Ocular involvement in patients with chronic myelomonocytic leukemia (CMML) is rarely reported, owing in part to the fact that the severe illness faced by many of these patients limits the feasibility of ocular examinations. Nevertheless, post-mortem examination of eyes from patients without ophthalmological symptoms and diagnosis of CMML has revealed ocular infiltration of atypical cells. We presented a 72-year-old man with two days of left-sided blurring of vision and an episode of transient visual obscuration associated to periorbitary pain. To our knowledge, this is the second case in peer-reviewed literature reporting the association between arteritic anterior ischemic optic neuropathy (AAION) and chronic myelomonocytic leukemia. A possible explanation is the fact that small vessel vasculitis, of unclear pathogenesis so far, complicates approximately 10% of CMML and presents as cutaneous vasculitis and lupus-like syndromes. Therefore, this may be in relation with the vasculitis of the short posterior ciliary arteries, which happens in cases of AAION.

The authors report a case presenting an spontaneous progressive enlarging lamellar macular hole through serial quantification by optical coherence tomography during a four year follow-up.

A patient with Birdshot retinochoroidopathy that presented with isolated optic nerve swelling is reported. Neuroimaging and serum testing for infectious or inflammatory etiologies were unremarkable. Indocyanine angiography revealed multiple round dark fundus lesions in both eyes. This raised suspicion for Birdshot retinochoroidopathy, which was confirmed with genetic testing. Ocular inflammation resolved following treatment with mycophenolate mofetil and a dexamethasone intravitreal implant.

We describe the clinical features in a case series of 64 patients presenting with a primary basal cell carcinoma (BCC) involving the lower lid and/or adjacent inferior periocular area, and present simple surgical guidelines for reconstruction based on the location and size of the lesion.

Cataract and glaucoma patients represent a challenge for the anterior segment surgeon due to either perform a cataract or glaucoma surgery alone or a combined procedure. We present the results of combined cataract phacoemulsification, intraocular lens implant and MMC trabeculectomy with releasable sutures. Sixty eyes of 44 patients were included from January 2008 to December 2011, with a mean age of 67.02±10,41) years old. 80% were primary open angle glaucoma (POAG) and 20% primary closed angle glaucoma (PCAG). Preoperative intraocular pressure was 23.28±5.89 mmHg; 26.08±10.66 for GPAA and 26.08±10.66 for GPCA with a cup/disc ratio of 0.81 and 0.74, respectively. Best corrected visual acuity (in LogMar) was 0.581 preoperatively, improved to 0.28±0.40 postoperatively in both groups with 0.60±0.41 to 0.25±0.37) in GPAA and 0.53±0.44 to 0.39±0.40 in GPCA. The intraocular pressure was reduced in 48.24% with 48.86% in GPAA and 52.72% in GPCA. The survival curve analysis was 0.91 in GPAA and 0.90 in GPCA at 50 and 30 months. In conclusion, combined surgery was successful in treatment patients with glaucoma and cataract. RESUMEN La asociación de catarata y glaucoma representa un reto para el oftalmólogo que debe decidir si realiza una cirugía de glaucoma o catarata o combinada. Presentamos nuestros resultados de cirugías de facoemulsificación de catarata, implante intraocular y trabeculectomía con MMC y suturas retirables.Se incluyen 60 ojos de 44 pacientes operados de Enero 2008 a Diciembre de 2011 con una edad promedio de 67,02±10,41) años. El 80% eran glaucomas de ángulo abierto (GAA) y 20% por cierre angular (GPCA). La presión intraocular previa fue de 23,28± 5,89 mmHg en GPAA y 26,08±10,66 en GPCA con una relación excavación/disco fue de 0,81 y 0,74, respectivamente. La agudeza visual preoperatoria mejor corregida (LogMar) fue de 0,581±0,41 mejorando a 0,28±0,38) en general y 0,60±0,41 a 0,25 ±0,37 en GPAA y 0,53±0,44 a 0,39±0,40 en GPCA. La reducción de la presión intraocular fue de 48,24% en promedio siendo del 48,86% en GPAA y 52,72% en GPCA. La sobrevida de la cirugía fue de 0,91 en el glaucoma de ángulo abierto y de 0,90 en el glaucoma por cierre angular a los 50 y 30 meses de seguimiento respectivamente. En conclusión, la cirugía combinada por un solo puerto es efectiva en el control del paciente con glaucoma y catarata. Palabras clave: catarata; glaucoma; tratamiento quirúrgico.

The purpose of this article is to review the plateau iris configuration demonstrating the importance of ultrasound biomicroscopy in the diagnosis. The possible non-pupillary block mechanism of angle-closure glaucoma and its management are also discussed. Resumen El objetivo de este trabajo es presentar una revisión de la configuración del iris en meseta demostrando la importancia de la biomicroscopía ultrasónica en el diagnóstico. También son discutidos los probables mecanismos del bloqueo no pupilar en el glaucoma de ángulo cerrado y su tratamiento.

Resumo Objetivo: Oferecer recomendações e orientação baseadas em evidências para o tratamento da retinopatia diabética (RD) e do edema macular diabético (EMD) conforme a evidência clínica publicada recentemente e a experiência clínica. Métodos: Foi realizada pesquisa bibliográfica nos bancos de dados PubMed e Cochrane utilizando os termos “edema macular diabético” ou “retinopatia diabética” para identificar os estudos publicados de janeiro de 2008 a novembro de 2013. Posteriormente, procedeu-se pesquisa manual das referências citadas em artigos selecionados, publicados em periódicos científicos especializados. As referências identificadas nessas pesquisas bibliográficas foram revistas e apresentadas pelos membros de uma comissão de peritos em EMD na América Latina a todo o grupo durante o encontro de consenso, de dois dias de duração. Durante a reunião, os especialistas formularam recomendações levando em conta as vantagens, os riscos e os efeitos adversos das intervenções para a saúde. Níveis de evidência foram atribuídos às referências utilizadas para apoiar as recomendações com base no sistema de classificação de evidências SORT (Strength of Recommendation Taxonomy) referente à força da recomendação. Resultados: Foram formuladas 31 recomendações de consenso. Entre elas, a recomendação do controle glicêmico precoce em pacientes diabéticos para reduzir o risco de evolução da doença ocular. O grupo de especialistas também recomendou a coleta de dados epidemiológicos para definir melhor a prevalência da RD e do EMD na América Latina e definir algoritmos para o manejo e tratamento nos vários estágios da doença. Foi destacada a necessidade da triagem precoce e o desenvolvimento da infraestrutura para garantir aos que precisam um acompanhamento e tratamento adequados. Para avaliar adequadamente a evolução da doença e a resposta ao tratamento faz-se necessário realizar uma angiografia de fluorescência (AF) e uma tomografia de coerência óptica (TCO). Com base em evidências de alto nível, recomendamos ranibizumabe como o padrão-ouro para o tratamento do EMD e a fotocoagulação panretiniana (FPR) com o padrão-ouro para a RD proliferativa. A vitrectomia deve ser considerada na presença de tração macular ou se o edema não responder à farmacoterapia. Como os esteroides intravítreos dão lugar a uma redução do edema, eles podem ser utilizados para melhorar os efeitos de outros tratamentos, bem como em olhos pseudofácicos. Finalmente, ao selecionar um tratamento para a RD ou o EMD, é de especial importância considerar o estado de saúde geral do paciente. Conclusão: Embora essas diretrizes não pretendam substituir a decisão clínica profissional individual, elas devem ajudar a otimizar o tratamento do EMD na América Latina e garantir que os pacientes recebam a melhor atenção disponível e de maneira oportuna.

Pressure to practice evidence-based medicine is increasing and has the potential to reduce malpractice claims. Sometimes the evidence may prove a specific therapy to be ineffective, but practice says it is effective. In Medicine, however, if you do not trust the evidence, you may expose yourself and your patients to untoward consequences. When we face a complex problem, most of the time it is better to rely on scientific evidence rather than on expert personal opinion.

Ocular surface squamous neoplasia (OSSN) encompasses a range of corneal and conjunctival lesions from intraepithelial dysplasia to invasive squamous cell carcinoma. The mainstay of treatment for OSSN has traditionally been surgical excision with wide margins and cryotherapy. Increasing evidence on the efficacy and safety of medical therapy and the avoidance of surgical complications has made topical chemotherapy increasingly popular among corneal specialists. The most common topical agents used for the treatment of OSSN include mitomycin C, 5-fluorouracil, and interferon α2b. Herein, we review recent advances in the surgical and medical management of OSSN and discuss advantages and disadvantages of each approach. The role of ultra high-resolution optical coherence tomography in the diagnosis and treatment of primary and recurrent OSSN lesions is also discussed.

Acanthamoeba keratitis is a sight-threatening disease that carries a favorable prognosis when diagnosed and treated early in the disease course. In some countries, the disease is more common than fungal keratitis, thus showing the importance of knowing and understanding this intriguing infection.

Currently, there are no level one evidence-based studies comparing systemic vs topical therapy for the management of fungal keratitis. Information on systemic efficacy alone or in combination with topical use is rare. Selection of the most appropriate antifungal for fungal keratitis remains a challenge, hindered by the diverse clinical presentation in fungal keratitis, delay in clinical and laboratory diagnosis, limited supply of effective antifungals, lack of ocular pharmacological profiles for current antifungals, nonstandard dosing intervals/routes of administrations, expanding list of causative agents, geographic diversity and the emergence of resistance. Efficacy is gleamed from personal observations, clinical experience, literature reviews, or retrospective data from small or single cases studies and or chart reviews. Taken together, the level of existing evidence is insufficient to determine the role of systemic vs topical therapy for fungal keratitis. Topical therapy remains the standard for treatment of fungal keratitis. Adjunctive therapy with oral or intravenous antifungals may be required for severe or recalcitrant ulcers. Well-powered randomized clinical trials involving diverse and common topical vs systemic therapies are needed to address this question.

Bacterial keratitis (BK) is one of the most frequent causes for emergency hospital admissions.¹ Identifying the causative microorganism promptly and properly is mandatory to achieve acceptable outcomes. Nevertheless, appropriate initial management of these cases requires laboratory-based diagnosis and even a modest laboratory set may not always be available at some clinical settings.

Blepharitis is one of the most common disorders encountered in ophthalmology. Despite this, it can often be overlooked and misdiagnosed. Blepharitis can manifest as anterior and/or posterior disease. The form of blepharitis can be determined based on patient symptoms or clinical presentation. An appropriate treatment plan can be made once the form of blepharitis is elucidated. Three key strategies should be addressed in the treatment of blepharitis: (1) management of symptoms, (2) control of any inflammation that is present to prevent long-term damage, and (3) prevention of recurrence. This review focuses on the treatment of this disease as well as suggestions for treating the most severe cases while keeping these goals in mind.

Corneal graft rejection is the most frequent cause for graft failure after penetrating keratoplasty (PK), an area in which we can improve by better prevention and management strategies. Corticosteroids remain the mainstay for both prevention and treatment of rejection; there seems to be a benefit of long-term topical steroids as prophylaxis and the use of pulsed IV steroids in the treatment of rejection itself. It is difficult to determine the role of other immunosuppressant's, but cyclosporine A, mycophenolate mofetil and tacrolimus are frequently used with good results in some studies. There is a need for well-designed randomized clinical trials to really evaluate the therapeutic benefit of these medications and new approaches on the pipeline.

The authors report a case of a 68-year-old 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. 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.

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.

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.

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 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.

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.

Conjunctival melanoma is an uncommon tumor of the ocular surface, representing only 1.6% of all non-cutaneous melanomas. Overall metastasis rates range from 14-27%, with 10-40% occurring within the central nervous system (CNS). CNS involvement has shown to be the major cause of morbidity and mortality in these patients, with a median survival of between 2 and 10 months. Therefore, it is crucial to follow these patients closely throughout their lifetime to monitor for disease recurrence. We present a unique case of a 65 year-old woman with a well-documented history of recurrent conjunctival melanoma after multiple excisions. Routine follow up imaging revealed a new intracranial lesion, which presented an interesting diagnostic challenge.

Resumen Objetivo: Ofrecer recomendaciones y orientación basadas en la evidencia para el tratamiento de la retinopatía diabética (RD) y del edema macular diabético (EMD) según la evidencia clínica publicada recientemente y la experiencia clínica. Métodos: Se realizó una búsqueda bibliográfica en las bases de datos PubMed y Cochrane utilizando los términos “edema macular diabético” o “retinopatía diabética” para identificar los estudios publicados de enero de 2008 a noviembre de 2013. Después de esto se realizó una búsqueda manual de referencias citadas en artículos selectos publicados en revistas revisadas por expertos, y se realizó una búsqueda manual de referencias citadas en artículos selectos publicados en revistas científicas revisadas por expertos. Los miembros del panel de expertos en EMD de América Latina revisaron las referencias identificadas en estas búsquedas de bibliografía y las presentaron ante el grupo en pleno durante la reunión de consenso, de dos días de duración. Durante esta reunión, los expertos formularon recomendaciones teniendo en cuenta los beneficios, riesgos y efectos adversos de las intervenciones para la salud. Se asignó a las referencias utilizadas como respaldo de las recomendaciones un nivel de evidencia basado en el sistema de clasificación de evidencias SORT (Strength of Recommendation Taxonomy) referente a la fortaleza de la recomendación. Resultados: Se formularon 31 recomendaciones consensuadas. Entre ellas se incluyeron la recomendación del control glucémico precoz en pacientes diabéticos a fin de reducir el riesgo de avance de la enfermedad ocular. El panel de expertos recomendó también la recolección de datos epidemiológicos para definir mejor la prevalencia de la RD y el EMD en América Latina, y definir algoritmos para el manejo y tratamiento en varios estadios de la enfermedad. Se hace un mayor énfasis en la necesidad de evaluación precoz y del desarrollo de infraestructura para garantizar a quienes necesitan un seguimiento y tratamiento adecuados. Tanto la angiografía con fluoresceína (AF) y la tomografía de coherencia óptica (TCO) son necesarias para la evaluación adecuada de la evolución de la enfermedad y la respuesta a la terapia. Sobre la base de evidencias de alto nivel, recomendamos el ranibizumab como la regla de oro para el tratamiento del EMD y la fotocoagulación panretiniana (FPR) como la regla de oro para la RD. Debe tenerse en cuenta una vitrectomía ante la presencia de una tracción macular o si el edema no responde a la farmacoterapia. Como los esteroides intravítreos generan una reducción del edema, se pueden usar para mejorar los efectos de otros tratamientos y también en ojos pseudofáquicos. Finalmente, al seleccionar un tratamiento para la RD o el EMD, es particularmente importante tener en cuenta el estado de salud general del paciente. Conclusión: Si bien estas pautas no pretenden ser un reemplazo del criterio clínico, deben ayudar a optimizar el tratamiento del EMD en América Latina y garantizar que los pacientes reciban la mejor atención disponible en tiempo y forma.

Lentigo maligna (LM) affecting the periocular skin represents a challenge in its diagnosis and management. LM has a very slow rate of malignant transformation; however, with our aging population the progression towards malignant melanoma is concerning and can have potential life threatening consequences. We present a case of a 79-year-old male with a suspicious LM, who underwent surgical excision and reconstruction, to discuss the treatment options and suggest guidelines when confronting these controversial cases.

A case of Ollier's disease is presented, in a male adult with multiple enchondromas. The patient was reclassified as a Maffucci lymphangioma syndrome after two periocular lymphangiomas were surgically excised.

Purpose: To compare the fluctuation of the ocular perfusion pressure (OPP) between eyes treated with glaucoma medication and eyes with a functioning filtering bleb. Study Design: cross-sectional controlled paired-eye design. Methods: Fourteen patients with primary open angle glaucoma (POAG) with one eye operated on (trabeculectomy) and the fellow eye treated with medication enrolled the study. Blood pressure and intraocular pressure were measured at 7 a.m., 1 p.m., and 7 p.m. Systolic, diastolic and mean OPP were calculated for the three time points and the fluctuation (range between the highest and the lowest values) compared between the eyes. Results: Mean values of the mean OPP fluctuation were 7.2 ± 3.9 mmHg and 8.5 ± 4.0 mmHg, for operated eyes and medically treated eyes, respectively (P = 0.149); mean systolic OPP fluctuation was 20.7 ± 11.2 mmHg for operated eyes and 21.2 ± 11.7 mmHg for medically treated eyes (P = 0.478); the mean diastolic OPP fluctuation was 8.4 ± 4.4 mmHg for operated eyes and 10.5 ± 5.4 mmHg for medically treated eyes (P= 0.085). Conclusion: In this small cohort of patients with POAG, the mean, systolic and diastolic OPP fluctuation did not differ between the operated eyes and medically treated ones.

Purpose: To provide evidence-based recommendations and guidance for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) based on recently published clinical evidence and clinical experience. Methods: A literature search using PubMed and the Cochrane Library was performed with the terms “diabetic macular edema” or “diabetic retinopathy” to identify studies published from January 2008 to November 2013. This was followed by a manual search of references cited in selected papers published in peer-reviewed journals. The references identified in these literature searches were reviewed and presented by members of the Latin America DME expert panel to the entire group during the 2-day consensus meeting. During this meeting, the experts formulated recommendations with consideration of the health benefits, risks, and adverse effects of interventions. References used to support recommendations were assigned a level of evidence based on the Strength of Recommendation Taxonomy (SORT) evidence rating system. Results: Thirty-one consensus recommendations were formulated. These include the recommendation for early glycemic control in diabetic patients in order to reduce the risk of progression of ocular disease. The expert panel also recommended the collection of epidemiological data to further define the prevalence of DR and DME in Latin America and to establish management and treatment algorithms for various stages of the disease. The need for early screening and development of infrastructure to ensure appropriate follow-up and treatment of those in need is further emphasized. Both fluorescein angiography (FA) and optical coherence tomography (OCT) are needed for proper assessment of disease progression and response to therapy. Based on available high-level evidence, we recommend ranibizumab as the gold standard for the treatment of DME and panretinal photocoagulation (PRP) as the gold standard for proliferative DR. Vitrectomy should be considered in the presence of macular traction or if edema is not responding to pharmacological therapy. As intravitreal steroids provide a reduction in edema, they can be used to ameliorate the effects of other therapies as well as in pseudophakic eyes. Finally, when selecting a therapy for DR and/or DME, it is of particular importance to consider the general health status of a patient. Conclusion: Although these guidelines are not intended to be a replacement for clinical judgment, they should help to streamline the management of DME across Latin America and ensure that patients receive the best available care in a timely manner.