en noviembre de 2011, con un objetivo puramente quirúrgico, contó con cinco oftalmólogos. La selección previa fue realizada acertadamente por personal local en áreas rurales y en Lodwar. Se realizaron 128 cirugías (123 pacientes) sobre 371 pacientes vistos en consulta. Objetivo: Describir la población pediátrica atendida en la última campaña del proyecto oftalmológico en Turkana. Método: Descripción del perfil de afecciones oculares presentadas por los niños atendidos durante esta campaña quirúrgica. Se expondrá la actitud diagnóstico-terapéutica tomada con relación a las limitaciones impuestas por las características del lugar y de la población. Resultados: De un total de 371 pacientes vistos en consulta, 54 eran menores de 15 años (14,5%); cuatro fueron intervenidos, del total de 123 pacientes operados (3,25%). En dos niños más se indicó la cirugía, por lo que seis de los 54 casos se podrían considerar quirúrgicos (11,1%).De los 54 niños atendidos, 17 sufrían enfermedades distintas a defectos de refracción o problemas leves de superficie ocular: cataratas traumáticas, impétigo, neuropatías, proptosis, distrofias retinianas, tumores dermoides, nictalopía… En 4 de los 17 niños, la causa eran traumatismos (23,5%). Conclusiones: Las campañas quirúrgicas en países en vías de desarrollo están en auge, aunque suelen ir enfocadas a tratar afecciones concretas como las cataratas o el tracoma. Esta serie muestra la necesidad de ir equipados para intervenir a menores de edad y de estar preparados para la complejidad de la situación que pueda surgir (AU)

Introduction: Turkana is the largest district in Kenya, situated in the Northwest of the country. It features a semi-nomadic population of 850,000. Around 60% of population lives below the poverty threshold. The ratio of doctors is 1:75,000 inhabitants. Five ophthalmologists took part in the last deployment in November. Local staff had previously selected the patients from the rural areas, as well as in Lodwar, the capital of the district. Of the 371 patients who attended the clinic, 128 required surgery. Objetive: To describe the pediatric population attended to in the last «Turkana Eye Project» Camp. Methods: Description of the ophthalmic pathologies of the children seen in the clinic in this surgical camp, and the diagnostic and therapeutic options according to the limitations of the environment. Results: Of the 371 patients, 54 were younger than 15 years old (14.5%). Four children had surgery (3.25% of the 128 patients). In 2 more cases surgery was the indicated but not performed. Therefore, of the total of 54 cases, 6 could be considered as surgical (11.1%), and 17 suffered ophthalmic problems other than refraction defects, or mild ocular surface pathologies: traumatic cataracts, neuropathies, impetigo, exophthalmos, retinal dystrophies, dermoid cysts, or nyctalopia. The etiology was traumatic in four of the 17 children (23.5%). Conclusion: Surgical camps are increasing in the developing countries. They are usually focused on particular pathologies, such as cataracts or trachoma. Our case series shows the importance of pediatric teams and the need to be prepared to face complex pediatric pathologies (AU)

[Pediatric case series in an ophthalmic camp in Turkana (Kenya)]. / Serie pediátrica en una campaña oftalmológica en Turkana (Kenia).

INTRODUCTION: Turkana is the largest district in Kenya, situated in the Northwest of the country. It features a semi-nomadic population of 850,000. Around 60% of population lives below the poverty threshold. The ratio of doctors is 1:75,000 inhabitants. Five ophthalmologists took part in the last deployment in November. Local staff had previously selected the patients from the rural areas, as well as in Lodwar, the capital of the district. Of the 371 patients who attended the clinic, 128 required surgery. OBJETIVE: To describe the pediatric population attended to in the last «Turkana Eye Project¼ Camp. METHODS: Description of the ophthalmic pathologies of the children seen in the clinic in this surgical camp, and the diagnostic and therapeutic options according to the limitations of the environment. RESULTS: Of the 371 patients, 54 were younger than 15 years old (14.5%). Four children had surgery (3.25% of the 128 patients). In 2 more cases surgery was the indicated but not performed. Therefore, of the total of 54 cases, 6 could be considered as surgical (11.1%), and 17 suffered ophthalmic problems other than refraction defects, or mild ocular surface pathologies: traumatic cataracts, neuropathies, impetigo, exophthalmos, retinal dystrophies, dermoid cysts, or nyctalopia. The etiology was traumatic in four of the 17 children (23.5%). CONCLUSION: Surgical camps are increasing in the developing countries. They are usually focused on particular pathologies, such as cataracts or trachoma. Our case series shows the importance of pediatric teams and the need to be prepared to face complex pediatric pathologies.

Long-term follow-up of tacrolimus treatment in immune posterior uveitis.

PURPOSE: To study the efficacy of tacrolimus in immune posterior uveitis. METHODS: Twenty-one eyes of 11 patients with immune posterior uveitis under tacrolimus treatment were prospectively followed for 1 to 5 years. Tacrolimus dosage was adjusted to maintain blood levels in the range of 7 to 10 ng/mL. Systemic and ophthalmic evaluations were performed at baseline and during follow-up. RESULTS: After a mean follow-up of 45 months, no treatment other than tacrolimus was necessary to control the inflammation in 6 cases (54.5%). The number of annual recurrences decreased from 3.2 to 1.29 during tacrolimus treatment (p=0.021). In four patients, tacrolimus was suspended after a treatment period of 27+/-3.5 months and a follow-up period of 12 months free of uveitis relapses. All four were free from relapses following tacrolimus withdrawal. Visual acuity remained unchanged in 16/21 (76%) eyes, deteriorated in 4/21 (19%), and improved in 1/21 (5%). Renal function transiently deteriorated in four patients from basal serum creatinine levels of 0.84, 1.1, 0.88, and 0.78 mg/dL to maximum levels of 1.33, 2.48, 1.38, and 1.39 mg/dL, respectively. This deterioration was directly related with elevated tacrolimus serum levels, returning to normal when doses were reduced. During the overall controlled evolution period, a slight increase of serum creatinine from a basal value of 0.89+/-0.2 mg/dL to a final of 1+/-0.19 mg/dL was detected, which was not statistically significant. All secondary effects were mild, transient, and did not require interruption of long-term treatment to be controlled. CONCLUSIONS: Tacrolimus was well tolerated and useful in controlling posterior immune uveitis. Tacrolimus could be considered a real alternative to cyclosporine, and not only in cases of cyclosporine resistance or toxicity.

Multifocal choroiditis after allogenic bone marrow transplantation.

PURPOSE: To describe the clinical manifestations of multifocal choroiditis presumed to be secondary to allogenic bone marrow transplantation after development of self-tolerance to chronic graft-versus-host disease (GVHD). METHODS: Case report. A 17-year-old male who received an allogenic bone marrow transplant (BMT) from his HLA-identical sister. RESULTS: One year after BMT, grade II chronic GVHD developed. Two years later, vision deteriorated to 20/50 R.E. and 20/400 L.E. Ophthalmoscopic examination showed multiple chorioretinal punched-out scars throughout the posterior pole and mid-periphery of both eyes. Fluorescein angiography showed four choroidal neovascular membranes (CNVMs) in the right eye that were surgically removed, and a subfoveal disciform scar in the left eye. CONCLUSIONS: Multifocal choroiditis is a possible complication related to allogenic BMT. It should be included as a late cause of BMT-associated choroidopathy. Surgical removal of vision-threatening CNVMs is a reasonable approach.

Treatment of multiple evanescent white dot syndrome with cyclosporine.

PURPOSE: To report the seven-year follow-up of a patient with multiple evanescent white-dot syndrome (MEWDS). CASE REPORT: A 46-year-old woman presented recurrent episodes of bilateral MEWDS. RESULTS: During the seven-year follow-up there were nine episodes of MEWDS. After four bouts in the first two, cyclosporine therapy was started. During two years of treatment there were no recurrences except when the dose was reduced or discontinued. CONCLUSIONS: The etiology of MEWDS is still unknown but the absence of new episodes during cyclosporine treatment and the recurrence immediately after decreasing or discontinuing the drug suggests an autoimmune origin, with the involvement of cellular immunity in the pathogenic process.

Improved outcome of cytomegalovirus retinitis in AIDS patients after introduction of protease inhibitors.

The objective of this study was to evaluate the influence of protease inhibitor therapy on the rate of progression and survival of 17 AIDS patients with stable Cytomegalovirus retinitis, who were receiving anti-CMV therapy. CD4+ count, HIV load, and CMV antigenemia assay were determined at baseline, at the first month, and every 3 months thereafter. Median CD4+ count increased from 11 to 87 cells/mm3, and median HIV RNA level decreased from 4.96 to 3.28 log10 copies/ml, after 6 months on therapy. Although 9 patients (53%) relapsed in a median time of 97 days (range, 15-152 days), no further episodes were observed during a median follow-up of 17 months (range, 5-18 months). Thus, the probability of remaining free of relapse was twofold higher than that observed in matched patients who did not receive protease inhibitors. Median CD4+ count at the 3rd month was higher in those individuals who went on to progress (p = .03), and a positive result to a CMV antigenemia test was associated with progression of retinitis (relative hazard, 4.45; p = .04). Survival rate was 94% at 17 months (89% increase). Therefore, protease inhibitor therapy reduces retinitis progression and improves survival. However, the immunologic response may not provide initial sufficient protection to avoid, or even may play a role on, early CMV progression.