Tratamiento de la hiperpigmentación periocular con fuentes de luz / Treatment of periorbital hyperpigmentation using light devices

El tratamiento de la ojera supone una de las demandas más habituales en la consulta de estética para mejorar la imagen de cansancio, tristeza o envejecimiento que perciben nuestros pacientes. Además, se trata de un problema de etiología multifactorial y frente al que disponemos de un amplio abanico de tratamientos.El objetivo de la presente revisión es analizar la mejor evidencia disponible para el tratamiento de la ojera hiperpigmentada con fuentes de luz. Se han revisado 208 artículos que cumplían los criterios de búsqueda, incluyendo finalmente 14 para dar plena consideración en la revisión.Múltiples fuentes de luz han demostrado ser eficaces para el tratamiento de la pigmentación periorbitaria. Los resultados más prometedores se obtienen con luz pulsada intensa y láser rubí en combinación con despigmentantes. Para el tratamiento de la pigmentación junto con redensificación y disminución de arrugas destacan el láser CO2 y el láser erbium:yttrium scandium gallium garnet. Los láseres neodymium-doped yttrium aluminium garnet, alejandrita y diodo fueron los que reportaron resultados más moderados con su uso aislado. El tratamiento adyuvante con despigmentantes mejora resultados y reduce la incidencia de hiperpigmentación postinflamatoria.Es necesaria una mejor estandarización en la medida de los resultados en los cambios de la pigmentación. Además, sería recomendable realizar ensayos clínicos con resultados objetivables y que combinen varias fuentes de luz para el tratamiento no solo de la pigmentación periorbitaria, sino de la ojera de forma integral. (AU)

The treatment of dark circles is one of the most common request from the patients attending to the esthetics clinic. A tired, sad or aged appearance is perceived by our patients. Moreover, it is a multifactorial problem and we could treat it with a wide range of treatments.With this systematic review, we want to check the best available evidence regarding the treatment of periorbital hyperpigmentation using light devices. We have reviewed 208 papers, including 14 of them for full consideration.Several light sources have demonstrated to be effective treating pigmented dark circles. The best results have been reported using intense pulsed light and rubi laser together with depigmenting substances. If we want to treat periocular hyperpigmentation, soft wrinkles, rhytides and skin density we should use carbon dioxide laser or erbium:yttrium scandium gallium garnet. The neodymium-doped yttrium aluminium garnet, alexandrite and diode lasers were the ones giving the worst outcome regarding pigmentation treatment. The concomitant use of depigmenting treatment may help getting better results and reducing the rate of post-inflammatory hyperpigmentation.A better standardization and measuring of the obtained results is needed regarding pigmentation changes. We must keep on investigating on this topic with new clinical trials measuring objective results and combining different light devices for a multifactorial treatment of the dark circles. (AU)

Treatment of periorbital hyperpigmentation using light devices.

The treatment of dark circles is one of the most common request from the patients attending to the esthetics clinic. A tired, sad or aged appearance is perceived by our patients. Moreover, it is a multifactorial problem and we could treat it with a wide range of treatments. With this systematic review, we want to check the best available evidence regarding the treatment of periorbital hyperpigmentation using light devices. We have reviewed 208 papers, including 14 of them for full consideration. Several light sources have demonstrated to be effective treating pigmented dark circles. The best results have been reported using intense pulsed light and rubi laser together with depigmenting substances. If we want to treat periocular hyperpigmentation, soft wrinkles, rhytides and skin density we should use carbo dioxide laser or Erbium:Yttrium Scandium Gallium Garnet. The Neodymium-Doped Yttrium Aluminium Garnet, alexandrite and diode lasers were the ones giving the worst outcome regarding pigmentation treatment. The concomitant use of depigmenting treatment may help getting better results and reducing the rate of post inflammatory hyperpigmentation. A better standardization and measuring of the obtained results is needed regarding pigmentation changes. We must keep on investigating on this topic with new clinical trials measuring objective results and combining different light devices for a multifactorial treatment of the dark circles.

Actualización clínica en nanoftalmos: características, enfermedades y complicaciones asociadas / Clinical update in nanophthalmos: Features, diseases and complications associated

El nanoftalmos es una condición congénita infrecuente del globo ocular que se caracteriza por un menor tamaño de los segmentos anterior y posterior en ausencia de una malformación ocular definida. Tradicionalmente se han descrito alteraciones anatómicas asociadas como una longitud axial corta, esclera engrosada, córnea con menor diámetro, cámara anterior estrecha y aumento de la relación entre el volumen del cristalino y el globo ocular. La causa se desconoce, aunque se han descrito múltiples mutaciones que podrían estar asociadas. En la actualidad, falta todavía una definición y una clasificación consensuada. Su relevancia clínica deriva de la asociación con múltiples afecciones oculares que pueden limitar la función visual como son hipermetropía elevada, ambliopía, glaucoma de ángulo cerrado, desprendimiento de retina y catarata. Asimismo, tanto la cirugía de catarata como la de glaucoma siguen constituyendo un desafío en estos ojos en los que el riesgo de numerosas complicaciones tanto intraoperatorias como postoperatorias es significativamente más elevado. El tratamiento del nanoftalmos tiene una doble orientación. Es preciso tratar las enfermedades asociadas y, además, reducir y controlar las complicaciones quirúrgicas. Esta revisión pretende realizar una actualización de lo publicado en los últimos años en relación con esta enfermedad. (AU)

Nanophthalmos is a rare congenital condition of the eyeball that is characterized by a smaller size of the anterior and posterior segments without associated ocular malformations. Typical features that have traditionally been described in these eyes are short axial length, thickened sclera, cornea with a smaller diameter, narrow anterior chamber, and an increased lens to globe volume ratio. However, at present, there is still a lack of recognized diagnostic criteria for nanophthalmos and a classification of its severity. Its clinical relevance stems from the increased risk of multiple ocular conditions, such as high hyperopia, amblyopia, angle-closure glaucoma, retinal detachment, and cataracts. Likewise, in relation to surgery in these eyes, there are particularities in cataract and glaucoma surgery and with a greater risk of associated intra- and postoperative complications. In this way, the treatment of nanophthalmos focuses on controlling the associated eye conditions and reducing and controlling surgical complications. This review aims to update what has been published in recent years regarding nanophthalmos. (AU)

Análisis comparativo de la calidad de vida en diferentes patologías de la retina / Comparative analysis of the quality of life among different retinal diseases

Objetivo Evaluar el impacto en la calidad de vida (CdV) entre diferentes enfermedades de la retina como el edema macular diabético (EMD), la oclusión venosa retiniana (OVR), la miopía patológica (MP), la degeneración macular asociada a la edad neovascular (DMAEn) y la coriorretinopatía serosa central (CSC). Métodos Se realizó un estudio transversal en 241 pacientes afectados de EMD (n=44), OVR (n=41), MP (n=34) y DMAEn (n=85) que recibieron inyecciones intravítreas por presencia de edema macular o neovascularización. Los pacientes con CSC incluidos (n=37) eran candidatos a tratamiento con láser. Los pacientes completaron el National Eye Visual Functioning Questioning-25 (NEIVFQ-25). Se registró la mejor agudeza visual corregida (MAVC). Resultados Existieron diferencias significativas entre subgrupos para todos los dominios, excepto para la visión general, en la que todas las puntuaciones entre enfermedades oscilaron entre 40,7 y 45,2 sobre 100 (p=0,436), a pesar de la diferencia en MAVC (CSC: 86,3±11,9; OVR: 78,5±15,5; EMD: 73,3±15,2; DMAEn: 72,9±12,6 y MP: 68,5±18,1 letras, respectivamente (p<0,001). La puntuación total más baja se observó en la MP (52,1±20,9), seguida de DMAEn (55,3±20,8), OVR (65,0±22,3), EMD (68,6±21,0) y CSC (70,9±16,2). El grupo con EMD tuvo la peor puntuación para la salud general (38,9±21,4). La salud mental y las dificultades de rol fueron más bajas en la MP (48,2±28,8 y 48,2±31,9, p<0,007). Conclusiones Este estudio revela las diferencias en la CdV entre EMD, OVR, DMAEn, MP y CSC, describiendo las diferentes repercusiones que pueden sufrir, observándose un mayor impacto en la MP y la DMAEn (AU)

Purpose To assess the impact on the quality of life (QoL) among different retinal diseases such as diabetic macular edema (DME), retinal vein occlusion (RVO), pathologic myopia (PM), neovascular age-related macular degeneration (nAMD) and central serous chorioretinopathy (CSC). Methods A cross-sectional study was carried out in 241 patients, affected by DME (n=44), RVO (n=41), PM (n=34) and nAMD (n=85) receiving intravitreal injections due to the presence of macular edema or choroidal neovascularization. The CSC patients included (n=37) were candidates for laser treatment. The patients included completed the National Eye Visual Functioning Questioning-25 (NEIVFQ-25). Best eye visual acuity (BEVA) was recorded using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. Results There were significant differences between subgroups for all the domains, except for the general vision in which all scores among diseases ranged from 40.7 to 45.2 out of 100 (P=.436), despite the difference in BEVA (CSC: 86.3±11.9; RVO: 78.5±15.5, DME: 73.3±15.2, nAMD: 72.9±12.6 and PM: 68.5±18.1 letters, respectively; P<.001). The lowest VFQ-25 total score was observed in the PM patients (52.1±20.9), followed by nAMD (55.3±20.8), RVO (65.0±22.3), DME (68.6±21.0) and CSC (70.9±16.2). The DME group reported the worst score for general health (38.9±21.4). Mental health and role difficulties were lowest for PM (48.2±28.8 and 48.2±31.9, P<.007). Conclusions This study reveals the differences in the QoL among DME, RVO, nAMD, PM and CSC, describing the different repercussions that they can suffer, observing a higher impact in PM and nAMD (AU)

Clinical update in nanophthalmos: Features, diseases and complications associated.

Nanophthalmos is a rare congenital condition of the eyeball that is characterised by a smaller size of the anterior and posterior segments without associated ocular malformations. Typical features that have traditionally been described in these eyes are short axial length, thickened sclera, cornea with a smaller diameter, narrow anterior chamber, and an increased lens to globe volume ratio. However, at present, there is still a lack of recognised diagnostic criteria for nanophthalmos and a classification of its severity. Its clinical relevance stems from the increased risk of multiple ocular conditions, such as high hyperopia, amblyopia, angle-closure glaucoma, retinal detachment, and cataracts. Likewise, in relation to surgery in these eyes, there are particularities in cataract and glaucoma surgery and with a greater risk of associated intra- and postoperative complications. In this way, the treatment of nanophthalmos focuses on controlling the associated eye conditions and reducing and controlling surgical complications. This review aims to update what has been published in recent years regarding nanophthalmos.

Comparative analysis of the quality of life among different retinal diseases.

PURPOSE: To assess the impact on the quality of life (QoL) among different retinal diseases such as diabetic macular edema (DME), retinal vein occlusion (RVO), pathologic myopia (PM), neovascular age-related macular degeneration (nAMD) and central serous chorioretinopathy (CSC). METHODS: A cross-sectional study was carried out in 241 patients, affected by DME (n=44), RVO (n=41), PM (n=34) and nAMD (n=85) receiving intravitreal injections due to the presence of macular edema or choroidal neovascularization. The CSC patients included (n=37) were candidates for laser treatment. The patients included completed the National Eye Visual Functioning Questioning-25 (NEI VFQ-25). Best eye visual acuity (BEVA) was recorded using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. RESULTS: There were significant differences between subgroups for all the domains, except for the general vision in which all scores among diseases ranged from 40.7 to 45.2 out of 100 (P=.436), despite the difference in BEVA (CSC: 86.3±11.9; RVO: 78.5±15.5, DME: 73.3±15.2, nAMD: 72.9±12.6 and PM: 68.5±18.1 letters respectively; P<.001). The lowest VFQ-25 total score was observed in the PM patients (52.1±20.9), followed by nAMD (55.3±20.8), RVO (65.0±22.3), DME (68.6±21.0) and CSC (70.9±16.2). The DME group reported the worst score for general health (38.9±21.4). Mental health and role difficulties were lowest for PM (48.2±28.8 and 48.2±31.9, P<.007). CONCLUSIONS: This study reveals the differences in the QoL among DME, RVO, nAMD, PM and CSC, describing the different repercussions that they can suffer, observing a higher impact in PM and nAMD.

Primary hyperaldosteronism in Acute Central Serous Chorioretinopathy: a real need for screening?

PURPOSE: Central Serous Chorioretinopathy (CSCR) is a prevalent ocular disease classified in the pachychoroidal spectrum with an elevated morbidity. Although the pathogenesis is yet unclear, mineralocorticoid-mediated pathways seem to be implicated. Primary hyperaldosteronism (PA) is a relatively frequent, albeit underdiagnosed, cause of hypertension, and has a specific therapy. A previous study assessed the prevalence of CSCR-like signs in a cohort of patients diagnosed with PA and found signs in seven out of thirteen PA patients. The present study aims to study the contrary, screening for PA in a cohort of acute CSCR patients. METHODS: Between March 2017 and September 2018 all patients with acute CSCR were systematically referred to Endocrinology Department after complete ophthalmic evaluation was performed with visual acuity, spectral domain optical coherence tomography, fundus autofluorescence, fluorescein and indocyanine green angiography. The method applied for detection of PA was the 2-h 25 mg captopril challenge test (CCT). RESULTS: Of the nineteen patients screened, two of them had a CCT positive for PA (2-h plasma aldosterone/renin ratio > 50 and/or an aldosterone level of 130 pg/ml or higher), and were treated with mineralocorticoid receptor antagonists (MRA). No ophthalmic pattern was identified in them in terms of time to resolution, recurrences or features of the acute episode. The only differential feature in the fundus of PA patients was pathological arteriovenous crossings (AVC) as well as elevated BP levels. CONCLUSION: a high incidence of PA was found among acute CSCR patients. This preliminary study suggests a need for screening for PA in hypertensive CSCR patients in real clinical practice.

Diagnóstico diferencial de las reacciones inflamatorias tras uso de medicación intravítrea en degeneración macular asociada a la edad: estéril vs. infeccioso / Differential diagnosis of endophthalmitis after intravitreal drug injection for age related macular degeneration: Sterile vs. infectious

El interés por las complicaciones inflamatorias tras la inyección intravítrea de fármacos antiangiogénicos ha aumentado tras la comercialización de brolucizumab y el desarrollo de nuevas moléculas como el abicipar pegol. Dichos fármacos se asocian a una tasa de complicaciones inflamatorias mayor a los antiangiogénicos clásicos. En este contexto resulta clave el diferenciar procesos infecciosos y estériles para realizar un tratamiento efectivo y precoz. El solapamiento del cuadro clínico entre procesos infecciosos y estériles, la baja tasa de positividad en los cultivos y la heterogeneidad en la terminología son barreras para el correcto diagnóstico y reporte de las complicaciones inflamatorias tras la inyección de medicación antiangiogénica intravítrea. Los cuadros estériles comienzan de forma precoz tras la inyección, dentro de las primeras 48 h, o alrededor de 20 días después en los casos de vasculitis asociada a brolucizumab. Los procesos infecciosos comienzan como promedio en el tercer día tras la inyección, y hasta una semana después de la misma. La disminución grave de la agudeza visual, el dolor severo, la hiperemia severa, el hipopion y un mayor grado de inflamación intraocular deben orientar hacia procesos infecciosos. En los casos en que exista duda sobre la etiología de la inflamación, debe procederse a un control muy estrecho del paciente o al tratamiento antimicrobiano empírico junto con la toma de muestra para evitar complicaciones derivadas de una endoftalmitis infecciosa. Por el contrario, los fenómenos estériles deben ser tratados con observación en los casos más leves o corticoterapia adaptada a la gravedad de inflamación en los casos más graves (AU)

The recent release of brolucizumab and the development of new antiangiogenic molecules as abicipar pegol has increased the interest towards inflammatory complications after intravitreal drug injection. Those drugs are associated to a higher rate of inflammatory adverse events compared to classic drugs. In this context it is essential to differentiate between sterile and infectious cases for a fast and effective treatment. The clinical similarities between infectious and sterile cases, the high rate of culture negative patients and the heterogeneity in the terminology used are obstacles for a correct diagnosis and report of these complications. Sterile cases appear early after the injection, before 48h; or 20 days after in brolucizumab-related vasculitis cases. Infectious cases show up around the third day after injection and up to a week after it. A severe visual impairment, severe pain, severe hyperemia, hypopyon and a more severe intraocular inflammatory process are signs of a likely infectious origin. If the cause of the inflammation is uncertain we must follow up the patient closely or “tap and inject” antimicrobial agents in order to prevent the eventual complications of an infectious endophthalmitis. On the other hand, sterile endophthalmitis might be observed in mild cases or treated with steroids according to the severity of the inflammation (AU)

Differential diagnosis of endophthalmitis after intravitreal drug injection for age related macular degeneration: sterile vs. infectious.

The recent release of brolucizumab and the development of new antiangiogenic molecules as abicipar pegol has increased the interest towards inflammatory complications after intravitreal drug injection. Those drugs are associated to a higher rate of inflammatory adverse events compared to classic drugs. In this context it is essential to differentiate between sterile and infectious cases for a fast and effective treatment. The clinical similarities between infectious and sterile cases, the high rate of culture negative patients and the heterogeneity in the terminology used are obstacles for a correct diagnosis and report of these complications. Sterile cases appear early after the injection, before 48 h; or 20 days after in brolucizumab-related vasculitis cases. Infectious cases show up around the third day after injection and up to a week after it. A severe visual impairment, severe pain, severe hyperemia, hypopyon and a more severe intraocular inflammatory process are signs of a likely infectious origin. If the cause of the inflammation is uncertain we must follow up the patient closely or "tap and inject" antimicrobial agents in order to prevent the eventual complications of an infectious endophthalmitis. On the other hand, sterile endophthalmitis might be observed in mild cases or treated with steroids according to the severity of the inflammation.