An 8-year-old girl, who underwent pars plana lensectomy and vitrectomy for non-infectious uveitis, was treated with a dexamethasone intravitreal implant (Ozurdex^®, Allergan Inc., Irvine CA), because of the persistence of cystoid macular edema. The implant migrated into the anterior chamber; however, no cornea edema was detected and a complete resolution of macular edema was observed.

El síndrome de isquemia ocular es una patología rara, secundaria a hipoperfusión debido a estenosis o oclusión de las arterias carótidas común o interna. Varón, de 78 años, que acudió por disminución de agudeza visual progresiva, de meses de evolución, en su ojo derecho (OD). La Mejor Agudeza Visual Corregida (MAVC) en su OD era de no percepción de luz. La exploración biomicroscópica del polo anterior en OD reveló la presencia de microhipema y neovascularización iridiana en los 360º. La presión intraocular era normal. Mediante la exploración funduscópica y la angiografía fluoresceínica, se confirmó la presencia de signos de isquemia retiniana y coroidea, todo ello compatible con un posible síndrome de isquemia ocular. Se realizó panretinofotocoagulación, y se solicitó Eco-Doppler de Troncos Supraaórticos y angio-TC que confirmaron la presencia de una obstrucción completa en la arteria carótida interna derecha, no susceptible de tratamiento quirúrgico. A los 7 meses, el paciente permanece estable clínicamente, desde el punto de vista ocular y sistémico. En estos casos, es de gran trascendencia la evaluación sistémica del paciente, incluyendo realización de Eco-Doppler de TSA o angio-TC, y el abordaje multidisciplinar, pues un adecuado y precoz diagnóstico puede condicionar no solo el pronóstico visual, infausto en nuestro caso, sino también la supervivencia del paciente. Palabras clave: obstrucción carotídea, isquemia ocular, glaucoma, neovascularización, agudeza visual. Abstract Ocular ischemic syndrome is a rare condition, secondary to hypoperfusion due to stenosis or occlusion of the common or internal carotid artery. A 78 year-old male, who complained of progressive acuity visual loss, in his right eye (RE). His Best Corrected Visual Acuity (BCVA) in RE was No light perception. Biomicroscopic exploration of anterior segment revealed the presence of microhyphema and iris neovascularization in 360 degrees. Intraocular pressure was normal. Fundoscopy and fluorescein angiography confirmed the presence of retinal and choroidal ischemia, compatible with an ocular ischemic syndrome. Panretinophotocoagulation was performed, and Eco-Doppler of supraaortic trunks (SAT) and angio-CT were requested, and they confirmed the presence of complete obstruction of right internal carotid artery, surgically untreatable. Seven months ago, the patient remains clinically stable, with no ocular nor systemic changes. In these cases, systemic evaluation of the patients, including performance of Eco-Doppler of SAT or angio-CT, and the multidisciplinary approach, is crucial, as a prompt and adequate diagnosis can influence visual prognosis, awful in our case, and patient survival.

A 45-year-old man submitted to radial keratotomy 19 years ago acquired Cladosporium sp. infection in one of the incisions of the left eye. The infection was resistant to topical amphotericin B, topical natamycin and systemic fluconazole. The keratitis was cured with voriconazole 200 mg PO, BID for 10 days.

Resumen Objetivo: Determinar las modificaciones de la curvatura posterior de la córnea en pacientes a los que se realizó queratomileusis subepitelial asistida por laser miópico en el período de abril a noviembre 2011. Método: Fueron estudiados 15 pacientes (29 ojos), a los que se realizó queratomileusis subepitelial asistida por laser miópico. Se analizaron variables como edad, sexo, equivalente esférico, paquimetría preoperatoria, cantidad de ablación, estroma residual y diferencia de elevación posterior corneal, esta última obtenida del mapa de diferencia del tomógrafo Pentacam HR con medición preoperatoria, al mes y tres meses de la cirugía. Se realizó análisis de regresión múltiple. Resultados: El equivalente esferico, la paquimetria, cantidad de ablacion y el estroma residual se encontraron dentro de los parametros de seguridad establecidos. La diferencia promedio de la elevacion posterior corneal fue de 3,3 μm al mes, disminuyendo a 2,4 μm a los tres meses. Se observo relacion con la cantidad de ablacion y el estroma residual. Conclusiones: La queratomileusis subepitelial asistida por laser determinó modificaciones en la superficie corneal posterior, las cuales fueron más evidentes en el primer mes del posoperatorio. El estroma residual fue el factor más relacionado con estas modificaciones. Palabras clave: LASEK, elevación corneal posterior, paquimetría, estroma residual, total de ablación. Abstract Purpose: To determine the posterior corneal surface forward shift in myopic patients after laser-assisted subepithelial keratectomy from April to November 2011. Material and methods: Fifteen patients (29 eyes) were submitted to laserassisted subepithelial keratectomy surgery. Age, sex, spherical equivalent, preoperative corneal thickness, total ablation, residual bed thickness and variations in the posterior corneal surface elevation were evaluated. Posterior corneal surface elevation maps were assessed by Pentacam HR tomography and compared with the data of maps obtained prior to the surgery, one and 3 months after the procedure. Results: The spherical equivalent, pachymetry, microns of ablation and residual bed thickness were within the established parameters. The posterior corneal surface displayed a forward shift of 3,3 μm after a month and 2,4 μm three months later. A relation was found between total ablation, and residual bed thickness. Stepwise lineal multiple regression was used. Conclusions: The use of the laserassisted subepithelial keratectomy determined a forward shift of the posterior corneal surface in the early postoperative that gradually decreased. Residual bed thickness was a relevant factor associated to this change.

Purpose: To assess the visual outcome and refractive error following wavefront (WF)-optimized laser in situ keratomileusis (LASIK) retreatment after previous WF-guided LASIK in myopic patients. Methods: A retrospective analysis of 19 eyes (14 patients) following WF-optimized LASIK retreatment after previous WF-guided LASIK that did not give desired refractive results was conducted. The primary LASIK procedures were performed using the Visx CustomVue™ laser with WF-guided technology. All of the subsequent retreatment LASIK procedures were performed with the Wavelight Allegretto™ Eye-Q 400 excimer laser using WF-optimized. Ophthalmic evaluations including uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA), and manifest refraction spherical equivalent (MRSE) were performed at baseline and postoperatively at 1, 3, 6 months. Results: UCVA and BSCVA improved following retreatment from 0.27±0.18 and 0.0±0.05 to 0.01±0.05 and -0.03±0.05 respectively at 6 months (p<0.001 and p=0.38). The MRSE decreased from -0.5 D pre-retreatment to -0.2 D at 6 months postretreatment. The pre-retreatment total HOA was 0.48±0.21 (0.24 to 1.01μm) and did not show correlation with the visual outcomes postoperatively. No intra-operative or postoperative complications occurred. Conclusions: The results of this small case series with patients presenting low degrees of residual ametropia indicate that WF-optimized LASIK retreatment could be considered as an option after primary WFguided LASIK. Retreatment with WF-optimized LASIK is safe and the results are predictable.

Age-related macular degeneration (AMD) is a chronic disease affecting the retina and is the most common cause of blindness in the ageing population in the developed world. Correct and timely diagnosis and classification allows physicians to estimate which patients are at high risk of progressing to more advanced stages of the disease In February 2012, 23 Latin American experts met in Cartagena, Colombia, to develop a Consensus on AMD. This paper summarizes the main points of the discussions including definitions, diagnosis, antiangiogenic treatments, and hopes for the future. Dry AMD remains untreatable but results from promising Phase II trials are awaited eagerly. Antiangiogenics, such as the licensed vascular endothelial growth factor (VEGF) inhibitors, aflibercept and ranibizumab, have revolutionized the treatment of wet AMD in recent years. These drugs work by inhibiting the choroidal neovascularization that causes the rapid vision loss in wet AMD. Another antiangiogenic, bevacizumab, is also commonly used off-label, but is not approved currently for intraocular use. However, barriers to treatment compliance, due to the frequency of monthly injections, can also affect the efficacy of these antiangiogenic therapies. Aflibercept has a longer duration of action compared with other treatments and thereby offers reduced injection frequency. By relieving patients of the need for monthly visits, it can help reduce the growing burden of AMD patients on healthcare resources.

Resumen La queratopatía cristalina es una infección corneal de evolución crónica en la que podemos encontrar un infiltrado estromal blanco arboriforme asociado a una mínima reacción inflamatoria. La mayoría de los casos ocurren en córneas transplantadas en tratamiento con corticoides tópicos. Mujer de 91 años con antecedentes de perforación ocular tratada mediante queratoplastia penetrante excéntrica. Un año después presentó una agudeza visual de percepción de luz, gran reacción inflamatoria y un infiltrado corneal blanquecino de aspecto arboriforme. Se inició tratamiento con vancomicina intravenosa y vancomicina y amikacina intravítreas, tópicas e intracamerulares y se obtuvieron muestras de humor acuoso y del infiltrado corneal mediante arrastre con aguja de safil de 8/0 con resultado microbiológico positivo para Candida Parapsilosis. Se inició entonces tratamiento con voriconazol y trimetroprimsulfametoxazol tópicos con respuesta favorable. En la queratopatía cristalina, la reacción inflamatoria inducida en el huésped suele ser leve debida, en parte, a la escasa replicación de los microorganismos implicados. El caso que presentamos es atípico puesto que encontramos una intensa reacción inflamatoria; sin embargo tanto el aspecto biomicroscópico de la córnea, como el resultado del análisis microbiológico y la respuesta positiva al tratamiento, apoyan el diagnóstico de queratopatía cristalina por Candida Parapsilosis. Palabras clave: queratopatía, cristalina, infección, corneal,cándida Crystalline keratopathy is a corneal infection with chronic evolution in which we can find white branching aggregates in corneal stroma in absence of host inflammatory response. It most frequently occurs in corneal grafts with chronic topic corticosteroid treatment. 91-years-old woman with tectonic keratoplasty because of ocular perforation who presented one year later of surgery a best corrected visual acuity of light perception with intense inflammatory response and white branching aggregates in corneal stroma. Treatment with intravenous vancomycin and topic, intravitreal and intracameral vancomycin and amikacin was started. Aqueous humor and corneal infiltrate samples were obtained. The second one was acquired by dragging using a safil 8/0 needle. Microbiological study showed an infection by candida parapsilosis, so treatment with topic voriconazol and trimethoprim sulfamethoxazole was started with good clinical evolution. Crystalline keratopathy usually associates a small host inflammatory response, in part due to the poor replication of involved microorganisms. The case presented previously is an atypical one because of the intense inflammatory response, however, clinical appearance, microbiological results and treatment response are typical of crystalline keratopathy.

We report a case of adult-onset foveomacular vitelliform dystrophy complicated with atrophic involution and subsequent choroidal neovascularization and treated with intravitreal ranibizumab. A 71-year-old woman diagnosed with adult-onset foveomacular vitelliform dystrophy experienced a progression of the vitelliform lesion to the atrophic stage in her left eye immediately after cataract surgery. Best-corrected visual acuity decreased from 0.5 to 0.16. Ten months later, the patient was referred with new worsening of her visual acuity (0.05) and metamorphopsia. The spectral-domain optical coherence tomography confirmed the presence of type 2 choroidal neovascularization next to the atrophic area. The patient was treated with 2 monthly injections of ranibizumab. Spectral-domain optical coherence tomography images improved significantly and her best-corrected visual acuity increased to 0.20 associated with subjective improvement of metamorphopsia. Ranibizumab may be effective for choroidal neovascularization in patients with adult-onset foveomacular vitelliform dystrophy.

A 27-year-old woman with bilateral high myopia had anterior chamber iris-claw phakic intraocular lens implantation in her left eye under local anesthesia and with no intraoperative complications. The preoperative slit-lamp examination was normal, and she had no relevant past medical history. On the second postoperative day, patient developed fixed, dilated mydriasis, and one month later, an IOL subluxation was noted on examination. She had no history of intraocular hypertension and no mydriatic drops were used. She was ultimately diagnosed with Urrets-Zavalia syndrome. We removed the IOL and observed the patient for six months after fitting her with a colored contact lens. During this period of time, she complained of glare and photophobia and developed contact lens intolerance. To bring more comfort to the patient, we implanted a posterior chamber Implantable Collamer Lens (ICL) and performed iris cerclage in the left eye with good aesthetic and refractive outcome. Posterior chamber ICL implantation with iris cerclage proved to be a simple and effective approach in the management of this situation.

Purpose: To present six cases of macular suberetinal hemorrhage who underwent intravitreal treatment with rtPA, ranibizumab and SF₆. Methods: Size and location of the hemorrhage and visual acuity were evaluated prior and after treatment. Results: Mean pretreatment visual acuity was hand movements at one meter, and three months later, 0.18 (decimal notation) (p>0.05). A partial displacement of de suberetinal hemorrhage from the fovea was achieved in all patients. Discussion: This triple procedure is an useful option for the treatment of suberetinal hemorrhage. However, the tissular damage associated to the subjacent disease in some cases does not allow significant functional improvement.

Purpose: To analyze the prevalence and morphometric characteristics of macular hole development in patients with neovascular age-related macular degeneration treated with ranibizumab. Methods: Patients diagnosed of neovascular age-related macular degeneration from January 2009 to December 2010 have been analyzed. Measurement of visual acuity and optical coherence tomography were scheduled. Results: Two hundred and thirteen eyes (patients) with exudative age-related macular degeneration were analyzed. Development of macular hole was evidenced in 4 eyes (1,9%) Discussion: Macular hole formation is a severe complication in patients with choroidal neovascularization treated with ranibizumab, frequently undervalued, which interferes with final outcome.

This article reviews the Bayesian statistical approach to diagnostic test analysis and application in the management of glaucoma patients. The central idea of the Bayesian method is the use of study data to update the state of knowledge about a quantity of interest. In diagnostic test analysis, the Bayesian approach explicitly elicits a clear interpretation of chances of a particular eye disease given a positive test result. The Bayesian method also provides a reasonable rationale for deciding whether to perform a laser iridotomy in a patient with occludable angles. We present several literature examples of Bayesian methods in practice, especially as it relates to glaucoma evaluation and progression.

Purpose: To review two cases of open angle glaucoma(OAG) refractory to medical and surgical treatment that underwent a novel surgical technique. Methods: Case reports of a novel surgical technique which consists in a trabeculectomy with Mitomycin C and aqueous diversion to the suprachoroidal space. Results: The target intraocular pressure remains stable after surgery without using any medical treatment. No severe complications were observed during follow-up. Conclusion: Managing intraocular pressure in refractory glaucoma has always been a challenge, and the need of both surgical and medical approaches is common. This novel surgical technique has the advantage of using 2 filtering pathways, which allows an adequate aqueous humor drainage even if one of the pathways fails.

We report the occurrence and management of a massive serous detachment of the macula, which followed trabeculectomy and lowering of the intraocular pressure (IOP) in a patient with central retinal vein occlusion (CRVO) and a previously undiagnosed complex coagulopathy with elevated plasma fibrinogen and homocysteine levels, as well as prothrombin 20210 and factor V Leiden mutations. Our case illustrates prompt resolution of the serous detachment with elevation of the IOP, and acute recurrence of the detachment following subsequent recurrence of hypotony after aqueous tube shunt surgery. Residual cystoid macular edema (CME) in the right eye, as well as hemiretinal vein occlusion with serous macular detachment and CME in the fellow left eye responded to bevacizumab. The occurrence of severe macular edema following lowering of intraocular pressure may warrant further evaluation for possible underlying venous occlusive disease or systemic coagulopathy.

PURPOSE To summarize the original literature on ab interno trabeculectomy with the Trabectome system and to review its efficacy and safety in the treatment of glaucoma. METHOD A literature search in PubMed was performed on ab interno trabeculectomy with the Trabectome system, and clinical relevant information was reviewed and summarized. RESULTS Ab interno trabeculectomy with the Trabectome system on average lowered intraocular pressure (IOP) to the mid-teens, and decreased the number of required glaucoma medications. Greater preoperative IOP correlated to a greater percent reduction in IOP. The success rates varied among studies, and the definition of success differed by authors. Intraoperative blood reflux was found in nearly all cases. Incidences of early hypotony and IOP spikes were low. No cases of endophthalmitis, wound leak, aqueous misdirection, choroidal hemorrhage or effusions, and irreversible visual acuity decrease (≥2 Snellen lines) have been reported. Available studies had a significant amount of data overlap. Only limited data on long-term results was available. There was no randomized controlled trial to date. CONCLUSIONS Ab interno trabeculectomy with the Trabectome system is an effective and safe surgical approach for patients with various types of open angle glaucoma. On average, the procedure at least in the short term lowers IOP to the mid teens regardless of preoperative IOP with or without the aid of topical medications.

Purpose: To report the results of a Latin American (LA) consensus panel regarding the diagnosis and management of primary open angle glaucoma, and to compare these results with those from a similar panel in the United States (US). Design: A RAND-like appropriateness methodology was used to assess glaucoma practice in LA. Methods: The 148 polling statements created for the RAND- like analysis in the US and 10 additional statements specific to glaucoma care in LA were presented to a panel of LA glaucoma experts. Panelists were polled in private using the RAND- like methodology prior to and after a panel meeting. Results: Consensus agreement or disagreement amongst LA experts was reached for 51.3% of statements prior to the meeting and increased to 66.5% in the private, anonymous post meeting polling (79.0% agreement, 21.0% disagreement). While there was a high degree of concordance (111 of 148 statements, 75%) between the results of this LA panel and the US panel, there were some notable exceptions relating to diagnostic and therapeutic decision-making. Conclusions: This RAND-like consensus methodology provides a perspective of how LA glaucoma practitioners view many aspects of glaucoma and compares these results with those obtained using a similar methodology from practitioners in the US. These findings may be helpful to ophthalmologists providing glaucoma care in LA and in other regions of the world.

A 57 year-old woman presented an irritated right eye and right-sided enophthalmos with hypoglobus for the past year. The patient previously had an extensive right-sided cystic orbital schwannoma removed with orbital reconstruction 5 years ago. Imaging revealed an enlarged right orbit with medial wall collapse and inferior displacement of a floor plate implant. An anterior orbitotomy with placement of an enophthalmos implant, three 1 mm Medpor sheets, an orbital rim implant, and an oral mucosa graft in inferior fornix with a lateral strip were used to reconstruct the ocular malposition and right lower lid retraction. We report a successful case of a complex orbital reconstruction in a patient with orbital deformity subsequent the removal of a massive cystic schwannoma.

Fetal rhabdomyoma is a rare neoplasm composed of immature striated muscle cells that resemble rhabdomesenchymal cells during weeks 6-10 of embryogenesis. This tumor, though well-described in many anatomic locations, is most commonly found in the head and neck region. We report a case which highlights the difficulty in diagnosing a fetal rhabdomyoma in the lacrimal gland of a 56 year old woman. This case report gives an overview of this rare neoplasm, detailing the presentation, diagnosis, and management.

Retinal phototoxicity caused by light from endoilluminator used in vitrectomy has been described in the scientific literature. Xenon light can be one of the most harmful sources of radiation to the retina if adequate filters are not used as that radiation is near ultraviolet spectrum. We present herein a case series of patients who developed retinal phototoxicity induced by xenon light, after macular hole surgery. Macular phototoxic damage with foveal involvement remains a factual danger during vitrectomy using Xenon light as endoilluminator with inadequate filters.

Purpose: To report the 6-month anatomic and Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) response after the combination of intravitreal adalimumab (Humira) and bevacizumab (Avastin) in patients with macular edema of various etiologies. Methods: Retrospective interventional case series. We reviewed the clinical records of 5 consecutive patients (7 eyes) with macular edema of various etiologies including pseudophakic macular edema, diabetic papillophlebitis, central retinal vein occlusion, branch retinal vein occlusion, and exudative age-related macular degeneration. All patients were treated with at least one intravitreal injection of 1.25 mg/0.05 mL of bevacizumab and 2 mg/0.08 mL of adalimumab. Results: The mean number of combined bevacizumab and adalimumab injections per eye was 2.14 (range: 1 to 4 injections) at 6 months. The baseline BCVA improved from 1.19 ± 0.6 logarithm of the minimum angle of resolution (logMAR) to 0.94 ± 0.59 logMAR at 6 months (P < 0.05). Four (57.1%) of seven eyes gained ≥ 3 ETDRS lines of BCVA. Central macular thickness (CMT) at baseline by optical coherence tomography (OCT) had a mean of 416 ± 150 µm which was reduced to a mean of 354 ± 205 µm at 6 months (P < 0.05). There were no ocular or systemic complications. Conclusions: Combined intravitreal bevacizumab at doses of 1.25 mg and adalimumab at doses of 2.0 mg seems to provide stability or improvement in BCVA, OCT, and fluorescein angiography in macular edema of various etiologies with no systemic complications at 6 months of follow up. Resumen Objetivo: Reportar la respuesta anatómica y de agudeza visual mejor corregida (AVMC) posterior a la combinación del adalimumab intravítreo (Humira) y bevacizumab (Avastin) en pacientes con edema macular de variadas etiologías. Métodos: Serie retrospectiva intervencional de casos. Se revisaron los registros médicos de cinco pacientes consecutivos (siete ojos) con edema macular de variadas etiologías, incluyendo edema macular pseudofáquico, papiloflebitis diabética, oclusión de la vena central de la retina, oclusión de rama venosa retiniana, y degeneración macular relacionada con la edad. Todos los pacientes fueron tratados con al menos una inyección intravítrea de 1,25 mg/0,05 mL de bevacizumab y 2 mg/0,08 mL de adalimumab. A los pacientes se les cuantificó su AVMC por cartilla del Estudio del Tratamiento Temprano de la Retinopatía Diabética (EDTRS), examen oftalmológico, tomografía de coherencia óptica (TCO) y angiografía fluoresceínica (AGF) al inicio, y a las visitas en el primer, tercer y sexto mes. Los resultados se basaron en las modificaciones de la AVMC y la TCO. Resultados: La edad media de los pacientes fue de 71,5 ± 9,4 años. La media de inyecciones combinadas de bevacizumab y adalimumab fue de 2,14 por ojo (rango: 1 a 4 inyecciones) a seis meses. La AVMC basal mejoró de 1,19 ± 0,6 logaritmo del mínimo ángulo de resolución (logMAR) a 0,94 ± 0,59 logMAR a sies meses (P < 0,05). Cuatro (57,1%) de los siete ojos ganaron ≥ 3 líneas ETDRS de AVMC. El espesor macular central (EMC) al inicio por TCO tuvo una media de 416 ± 150 µm, el cual se redujo a una media de 354 ± 205 µm a seis meses (P < 0,05). No hubo complicaciones oculares o sistémicas. Conclusiones: El tratamiento intravítreo combinado de bevacizumab y adalimumab a dosis de 1,25 mg y 2,0 mg respectivamente impresiona proporcionar mejoría o estabilidad en la AVMC, TCO y AGF en edema macular de variadas etiologías sin complicaciones sistémicas a los seis meses de seguimiento. A pesar de las limitaciones por el pequeño tamaño de la muestra, corto seguimiento, y la falta de un grupo control, los resultados sugieren una potencial bioactividad relacionada con los favorables resultados anatómicos y visuales.

Anterior segment optical coherence tomography (OCT) is an innovative technique that provides detailed images of internal structures in biological tissues with a noncontact, noninvasive, high resolution exam for evaluation of anterior segment and ocular surface. This article reviews the fundamentals and clinical applications of OCT, considering relevant information about advantages and limitations, describing its role in the diagnosis, surgical planning and clinical evaluation of patients with a variety of conditions from anterior segment. We included images of clinical cases evaluated at the department of cornea and external diseases at UC Davis Medical Center, using high resolution spectral-domain OCT (Heidelberg Engineering GmbH. Germany) for the study of the anterior segment. Resumen La Tomografía de Coherencia Óptica (OCT) del segmento anterior de ojo es una innovadora técnica que provee imagen detallada de la estructura interna de tejidos biológicos con un examen no invasivo, sin contacto y de alta resolución, para la evaluación de segmento anterior y superficie ocular. Este artículo revisa los fundamentos y aplicaciones clínicas de OCT, considerando información relevante acerca de las ventajas, limitaciones y describiendo su rol en el diagnóstico, planificación quirúrgica y evaluación clínica de pacientes con una variedad de condiciones del segmento anterior. Hemos incluido imágenes de casos clínicos evaluados en el Departamento de córnea y enfermedades externas de UC Davis Medical Center, utilizando OCT Spectralis (Heidelberg Engineering GmbH. Germany), de alta resolución, para el estudio de segmento anterior.