Thyroid orbitopathy. Review of key points for diagnosis and treatment

Introduction and objective: Thyroid orbitopathy (TO) is an autoimmune disease of unknown etiology. It is a chronic and sometimes subacute or acute edematous and inflammatory disease, the main characteristics of which are eyelid edema, corneal ulcers, ocular hypertension, generally bilateral exophthalmos, restrictive strabismus, diplopia and optic neuropathy. To review and to update the current diagnostic and therapeutic approaches. Objective: To propose a practical, basic and precocious approach based in the knowledge of the TO. Methods: Literature review and exposition of our experience in the management of TO. Results: TO is an inflammatory orbital disease that probably has an autoimmune origin and most of the time is related to systemic disorders of the thyroid gland. Pathogenesis of the disease is not yet fully understood. Women are more likely to develop TO, and the disease is clearly affected by several factors such as smoking, age, sex and race. It is crucial to determine TO severity and activity for a correct management. Conclusions: Clinical knowledge is essential for the early diagnosis of this disorder, and it is the most important factor for the proper management of the disease. The medical treatment must be initiated promptly and should be aggressive and based in the current phase of the disease, in order to avoid the severe damage that follows TO. The surgical approach must be logical and sequential, but, on the other hand, must be rapid and aggressive in order to return the patient to his/her labour, social and familiar environment.Introducción y objetivo: La orbitopatía tiroidea (OT) es una patología autoinmune de etiología desconocida. Se trata de una enfermedad edematosa e inflamatoria crónica y a veces subaguda o aguda, cuyas características principales son edema palpebral, úlceras corneales, hipertensión ocular, exoftalmos generalmente bilateral, estrabismo restrictivo, diplopía y neuropatía óptica. Objetivo: Realizar una revisión y actualización acerca del enfoque diagnóstico y terapéutico de la OT. Métodos: Revisión de la literatura publicada referente a la OT y manera actual de enfocar esta patología. Resultados: OT es una enfermedad inflamatoria orbitaria con un posible origen autoinmune y que suele asociarse a trastornos metabólicos de la glándula tiroidea. Fisiopatológicamente su mecanismo no está claro. Afecta mayormente a mujeres y está negativamente influenciada por factores como el tabaquismo, la edad, el sexo y la raza. Es imprescindible clasificarla en cuanto a su severidad y su actividad para un correcto manejo. Conclusiones: El conocimiento clínico de OT es esencial para el diagnóstico precoz de la enfermedad. El tratamiento médico, en caso de OT activa, debe ser precoz, agresivo y acorde a la fase en que se presente el paciente con el fin de evitar las graves consecuencias de la OT. El tratamiento quirúrgico deberá ser lógico y ordenado, pero a su vez rápido, con el fin de devolver al paciente al entorno laboral, social y familiar

Upper lid crease approach for margin rotation in trachomatous cicatricial entropion without external sutures

ABSTRACT Purpose: To describe the use of a lid crease incision for upper eyelid margin rotation in cicatricial entropion combining internal traction on the anterior lamella, tarsotomy, and tarsal overlap without external sutures. Methods: Surgical description: The main steps of the procedure consisted of exposure of the entire tarsal plate up to the eyelashes followed by tarsotomy through the conjunctiva. A double-armed 6.0 polyglactin suture was then passed through the distal tarsal fragment to the marginal section of the orbicularis oculi muscle. As the sutures were tied, the distal tarsus advanced over the marginal section, and traction was exerted on the marginal strip of the orbicularis muscle. There were no bolsters or external knots. The pretarsal skin-muscle flap was closed with a 6.0 plain gut suture. Results: We used this procedure at a tertiary hospital in Saudi Arabia from 2013 to 2014. Sixty upper lids of 40 patients (23 women and 17 men) were operated on, with an age range of 44-99 years [mean ± standard deviation (SD) = 70.9 ± 13.01 years]. Bilateral surgery was performed on 21 patients. Follow-up ranged from 1 to 12 months (mean 3.0 ± 2.71 months). Forty percent of the patients (24 lids) had more than 3 months' follow-up. The postoperative lid margin position was good in all cases. Trichiasis (two lashes) was observed in only one patient with unilateral entropion on the medial aspect of the operated lid. Conclusions: The upper lid margin can be effectively rotated through a lid crease incision with internal sutures. The technique combines the main mechanisms of the Wies and Trabut approaches and avoids the use of bolsters or external sutures, which require a second consultation to be removed. Some other lid problems, such as ptosis, retraction, or dermatochalasis, can be concomitantly addressed during the procedure

Hyperbaric oxygen in the management of wound tissue necrosis after external dacrocystorhinostomy

Hyperbaric oxygen is an adjunctive treatment for promoting wound healing and reducing infection. We present an unusual case of wound tissue necrosis occurring after external dacryocystorhinostomy (ExtDCR) that was subsequently treated with hyperbaric oxygen (HBO) and advancement flaps with good outcome. HBO improves vascularization of ischemic tissues after ExtDCR for greater success after reconstructive surgery

External dacryocystorhinostomy, conjunctivo-dacryocystorhinostomy and Inferior nasal meatus lacrimal surgery

Introducción y objetivo: Realizar una revisión sobre la dacriocistorrinostomía externa (DCR-ext), sondaje de la vía lagrimal y conjuntivodacriocistorrinostomía(CDCR) empleadas ante la obstrucción de la vía lagrimal./nMaterial y métodos : Revisión bibliográfica sobre técnicas quirúrgicas mencionadas./nDiscusión: La obstrucción de la vía lagrimal puede dividirse según su localización en proximales y distales. Ante obstrucciones distales, la DCR ext es la técnica gold standard con porcentajes de éxito superiores al 95%, y la CDCR en caso de obstrucciones proximales.El sondaje de la vía lagrimal es la primera indicación quirúrgica en obstrucción congénita

Approach to the patient with tear duct pathology: Surgical indications

Introduction and objective: To carry out a update review on the current diagnoses and therapeutic indications of tear duct obstruction (NLO) and propose a simple, early and practical clinical management. Method: Review of published literature regarding NLO and the current way of approaching this pathology. Results: The alteration of the natural tear flow (epiphora) may have a functional or anatomical origin. Functional obstructions are secondary to the failure of the tear pump, while the anatomical obstruction is caused by a physical obstacle along the tear duct that prevents drainage in the nasal cavity. Pseudoepiphora (tearing), on the other hand, is secondary to the presence of pathology of the ocular surface (dry eye) or secondary to mechanical, chemical, infectious or psychic stimuli. Up to 40% of patients referred to ophthalmology consultations for tearing / epiphora, have a dry eye with tear reflex, without anatomical obstruction of the tear duct. Conclusions: Tearing is one of the most frequent symptoms in ophthalmology consultations. However, the etiological factors that can lead to this complaint are very numerous. A multidisciplinary study (ophthalmology and ENT) is essential to make a correct etiological diagnosis. The success of tear surgery lies in a correct surgical indication.Introducción y objetivo: Realizar una revisión y actualización del diagnóstico e indicaciones terapéuticas de la obstrucción de la vía nasolagrimal (ONL), así como un abordaje clínico sencillo, precoz y práctico. Método: revisión de la literatura publicada referente a la ONL y sobre la manera actual de enfocar esta patología. Resultados: El lagrimeo excesivo (epífora) puede tener un origen funcional o anatómico. Las obstrucciones funcionales son secundarias al fracaso de la bomba lagrimal, mientras que la obstrucción anatómica es causada por un obstáculo físico a lo largo de la vía lagrimal que impide el drenaje de la misma en la cavidad nasal. La pseudoepífora (lagrimeo reflejo), por el contrario, es secundaria a la presencia de patología de la superficie ocular (ojo seco) o a estímulos mecánicos, químicos, infecciosos o psíquicos. Hasta un 40% de los pacientes referidos a consultas de oftalmología por lagrimeo/epífora, presentan un ojo seco con lagrimeo reflejo, sin obstrucción anatómica de la vía lagrimal. Conclusiones: El lagrimeo es uno de los síntomas más frecuentes en las consultas de oftalmología. Sin embargo, son muy numerosos los factores etiológicos que pueden conducir a esta queja. Es fundamental un estudio multidisciplinar (oftalmología y otorrinolaringología) para realizar un correcto diagnóstico. El éxito de la cirugía lagrimal reside en una correcta indicación quirúrgica

Recommendations for ophthalmologic practice during the easing of COVID-19 control measures

In the context of the COVID-19 pandemic, this paper provides recommendations for medical eye care during the easing of control measures after lockdown. The guidelines presented are based on a literature review and consensus among all Spanish Ophthalmology Societies regarding protection measures recommended for the ophthalmologic care of patients with or without confirmed COVID-19 in outpatient, inpatient, emergency and surgery settings. We recommend that all measures be adapted to the circumstances and availability of personal protective equipment at each centre and also highlight the need to periodically update recommendations as we may need to readopt more restrictive measures depending on the local epidemiology of the virus. These guidelines are designed to avoid the transmission of SARS-CoV-2 among both patients and healthcare staff as we gradually return to normal medical practice, to prevent postoperative complications and try to reduce possible deficiencies in the diagnosis, treatment and follow-up of the ophthalmic diseases. With this update (5th) the Spanish Society of Ophthalmology is placed as one of the major ophthalmology societies providing periodic and systematized recommendations for ophthalmic care during the COVID-19 pandemic

Genetic Testing for Wolfram Syndrome Mutations in a Sample of 71 Patients with Hereditary Optic Neuropathy and Negative Genetic Test Results for OPA1/OPA3/LHON

In this study, the authors present a sample of 71 patients with hereditary optic neuropathy and negative genetic test results for OPA1/OPA3/LHON. All of these patients later underwent genetic testing to rule out WFS. As a result, 53 patients (74.7%) were negative and 18 patients (25.3%) were positive for some type of mutation or variation in the WFS gene. The authors believe that this study is interesting because it shows that a sizeable percentage (25.3%) of patients with hereditary optic 25 neuropathy and negative genetic test results for OPA1/OPA3/LHON had WFS mutations or variants