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.