Evaluacion de factores de riesgo exógenos y endógenos para la retinopatía diabética en pacientes con diabetes mellitus tipo 2 de larga evolución en un seguimiento a 18 meses

La diabetes mellitus se ha convertido en la enfermedad metabólica más frecuente hasta el punto de considerarse como la epidemia del siglo XXI. La retinopatía diabética (RD) es la complicación microvascular más frecuente de dicha enfermedad siendo la causa principal de pérdida de visión y ceguera legal en adultos en edad laboral, entre 20 y 65 años, en los países industrialmente desarrollados. OBJETIVO PRINCIPAL: Determinar las posibilidades de predecir el riesgo de presentación o progresión de la RD en base a la integración de diversos factores de riesgo exógenos y endógenos en una población mediterránea de pacientes con diabetes tipo 2 de larga duración. MATERIAL/MÉTODOS: Planteamos un estudio multicéntrico transversal y longitudinal en el contexto del ESTUDIO VALENCIA sobre RETINOPATIA DIABÉTICA (EVRD). Se incluyeron 200 participantes: 75 participantes sanos (grupo control) y 125 pacientes con DM2 de más de 5 años de evolución que a su vez fueron subdivididos en función de la presencia (55) o ausencia (75) de RD. En todos ellos se llevó a cabo una anamnesis inicial detallada, un cuestionario nutricional validado sobre dieta mediterránea, determinación del índice de masa corporal, exploración oftalmológica completa cada 6 meses hasta la visita final a los 18 meses y extracción de muestras sanguíneas en la visita inicial y 18 meses para determinar hemoglobina glicosilada (HbA1c), glucemia, triglicérdidos (TG) y análisis del estado oxidativo en plasma el cual se realizó mediante la prueba enzimático colorimétrica para la determinación del malonildialdehido (MDA) como producto de la peroxidación lipídica mediante el test del ácido tiobarbitúrico (TBA) y de sus especies reactivas (TBARS) y el análisis del estado antioxidante que se realizó mediante la prueba antioxidante total (AOX). Todos los datos se recogieron en hojas Excel específicamente diseñadas y procesaron con el programa SPSS versión 20. Los datos se corrigieron en función de la edad y sexo para evitar sesgos. RESULTADOS Y CONCLUSIONES: En nuestro estudio a 18 meses destacan como principales factores de riesgo para el desarrollo o progresión de la RD: el tiempo de evolución de la DM, la hipertensión arteria, la inactividad física, los hábitos tabáquico y alcohólico, el escaso cumplimiento de la dieta Mediterránea, y el aumento de HbA1c y parámetros relacionados el estrés oxidativo determinado por el aumento de los marcadores hemáticos pro-oxidantes (MDA/TBARS) y la disminución de las defensas antioxidantes. La concentración sanguínea de MDA/TBARS y la AOX se erigen como potenciales biomarcadores del riesgo de RD y podrían incorporarse a la práctica clínica para pautar, en base a ellos posibles cambios en los hábitos nutricionales o suplementos micronutricionales. El análisis integral de los datos demográficos, características del estilo de vida, examen oftalmológico y hematología de la población con DM2 nos ha aportado una serie de cifras y datos circunstanciales que nos han permitido diseñar una calculadora de riesgo para la RD, útil para oftalmólogos y aplicable en medicina de atención primaria, para ayudar a identificar a los pacientes que precisen optimizar las medidas preventivas y terapéuticas para prevenir la pérdida de visión que esta enfermedad provoca.Diabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus (DM) and is the leading cause of acquired blindness in people of working age in developed countries. Risk factors (RF) are really important in the development and progression of eye diseases so their study is extremely important to prevent their threatening effects. MAIN OBJECTIVE: To determine the possibilities of predicting the risk of development or progression of DR based on the integration of various exogenous and endogenous RF in a Mediterranean population of type 2 diabetes mellitus (T2DM) patients. MATERIAL / METHODS: We propose a multicenter and longitudinal study lasting for 18 months in the context of “The Valencia Study on Diabetic Retinopathy (VSDR)”. Suitable participants (200) were distributed into two main groups: controls (75) and T2DM patients (125) subdivided according to the presence (55) or absence (75) of RD. Data collected including demographics, anthropometrics, characteristics/lifestyle, a validated nutritional questionnaire of Mediterranean diet, complete ophthalmic examination (every 6 months), and blood parameters (glucose, glycosylated hemoglobin, triglycerides, malondialdehyde (MDA), and total antioxidant capacity (AOX)) at the initial and final visit were registered, integrated, and statistically processed by the SPSS 20 program. Age and sex data were adjusted to avoid bias. RESULTS AND DISCUSSION: In our study we have identified significant risk factors for the development or progression of DR, such as: duration of DM, hypertension blood pressure, physical inactivity, the smoking and drinking habits, poor compliance of Mediterranean diet, and increased HbA1c and oxidative stress related parameters determined by the increase of plasmatic oxidative stress biomarkers (MDA / TBARS) and decrease of AOX. The blood concentration of MDA / TBARS and AOX stand as potential biomarkers of risk of DR and could be incorporated into our clinical practice to indicate dietary changes or micronutrient supplements. With the analysis of demographic and lifestyle data, ophthalmological examination and blood parameters of T2DM population we have designed a RF calculator, useful for ophthalmologists and primary care, to help manage diabetic at risk of DR and vision loss

Treatment of Interface Fluid Syndrome after Laser-Assisted In Situ Keratomileusis with Descemet Membrane Endothelial Keratoplasty in Three Patients with Corneal Endothelial Dysfunction

Descemet Membrane Endothelial Keratoplasty (DMEK) has become a first-line treatment in corneal endothelial diseases owing to its exceptional clinical outcomes and low complication rates. Thanks to its refractive predictability and the ability to reshape the superficial cornea, DMEK is now also considered for managing cases with endothelial decompensation following previous refractive procedures. This article reviews the clinical outcomes of DMEK in three patients with Interface Fluid Syndrome (IFS), a complication of laser-assisted in situ keratomileusis (LASIK) in which endothelial failure can play a major role

Característiques de les poblacions larvaries hivernants de Chilo Suppressalis Walker al delta de l'Ebre (Lepidoptera: Crambidae)

Un aspecte interessant i, probablement, un dels menys coneguts del cicle biològic de Chilo suppressalis Walker és la capacitat que tenen algunes formes larvàries per fer front a l'hivern. El present estudi, dut a terme a la zona arrossera del Delta de l'Ebre, s'ha centrat en la caracterització de les larves de C. Suppressalis, comparant les que es troben en el rostoll d'arròs amb les que es refugien a les canyes de senill (Phragmites sp.), i en la tipificació de la pauta de crisalidacià d'aquestes larves, a partir de les quals s'inicia la primera generació que ataca les plantes d'arròs. Els resultats obtinguts posen de manifest, per un cantó, una sèrie de característiques que diferencien clarament a les larves que passen l'hivern en el rostoll de les que ho fan en el senill, i, per l'altre, demostren que, si bé a nivell local les poblacions hivernants crisaliden en un espai de temps relativament curt (15-20 dies), en el conjunt del Delta aquest s'estén, com a mínim, fins a un mes i mig.Features of ¡he wintering larvae populations of Chilo suppressalis Walker at the Ebro Delta (Lepidoptera: Crambidae). The rice stern borer (Chilo suppressalis Walker) spends the winter as larvae. This matter is probably one of the least known aspects of the life cycle of this lepidoptoran. In this study, the main morphological features of the wintering larvae suppressalis of C. in the paddy-fields of the Ebro Delta (Northeastem Spain) have been analyzed. The larvae that overwinter in the rice stubble are compared with those that shelter in the reed stems (Phragmites sp.). Moreover, the pupation pattern of such oligopausing larvae has been anal yzed, so as to typify the eclosion of the first generation of the rice season. The results obtained show that according to the plant used as refuge the larvae exhibit different morphological characters. Further, although at local level the wintering populations pupate in a brief time interval (15-20 days), for the whole Ebro Delta the average minimum to pupation is 40-50 days

The Efficacy and Patient Satisfaction with a Mini-Scleral Lens after penetrating Keratoplasty

Background: To analyse the efficacy and patient satisfaction of fitting a mini-scleral lens (SL) after keratoplasty surgery in patients unsatisfied with their visual outcomes. Material and Methods: A retrospective chart review of 22 consecutive patients was performed between 2018 and 2019. Demographic data, indications for keratoplasty, ocular parameters, and visual results were evaluated. In addition, subjective visual quality (SVQ) and comfort, complications, daily wear time, and the reason for discontinuing SL wear during the 6-month follow-up were analysed. Results: Twenty-two eyes of 22 patients (6 females and 16 males; mean age 48.82 ± 17.19 years) were assessed. Keratoconus was the main indication for keratoplasty (9 eyes, 40.9%), followed by corneal opacities (5 eyes), and Fuchs endothelial dystrophy (4 eyes). High refractive anisometropia was found in 14 eyes (63.6%) and 6 eyes presented significant irregular astigmatism. LogMAR visual acuity improved significantly with SL when compared with the best spectacle-correction (mean, 0.12 ± 0.12 vs 0.52 ± 0.33, respectively; p < 0.01). Six patients discontinued SL wear (27.3%). Among the other 16 patients, the mean daily wear time was 11.47 ± 1.52 h; of these, 14 (87.5%) were successfully fitted and enjoyed favourable SVQ and comfort. No significant complications were found during the follow-up period. Conclusions: Mini-scleral lenses may be a safe and effective alternative for treating complicated eyes after keratoplasty; they may provide optimal visual rehabilitation and/or restore binocular vision with significant efficacy and patient satisfaction

Evaluation of a new nomogram for Ferrara ring segment implantation in keratoconus

AIM: To evaluate the short-term clinical outcomes of Ferrara rings in keratoconus using an optimized nomogram developed after several years of research and retrospective analysis of clinical data. METHODS: This prospective longitudinal non-comparative clinical trial evaluated 88 eyes of 88 patients (age 18-62y) with keratoconus diagnosis from two Spanish centers. Ferrara ring segment (AJL Ophthalmic) implantation was performed in all cases, using the mechanical procedure in 25 eyes (28.4%) and a femtosecond laser-assisted procedure in 63 eyes (71.6%). The ring segments implanted in each case were selected using a new optimized nomogram that considered variables such as anterior corneal asphericity and astigmatism or the discrepancy among astigmatism and coma orientations. Visual, refractive, corneal topographic, aberrometric, and pachymetric changes after surgery were evaluated during a 3-month follow-up. RESULTS: The implants induced a significant refractive change as well as an improvement in uncorrected (UDVA) and corrected distance visual acuity (CDVA; P<0.001). Postoperative CDVA of 0.10 logMAR or better was achieved in 28.4% and 46.5% of eyes, respectively. Two eyes (2.3%) lost two or more lines of CDVA whereas a total of 53.5% of eyes gained lines of CDVA. A significant central anterior and posterior corneal flattening was induced (P≤0.003), with a significant reduction of anterior (P<0.001) and posterior corneal astigmatisms (P=0.048), and a change in anterior asphericity (P<0.001). Total primary coma (6 mm pupil) change was also statistically significant (preoperative 3.66±3.04 ?m vs postoperative 2.33±2.26 ?m, P<0.001). No significant differences were found in the effect of ring segments between cases implanted using the mechanical and femtosecond techniques (P≥0.101). CONCLUSION: The implantation of Ferrara rings based on the nomogram evaluated is safe and effective for promoting a visual rehabilitation in keratoconus, with a relevant control of primary coma aberration.Supported by the Ministry of Economy, Industry and Competitiveness of Spain within the program Ramón y Cajal (RYC-2016-20471)

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

Background: Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this. Objectives: To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids. Search methods: We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors. Selection criteria: We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake. Data collection and analysis: Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression. Main results: We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted. Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and it may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence), and probably reduces risk of CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs), and arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear. Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression. There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, although LCn3 slightly reduced triglycerides and increased HDL. ALA probably reduces HDL (high- or moderate-quality evidence). Authors' conclusions: This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event risk, CHD mortality and arrhythmia

Improving Visual Comfort during Computer Gaming with Preservative-Free Hyaluronic Acid Artificial Tears Added to Ergophthalmological Measures

Digital asthenopia (DA) or Computer Vision Syndrome can occur after prolonged use of digital devices and is usually managed with ergophthalmological measures and the use of artificial tears. This prospective, controlled study evaluated the use of hyaluronic acid artificial tears on the signs and symptoms of DA in participants of a videogame convention. Subjects (n = 56) were randomized into a control group (CG, n = 26), which followed ergophthalmological measures, and a study group (SG, n = 30), which followed ergophthalmological measures and instilled 1 drop of artificial tears with hyaluronic acid 0.15% four times a day. Subjects were evaluated before and after playing for three consecutive days for eye dryness (SPEED questionnaire), conjunctival hyperemia, corneal fluorescein staining, conjunctival lissamine green staining, tear breakup time, Schirmer I test, near convergence and accommodation, and using questionnaires for DA symptoms. After 3 days of intense videogaming, the SPEED score of CG increased significantly (p = 0.0320), while for the SG it was unchanged. Similarly, the CG presented significant increases in ocular fatigue (p = 0.0173) and dryness (p = 0.0463), while these parameters decreased significantly in the SG (p = 0.0149 and p = 0.00427, respectively). This study confirms the protective effect of hyaluronic acid artificial tears against DA symptoms associated with prolonged visual display terminal use.This study was funded by Laboratoires Théa SA.Medicin

Effect of the variability in implantation depth of intracorneal ring segments using the femtosecond laser technology in corneal ectasia

Purpose: To analyze the impact of the depth of implantation of intracorneal ring segments on morphological, biomechanical, and clinical outcomes in ectatic corneas. Methods: This prospective longitudinal study enrolled 40 eyes of 29 patients (age 20–51 years) with corneal ectasia that underwent intracorneal ring segments implantation (KeraRing, Mediphacos). Changes in visual acuity, refraction, corneal tomography, and corneal biomechanics (Ocular Response Analyzer, Reichert) were evaluated during a 6 month follow-up. Likewise, changes in ring segment implantation depth measured by optical coherence tomography (Visante OCT, Carl Zeiss Meditec) were also evaluated. Results: Mean relative depth of implantation was 71.6 ± 5.8%, 71.5 ± 6.5%, and 71.9 ± 6.3% at 1, 3, and 6 months after surgery, respectively (p = 0.827). The difference between the real relative depth of implantation and the theoretical attempted value of 70% was not statistically significant (p = 0.072). Differences in spherical equivalent during the follow-up changed significantly depending on the level of relative depth of implantation (p = 0.036), with an increase of 0.114 D per each 1% increase in relative depth of implantation. Likewise, a decrease of –0.194 D in the steepest keratometric reading was found per each decrease of 1% in relative depth of implantation (p = 0.026). Changes in corneal thickness (p = 0.092) and biomechanics (p = 0.080) were not related to relative depth of implantation. Conclusion: The effect on visual acuity and refraction of intracorneal ring segments when implanted in corneal ectasia is less clinically relevant when the implantation is done at a very deep plane. The variability of the depth of intracorneal ring segments implantation when using femtosecond laser technology is minimal and with no clinically significant effect on clinical outcomes.The author David P Piñero has been supported by the Ministry of Economy, Industry and Competitiveness of Spain within the program Ramón y Cajal, RYC-2016-20471

Two-Year Follow-up of Intracorneal Ring Segments Implantation in Adolescent Patients With Keratoconus

PURPOSE:To evaluate the visual, refractive, topographic, and aberrometric outcomes after intracorneal ring segments (ICRS) implantation in adolescent patients with keratoconus. METHODS:A retrospective longitudinal study was undertaken with a total of 61 eyes from 47 patients with keratoconus, aged between 13 and 18 years, implanted with a Ferrara-type ICRS. Topography (flattest keratometry, steepest keratometry, and asphericity), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive error (sphere and cylinder), and aberrometric measurements (spherical aberration and vertical coma) were evaluated before surgery and at 1 month, 6 months, 1 year, and 2 years after surgery. RESULTS:UDVA exhibited a statistically significant increase at all times from 1 month to 2 years postoperatively (P < .001), whereas CDVA showed a statistically significant improvement at 1 month, 6 months, and 2 years (P < .002), but dropped in significance at 1 year postoperatively (P = .097). The refractive error analysis showed no variation in statistical significance in the sphere (P = .712) after 2 years. The cylinder presented a statistically significant decrease in diopters at all times from preoperatively to 2 years postoperatively (P < .007). Steepest keratometry manifested a statistically significant decrease in steepness at all times after surgery (P < .001), whereas flattest keratometry lost significance at 1 year (P = .298) and 2 years (P = .053) postoperatively. There was no statistically significant change in the spherical aberration at any of the measured times. The vertical coma was only significantly different at 2 years postoperatively (P = .001). CONCLUSIONS:ICRS implantation is a safe and effective treatment for improving visual and corneal morphological parameters as shown at 2 years of follow-up in adolescent patients with keratoconus. It is a good option to flatten and regularize the cornea and to temporarily improve the quality of life of young patients and delay the need for keratoplasty.Programa Nacional de Cooperación Público-Privada. Subprograma INNPACTO 2015 ECTASIA Project (CP-M).Medicin