PAAO vol 12 No. 2

VISION THE PAN-AMERICAN JOURNAL OF OPHTHALMOLOGY ISSN 2219-4665 June 2014, Vol. 13(2)

Editorial Dantas PEC

Message from the President Hofling-Lima AL

Management of epiphora and lacrimal obstruction in adults Savar L et al

Demographic characteristics of the sample

Age

Mean

Range

31.31

2-60 %

29

82.9

6

17.1

Gender Male Female

Therapeutic outcomes in patients with post-traumatic strabismus

N

Suazo AL et al

Location of Residence Urban

32

Rural

91.4

3

8.6

Aggression

20

57.1

Cause of trauma

Fall

6

17.1

Traffic Accident

5

14.3

Other

4

11.4

Orbital Fracture

13

37.1

Penetrating eye injury

6

17.1

Combined hamartoma of the retina and retinal pigment epithelium

Type of lesion

Garcia-Fernandez M & Castro-Navarro J

Blunt trauma

6

17.1

Direct muscle trauma

5

14.3

Other

2

5.7

Penetrating eye injury and orbital fracture

2

5.7

Blunt trauma and orbital fracture

1

2.9

Type of Strabismus

A deadly droop: small cell lung cancer presenting as upper eyelid ptosis

Paralytic

24

68.6

Restrictive

9

25.7

Paralytic and restrictive

2

5.7

Right eye

21

60.0

Left eye

14

40.0

Eye involvement

Valenzuela A et al

Vertical ocular alignment in first evaluation Normal

17

48.6

Hypertropia and hypotropia

18

51.4

Horizontal ocular alignment in first evaluation Normal

8

22.9

Esotropia

13

37.1

Exotropia

14

40.0

Entrampamiento de iris en implante Ex-Press Morales-Leon JE et al

Letter from the Chairman of the PAOF Board De La Pe単a W

Announcements Proud to be PAN-AMERICAN

Preserva la visión alcanzando las menores presiones-objetivo en más pacientes Investigadores de diversos estudios, (AGIS, Shirakashi, Shields) han comprobado que alcanzar y mantener la PIO entre 14 y 15 mmHg reduce la progresión de pérdida del campo visual1,2,3. Lumigan® alcanza la PIO-objetivo de 14/15 mmHg en un mayor número de pacientes: ®

vs. timolol 4

®

vs.

dorzolamida/ timolol 5

®

vs. latanoprost 6

Porcentaje de Pacientes que alcanzaron la PIO-Objetivo ≤14

21%

9%

17%

2%

19%

9%

Porcentaje de Pacientes que alcanzaron la PIO-Objetivo ≤15

31%

16%

24%

9%

29%

14%

Lumigan ® (bimatoprost) Forma farmacéutica y pr esentación. Composición. Cada ml contiene: 0,3 mg de bimatoprost. Vehículo: cloreto de sódio, fosfato de sódio presentación. esentación.Frascos cuenta-gotas conteniendo 5 ml de solución oftalmológica estéril de bimatoprost a 0,03%. USO ADULTO.Composición. hepta-hidratado, ácido cítrico mono-hidratado, ácido clorídrico y/o hidróxido de sódio, cloruro de benzalconio y agua purificada qsp. Indicaciones. LUMIGAN® (bimatoprost) es indicado para la reducción de la presión intra-ocular elevada en pacientes con glaucona o hipertensión ecauciones y Adver tencias. Advertencias. Fueron relatados aumento gradual del crescimiento Contraindicaciones. LUMIGAN ® (bimatoprost) está contraindicado en pacientes con hipersensibilidad al bimatoprost o cualquier otro componente de la fórmula del producto. Pr Precauciones Advertencias. ocular.Contraindicaciones. de las pestañas en el largo y espesura, y oscurecimiento de las pestañas (en 22% de los pacientes después 3 meses, y 36% después 6 meses de tratamiento), y, oscurecimiento de los párpados (en 1 a <3% de los pacientes después 3 meses y 3 a 10% de los pacientes después 6 meses de tratamiento). También fue relatado oscurecimiento del íris en 0,2% de los pacientes tratados durante 3 meses y en 1,1% de los pacientes tratados durante 6 meses. Algunas de esas alteraciones pueden ser permanentes. Pacientes que deben recibir el tratamiento ecauciones LUMIGAN® (bimatoprost) no fue estudiado en pacientes con insuficiencia renal o hepática y por lo tanto debe ser utilizado con cautela en tales pacientes.Las lentes de contacto deben Precauciones de apenas uno de los ojos, deben ser informados a respecto de esas reacciones. Pr ser retiradas antes de la instilación de LUMIGAN® (bimatoprost) y pueden ser recolocadas 15 minutos después. Los pacientes deben ser advertidos de que el producto contiene cloruro de benzalconio, que es absorvido por las lentes hidrofílicas.Si más que un medicamento de uso tópico ocular estuviera siendo utilizado, se debe respetar un intervalo de por lo menos 5 minutos entre las aplicaciones.No está previsto que LUMIGAN® (bimatoprost) presente influencia sobre la capacidad del paciente conducir vehículos u operar máquinas, sin embargo, así como para cualquier colírio, puede ocurrir visión borrosa transitoria después de la instilación; en estos casos el paciente debe aguardar que la visión se normalice antes de conducir u operar máquinas. Interacciones medicamentosas. medicamentosas.Considerando que las concentraciones circulantes sistemicas de bimatoprost son extremadamente bajas después múltiplas instilaciones oculares (menos de 0,2 ng/ml), y, que hay varias vías encimáticas envueltas en la biotransformación de bimatoprost, no son previstas interacciones medicamentosas en humanos. eacciones adversas. LUMIGAN® (bimatoprost) es bien tolerado, pudiendo causar eventos adversos oculares leves a moderados y no graves.Eventos adversos ocurriendo en 10-40% de los pacientes que recibieron doses únicas diarias, durante No son conocidas incompatibilidades. RReacciones 3 meses, en orden decreciente de incidencia fueron: hiperenia conjuntival, crecimento de las pestañas y prurito ocular.Eventos adversos ocurriendo en aproximadamente 3 a < 10% de los pacientes, en orden decreciente de incidencia, incluyeron: sequedad ocular, ardor ocular, sensación de cuerpo estraño en el ojo, dolor ocular y distúrbios de la visión.Eventos adversos ocurriendo en 1 a <3% de los pacientes fueron: cefalea, eritema de los párpados, pigmentación de la piel periocular, irritación ocular, secreción ocular, astenopia, conjuntivitis alérgica, lagrimeo, y fotofobia.En menos de 1% de los pacientes fueron relatadas: inflamación intra-ocular, mencionada como iritis y pigmentación del íris, ceratitis puntiforme superficial, alteración de las pruebas de función hepática e infecciones (principalmente resfriados e infecciones de las vías respiratorias).Con tratamientos de 6 meses de duración fueron observados, además de los eventos adversos relatados más arriba, en aproximadamente 1 a <3% de los pacientes, edema conjuntival, blefaritis y astenia. En tratamientos de asociación con betabloqueador, durante 6 meses, además de los eventos de más arriba, fueron observados en aproximadamente 1 a <3% de los pacientes, erosión de la córnea, y empeoramiento de la acuidad visual. En menos de 1% de los pacientes, blefarospasmo, depresión, retracción de los párpados, Posología y Administración. hemorragia retiniana y vértigo.La frecuencia y gravedad de los eventos adversos fueron relacionados a la dosis, y, en general, ocurrieron cuando la dosis recomendada no fue seguida.Posología Administración.Aplicar una gota en el ojo afectado, una vez al día, a la noche. La dosis no debe exceder a una dosis única diaria, pues fue demostrado que la administración más frecuente puede disminuir el efecto hipotensor sobre la hipertensión ocular.LUMIGAN® (bimatoprost) puede ser administrado concomitantemente con otros productos oftálmicos tópicos para reducir la hipertensión intra-ocular, respetándose el intervalo de por lo menos 5 minutos entre la administración de los medicamentos. VENTA BAJO PRESCRIPCIÓN MÉDICA.“ESTE PRODUCTO ES UM MEDICAMENTO NUEVO AUNQUE LAS INVESTIGACIONES HAYAN INDICADO EFICACIA Y SEGURIDAD, CUANDO CORRECTAMENTE INDICADO, PUEDEN SURGIR REACCIONES ADVERSAS NO PREVISTAS, AÚN NO DESCRIPTAS O CONOCIDAS, EN CASO DE SOSPECHA DE REACCIÓN ADVERSA, EL MÉDICO RESPONSABLE DEBE SER NOTIFICADO. 1. The AGIS Investigators: The Advanced Glaucoma Intervetion Study - The Relationship Between Control of Intraocular Pressure and Visual Field Deterioration. Am. J. Ophthalmol, 130 (4): 429-40, 2000. 2. Shirakashi, M. et al: Intraocular Pressure-Dependent Progression of Visual Field Loss in Advanced Primary Open-Angle Glaucoma: A 15-Year Follow-Up. Ophthalmologica, 207: 1-5, 1993. 3. Mao, LK; Stewart, WC; Shields, MB: Correlation Between Intraocular Pressure Control and Progressive Glaucomatous Damage in Primary Open-Angle Glaucoma. Am. J. Ophthalmol, 111: 51-55, 1991. 4. Higginbotham, EJ et al. One-Year Comparison of Bimatoprost with Timolol in Patients with Glaucoma or Ocular Hypertension. Presented at American Academy Ophthalmology, Nov 11-14, 2001. 5. Gandolfi, S et al. Three-Month Comparison of Bimatoprost and Latanoprost in Patients with Glaucoma and Ocular Hypertension. Adv. Ther, 18 (3): 110-121, 2001. 6. Coleman, AL et al: A 3-Month Comparison of Bimatoprost with Timolol/Dorzolamide in Patients with Glaucoma or Ocular Hypertension. Presented at American Acedemy of Ophthalmol, New Orleans, La, 2001.

Mejor comodidad posológica: 1 vez al día. No requiere refrigeración. Presentación conteniendo 3 ml.

June 2014, Vol. 13(2) Indexed Editor-in-Chief: Paulo Elias C. Dantas, MD Prof. of Ophthalmology Department of Ophthalmology Santa Casa of São Paulo, Brazil Vision Pan-America is also listed at the collection of the National Library of Medicine Catalog under the serial #101553235

Membership, Associations and Editorial Guidelines

Vision Pan-America (printed version ISSN 2219-4665, electronic version ISSN 2219-4673), the official publication of the Pan-American Association of Ophthalmology, is a quarterly fully peer reviewed scientific publication that publishes original research in Ophthalmology, including review articles on ophthalmic diseases and surgical techniques, clinical scientific studies, basic investigation, case reports, brief communications and letters to the editor in four languages: Spanish, English, Portuguese and French. In addition, the journal publishes critical reviews of new texts in ophthalmology deemed to be of importance to the Pan-American practitioner.

Section Editor, Cataracts: Nestor Gullo, MD (La Plata, Argentina)

Section Editor, Neurophthalmology: Karl Golnik, MD (Cincinnati, OH, USA)

Section Editor, Prevention of Blindness: Fernando R. Barría von Bischhoffshausen, MD (Concepción, Chile)

Section Editor, Oncology: Rubens N. Belfort, MD (São Paulo, Brazil)

Section Editor, Refractive Surgery: Luis Izquierdo Jr, MD (Lima, Peru)

Section Editor, Ophthalmic Section Editor, Eye Banking: Luciene Barbosa de Sousa, MD Plastics and Orbital Diseases: Chun Cheng Lin Yang, MD (São Paulo, Brazil) MSc (San José, Costa Rica) Section Editor, Genetics: Eduardo José Gil Duarte Silva, Section Editor, Pathology: MD (Figueira da Foz, Portugal) J. Oscar Croxatto, MD (Buenos Aires, Argentina) Section Editor, Glaucoma: Section Editor, Pediatric James C. Tsai, MD (New Ophthalmology and Strabismus: Haven, CT, USA) Maria Estela Arroyo Yllanes, MD (México City, México)

Section Editor, Retina and Vitreous: Mauricio Maia, MD (São Paulo, Brazil) Section Editor, Statistics and Epidemiology: Niro Kasahara, MD (São Paulo, Brazil) Section Editor, Uveitis and Immunology: Lourdes Arellanes-García, MD (Mexico City, Mexico)

Editorial Advisory Board

Editorial Review Board

Denise de Freitas, MD (São Paulo, Brazil)

Alejandro Lichtinger, MD (Toronto, Ontario, Canada)

Maria Audina Berrocal, MD (Miami, FL, USA)

Eduardo Alfonso, MD (Miami, FL, USA)

Ashley Behrens, MD (Riyadh, Saudi Arabia)

Daniel Weil, MD (Buenos Aires, Argentina)

Eduardo Arenas, MD (Bogotá, Colombia)

Ana Luisa Höfling-Lima (S o Paulo, Brazil)

Marian Macsai, MD (Chicago, IL, USA)

J. Fernando Arévalo, MD (Riyadh, Saudi Arabia)

Bruno Fontes, MD (Rio de Janeiro, Brazil)

Marie Eve Legare, MD (Quebec City, Canada)

Alfredo Sadun, MD (Los Angeles, CA, USA)

Carol L. Karp, MD (Miami, FL, USA)

Natalio Izquierdo, MD (San Juan, Puerto Rico)

Enrique Graue-Hernández, MD (Mexico City, Mexico)

Peter Quiros, MD (Los Angeles, CA, USA)

Eugenio Maul de La Puente (Santiago, Chile)

Renato Ambrósio Jr. (Rio de Janeiro, Brazil)

3TouchMedia strategy

Follow us on Facebook and Twitter

Administrative Editorial Council: Ana Luisa Hofling-Lima,MD (PAAO President.), Mark Mannis, MD (PAAO Imediate Past-President, Sacramento, CA, USA.) and William De La Peña, MD (PAOF Chairman, Montebello, CA, USA)

Section Editor

Section Editor, Cornea and External Disease: Allan R. Slomovic, MD (Ontario, Canada)

Aims and scope:

Associate Editor-in-Chief: Lihteh Wu, MD (San José, Costa Rica)

marketing

communication

Pan-American Association of Ophthalmology

Ivan Schwab, MD (Sacramento, CA, USA)

@paao_vision Office Staff

F Pan-American Association of Ophthalmology (PAAO) Pan-American Ophthalmological Foundation (PAOF) 1301 S Bowen Road #450, Arlington TX 76013 USA Tel: (817) 275-7553 • Fax: (817) 275-3961 Email: info@paao.org • www.paao.org

Managing Editor Teresa Bradshaw (Arlington, TX, USA)

Production Editor Mapy Padilla (Lima, Peru)

PAOF INDUSTRY SPONSORS Abbott Medical Optics Inc. Alcon Inc. Allergan Inc.

3TouchMedia strategy

CREATIVE LATIN MEDIA, LLC. 2901 Clint Moore PMB. 117 Boca Raton FL. 33496 USA Tel: (561) 443 7192 Fax: (561) 443 7196 Atención al cliente: E-mail: suscripciones@clatinmedia.com

Production Editor Terri Grassi (Arlington, TX, USA)

marketing

communication

Bausch Lomb Inc. Johnson Johnson Vision Care Latin America

Oculus GmbH Oculus Surgical Rayner Intraocular Lenses Ltd. Merck

Co Inc.

Producida / Editada / Diseñada / Distribuida por: 3 Touch Media S.A.S.

Printed in Printer Colombiana S.A. – Colombia PAN-AMERICA

PAAO EXECUTIVE COMMITTEE 2013-2015 President Ana Luisa Höfling Lima, MD

Secretary, English Language Region James C. Tsai, MD MBA

Secretary, Spanish Language Region Lihteh Wu, MD

Associate Secretary, English Language Region Carol L. Karp, MD

Associate Secretary, Spanish Language Region Jorge E. Valdez, MD MA

Vice President José Antonio Roca, MD

Secretary, Portuguese Language Region Paulo E. C. Dantas, MD

Executive Director Teresa J. Bradshaw

Executive Vice President J. Fernando Arévalo, MD FACS

Associate Secretary, Portuguese Language Region Maurício Maia, MD

President Elect Eduardo C. Alfonso, MD Past President Mark J. Mannis, MD

PAOF BOARD Chairman of the Board William De La Peña, MD Past Chair Mr. Nelson Marques Vice Chair Mark J. Mannis, MD Secretary-Treasurer Liana Ventura, MD Executive Director Teresa J. Bradshaw

PAAO BOARD OF DIRECTORS 2013-2015 ARGENTINA Carlos Ignacio Zeolite MD1 Enrique S. Malbrán Sr. MD2 Ernesto Ferrer Abad MD1,3 Gustavo Federico Bodino MD1 Javier Fernando Casiraghi MD1 Joaquín Alfredo Bafalluy, MD1 Juan Oscar Croxatto, MD4 Pablo Luis Daponte MD1

DOMINICAN REPUBLIC Delfina Ortiz, MD4 Jaime A. Núñez Guerra, MD1,3 Juan Francisco Batlle Pichardo, MD1

BOLIVIA Carlos Walter Arzabe A., MD1,3 Gustavo Aguirre Urquizu, MD1

EL SALVADOR Emmanuel Jesús Salvador Mena Méndez, MD1,3

SPAIN José A. Cristóbal Bescos MD1 Luis Fernández Vega, MD3 Miguel A. Zato Gómez de Liaño MD PhD1

GUATEMALA Byron Polanco, MD4 Cristián Rolando Acevedo Campos, MD1 Paulina Castejón, MD1,3

URUGUAY Alicia Martínez de Pacheco, MD1 Andrea Fernández López MD1 Martín Sánchez, MD3

HAITI Frantz Large, MD1,3

USA Alice R. McPherson, MD2 Arun D. Singh, MD4 Bradley R. Straatsma MD JD2 Cynthia Ann Bradford MD1 Daniel J. Briceland MD1 J. Bronwyn Bateman, MD2 Gregory Skuta, MD3 Lynn D. Anderson, PhD4 Lynn K. Gordon MD PhD1 Mark J. Mannis, MD2 Mildred M.G. Olivier MD1 Paul R. Lichter MD2 Paul Sternberg MD3 Peter A. Quiros MD1 R.V. Paul Chan, MD1 Richard L. Abbott MD2 Robert C. Drews MD2 Robert Weinreb, MD4 Victor L. Pérez, MD1 Zélia Correa, MD PhD1

BRAZIL André Correa de Oliveira Romano, MD1 Bruno Machado Fontes, MD PhD1 Eduardo Büchele Rodrigues MD1 José Alvaro P. Gomes, MD4 Luciene Barbosa De Sousa, MD1,4 Marcus Vinicius Abbud Safady, MD1 Milton Ruiz Alves, MD1,3 Rubens Belfort Jr., MD PhD2 Sergio Felberg, MD1 Vinícius Coral Ghanem, MD1 CANADA Allan R. Slomovic MA MD FRCS(C)1 Paul E. Rafuse, MD PhD FRCS(C)1,3 CHILE Alejandro Vázquez de Kartzow, MD4 Cristián Luco, MD2 Fernando R. Barría von B., MD4 Gonzalo Vargas Díaz, MD1 Juan Verdaguer Taradella, MD2 Rodigo Vidal Sobarzo, MD1 Verónica Azócar G., MD3 Verónica Fernández Salgado, MD4 COLOMBIA Alvaro Rodríguez González, MD2 Angela María Fernández Delgado, MD1,4 Angela María Gutiérrez Marín, MD1 Carlos Alberto Restrepo Pelaez, MD1,3 Hugo Hernán Ocampo Domínguez, MD1,4 José Ramiro Prada Reyes MD1 Pedro Ivan Navarro Naranjo MD1 Roberto Baquero H., MD1 COSTA RICA Claudio Orlich Dundorf, MD3 Joaquín Martínez Arguedas, MD1 Teodoro Evans MD1 CUBA Armando Capote Cabrera, MD3 Beatriz N. Rodríguez Rodríguez, MD1 Ibrain Piloto Díaz, MD1

ECUADOR Luis Sarrazin Moreira, MD3 Mario Pólit Macias, MD1 Robin Alberto Ríos Arreaga, MD1

HONDURAS Eduardo José Flores Sauceda MD1 Erwin Ochoa, MD1,3 MEXICO Anselmo Fonte Vázquez, MD1 Cecilio Francisco Velasco Barona, MD4 Eduardo Chávez Mondragón, MD4 Enrique Graue Hernández, MD1 Enrique L. Graue Wiechers, MD2 Francisco Martínez Castro, MD1 Lourdes Arellanes García, MD4 María Elena Morales Gómez, MD1 Oscar Baca Lozada, MD1 Sergio Rojas Juárez1 Valeria Sánchez Huerta, MD1 NICARAGUA Marcelo Figueroa Bravo, MD1,3 PANAMA Benjamín F. Boyd MD2 Félix Emilio Ruiz Díaz, MD3 Samuel Boyd Lewis MD1 PARAGUAY Pablo Rubén Cibils Farrés, MD1 Walter Timcke Holst, MD1,3 PERU Dino Fernando Natteri Marmol, MD1 Francisco Contreras Campos MD2 José Antonio Roca Fernández, MD3 Juan Carlos Corbera Gonzalo, MD1 Juan Fernando Mendiola Solari, MD1 Miguel Guzmán Ahumada, MD1 Rocío Ardito Vega MD1

PORTUGAL Eduardo José Gil Duarte Silva MD PhD1 Paulo F. de Ancede Aires S Torres, MD PhD1,3 PUERTO RICO Héctor Villarrubia, MD1,3 María Berrocal, MD1,4

VENEZUELA Claudia Luz Pabón Bejarano, MD1 Fernando L. Colombo Rengel, MD4 José Luis Rincón Rosales, MD1 María Angélica Cortez Bernal, MD1 Morayma Acevedo Sorondo, MD3 Oscar Vicente Beaujón Balbi, MD1 WEST INDIES Lizette Mowatt, MB BS MMedSci1,3 Sonja E. Johnston BSc MB BS FRCS1

Delegate PAAO Past President 3 President, Affiliated National Society 4 President, Affiliated Subspecialty Society

1

2

EDITORIAL

Editorial Paulo E.C. Dantas, MD Editor-in-Chief

Volunteerism By definition, volunteerism is the policy or practice of volunteering one’s time or talents for charitable, educational, or other worthwhile activities, especially in one’s community. The Oxford Dictionary defines volunteerism as the use or involvement of volunteer labor, especially in community services. Formal volunteering is an activity that takes place in not for profit organizations or projects and is undertaken to be of benefit to the community, on the volunteer’s own free will, without coercion and for no financial payment. This short introduction is necessary to try to explain how the Pan-American Association of Ophthalmology and the Pan-American of Ophthalmology Foundation works in all instances, including Vision Pan-America Editorial Committee. It is frequent, even at home, to hear things like “How much do you earn working so hard for PAAO?” or “Are you getting paid by PAAO?” or even “You are traveling too much. Hope PAAO is paying your expenses!” and other pearls. The truth is that ALL medical members of the PAAO Executive Committee, the PAOF Board of Directors and from the Editorial Board, as well as the respective members of the Board of Directors volunteer their time and knowledge to our association without financial payment of any expenses. To be brief: our work is unpaid! We donate time and knowledge to benefit our community as a matter of personal choice to address human, social and scientific needs of our Association.

We work actively to accomplish the mission of the PAAO that is to offer continuing education for ophthalmologists, to establish and coordinate politics for prevention of blindness and promotion of scientific and cultural exchange among ophthalmologists of the Western Hemisphere and beyond. As a matter of fact, the PAAO provides a forum for professionals from all over the world to meet and focus on ways to standardize and improve ophthalmic knowledge and skills for the improvement of patient care. This, of course, does not mean to say that we do not get some benefits. Yes, we all like international recognition, praised our increased networking and friendship with colleagues from around the world. We all believe that it is a privilege and honor working for our community. We all believe that our work is a legitimate way in which citizens can be involved in the activities of their community and we certainly stimulate colleagues to work with us and our association. Volunteer yourself! Join us at www.paao.org Best regards

Paulo E.C. Dantas, M.D. Editor-in-Chief Vision Pan-America, The Pan-American Journal of Ophthalmology pauloecdantas@uol.com.br pauloecdantas@me.com

PAN-AMERICA

35

Vis. Pan-Am. 2014;13(2):36

Message from the President Ana Luisa Hofling-Lima President of the Pan- American Association of Ophthalmology 2013-2015

Twelve years of the Pan-American Research Day â&#x20AC;&#x201C; PARD at ARVO Twelve years ago, Rubens Belfort Jr, PAAO pastpresident, noticing that so many fellows, residents and ophthalmologists from Latin America and related to the Pan-American Association were coming to ARVO to present a scientific poster, found the perfect opportunity to create a forum for oral presentations and discussions of their research in a special environment. Pan American Research Day (PARD) was created, starting one day before ARVO begins. In this meeting, young ophthalmologists and researchers, mostly from Spanish or Portuguese speaking countries, are selected and invited to participate in an oral presentation in a meeting that has been sponsored exclusively by Allergan since its creation. Rubens coordinated this event until 2009. Since 2010, Paulo Dantas, Editor-in-Chief of Vision PanAmerican and Secretary for Portuguese Language, took over and has been the main coordinator with the help of the organizing committee (Peter Quiros, Fernando Arevalo, Lihteh Wu, Mauricio Maia, Luis Isquierdo, Jorge Valdez, Carol L. Karp, Eduardo Arenas and JosĂŠ Antonio Roca) and the always valuable help of Teresa Bradshaw and Terri Grassi. In recent years, the number of requests for presentation increased so much that it was necessary to

36

PAN-AMERICA

divide the event in two conference rooms: one for retina, uveitis ophthalmic exams and the other for cataract, cornea, refractive surgery and glaucoma. None of the presenters had conflicts of interest with the sponsor, which has been providing infrastructure for the meeting. At the end of the event, an award ceremony is held to recognize the best papers presented and to hand the travel awards. It is important to emphasize that in order to participate, the research needs to be accepted by ARVO in the current year. It is very important also to recognize that, for twelve years, the Pan-American Association, through her staff, coordinates all information about the meeting, Our plan is to continue and improve the event with the partnership that we developed with Allergan. We can expect always a better meeting each year!

Ana Luisa Hofling-Lima MD President of the Pan- American Association of Ophthalmology 2013-2015

Savar L et al. Management of lacrimal obstruction

Management of epiphora and lacrimal obstruction in adults Louis Savar, MD1,2, Stuart R. Seiff, MD, FACS1,2, Angela Maria Dolmetsch, MD3

Corresponding author address:

1. Department of Ophthalmology, University of California, San Francisco, San Francisco, California.

Stuart R. Seiff, MD, FACS 2100 Webster Street, suite 214 San Francisco, CA 94115 Phone: 415-923-3007 Email: sseiff@sfgh.ucsf.edu

2. Department of Ophthalmology, California Pacific Medical Center, San Francisco, California. 3. Clinica de OftalmologĂ­a de Cali, Universidad del Valle, Cali, Colombia. Funding: None

Date of submission: 24/03/2014 Date of approval: 16/04/2014

Proprietary/financial interest: None

ABSTRACT

While tearing patients have similar complaints, the etiology of their symptoms may vary widely and thus require a meticulous evaluation. A thorough history followed by systematic examination of the lids, ocular surface, anterior segment, and lacrimal system will lead the clinician to the proper diagnosis. Treatment options for lacrimal obstruction are varied and as surgical techniques continue to evolve, new studies are indicated to determine the approaches that provide the most successful outcomes while ensuring patient safety. Key words: Tears; Epiphora; Lacrimal obstruction; Dacryocystorhinostomy

INTRODUCTION

The tearing patient commonly presents to the office of an oculofacial plastic surgeon. In order to make the proper treatment decision, a thorough understanding of the physiology of tear production and drainage is necessary.1 A methodical approach to these patients is critical.

EVALUATION

Before the patient is examined, key points of the history should be collected which may lead to the correct diagnosis. It is important to determine if tearing is intermittent or constant, unilateral or bilateral, associated with irritation or allergy, and any history of trauma or surgery.

Figure 1. Lower lid ectropion

PAN-AMERICA

37

REVIEW / Vis. Pan-Am. 2014;13(2):37-43

In addition, medication history should be reviewed.2,3 Constant tearing that runs down the patientâ&#x20AC;&#x2122;s face is highly suspicious for an obstruction, whereas intermittent tearing with irritation is more likely due to ocular surface abnormalities. After a complete history is taken, a full ophthalmic evaluation is performed. Particular attention must be paid to facial and trigeminal nerve function, ocular motility, palpation of the lacrimal sac, lid position, and the anterior segment. Next, testing is used to demonstrate evidence of abnormal tear production. This includes examination of the tear film, ocular surface, and tear production studies such as the Schirmer and basal tear production tests. If no evidence exists for reflex tearing, further testing includes probing and irrigation of the lacrimal drainage system in order to demonstrate patency or obstruction of the outflow passages. Treatments are based on the findings of this algorithmic approach to the patient with epiphora. Physical examination begins with the face as a whole. Orbicularis weakness, for example, in the setting of facial nerve palsy, may lead to a poor blink reflex, lagophthalmos, and lower lid ectropion (Figure 1). Each of these entities leads to exposure of the ocular surface and increased reflex tearing. Poor lid position also disrupts the natural pathway for tears to enter the lacrimal drainage system as well as its pump function.4 Ectropion may also be seen in patients with floppy eyelid syndrome, involutional lid laxity, anterior lamellar shortening from cicatricial processes, mechanical deformity, and less frequently, congenital malformations. Careful slit lamp examination to rule out trichiasis, blepharitis, conjunctivitis, keratopathy or any evidence of intraocular inflammation is crucial before considering a diagnosis of lacrimal obstruction as the cause of epiphora. Evaluation of the tear lake may demonstrate an abnormally high or low tear meniscus. Evaluation of the punctum may reveal ectropion, stenosis or even atresia. An inflamed punctum may indicate canaliculitis, which is typically associated with chronic discharge and recurrent swelling of the lids. Palpation of the lacrimal sac may demonstrate tenderness, reflux, or mass, which may

38

PAN-AMERICA

be associated with nasolacrimal duct obstruction, dacryocystitis, mucocele, dacryolith, or neoplasm. Paradoxically, inadequate and abnormal tear production are the most common causes of tearing. This may be part of the Dysfunctional Tear Syndrome (DTS).5 In this syndrome, there is an abnormality of several aspects of tear production including the lipid (Meibomian and Zeis glands), aqueous (Krauss, Wolfring, and main glands), and mucinous (goblet cells) components. A distinction may be made between abnormalities of the anterior and posterior lamellae. Chronic irritation of the anterior lid margin, with associated crusting and lash loss (cilliary madarosis) is often due to seborrheic dermatitis, staphylococcal overgrowth and even demodex infection. Involvement of the posterior lamella, referred to as Meibomian gland dysfunction, is typically seen as increased lipid production, glandular obstruction, and glandular infection (meibomitis). This is all accentuated by an inadequate production of aqueous tear lysozyme, which typically produces an antimicrobial effect for the ocular surface. Thus, a situation of cycling infection and irritation is produced. These conditions are worse in the setting of underlying seborrhea or acne rosacea. Much of this can be identified by careful slit lamp evaluation of the lid margins and ocular surface. Poor production of mucin and lipid can be identified by a rapid corneal tear break up time. Further, in the absence of adequate aqueous tears, there may be overproduction of mucus (mucus stranding) and lipid (oily tear film). There are several tests to help identify inadequate aqueous tear production.6 The Schirmer I test may be performed by wiping away excess lower fornix fluid, and placing a Schirmer strip into the lower fornix and draping the filter paper over the lower lid margin (Figure 2). After 5 minutes, a measurement of <10 mm on the strip is considered indicative of decreased basal tear production. Measurements of <5 mm are commonly seen in the setting of keratoconjunctivitis sicca. In patients with hypersecretion, such as those with crocodile tear syndrome after facial

Savar L et al. Management of lacrimal obstruction

palsy, measurements >30 mm are common. However, due to variability of response to the irritation from the paper strips in the fornix, results of the Schirmer I are extremely variable. This potential irritation can be minimized by placing a drop of topical anesthetic, such as 0.5% proparacaine. This reduces the sensation and theoretically gives a better indication of base line tear production. Thus, this modification of the Schirmer I is termed the Basal Secretion Test. When extremely poor tear production is suspected, such as in Sjögren’s Syndrome, a Schirmer II test may be performed in an effort to see if any tears can be produced in a situation of “maximal” irritation. In this test, the paper strips are placed in the inferior fornix without anesthetic and the nasal mucosa is irritated with a swab. The goal here is typically to see if any tears can be produced in the setting of severe “dry eyes.” The lacrimal outflow system can be evaluated in a simple fashion with the dye disappearance test. Here, a drop of fluorescein is placed in the inferior fornix of both eyes. After 5 minutes, if residual yellow dye is present, there may be poor lacrimal outflow. Further information may be gathered by comparing the two sides in a case of asymmetric tearing. The side with more retained dye is more likely to have poor outflow.

Figure 2. Schirmer testing

PAN-AMERICA

39

REVIEW / Vis. Pan-Am. 2014;13(2):37-43

Figure 3. External dacryocystorhinostomy Probing and irrigation is the definitive test for obstruction within the lacrimal drainage apparatus. In order for the test to be useful it must be done in a systematic manner.7 First, a drop of topical anesthetic is placed in the fornix. A punctal dilator is then inserted vertically into the punctum approximately 2 mm and turned 90 degrees along the plane of the lid and advanced toward the medial canthal tendon. It is important to avoid using excessive force as this could inadvertently create a false passage. A 23-gauge cannula on a glass syringe filled with saline solution is then introduced into the canalicular system in the same fashion as the dilator, while placing lateral horizontal traction on the lid. The cannula should pass with minimal resistance until a â&#x20AC;&#x153;hard stopâ&#x20AC;? is felt, indicating the cannula has reached the bony wall of the lacrimal sac fossa. If a soft stop is felt, this may indicate the presence of stenosis or obstruction proximally within the canaliculus or in the lacrimal sac. The syringe is then pulled back approximately 1-2 mm and gently emptied. The patient should feel fluid enter the nasopharynx. This indicates that the outflow system is generally patent, but does not rule out a functional obstruction of the nasolacrimal duct.7 If no fluid passes into the nasopharynx, there is a complete nasolacrimal drainage system obstruction.

40

PAN-AMERICA

Canalicular reflux is generally not of diagnostic significance. During syringing, a canalicular blockage may also be identified that may account for the epiphora. If there is tearing in the presence of a system open to irrigation, Jones testing is indicated. In this case, 2% fluorescein dye is instilled in the conjunctival cul de sac. Five minutes is allowed to pass and the region under the inferior turbinate in the nose is inspected for evidence of the dye. If dye is found (Positive Jones 1 test), this means the drainage system is open and hypersecretion may be present due to ocular surface disease or aberrant regeneration, such as is seen with crocodile tears. If no dye is recovered, the test is negative and we proceed to the Jones 2 test. Here, the system is irrigated after the negative Jones I test, as above, with saline, and the nose again inspected for evidence of dye. If dye is identified (positive Jones 2), this indicates that dye entered the sac, but could not pass inferiorly. This identifies a functional nasolacrimal duct obstruction. If no dye is found (negative Jones 2), then the dye could not enter the open sac and duct due to a failure of the lacrimal pump (eg lid laxity), or a punctal abnormality, such as ectropion.

TREATMENT

Treatment of tearing is thus targeted at the specific cause determined by

Savar L et al. Management of lacrimal obstruction

this stepwise approach. Ocular surface disease and anterior segment inflammation are treated as necessary. This may require the use of topical lubricants, antibiotics and/or steroids. Lid position abnormalities are corrected. Depending on the type of ectropion, repair may be carried out via lid tightening, skin grafting and/or midface lifting procedures. Punctal ectropion may be corrected via a medial conjunctivoplasty, also referred to as a medial spindle technique. Lagophthalmos may require lid loading such as a gold weight to treat ocular exposure. Lacrimal hypersecretion has been successfully treated with botulinum toxin.8 Lacrimal obstruction is a surgical disease and the location of the obstruction within the lacrimal drainage system dictates the treatment modality. Complete nasolacrimal duct obstruction, commonly seen after dacryocystitis, is treated via dacryocystorhinostomy (DCR)- creation of a new connection between the lacrimal sac and the nasal cavity. Common techniques include an external or endonasal approach with or without endoscopy. Preparation for either of these techniques includes general anesthesia or conscious sedation, with local anesthetic injected into the medial lids around the canaliculi, medial canthal area, and nasal mucosa around the lateral wall and middle turbinate. Additionally, neurosurgical pledgets soaked in cocaine 4% (or a 50/50 mixture of 4% lidocaine and oxymetazoline 0.05%) are packed under the middle turbinate in the middle meatus. When approaching the DCR externally, a vertical skin incision is made between the medial canthus and nasal bridge after local anesthetic has been injected in the area. Some prefer to make the incision slightly more inferiorly along the tear trough to help conceal any future scar. The periosteum is opened and then carried to the anterior lacrimal crest. A Freer elevator is used to elevate the lacrimal sac from the fossa. The lacrimal bone is then fractured using the elevator or a curved hemostat. The osteotomy is then enlarged anteriorly using a bone punch and rongeurs to approximately 15mm in diameter, taking care not to traumatize the underlying nasal mucosa. A Bowman probe is then introduced into the canaliculus and used to tent the lacrimal sac, which is incised along its length (Figure 3). Posterior and anterior flaps are fashioned by making a perpendicular cut at each end. A portion of the posterior sac may be submitted for pathologic evaluation, as well as any fluid or stone within the sac. A U shaped incision is made in the nasal mucosa. A silicone stent may then be passed through the superior and inferior canaliculi and externalized at the incision site. The two ends of the silicone are tied with several knots taking care not to place excessive tension on the puncta. Many surgeons are not using stents in the absence of canalicular disease. The nasal packing is removed and a curved hemostat is used to pull the ends of the tube out of the nostril. The ends are trimmed and allowed to retract back into the nasal cavity. The anterior mucosal flaps are then sutured to each

PAN-AMERICA

41

REVIEW / Vis. Pan-Am. 2014;13(2):37-43

Figure 4. DacriocistorrinostomĂ­a con endoscopia

Figure 4. Endoscopic dacryocystorhinostomy

42

PAN-AMERICA

other, thereby completing the mucosal anastomosis, followed by a layered closure of muscle and skin. The endonasal approach may be considered for various reasons including failed external DCR, and patient or surgeon preference. It has several advantages over the external approach including avoidance of a scar, shorter postoperative period, preservation of the medial canthal structures and a shorter surgical time. The technique is contraindicated in cases of suspected lacrimal tumor or stone, patients with complex anatomy, or implants after trauma. A 20 gauge disposable vitrectomy

light pipe is introduced through the canaliculus and used to transilluminate the lacrimal bone to ensure proper location of the incision. The nasal packing is then removed and a crescent blade is used to incise the nasal mucosa just anterior to the base of the middle turbinate, corresponding to the location of the lacrimal sac fossa. The mucosa is reflected back with an elevator and an osteotomy is created, the lacrimal sac is tented using a probe and then incised (Figure 4). A silicone stent is passed through the canaliculi and the ends secured, again making sure not to place excessive tension on the puncta. Mitomycin

Savar L et al. Management of lacrimal obstruction

C placed on a pledget at the osteotomy site may be used to help prevent reobstruction and scarring.9 In either approach, patients are typically treated with a course of topical combination antibiotic and steroid eye drops and intranasal steroid spray. The silicone tube is usually removed between 6 weeks to 6 months postoperatively. A recent meta-analysis including five randomized controlled trials and four cohort studies found no benefit with silicone intubation in primary DCR cases even though most surgeons still intubate at the time of DCR.10 A recent survey of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery found that the majority of respondents perform more external than endonasal DCRs, although success rates in the literature vary, ranging from 65-100% and 68-98% for external and endonasal, respectively.11,12 In cases of lacrimal obstruction within the canaliculus, a DCR will not be sufficient. If a canalicular obstruction is focal, reconstruction may be an option whereby the obstruction is excised and the canaliculus is reanastamosed over a stent, or a trephine is passed through the obstruction, followed by nasolacrimal duct intubation to prevent recurrence of scar formation. Canalicular reconstruction is not always possible, in which case a lacrimal bypass must be created.13 The conjunctivodacryocystorhinostomy procedure creates a direct connection between the medial fornix and the nasal cavity. A DCR ostium is created as described above, if not already present from prior surgery. Then a passage is created from the medial conjunctival cul de sac into the DCR passage, posterior to the caruncle. This is typically done with a trephine. Then a Jones tube, made of Pyrex glass, is passed over a guide angling inferiorly through the ostium into the nasal cavity. Correct tube position and length are critical for proper function. In some cases the anterior portion of the middle turbinate may be excised or a septoplasty performed to allow enough room for the tube to enter the nasal cavity without obstruction. The tube is then secured in place with an

absorbable suture in the conjunctiva. In cases where the above evaluation suggests that a functional outflow obstruction may be the cause for epiphora, silicone intubation of the lacrimal system has been shown to be effective.7 Canaliculitis that does not resolve with a course of topical antibiotic and steroid may require canalicular curettage, removal of debris or stones, and intubation.

"La versión completa de este artículo en Español está disponible gratuitamente en www.paao.org o en http://journals.sfu.ca/paao/ "

REFERENCES 1.

2.

3.

4. 5.

6.

7.

8.

9.

10.

11.

12.

13.

Jones LT. The lacrimal apparatus: practical fundamentals of anatomy and physiology. Trans Am Acad Ophthalmol Otolaryngol 1958;62:669 –78. Seiff SR, Shorr N, Adams T. Surgical treatment of punctalcanalicular fibrosis from 5-fluorouracil therapy. Cancer 1985;56:2148-2149. Esmaeli B, Valero V, Ahmadi MA et al. Canalicular Stenosis Secondary to Docetaxel (Taxotere). Ophthalmology 2001;108:994-995. Becker BB. Tricompartment model of the lacrimal pump mechanism. Ophthalmology 1992;99:1139 – 45. Behrens A, Doyle JJ, Stern L et al. Dysfuntional tear syndrome: a Delphi approach to treatment recommendations. Cornea 2006;25:900-7. Espinoza GM, Israel H, Holds JB. Survey of oculoplastic surgeons regarding clinical use of tear production tests. Ophthal Plast Reconstr Surg 2009;25:197-200. Moscato EE, Dolmetsch AM, Silkiss RZ, Seiff SR. Silicone intubation for the treatment of epiphora in adults with presumed functional nasolacrimal duct obstruction. Ophtal Plast Reconstr Surg 2012;28:35-39. Montoya FJ, Riddell CE, Caesar R, Hague S. Treatment of gustatory hyperlacrimation (crocodile tears) with injection of botulinum toxin into the lacrimal gland. Eye 2002;16:705-9. Dolmetsch AM: NonLaser endoscopic endonasal dacryocystohinostomy with adjunctive mitomycin C in nasolacrimal duct obstruction in adults. Ophthalmology 2010;117(5):1037-40. Feng YF, Cai JQ, Zhang JY, Han XH. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011;46:521-7. Barmettler A, Erlich J, Lelli G. Current preferences and reported success rates in dacryocystorhinostomy amongst ASOPRS members. Orbit 2013;32:20-6. Karim R, Ghabrial R, Lynch TF, Tang B. A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Steinsapir KD, Glatt HJ, Putterman AM. A 16 year study of conjunctival dacryocystorhinostomy. Am J Ophthalmol 1990;109:387-93.

PAN-AMERICA

43

CLINICAL SCIENCES / Vis. Pan-Am. 2014;13(2):44-52

Therapeutic outcomes in patients with post-traumatic strabismus from a tertiary center in Chile Luis Alberto Suazo, MD1, Paulina Liberman, MD2, Fuad Gauro, MD2, Mario T. Zanolli, MD3 1. Unidad de Trauma Ocular, Hospital del Salvador, Santiago – Chile 2. Facultad de Medicina, Universidad de Chile, Santiago – Chile 3. Departamento de Oftalmología Pediátrica y Estrabismo, Hospital Padre Hurtado, Santiago - Chile Funding: None

Corresponding author: Luis A. Suazo MD Departamento de Oftalmología y Estrabismo, Hospital San Juan de Dios Huérfanos 3355, Santiago Centro. Santiago (Chile). E-mail: somostres@vtr.net Telephone number: +56 9 9863 7218

Date of submission: 27/04/2014 Date of approval: 10/05/2014

Proprietary/financial interest: None

Abstract

Purpose: Strabismus (heterotropia) is one of several possible complications of ocular traumatic injury. This condition is associated with a decreased quality of life. The purpose of this study is to report the functional outcomes of a series of 35 patients presenting with strabismus secondary to eye trauma. Methodology: Retrospective study. Treatments for each type of post-traumatic ocular lesion were categorized, which included conservative management by clinical observation; use of a lens with prismatic addition; intramuscular injection of botulinum toxin; or surgery. Strabismus conditions were evaluated prior to the treatment and six months after the last treatment had been received. The rate of therapeutic success, defined as ±10 PD (prism diopters) was assessed. Results: The orbital injuries that most commonly caused strabismus were found to be orbital fracture, penetrating eye injury and direct muscle trauma. All cases of direct muscle trauma received surgical treatment; 54% of orbital fractures resolved spontaneously during clinical observation, whereas 38% required surgery. Three cases of penetrating eye injury were observed and three were treated surgically. The rate of therapeutic success was 88.57%. A single treatment was sufficient for 88.6% of all cases. Conclusions: Non-surgical therapeutic

44

PAN-AMERICA

clinical observation is sufficient in a significant percentage of cases because a large number of patients tend to spontaneous recovery. Additional techniques, such as treatment with botulinum toxin, can have a useful complementary role. Surgical intervention, assessed on a case by case basis, also turned out to be highly effective in the minority of cases where it was required. Keywords: Diplopia; Strabismus; Ocular traumatic injury, Botox, Trauma

Introduction

Surgical treatment is a good option in selected cases of orbital fractures1 and globe rupture2, both consequences of orbital trauma. In addition, there are reports associated with the clinical management of ocular muscle section’s cases secondary to ocular trauma3,4 In fact, it has been reported that 82% of all traumatic strabismus evolve towards spontaneous resolution without requiring surgical resolution5. However, strabismus and diplopia are common sequels of orbital trauma6 and there are few descriptive studies concerning therapeutic management conducted in groups of patients with traumatic strabismus. In Chile, cases of serious eye trauma are covered by Law 19.966 which warranties that all such patients must be referred to the Ocular Trauma Unit of Hospital del Salvador. These conditions create a unique opportunity to describe the routine clinical

Suazo LA et al. Outcomes in post-traumatic strabismus

Table 1. Demographic characteristics of the sample and characteristics of post-traumatic ocular lesions Demographic characteristics of the sample Mean

Range

31.31

2-60

N

%

Male

29

82.9

Female

6

17.1

Age Gender

Location of Residence Urban

32

91.4

Rural

3

8.6

Aggression

20

57.1

Fall

6

17.1

Traffic Accident

5

14.3

Other

4

11.4

Orbital Fracture

13

37.1

Penetrating eye injury

6

17.1

Blunt trauma

6

17.1

Direct muscle trauma

5

14.3

Other

2

5.7

Penetrating eye injury and orbital fracture

2

5.7

Blunt trauma and orbital fracture

1

2.9

Paralytic

24

68.6

Restrictive

9

25.7

Paralytic and restrictive

2

5.7

Right eye

21

60.0

Left eye

14

40.0

Cause of trauma

Type of lesion

Type of Strabismus

Eye involvement

Vertical ocular alignment in first evaluation Normal

17

48.6

Hypertropia and hypotropia

18

51.4

Horizontal ocular alignment in first evaluation Normal

8

22.9

Esotropia

13

37.1

Exotropia

14

40.0

PAN-AMERICA

45

CLINICAL SCIENCES / Vis. Pan-Am. 2014;13(2):44-52

Table 2. Therapeutic management according to type of lesion. We present the type of lesion associated with post-traumatic strabismus. For each group we describe the frequency of the therapeutic decisions adopted. Type of lesion

Observation

Lens

Botulinum toxin

Surgery

Total

n

%

n

%

n

%

n

%

n

Penetrating eye injury

3

50.0%

0

0.0%

0

0.0%

3

50.0%

6

Orbital fracture

7

53.8%

1

7.7%

0

0.0%

5

38.5%

13

Direct muscle trauma

0

0.0%

0

0.0%

0

0.0%

5

100.0%

5

Blunt trauma

5

83.3%

0

0.0%

1

16.7%

0

0.0%

6

Other

1

50.0%

0

0.0%

0

0.0%

1

50.0%

2

Penetrating eye injury and orbital fracture

0

0.0%

1

50.0%

0

0.0%

1

50.0%

2

Blunt trauma and orbital fracture

1

100.0%

0

0.0%

0

0.0%

0

0.0%

1

management of patients with strabismus associated with trauma. It is also a privileged position to describe the variety of possible treatments according to specific damage resulting from ocular trauma. In this paper, we illustrate the clinical management carried out in the Ocular Trauma Unit of Hospital del Salvador. The aim is to describe the therapeutic management conducted in different cases of traumatic strabismus, according to specific injury, and analyze the objective results per treatment.

Materials and Methods

We designed a retrospective study based on a random series of 35 patients evaluated and treated for traumatic strabismus in the Ocular Trauma Unit of el Hospital del Salvador between the years 2009 and 2013. The study was conducted in accordance with the principles of the Declaration of Helsinki7, and it was evaluated and approved by the ethical committee of Hospital del Salvador. An initial characterization of the sample was achieved based on a socio-demographic profile, which considers age, gender and place of residence. In each case, the cause of the ocular trauma was identified and specific lesions associated with the development of strabismus noted. The cases were classified

46

PAN-AMERICA

according to two types of strabismus: paralytic -which include both neurological and muscular section- or restrictive. Laterality of the affected eye and a description of ocular alignment (both vertical and horizontal) at the time of first evaluation were also registered. We evaluated the treatments chosen for each post-traumatic ocular lesion which could belong to one of following: conservative management by clinical observation and use of an eye patch to avoid diplopia; use of a lens with prismatic addition; intramuscular injection of botulinum toxin; or surgery. The sample was split into two groups: patients who received only one treatment and patients who had received more than one treatment. Each one of these groups was subdivided depending on the type of treatment. The values of the sensorial and motor study were assessed in prism diopters and were obtained in the primary gaze position (PGP) and downward gaze position twice: before the first treatment and six months after the latter treatment was performed. Trained medical technicians performed sensorial and motor studies. According to the standards proposed in the Symposium CLADE 2013, the current nomenclature considers positive values for alignments D/I and negative values for alignments I/D.

Suazo LA et al. Outcomes in post-traumatic strabismus

Finally, the sample was divided into three groups according to the initial clinical ocular deviation: esotropia, exotropia and vertical strabismus (which included both hypertropia and hypotropia). For each one of these groups, we exhibit the strabismus study’s results assessed prior to the treatment and six months after the last treatment had been received. When the sample is split into these three groups of ocular deviation, we consider only absolute values that point to the grade of ocular misalignment. Thereby, the obstacle consisting of positive and negative signs is deleted, allowing the calculation of averages for each group. The therapeutic success and failure rates were computed for each of these groups. We have defined success as a sensory-motor study with values in the range of ±10 PD (prism diopters). Means and SD were computed for continuous variables and percentages for discrete variables. We made use of IBM SPSS Statistics package (version 20.0) for data analysis.

Results

The demographic characteristics of the sample show an average age of 31.31 years-old with a range between 2 and 60 at the time of presentation. Male gender was predominant, representing 82.9% of patients and the majority of patients came from an urban environment (91.4%). Among the causes of ocular trauma, assaults were the most frequent (57.1%), followed by falls (17.1%) (Table 1). Precursor lesions of strabismus were, in order of frequency: orbital fracture (37.1%), ocular penetrating injury (17.1%), blunt trauma (17.1%) and direct muscle trauma (14.3%). There were instances where more than one injury occurred simultaneously, such as the association of orbital fracture and ocular penetrating injury (5.7%); and the association of orbital fracture and blunt trauma (2.9%). The paralytic form of strabismus was prevalent, with 68.6% of cases. The restrictive strabismus variety occurred in 25.7% of the sample. In the remaining 5.7% a mixed pattern was found which was represented by a case in which both a neurological injury and muscle

entrapment in a fissure fracture occurred. The right eye was involved in 60% of cases. Clinical ocular deviation at the initial medical appointment was: 51% alteration in vertical alignment and 53.3% alteration in horizontal alignment. In this latter group, 37.1% and 40.0% of patients presented esotropia and exotropia respectively (Table 1). Regarding cases of penetrating eye injury, three were observed and three were treated surgically. Regarding cases of orbital fracture, seven were resolved spontaneously during clinical observational time, one received lens therapy and five required surgical treatment. Five cases of blunt ocular trauma had spontaneous resolution during clinical observation. Just one of these cases required botulinum toxin injection. Five cases of direct muscle trauma received a definitive surgical resolution (Table 2). Most of the patients received just one treatment (N=31). The first treatments conducted, considering the whole sample, were: clinical observation (54.3%), surgery (8.6%), botulinum toxin injection (8.6%) and lens with prismatic addition (5.7%). We assessed the results of sensory-motor study in 31 patients pre-treatment and six months after treatment. The total number of patients was divided depending on the type of treatment received. Patients under clinical observation showed average values of vertical alignment in PGP of 3.0 PD (range from 0 to 20) before treatment and 0.5 PD (range from 0 to 5) after treatment. The horizontal alignment average values were -2.2 PD (range from -30 to 30) pre-treatment and -3.1 PD (range from -30 to 20) after treatment. Regarding vertical alignment, in cases with downward gaze these registered average values of -0.1 PD (range from -20 to 16) prior to treatment and 1.2 PD (range from 0 to 8) post treatment. Average values of horizontal alignment were 2.4 PD (range from -20 to 25) and -2.0 PD (range from -30 to 20) respectively (Table 3). Patients treated by the ‘lens with prismatic addition’ method showed only alteration in the downward gaze, while the PGP was normal. The average value of vertical alignment in the downward gaze was 5.0 PD (range from 0 to 10) prior the treatment. After six months of treatment, it

PAN-AMERICA

47

CLINICAL SCIENCES / Vis. Pan-Am. 2014;13(2):44-52

Table 3. Results of sensory-motor study in patients undergone to only one treatment. We exhibit the results of strabismus study before and after 6 months to the single treatment received, which could be observation, lens with prismatic addition, botulinum toxin injection and surgery. Results are expressed in Prism Diopetrs (PD). N/A= not applicable; because it is just one case. Patients undergone to one treatment n=31

Before treatment

After treatment

Mean

Range

Mean

Range

Vertical alignment in PGP

3.0

0 to 20

0.5

0 to 5

Horizontal alignment in PGP

-2.2

-30 to 30

-3.1

-30 to 20

Vertical alignment in downward gaze

-0.1

-20 to 16

1.2

0 to 8

Horizontal alignment in downward gaze

2.4

-20 to 25

-2.0

-30 to 20

Vertical alignment in PGP

0.0

0 to 0

0.0

0 to 0

Horizontal alignment in PGP

0.0

0 to 0

0.0

0 to 0

Vertical alignment in downward gaze

5.0

0 to 10

0.0

0 to 0

Horizontal alignment in downward gaze

-2.5

-5 to 0

0.0

0 to 0

Vertical alignment in PGP

15.0

N/A

0.0

N/A

Horizontal alignment in PGP

0.0

N/A

0.0

N/A

Vertical alignment in downward gaze

17.0

N/A

0.0

N/A

Horizontal alignment in downward gaze

0.0

N/A

0.0

N/A

Vertical alignment in PGP

7.2

-25 to 50

3.0

0 to 12

Horizontal alignment in PGP

-14.0

-60 to 10

2.0

-2 to 14

Vertical alignment in downward gaze

12.6

-25 to 60

7.8

-2 to 35

Horizontal alignment in downward gaze

-23.1

-50 to -6

1.2

-3 to 10

Observation (n=18)

Lens with prismatic addition (n=2)

Botulinum Toxin (n=1)

Surgery (n=10)

had returned to normal. The average value of horizontal alignment in the downward gaze was 2.5 PD (range from -5 to 0) and it had the same outcome after six months. There was only one patient in this group who was treated with botulinum toxin. In this case, the average initial values in vertical alignment were 15 PD in PGP and 17 in downward gaze, with no alteration in the horizontal alignment. After six months of treatment, this case turned to normalization

48

PAN-AMERICA

in the sensorio-motor study. (Table 3). For the group of ten patients who received an initial surgical treatment, the average values of vertical alignment in PGP were 7.2 PD (range from -25 to 50) pre-treatment and 3.0 DP (range from 0 to 12 PD) after treatment. The average values of horizontal treatment of PGP were -14 PD (range from -60 to 10) pre-treatment and 2.0 PD (range from -2 to 14) after it. Regarding vertical alignment in the

Suazo LA et al. Outcomes in post-traumatic strabismus

downward gaze, this showed an average value of 12.6 PD (range from -25 to 60) pre-treatment and 7.8 PD (range from -2 to 35) after treatment. Horizontal alignment in the downward gaze showed average values of -23.1 PD (rage from -50 to 6) and 1.2 PD (range from -3 to 10) respectively (Table 3). Of the group of patients who received more than one treatment, just one patient

underwent botulinum toxin injection and surgery. Initially, his values in PGP were 6 PD and 55 PD in vertical and horizontal alignment; and in downward gaze were 5 and 55 PD in vertical and horizontal alignment. Six months after surgery, the patient had fully recovered (Table 4). Two patients underwent three treatments: one for clinical observation,

Table 4. Results of sensory-motor study in patients undergone to more than one treatment. We exhibit the results of strabismus studies before any treatment and after 6 months to the last treatment received. Results are expressed in prism diopetrs (PD) .N/ A= not applicable; because it is just one case. N/F: not feasible; eye fixed in PGP due to medial rectus attached to periosteum. Patients undergone to more than one treatment n=4 Patients undergone to two treatments (n=1) Treatments conducted: Botulinum toxin and surgery. Before any treatment

After last treatment

Mean

Range

Mean

Range

Vertical alignment in PGP

6

N/A

0

N/A

Horizontal alignment in PGP

55

N/A

0

N/A

Vertical alignment in downward gaze

5

N/A

0

N/A

Horizontal alignment in downward gaze

55

N/A

0

N/A

Treatments conducted: First patient: observation, botulinum toxin, surgery; Second patient: surgery, botulinum toxin, surgery

Patients undergone to three treatments (n=2)

Before any treatment

After last treatment

Mean

Range

Mean

Range

Vertical alignment in PGP

6

0 to 12

0

0 to 0

Horizontal alignment in PGP

-9.5

-56 to 37

5

-35 to 45

Vertical alignment in downward gaze

0

0 to 0

0

0 to 0

Horizontal alignment in downward gaze

24

0 to 48

11

0 to 22

Patients undergone to five treatments (n=1) Treatments conducted: Botulinum toxin and four surgeries. Before any treatment

After last treatment

Mean

Range

Mean

Range

Vertical alignment in PGP

0

N/A

0

N/A

Horizontal alignment in PGP

-110

N/A

30

N/A

Vertical alignment in downward gaze

0

0

N/F

N/A

Horizontal alignment in downward gaze

N/F

N/A

N/F

N/A

PAN-AMERICA

49

CLINICAL SCIENCES / Vis. Pan-Am. 2014;13(2):44-52

Table 5. Objective results of according to type of clinical ocular deviation: sensory-motor study and rate of therapeutic success. We detail the values of sensory-motor study before any treatment and after 6 months of single/last treatment received according to groups of clinical ocular deviation: exotropia (XT), esotropia and alterations on vertical alignment, which include hypertropia and hypotropia. Also we show therapeutic success and failure for each group. The addition of cases for each group is not concordant with the total of the sample, because some cases presented alteration in vertical and horizontal alignment simultaneously. For these cases, each alteration for each axis was considered independent to be analyzed. N/A= not applicable; because it is just one case. Ocular axis alterations

Frequency

Study before any treatment. (Mean ± SD)

Study 6 months after last treatment. (Mean ± SD)

Therapeutic success

Therapeutic Failure

Rate of Therapeutic success

XT

14

14.8 ± 20.4

3.3 ± 8.2

13

1

92.86%

ET

13

-30.3 ± 37.9

-11.5 ± 16.3

11

2

84.62%

hT + HT

18

5.2 ± 24.5

1 ± 2.4

17

1

94.44%

Total

35

N/A

N/A

31

4

88.57%

followed by botulinum toxin injection and finally surgery; and the other one to surgery, followed by botulinum toxin injection and finally to further surgery. The average values in PGP were 6 PD (range from 0 to 12) and 9.5 PD (range from -56 to 37) in vertical and horizontal alignment respectively. In downward gaze they were 0 PD (range from 0 to 0) and 24 PD (range from 0 to 48) in vertical and horizontal alignment. Six months after the final treatment, the average values in PGP were 0 PD (range from 0 to 0) and 5 PD (range from -35 to 45) in vertical and horizontal alignment respectively. In downward gaze, the average values were 0 PD (range from 0 to 0) and 11 PD (range from 0 to 22) respectively (Table 4). One patient received five treatments: first, starting with serial clinical observation and, then, four phases of surgery. This patient had a traumatic optic nerve section. The alteration to horizontal ocular alignment on admission was -110 PD in PGP and, after the last surgery, showed 30 PD in the same gaze position (Table 4). The sample was broken down according to the altered axis of ocular alignment. Six months after the last treatment values were 3.3 ±8.2 PD. -11.5 ± 16.3 PD; and 1 ± 2.4 PD for these groups respectively. The

50

PAN-AMERICA

therapeutic success rate was 88.57% for the 31 patients of the complete sample. The detail of therapeutic success rate according to groups corresponds to 92.86%, 84.62% and 94.44% for esotropia, endotropia and the vertical strabismus group respectively (Table 5).

Discussion

In this study, we encountered a wide variety of lesions as causes of strabismus. In contrast to a previous report conducted in Chile8 in which the most frequent lesion was the ocular penetrating injury, in this study the orbital fracture was the most common initial injury with 37.1%, followed by the ocular penetrating injury and blunt trauma with 17.1% each. This difference is influenced by two factors: the small sample size of the study and the fact that in our study we included all clinical management strategies, in contrast to the previously noted report which only considered patients treated by surgery. Considering the type of strabismus, the high frequency of paralytic strabismus (2.6 times more frequent than restrictive strabismus) is linked to the high incidence of paresis or paralysis of the cranial nerves associated with ocular trauma and traumatic

Suazo LA et al. Outcomes in post-traumatic strabismus

brain injury9,10 It is important to mention the fact that in this study we considered direct muscle injuries as paralytic strabismus. However, just three cases of the 24 patients who presented with paralytic strabismus had a muscular section, so that this type of strabismus remains the most frequent one, independent of these three cases. Regarding treatment, it is interesting to notice that 88.6% of patients received a single treatment. The conservative treatment, based on clinical observation and eye patches to avoid diplopia, was the most commonly used clinical management in the first instance with 54.3% of the total, followed by surgical treatment in 31.4% of cases. Due to the limited number of cases considered as the sample, it is not feasible to perform a robust analytical study of association. However, we can predict some trends. Patients with vertical strabismus, treated by clinical observation, tend to spontaneous resolution with time, which is evidenced in the shortened range of prism diopters. This is consistent with the premise that a significant percentage of patients improve spontaneously over time5. Regarding horizontal strabismus, this evolution does not seem to be so evident. This could be caused by a number of patients rejecting surgical treatment, because it is done to the eye that does not suffer strabismus (considered by patients to be a ‘healthy’ eye). The ‘Lens with prismatic addition’ technique was used as therapy in patients that presented initially with alterations in downward gaze (5.7% of cases). It is linked to revisions which advocate conservative management of diplopia and subsequent evaluation of the need for surgery6. Indeed, patients treated initially in this way did not require additional surgery. Management of strabismus with botulinum toxin was described more than three decades ago11. A recent review of the topic conclude that there is insufficient evidence to compare the effectiveness of botulinum toxin injection and conventional surgery in post traumatic strabismus12. Treatment with botulinum toxin consists in its injection to the antagonist muscle of the paretic one in order to avoid

a muscle contracture and the subsequent diplopia. While the toxin’s effect over the ocular muscle persists – for between 2 and 4 months - we can monitor the progress of the strabismus, which may resolve spontaneously. In this study, three patients received intramuscular injection with botulinum toxin: one went into spontaneous remission and two required additional surgery. Surgery, as the first treatment, was indicated according to evaluation on a case by case basis. Surgical results were considered satisfactory because values in vertical and horizontal prisms obtained by patients in PGP are within the target values ± 10 DP.13 It is important to note the patient who received five treatments: the first one with botulinum toxin and then four phases of surgery on a blind eye. In his latest surgery, the eye affected was fixed in PGP through medial rectus muscle fixation to periosteum. Initially normal ocular alignment was recovered, but then the fixation was lost so that it produced a residual misalignment of 30 PD. Despite being a sightless eye, this type of treatment is relevant because of psychosocial sequelae produced by the strabismus. It has a negative impact on social function and employability related to the presence of strabismus14, so that surgery has a reconstructive role to help people to reintegrate into society. The rate of therapeutic success in this study is 88.57%, which is very encouraging. It is difficult to find in the literature studies that have shown the results of therapeutic global management of both paralytic and restrictive strabismus, because most of the studies select patients with only one cause of traumatic strabismus. Consequently there is plenty of literature related to orbital trauma. There is one study which evaluates the results of therapeutic management of 12 patients with traumatic strabismus secondary to a variety of lesions, similar to our study15. In this example the therapeutic success rate was 91.7%, consistent with our results. In our study, two therapeutic failures were related to patients who refused surgical treatment: one was indicated as an initial intervention and the second one

PAN-AMERICA

51

CLINICAL SCIENCES / Vis. Pan-Am. 2014;13(2):44-52

after a period of clinical observation. There is no significant difference in therapeutic success rate between groups of exotropia, esotropia or vertical strabismus. Regarding invasive treatments, botulinum toxin injection is a complement to clinical observation in order to avoid the reflect contraction of antagonist muscle. A proper indication of surgery may have excellent results as either initial treatment or second line treatment. In our center the results of management of this condition are very satisfactory; this is advantageous for all patients suffering this condition in Chile. It is important to remember the psychosocial influence that strabismus produces in a patient’s life. Therefore, surgery, in cases of patients with low visual acuity, is not regarded as cosmetic but rather reconstructive in order reintegrate the patient into society. This is the second national report on traumatic strabismus and the first one that consider diverse strategies of treatments and its results. We hope it could be the first one of many others developed in the future, because the experience in these series is useful to optimize the attention given to this condition in our country. Our study holds the characteristic limitations of a retrospective analysis. Further prospective and collaborative studies with well-defined patterns of strabismus and similar trauma mechanisms should be carried out to get conclusions that can lead to guidelines in this condition. In conclusion, post-traumatic strabismus corresponds to a pathology that mainly affects young people. It is caused by a wide variety of conditions secondary to trauma. Most patients can be treated with a single treatment, which must be selected on a case-by-case basis according to the characteristics of the initial injury and the resulting type of strabismus. A clinical observation is enough in a significant percentage of cases because a large number of patients tend to spontaneous recovery.

52

PAN-AMERICA

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

Lee SH, Lew H, Yun YS. Ocular Motility Disturbances in Orbital Wall Fracture Patients. Yonsei Med J. 2005 Jun 30;46(3):359–67. Gosse EM, Ferguson AW, Lymburn EG, Gilmour C, MacEwen CJ. Blow-out fractures: Patterns of ocular motility and effect of surgical repair. Br J Oral Maxillofac Surg. 2010 Jan;48(1):40–3. Warrier S, Wells J, Prabhakaran VC, Selva D. Traumatic rupture of the superior oblique muscle tendon resulting in acquired Brown’s syndrome. J Pediatr Ophthalmol Strabismus. 2010 Jun;47(3):168–70. Harish AY, Ganesh SC, Narendran K. Traumatic superior oblique tendon rupture. J AAPOS Off Publ Am Assoc Pediatr Ophthalmol Strabismus Am Assoc Pediatr Ophthalmol Strabismus. 2009 Oct;13(5):485–7. Al-Qurainy IA, Stassen LF, Dutton GN, Moos KF, el-Attar A. Diplopia following midfacial fractures. Br J Oral Maxillofac Surg. 1991 Oct;29(5):302–7. Arnoldi K, Mattheu J. Diagnosis and nonsurgical management of strabismus secondary to orbital fracture. Am Orthopt J. 2004;54(1):7–12. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA J Am Med Assoc. 2013 Nov 27;310(20):2191–4. Manieu M. D, López G. JP, Villaseca D. E, Roizen B. A, González N. M. Resultados quirúrgicos en estrabismo post trauma

9.

10.

11.

12.

13.

14.

15.

ocular y orbitario; Surgical outcome of strabismus secondary to trauma. Arch Chil Oftalmol. 2010;65(2):51–7. Richards R. Ocular motility disturbances following trauma. Adv Ophthalmic Plast Reconstr Surg. 1987;7:133–47. Sabates NR, Gonce MA, Farris BK. Neuroophthalmological findings in closed head trauma. J Clin Neuroophthalmol. 1991 Dec;11(4):273–7. Scott AB. Botulinum toxin injection of eye muscles to correct strabismus. Trans Am Ophthalmol Soc. 1981;79:734–70. Crouch ER. Use of botulinum toxin in strabismus. Curr Opin Ophthalmol. 2006 Oct;17(5):435–40. Pratt-Johnson JA, Tillson G. Management of Strabismus and Amblyopia: A Practical Guide. Thieme; 2001. 344 p. Olitsky SE, Sudesh S, Graziano A, Hamblen J, Brooks SE, Shaha SH. The negative psychosocial impact of strabismus in adults. J Am Assoc Pediatr Ophthalmol Strabismus. 1999 Aug;3(4):209–11. Subramanian PS, Birdsong RH. Surgical management of traumatic strabismus after combat-related injury. Mil Med. 2008 Jul;173(7):693–6.

García-Fernández M & Castro Navarro J. Evolution of combined hamartoma.

Long term evolution of combined hamartoma of the retina and retinal pigment epithelium Miriam García Fernández1, Joaquín Castro Navarro1

Corresponding author:

1 Department of Ophthalmology, Central University Hospital of Asturias,

Miriam García-Fernández, MD. Department of Ophthalmology, Central University Hospital of Asturias C/Dionisio Ridruejo, nº5, 11ºD. CP: 33007 Oviedo, Asturias (Spain) Tel:+34-629-85-38-00 Email: migarci@hotmail.es

Oviedo, Asturias, Spain. Funding: none Proprietary/financial interest: none

Date of submission: 08/07/2012 Date of approval: 22/09/2012

ABSTRACT Introduction

Combined hamartoma of the retina and of the retinal pigment epithelium are extremely rare benign tumors distinguished by retinal pigment epithelium (RPE) and glial tissue proliferation, provoking severe peripapillary and retinal distortion. There is no established management for combined hamartoma of the retina and of the retinal pigment epithelium.

Case Reports

A 46-year-old male and a 35-year-old female, diagnosed as having a combined hamartoma of the retina and retinal pigment epithelium were observed for four years. One of them was treated with pars plana vitrectomy due to large associated epiretinal membrane (ERM), and the other patient declined surgery. Initially, the evolution was satisfactory in the patient who underwent vitreoretinal surgery, with anatomic improvement and visual acuity stabilization. However, four years later, he complained of visual loss, presenting severe macular distortion, and, consequently, decrease in visual acuity. The patient who preferred a conservative management, showed no funduscopic changes during the follow-up.

Conclusion

Vitreoretinal surgery for combined hamartoma of the retina and retinal pigment epithelium may improve retinal architecture and visual acuity, but in the long-term functional recovery is frequently not possible, leading to a decrease in VA. We can conclude that the evolution of this

pathology can be similar in both cases treated with vitreoretinal surgery and in cases without surgery. Therefore, conservative management may be adopted. A larger number of cases are required to be studied to confirm our clinical observations. Key words: Combined Hamartomas of Retina; Retinal Pigment Epithelium, vitrectomy.

Introduction

Combined hamartoma of the retina and retinal pigment epithelium are extremely rare benign tumors, characterized by retinal pigment epithelium (RPE) and glial tissue proliferation, provoking severe peripapillary and retinal distortion. It is nearly always a solitary, unilateral lesion, usually located over the optic disc, macula and, less commonly, close to the peripheral retina. It may cause significant visual loss related to direct involvement of the fovea, papillomacular bundle or optic nerve. The most frequent funduscopic findings are: vascular tortuosity in variable degrees, hyperpigmentation, and presence of an elevated lesion and epiretinal membrane (ERM).1 There are several systemic associations of combined hamartoma of the retina and retinal pigment epithelium such as neurofibromatosis, tuberous sclerosis, facial hemangioma, and incontinentia pigmenti. There are also several ocular abnormalities associated such as choroidal neovascularization. ERM with or without macular hole formation, optic nerve head pits and optic nerve head drusen.1-2 To the best o four knowledge, there is a lack of established management for combined hamartoma of the retina and retinal pigment epithelium.3

Figure 1. Fundus photograph at baseline examination in case 1. Combined Hamartoma of Retina and Retinal Pigment Epithelium with associated epiretinal membrane extended through the retina with an extension of approximately seven disc diameter (DD) in size.

Figure 2. Fluorescein angiography prior surgery in case 1. Hypofluorescence and hyperfluoresce of the lesion in early and late phases, respectively, occupying an area of approximately 2,5 disc diameter (DD). PAN-AMERICA

53

CASE REPORT / Vis. Pan-Am. 2014;13(2):53-55

Case Reports Case 1

Figure 3. Fundus photograph four years after surgery in case 1. We appreciated a similar aspect respect to baseline examination (figure 1).

Figure 4. Optical coherence tomography four years after vitrectomy in case 1: hyperreflectivity related to the epiretinal membrane, increase of retinal thickness with intrarretinal cysts, and overwhelming macular distorsion.

Figure 5. Fundus photograph at baseline examination in case 2. Combined Hamartoma of Retina and Retinal Pigment Epithelium with associated epiretinal membrane.

A 46-year-old Spanish man with history of a craneoencephalic trauma two years before presentation, who presented with visual acuity (VA) loss in the right eye (RE). Best corrected visual acuity (BCVA) in RE was 0.1 (decimal notation), and 1.0 in the left eye (LE). Anterior segment examination revealed a bilateral nuclear sclerosis with no further abnormalities. Fundoscopy revealed a hyperpigmentated and elevated peripapillary lesion, with macular involvement and a huge epiretinal membrane over macular and perimacular region. Tortuous and telangiectasic vessels over the lesion were noted (Figure 1). Fluorescein angiography (FA) showed hypofluorescence and telangiectasic vessels with diffusion of contrast in the early frames, and hyperfluorescence in late phases, without signs of neither choroidal nor retinal neovascularization (Figure 2). Considering the diagnosis of combined hamartoma of the retina and retinal pigment epithelium, the patient was forwarded to the Internal Medicine department to rule out any associated diseases. A complete systemic examination was performed, including magnetic resonance and contrast CT Scan in order to identify the presence of any neurofibroma. Based upon diagnostic criteria, neurofibromatosis was excluded. Due to the important VA impairment and the presence of large ERM, we decided to perform 20-gauge three-port pars plana vitrectomy (PPV) with membrane peeling. Vitreoretinal surgery resulted in an anatomic improvement and VA stabilization at six months postoperatively. Complete ocular examination was performed every six months, showing the lesion to remain unchanged. However, four years after PPV, the patient presented complaining of decreased vision in his right eye. Examination revealed a BCVA on RE of hand motion at 1 meter. Funduscopic examination (Figure 3) and Optical Coherence Tomography (OCT) (Cirrus SD, Carl Zeiss, Germany) (Figure 4) showed the lesion to remain unchanged. OCT also demonstrated severe macular distorsion with areas of significant increase in retinal thickness with intraretinal cysts, associated to severe RPE atrophy, all contributing to poor visual acuity.

Case 2

A 35-year-old Spanish woman, referred to our department complaining of progressive loss of vision in her LE. BCVA in RE was 1.0 (decimal notation), and 0.4 in the LE. Anterior segment examination revealed no abnormalities. Fundoscopy showed a hyperpigmentated and elevated macular lesion, with an associated epiretinal membrane (Figure 5). Fluorescein

54

PAN-AMERICA

García-Fernández M & Castro Navarro J. Evolution of combined hamartoma.

angiography showed hypofluorescence of the lesion and telangiectasic vessels with diffusion of contrast in late phases, similar to the previous case (Figure 6). OCT showed the presence of a continuous line of hyperreflectivity attached to the inner retinal surface corresponding to an ERM, and a hyporreflective space corresponding to a neurosensorial retinal detachment. OCT also revealed the presence of intraretinal cysts and a foveal defect compatible with macular pseudohole (Figure 7). The patient also showed melanocytic lesions in several regions of the body which remained us to “Café au lait” spots. She was referred to the Dermatology department in order to discard neurofibromatosis. However, the final diagnosis was solar lentigo. The patient declined surgery. Therefore, a conservative approach with a rigorous followup was performed. Four years later, the lesion remained unchanged with a visual acuity of 0.3 in her LE (Figure 8).

Figure 6. Fluorescein angiography in case 2, showing the diffusion of contrast in late phases corresponding to the telangiectasic vessels.

Discussion

The progression of combined hamartoma of the retina and retinal pigment epithelium is used to be stationary. This is why most cases require no treatment. However, VA decrease related to choroidal neovascularization, vitreous hemorrhage, macular edema, macular hole or retinal detachment formation are described in the literature. 1,4-5 There have been several management options described such as photodynamic therapy with Verteporfin6 (for cases with vascular leakage), a combination therapy consisting of vitrectomy, laser photocoagulation and intravitreal triamcinolone3, and vitrectomy associated to ERM peeling7, all of them with good surgical outcomes and a low rate of intra and postoperative complications. The recurrence of the ERM is possible, but most authors consider that VA may improve despite this recurrence.8 We report two cases of combined hamartoma of the retina and retinal pigment epithelium with different management approaches (PPV with ERM peeling in one case and conservative treatment in the other case). Both cases showed a similar evolution in the long term, after four years of follow-up.

Conclusion

Vitreoretinal surgery for combined hamartomas of retina and retinal pigment

Figure 7. Optical Coherence Tomography (Cirrus OCT) in case 2, showing the presence of ERM and a neurosensorial retinal detachment.

REFERENCES 1.

2.

3.

Figure 8. Funduscopic appearance after four years of follow-up in case 2. We appreciated not significant changes compared with baseline examination (figure 4). epithelium may improve retinal architecture and visual acuity in the short term. However, functional outcomes in the long term can be identical to those managed conservatively. This is why we propose a conservative management approach of combined hamartoma of the retina and retinal pigment epithelium, especially for those hamartomas with macular involvement and severe retinal distortion.

4.

5.

6.

7.

8.

Pérez-Alvarez MJ, Alejandre-Alba N, García-Sánchez J. Combined hamartoma of the retina and retinal pigment epithelium diagnosed by retinal angiography and optical coherence tomography. Arch Soc Esp Oftalmol. 2008, 83:193-6. Damasceno NA, Damasceno EF. Combined hamartoma of the retina and retinal pigment epithelium associated with optic coloboma. Clin Ophthalmol. 2011, 5:353-4. Nam DH, Shin KH, Lee DY, Sohn HJ. Vitrectomy, Laser Photocoagulation, and Intravitreal Triamcinolone for Combined Hamartoma of the Retina and Retinal Pigment Epithelium. Ophthalmic Surg Lasers Imaging. 2010, 9:1-4. Helbig H, Niederberger H. Presumed combined hamartoma of the retina and retinal pigment epithelium with preretinal neovascularization. Am J Ophthalmol. 2003, 136:1157-9. Inoue M, Noda K, Ishida S, Yamaguchi T, Nagai N, Shinoda K, et al. Successful treatment of subfoveal choroidal neovascularization associated with combined hamartoma of the retina and retinal pigment epithelium. Am J Ophthalmol. 2004, 138:155-6. Cilliers H, Harper CA. Photodynamic therapy with Verteporfin for vascular leakage from a combined hamartoma of the retina and retinal pigment epithelium. Clin Experiment Ophthalmol. 2006, 34:186-8. Zhang X, Dong F, Dai R, Yu W. Surgical management of epiretinal membrane in combined hamartomas of the retina and retinal pigment epithelium. Retina. 2010, 30:305-9. Cohn AD, Quiram PA, Drenser KA, Trese MT, Capone A Jr. Surgical outcomes of epiretinal membranes associated with combined hamartoma of the retina and retinal pigment epithelium. Retina. 2009, 6:825-30.

PAN-AMERICA

55

CASE REPORT / Vis. Pan-Am. 2014;13(2):56-58

A deadly droop: small cell lung cancer presenting as upper eyelid ptosis Son T. Ho MD, Alejandra A. Valenzuela MD

Corresponding author:

From the Department of Ophthalmology, Tulane University School of Medicine, New Orleans, Louisiana, USA

Alejandra A. Valenzuela, MD 1430 Tulane Ave SL 69, New Orleans, LA 70112 avalenz1@tulane.edu Phone: 504-988-5804 Fax: 504-988-2684

Funding: None Proprietary/financial interest: None

Date of submission: 16/01/2014 Date of approval: 12/04/2014

Abstract

Orbital metastases are a rare manifestation of systemic malignancies, most commonly originating from the breast or lung in adults. Not infrequently there is not any diagnosis of cancer at the time of presentation with orbital metastatic disease. This is a case of a 62-year-old man whose initial presentation of metastatic small cell lung cancer was left upper lid ptosis and hypoglobus. Key Words: Orbit, metastatic small cell lung cancer, orbital metastases, ptosis

Introduction

Metastatic orbital lesions account for approximately 1-13% of all orbital tumors.1,2 Small cell lung cancer (SCLC) is the most aggressive histological subtype of lung cancer and represents 13â&#x20AC;&#x201C;20% of all new lung cancer diagnoses.3 Early and rapid metastasis to multiple organ systems are typical of these tumors, but spread to the orbit is seldom reported. Outlined below is a case of a 62-year-old man whose initial presentation of metastatic small cell lung cancer was upper lid ptosis and hypoglobus.

Case Report

A 62 year-old Caucasian man was evaluated in the eye clinic for left upper eyelid swelling and ptosis, which started a

56

PAN-AMERICA

month ago. Past medical history included diabetes and hypertension. He is a continuous cigarette smoker with a 45pack per year history but denies symptoms of dyspnea, cough, or fever. On examination, he had a 4cm firm left supero-temporal mass that was tender to palpation. He had a left upper lid ptosis with a superior marginal reflex distance of +4 mm and -2 mm, palpebral apertures of 9mm and 4mm, and levator function of 18mm and 9mm, respectively. Naugle exophthalmometry was 16 and 17 respectively and a 2mm of left hypoglobus was noted. A mechanical elevation deficit on the left eye was also noted. The remainder of the ophthalmic evaluation was within normal limits including normal lymph nodes on palpation. Computerized tomography (CT) of his orbits revealed an anteriorly located left superior orbital homogenous mass that molded to the superior orbital rim and was located in close relation to the lacrimal gland (Figure 1). He underwent a left anterior orbitotomy through an eyelid skin crease approach with excision of the lesion for diagnostic purposes. Histopathology examination confirmed a metastatic small cell lung cell tumor (SCLC). Tumor cells expressed synaptophysin, chromogranin, CD 56, and focal expressivity of CK7. Additional imaging with CT of the chest

Ho ST & Valenzuela AA. Upper eyelid ptosis.

and abdomen revealed abnormal soft tissue masses in a conglomerate measuring 5.9 x 3.4cm of the right middle lobe surrounding the main stem bronchus and abnormal lesions in the liver and adrenal glands. He was referred to oncology for staging and started on palliative treatment with thoracic radiotherapy (1500 cGy fractionated over 3 sessions) and chemotherapy consisting of carboplatin/etoposide. He responded well to treatment, showing a dramatic reduction of the lesions in the mediastinum, liver and left orbit. At 6 months follow-up he had a normal ocular/orbital examination and a resolution of his orbital/ocular symptoms (Figure 2).

Discussion

Orbital metastasis is considered to occur in approximately 2% to 3% of patients with systemic cancer and can be the first sign of malignancy in 15-25% of patients.1 Published reports indicate tumors of the breast, lung, and melanoma to be the most common primary neoplasms leading to ocular metastasis.1,2 Metastases to the eye or orbit develop in approximately 0.7â&#x20AC;&#x201C;12% of patients with lung cancer.3 Metastases are predominantly localized in the highly vascular choroids, followed by the anterior segment, orbit/adnexa, and the optic nerve.1-3 Clinically, the most common manifestations of orbital metastasis are diplopia, proptosis, decreased visual acuity, pain, ptosis, and eyelid edema, depending on the site affected.1,2 Symptoms usually occur acutely and progress rapidly over the course of weeks to months and may indicate early disease. Cancer type and tumor histology determine the clinical course and treatment approach. The aim in treating orbital metastases is in order to relieve symptoms and discomfort. Treatment by surgical removal of the mass is not recommended, however, it is only considered for diagnostic

Figure 1. Sagittal CT image revealing a left superior orbital homogenous mass that molds to the superior orbital rim.

PAN-AMERICA

57

CASE REPORT / Vis. Pan-Am. 2014;13(2):56-58

Figure 2. A, 62 year-old man with left upper eyelid ptosis, edema and hypoglobus B, 3 months post-operation showing resolution of left upper eyelid ptosis and facial symmetry.

purposes, as this case highlights.1,2 After confirming the diagnosis of a metastatic SCLC, palliative fractionated radiation to the orbit is commonly employed, particularly for symptomatic patients but systemic disease is predominantly approached with chemotherapy.3-5 Prognosis depends on the overall prognosis of metastatic disease and is frequently grim, with most succumbing to their disease within the first year of orbital metastases diagnosis.5 This case report highlights orbital metastasis from SCLC presenting as unilateral upper eyelid ptosis and hypoglobus. Although orbital metastases are uncommon, prevalence is likely increasing with our aging population and improved diagnostic capabilities. When orbital lesions are detected, the differential diagnosis should include secondary metastasis, in particular for those with orbital/ocular symptoms that present acutely and progress rapidly. Ophthalmologists have an important role in the diagnosis of metastatic orbital cancer, providing valuable information that can guide specific therapy for palliative care and/or potentially offer remission with advanced multidisciplinary therapies.

REFERENCES 1.

2.

58

Ahmad SM, Esmaeli B: Metastatic tumors of the orbit and ocular adnexa. Curr Opin Ophthalmol 2007;18:405â&#x20AC;&#x201C;413. Valenzuela AA, Archibald CW, Fleming B, Ong L, Oâ&#x20AC;&#x2122;Donnell B, Crompton J J,Selva D, McNab AA, Sullivan TJ. Orbital metastasis: clinical features, management and outcome. Orbit. 2009;28(23):153-9.

PAN-AMERICA

3.

4.

Konoglou M, Zarogoulidis P, Porpodis K, Androudi S, Papakosta D, Matthaios D, Kontakiotis T, Zervas V, Kalaitzidou E, Mitrakas A, Touzopoulos P, Zarogoulidis K. Exophthalmos as a first manifestation of small cell lung cancer: a long-term follow-up. Case Report Ophthalmol. 2011;2(3):360-6. Zarogoulidis P, Terzi E, Kouliatsis G, Androuli

5.

S, Kontakiotis T, Zaramboucas, T, Zarogoulidis K. Orbital metastases as the first manifestation of lung adenocarcinoma. Case Rep Ophthalmol. 2011;2(1):34-8. Henning M, Hu Q, Siegelmann-Danieli N. Orbital metastasis as the presenting symptom of extensive stage small cell lung cancer. Eur J Intern Med. 2008;19(1):65-6.

Morales-Leon JE et al. Implante ExPress

Entrampamiento de iris en implante Ex-Press liberado por YAG laser: Reporte de un caso Iris entrapment in an Ex-Press implant treated with YAG Laser: Case Report Jorge Emmanuel Morales-Leon, M.D., Karla Dueñas-Ángeles M.D., Curt Hartleben-Matkin, M.D. Departamento de Glaucoma. Instituto de Oftalmologia Fundación Conde de Valenciana I.A.P. Funding: None Financial/proprietary interest: None Date of submission: 29/10/2013 Date of approval: 29/04/2014

Resumen

Los autores reportan el caso de un paciente femenino de 68 años que cursó con hipotonía y cámara plana en el postoperatorio de un implante Ex-Press. Tras resolverse el cuadro se observó obstrucción de la luz de entrada del implante por iris, el cuál fue liberado por medio de YAG laser. Reportamos nuestros resultados y discutimos los casos que se abordaron de manera similar en la literatura. Palabras clave: glaucoma; cirugía filtrante; complicaciones postoperatorias; iris; terapia con láser

Abstract

The authors report a case of a 68-yearold woman who developed hypotony and a narrow anterior chamber after an Ex-Press shunt implant. After resolution, tube was obstructed by iris hanging to the end of the shunt, which was liberated using Nd:YAG laser. We discuss our results compared with others shown in the literature. Keywords: glaucoma; filtering surgery; postoperative complications; iris; laser therapy

Introducción

El implante “Ex-Press”, aprobado por la FDA desde el 2002, está diseñado para regular la presión intraocular. Es un dispositivo de acero inoxidable, que mide 3 mm de largo con un diámetro externo de 400 micras y un lumen de 50 micras. Tiene un espolón para evitar extrusión y una placa posterior en forma de disco para evitar intrusión. Es compatible con resonancia magnética de hasta 3 teslas. El dispositivo actúa como medio de transporte del humor acuoso hacia el espacio

Autor correspondiente: Jorge Emmanuel Morales-Leon, M.D. Dr. Jorge-Emmanuel Morales-León Assistant professor at Glaucoma Department Instituto de Oftalmología Fundación Conde de Valenciana I.A.P. Chimalpopoca 14 Colonia Obrera. CP 06800 Delegación Cuauhtemoc. México, Distrito Federal. Teléfono +52 55 54421700 ext 3713 Email: jorge.morales@institutodeoftalmologia.org

intraescleral y a la bula. Originalmente fue desarrollado para implantarse por debajo de la conjuntiva, sin embargo, se encontró hipotonía y extrusión del dispositivo, por lo que se modifico el diseño para ser implantado por debajo de un flap escleral. Presentamos el caso de una paciente que presentó entrampamiento de la luz interna del implante después de un episodio de desprendimiento coroideo y cámara plana, así como su resolución utilizando un láser nd:YAG.

Presentación del caso

Paciente del sexo femenino de 68 años, con diagnóstico de glaucoma primario de ángulo abierto. La paciente fue sometida a cirugía filtrante con colocación de implante Ex-Press debajo de flap escleral en ojo izquierdo. La cirugía se indicó por glaucoma descontrolado con terapia tópica máxima (dos medicamentos de primera línea y uno de segunda línea). No hubo complicaciones registradas en el transquirúrgico. En la revisión del postoperatorio de 24 horas, la paciente se presentó con disminución de la agudeza visual, cámara estrecha grado 2 y una presión intraocular de 5 mmHg. Se detectó un desprendimiento coroideo seroso periférico tras dilatación pupilar. Se indicó atropina al 1%, esteroide tópico y antibiótico. El desprendimiento coroideo se resolvió en el transcurso de una semana, encontrándose la cámara formada, bula plana y presión intraocular de 22 mmHg. A la exploración gonioscópica se observó una obstrucción franca del implante por entrampamiento iridiano (Figura 1a). Se PAN-AMERICA

59

CASE REPORT / Vis. Pan-Am. 2014;13(2):59-60

Imagen 1. (a) Implante Ex-Press obstruido por la raíz del iris. (b) Imagen gonioscópica después de 1 semana de aplicación de láser. decidió aplicar laser YAG con el espejo de un lente de Ritch para liberar la luz interna del implante. Se utilizaron 3 disparos de 2 mJ dirigidos hacia la localización más probable de la luz interna del implante. Se comenzó con ese poder debido a la pigmentación y grosor aparente del iris sin necesidad de incrementos. La bula se formó de manera inmediata, la presión se normalizó y no hubo recidiva del desprendimiento coroideo. La exploración gonioscópica a la semana de la aplicación de laser se muestra en la Figura 1b. Se decidió colocar implante Ex-Press en el segundo ojo, dejando puntos apretados en el flap escleral para disminuir el riesgo del evento presentado en el primer ojo. Se realizó suturolisis con argón al cuarto día del postoperatorio y la paciente cursó sin complicaciones.

Discusión

Algunos estudios1-3 y la información comercial, establecen que el implante Ex-Press es seguro en el tratamiento de pacientes con glaucoma y ayuda a regular el flujo de salida de humor acuoso para

REFERENCES 1.

2.

3.

4.

60

Dahan E, Carmichael TR. Implantation of a miniature glaucoma device under a scleral flap. J Glaucoma. 2005; 14:98-102 Kanner EM, Netland PA, Sarkisian SR Jr, et al. Ex-Press miniature glaucoma device implanted under a sclera flap alone or combined with phacoemulsification cataract surgery. J Glaucoma. 2009;18:488491 Traverso CE, De Feo F, Messas-Kaplan A, et al. Long term effect on IOP of a stainless steel glaucoma drainage implant (Ex-Press) in combined surgery with phacoemulsification. Br J Ophthalmol. 2005;89:425–429 Bermudez-Magner JA, Dueñas-Angeles K, Hartleben-Matikin C. Frecuencia de Complica-

PAN-AMERICA

5.

6.

7.

ciones del Implante Ex-Press en Cirugía de Glaucoma en el Instituto de Oftalmología Conde de Valenciana. Tesis para obtener el diplomado de alta especialidad de Glaucoma. Universidad Nacional Autonoma de México 2013. Copia en Instituto de Oftalmologia Fundación Conde de Valenciana IAP. Stewart RM, Diamond JG, Ashmore ED, et al. Complications following ex - press glaucoma shunt implantation. Am J Ophthalmol. 2005;140:340-341 Bagnis A, Papadia M, Scotto R, Traverso CE. Obstruction of the Ex-Press miniature glaucoma device: Nd: YAG laser as a therapeutic option. J Glaucoma. 2011; 20(4):271 De Feo F, Bagnis A, Bricola G, et al. Efficacy

8.

9.

and safety of a steel drainage device implanted under a scleral flap. Can J Ophthalmol. 2009;44:457–462. Maris PJ Jr, Ishida K, Netland PA. Comparison of trabeculectomy with Ex-Press miniature glaucoma device implanted under scleral flap. J Glaucoma. 2007;16:14–19. Rivier D, Roy S, Mermoud A. Ex-Press R-50 miniature glaucoma implant insertion under the conjunctiva combined with cataract extraction. J Cataract Refract Surg. 2007;33:1946–1952.

evitar un flujo excesivo y descontrolado. La experiencia en nuestra institución, nos dice que la hipotonía postoperatoria es una de las complicaciones más frecuentes4, así como la obstrucción del implante por iris o vítreo.2, 5-6 Algunas series no reportan obstrucciones del implante, mientras que otras reportan el evento como la complicación más frecuente aunque en ocasiones exista toque iridiano sin presencia de obstrucción.3, 7-9 En este caso, se presenta una solución documentada previamente en series y casos.2, 6 En uno de los casos reportados en la literatura, se menciona que se desconoce la causa por la cual existió obstrucción del implante siendo que la colocación era correcta y se plantea la posibilidad de que el iris se hubiera colgado del implante en algun episodio de cámara plana.6 Nuestro caso documenta y confirma esta posibilidad, con fotos antes y después de la aplicación de laser. Asimismo, sugerimos realizar gonioscopía de indentación en penumbra en la revisión prequirúrgica de los pacientes en los que se asume un diagnóstico de glaucoma primario de ángulo abierto, sobretodo en aquellos ojos fáquicos ya que estos pacientes son los que tienen mayor predisposición a presentarse con desprendimientos coroideos, resultando en un “iris colgado” sobre el implante.

Conclusiones

Ante una obstrucción iridiana postoperatoria de la luz interna del implante Ex-Press se puede considerar su liberación por medio de láser Nd:YAG.

Message from the Chairman of the PAOF Board

Message from the Chairman of the PAOF Board William De La Peña, MD Chairman of the PAOF Board, Pan-American Ophthalmological Foundation

The 2014 Pan-American Research Day (PARD) recently took place on Saturday, May 3, 2014 in Orlando, Florida, one day before the ARVO meeting. This is a unique meeting because its participants are primarily the young researchers, residents and fellows from throughout the world. PARD is an excellent example of the PanAmerican’s mission to provide continuing education, cultural exchange and topics on the prevention of blindness. 90 speakers meet to present their papers. In a speed presentation format, the speaker presents his or her work in three minutes and this is followed by a two minute Q & A session. The education was broad and the interaction lively. Paulo Dantas from Brazil and his team of co-coordinators (Peter Quiros, Fernando Arevalo, Lihteh Wu, Mauricio Maia, and Luis Izquierdo) put together an excellent program. Invited moderators were Eduardo Arenas-Archila, Carol L. Karp, Jorge Valdez and José Antonio Roca. The two featured keynote speakers were Mark Humayun, MD (USA) who spoke on “Advanced Implants for Retinal Diseases” and Victor L. Pérez MD (USA) featuring “Pre-Clinical Models of Ocular Immune Responses: What we see, we can treat.” This meeting features several scholarships, prizes and travel awards. Through the generous donation of its patrons, the Pan-American Ophthalmological Foundation (PAOF) offers several scholarship awards to attend this meeting. The Allergan Foundation sponsors three Arno Habicht Awards for Research Sciences and the David & Juliana Pyott

Foundation offers one travel award. This is the final year of collaboration with the Retina Research Foundation for the Tyson Research Initiative/ Retina Research Foundation/PAOF Travel Grant. Allergan International offers six awards, two each in the fields of Cornea, Glaucoma and Retina. • Arno Habicht Awards for Research Sciences - Emmerson Badaró MD PhD (Argentina) - Gustavo Alfredo Ortiz (Argentina) - María Fernanda Suárez MD (Argentina) • David & Juliana Pyott Foundation Travel Award - Natalia Alpízar Alvarez MD (Costa Rica) • Allergan Latin America Research Incentive Awards in Glaucoma - 1st place –Carolina Pelegrini Barbosa Gracitelli MD (Brazil) - 2nd place –Rafael Lacerdo Furlanetto MD (Brazil) • Allergan Latin America Research Incentive Awards in Cornea - 1st place –Jeremías Gastón Galletti MD PhD (Argentina) - 2nd place –Marcony R. Santhiago MD PhD (Brazil) • Allergan Latin America Research Incentive Awards in Retina - 1st place – María Alejandra Henríquez Bertaggia MD (Peru) - 2nd place – Damian Dorfman MD (Argentina) • Tyson Research Initiative/Retina Research Foundation/PAOF Travel Grant - Laura Emptage (Canada) - Ka Yee So (USA) - Daniela Alejandra Quinteros (Argentina) We would like to thank ARVO for co-sponsoring this important educational event and also to thank Allergan International for their generous sponsorship of this important educational event. And finally we extend our gratitude for our supporters of scholarships and awards: the David & Juliana Pyott Foundation, the Retina Research Foundation, and Allergan International.

William De La Peña, MD Chairman of the PAOF Board Pan-American Ophthalmological Foundation

PAN-AMERICA : 61

PAAO / Vis. Pan-Am. 2014;13(2):62-63

Dr. Peter McDonnell and Dr. Fernando Arevalo Elected to AOI

Peter McDonnell, MD (left) and Fernando Arevalo, MD (right)

A LA ALTURA DE TUS DESEOS

62

PAN-AMERICA

4/8/2014 Dr. Peter J. McDonnell, Wilmer director and Willliam Holland Wilmer Professor of Ophthalmology, and Dr. Fernando Arevalo, Edmund F. and Virginia Ball Professor of Ophthalmology, have been elected to Academia Ophthalmologica Internationalis (AOI). The AOI is a universitycentered international organization dedicated to preserving and restoring vision of people throughout the world. Active membership is limited to 70. Members must be formally nominated and must be engaged in the study, research or practice of ophthalmology for at least 15 years and published at least 100 scientific papers, reports or books. Wilmer Eye Institute is proud to now have four AOI members among its faculty; Drs. McDonnell and Arevalo join Dr. Alfred Sommer and Dr. Mark Tso in this prestigious organization.

Announcements

¡Hasta siempre Dr. Quevedo! Dicen que cuando alguien nos deja, se lleva una parte de nosotros, mientras más influencia tuvo esta persona, más grande es nuestro sentimiento de pérdida. Tuve este sentimiento este pasado 8 de Marzo. Ese día nos dejó el Dr. Arturo Roberto Quevedo Labereé. El Dr. Quevedo realizó sus estudios de bioquímicaen Harvard University y medicina en McGill University; posteriormente, tuvo su formación en oftalmología con subespecialidad en cirugía de Retina en Massachusset Eye & Ear Infirmary, Harvard University. Con tan formidable preparación en 1969 regresó a su natal Guatemala. Tuvo siempre desde su inicio la visión y la misión de brindar ayuda a la comunidad guatemalteca en especial los menos privilegiados con prevención, detección y tratamiento de las enfermedades oculares a través de una entidad no lucrativa. Y más importante aún, siempre tuvo en claro el objetivo de formar oftalmólogos y profesoresen oftalmología con excelencia. En 1970 fundó el primer postgrado en oftalmología (La Unidad Nacional de Oftalmología) en Guatemala y fundó el servicio de oftalmología en el Hospital Roosevelt que cuatro años después se tornó el departamento de oftalmología. La Universidad de San Carlos desde 1975 hasta el día de hoy otorga el grado académico de Magister Scientificae en oftalmología. El postgrado ha graduado más de 40 promociones (más de 200) oftalmólogos de toda América con egresados en Canadá, Estados Unidos de Norte América, México, Guatemala, Belice, Salvador, Honduras, Nicaragua, Costa Rica, Panamá, Colombia, Ecuador, Perú, España, Suecia y Chile. Para mí el Dr. Quevedo fue la persona que me abrió las puertas y me llevó de la mano en este recorrido del fascinante mundo de la oftalmología. Me enseño la importancia de las ciencias básicas como la base en la oftalmología. Me mostró lo gratificante que es enseñar y compartir los conocimientos. Fue mi ejemplo de

disciplina, perseverancia y dedicación. Era un gran apasionado de la docencia. Invertía en la última literatura posible (biblioteca con más de 2000 títulos). Llegaba a dar clases a los residentes de 7 a 9 de la mañana de lunes a viernes y los sábados de 8 a 12 medio día desde el primer año de residencia hasta el último. No faltaba a las reuniones de la Academia Americana de Oftalmología ni los congresos regionales. A los cursos que iba, siempre estaba en punto y en primera fila escuchando y tomando apuntes en las pláticas. Esta perseverancia tiene historia desde que fue fundado el postgrado. Estuvo en los momentos cruciales probablemente en los mejores cuatro años de mi vida. Compartimos tantos casos interesantes, nos sentamos tantas veces saboreando un café en busca de mejorías en el programa del postgrado cuando fui jefe de residentes. Estuvo en mi boda. Encontré en él la sabiduría para los mejores consejos para la vida y el trabajo. Siempre estuvo pendiente de mi progreso

y crecimiento profesional y personal a mi regreso a Costa Rica. Con la partida del Dr. Quevedo, la oftalmología centroamericana y latinoamericana pierde al gran maestro de la docencia en oftalmología; su familia a un generoso, noble e insustituible ser; el postgrado a su fundador; y yo a mi maestro, mentor y amigo. Gracias Dr. Quevedo por todo lo que fue, por lo que hizo con amor para los guatemaltecos y sus alumnos de todo centroamérica y latinoamérica sin buscar reconocimiento alguno, y por el gran legado que nos deja con el Postgrado. Hasta Siempre Dr. Quevedo Dr. Chun Cheng Lin Yang San José, Costa Rica

PAN-AMERICA

63

{

TORIC Aspheric IOL

T

toric

}

4 :

PAN-AMERICA