Keratoacanthoma (KA) and Squamous Cell Carcinoma (SCC) are entities that often have been difficult to differentiate. Current thought establishes that Keratoacanthoma behaves similarly to a lowgrade squamous cell carcinoma. We present a case of an 80 year old female which history of present illness as well as clinical impression mimics Keratoacathoma (KA), but on histopathological examination resulted in Squamous Cell Carcinoma (SCC). We posit the use of novel histopathological and cytological advances, such as TGF-β sequencing and TGF-Alpha staining in assessing the specimen. Subtle differences should guide treatment for patients that need further resection and that might have orbital involvement.

Resumen Introducción: La arteritis de células gigantes (ACG) es una inflamación granulomatosa y necrotizante de arterias de mediano y gran calibre de etiología desconocida. La pérdida de visión rápidamente progresiva es una de sus complicaciones más graves dada su potencial bilateralidad e irreversibilidad. La enfermedad de Crohn (EC) es debida a la inflamación transmural y segmentaria del tracto gastrointestinal. Ambas entidades poseen una baja incidencia en nuestro medio, siendo excepcional la coexistencia de éstas simultáneamente en el mismo paciente. Caso clínico: Mujer de 77 años de edad con antecedentes personales de EC en tratamiento activo con Infliximab que acudió por disminución súbita de agudeza visual (AV) por su ojo izquierdo (OI). A la exploración oftalmológica la AV por su OI era de cuenta dedos a 30 cm y mostraba un defecto pupilar aferente relativo izquierdo muy manifiesto. Funduscópicamente el OI mostró un edema de papila pálido con hemorragias peripapilares. La paciente refería síntomas de ACG y alteraciones analíticas compatibles, por lo que tras ser diagnosticada de neuritis óptica isquémica anterior arterítica se procedió a la administración de dosis altas de glucocorticoides experimentando una mejoría analítica y clínica, aunque la pérdida de función visual fue permanente. Conclusiones: El Infliximab es un farmaco anti-TNFα empleado en la EC activa en casos refractarios al tratamiento corticoideo. Existen datos que sugieren que puede ejercer un efecto beneficioso en la inhibicion de la ACG al estar implicado el TNFα en la etiopatogenia de ambos cuadros. Sin embargo, en nuestra paciente no fue suficiente como medicacion previa y preciso dosis altas de corticoides, previniendo asi la bilateralidad del cuadro de ACG. Palabras clave: Neuropatia óptica isquémica anterior; arteritis células gigantes; enfermedad de Crohn;, Infliximab. Abstract Introduction: Giant Cell Arteritis (GCA) is a granulomatous and necrotizing inflammation of medium and large calibre arteries due to unknown etiology. Rapidly progressive loss of vision is one of the most serious complications given its irreversibility. Crohn's disease (CD) is a segmental and transmural inflammation of the gastrointestinal tract. Both entities have a low impact in our environment and it is exceptional the coexistence of these conditions in the same patient. Clinical case: We present a 77 year old woman with a personal history of CD in active treatment with Infliximab who showed a sudden visual loss in her left eye (LE). In the ophthalmological examination, the visual acuity was counting fingers at 30 cm and we observed a very clear left relative afferent papillary defect. Fundus showed a papiledema with peripapillary haemorrhages. The patient reported symptoms and laboratory abnormalities compatibles with GCA, so after being diagnosed of arteritic anterior ischemic optic neuritis we proceeded to the administration of high doses of glucocorticoids leading to analytical and clinical improvement, although the visual loss was permanent. Conclusion: Infliximab is an anti-TNFα drug used in active CD in cases refractory to corticosteroid treatment, data suggest that may have a beneficial effect on GCA inhibition because TNFα participate in the pathogenesis of both diseases. However, in our patient, it was not enough and she needed high doses of corticosteroids to avoid the bilateralism of the disease.

Purpose: To document the prevalence of vision impairment among children in a resource-poor community in Peru. Methods: Cross-sectional study of children 5 to 18 years old in Puente Piedra, Peru from March to April, 2011. Participants underwent standard vision screening exam, consisting of distance visual acuity (VA), stereopsis, external eye exam, and color vision testing and completed a socio-demographic and health risk factor questionnaire. Results: 380 children were examined. The mean uncorrected VA was 0.07 ± 0.13 Log Mar. Children wearing eyeglasses were 3.7%. Visual impairment was found in both eyes in 8.9% and in one eye in 26.3%. Severe visual impairment (<20/200) was found in both eyes in one child (0.3%) and in the worse eye of 3 (0.7%) children. Thirteen (3.5%) children failed the stereopsis exam and 20 (5.5%) boys and 7 (1.9%) girls failed the color vision exam. Overall, 37.3% of children met the criteria for referral to an ophthalmologist. Major factors for referral included the history of eyeglasses use, previous eye exam, or parental concern about the child's vision. Factors for untreated vision impairment included not having seen a physician regularly, no previous eye exam, and having a blind family member. Conclusion: There is a high prevalence of vision impairment in children living in Puente Piedra, Peru. Few children wore glasses or have ever been examined before. Basic eye care is needed for this underprivileged population.

Purpose: Determine if anterior stromal puncture (ASP) has a more effective decrease in symptomatology (pain, photophobia, and foreign body sensation) than annular keratotomy (AK) in patients with painful bullous keratopathy (PBK) and poor visual prognosis. Methods: Patients with PBK, refractory to combined medical treatment and poor visual prognosis were randomly assigned to one of two surgical procedures. Symptomatology, central corneal thickness (CCT), visual acuity (VA), and best corrected (BCVA) were evaluated with a 12-month follow up. Results: From 78 patients with PBK, 13 met inclusion criteria; ASP was performed to 7 and AK to 6 of them. There was improvement in the magnitude of symptoms in both groups; however, there was no difference when groups were compared. CCT showed in the 7-month follow-up a significant reduction of 10.4% in the ASP group compared with a 9.6% increase in the AQ group (p=0.05). Twelve-month-follow up CCT presented a non-significant reduction of 9.3% in the ASP group compared with a 3.3% increase in the AQ group. VA and BCVA in both groups were not modified. None of the groups presented complications related to the surgical procedures. Conclusion: In this clinical trial, we documented that ASP and AQ produce a similar improvement in the symptomatology of patients with PBK refractory to combined medical treatment and poor VA potential. The ASP group additionally presented a significant decrease in CCT at 7 months of follow up, which looses statistical significance at 12 months of follow up, but maintains a clinical reduction of 9.3%. A longer follow-up period would be required to evaluate if this CCT reduction is able to modify the frequency of bullae development and symptoms relapse. Furthermore, the material used for ASP has a lower cost than the one used for AQ, which could represent an economic advantage for patients that attend our Hospital.

Purpose: To compare the prevalence of angle closure disease (ACD) diagnoses in a glaucoma department of an ophthalmology teaching hospital at two cut points, before and after encouragement of a supervised, mandatory gonioscopy for all patients, during all visits as well as to profile patients with angle closure disease in terms of age, gender, intraocular pressure, visual acuity, cup-to-disc ratio and refractive error parameters when divided by Foster's classification. Study design: Retrospective, two cut-point observational study. Material and methods: A 1-month sample of electronic medical records from 2010 and from 2013 was analyzed. Between those two cut points, gonioscopy was encouraged as a mandatory procedure and execution was supervised systematically. The prevalence of angle closure disease was obtained from the diagnosis of electronic medical records and patients with ACD were divided according to Foster's ACD classification in order to profile them. Results: A total of 2112 medical records from 2010 and 2549 medical records from 2013 were included. Angle closure disease prevalence went from 7.29% (n=154) in 2010 to 20.36% (n=519) in 2013. Prevalence of primary open angle glaucoma (POAG) decreased from 23.20% to 10.84% in the same time period. Conclusions: A comparison between the prevalence of angle closure disease between these two cut points showed a considerable increase. Angle closure disease was diagnosed 1.79 times more as opposed to when gonioscopy was not previously encouraged or supervised. ACD patients are generally women, with decreasing low hyperopia and intraocular pressure within normal ranges.

Leber's Hereditary Optic Neuropathy (LHON) is a mitochondrially inherited disorder characterized by rapid, subacute vision loss. LHON has historically been a difficult disease to study due to its low incidence. Many questions concerning its pathophysiology have remained unanswered. A significant enigma concerns LHON's gender bias as represented by the male-to-female ratio of about 4:1. Another source of confusion includes the variable penetrance, since the mitochondrial mutation is necessary, but not sufficient, to cause conversion. A third challenge involves the tissue specificity, since typically only the optic nerve is involved with a specific pattern of optic atrophy due to primary loss of the papillomacular bundle (PMB) in affected individuals. The fourth remaining complexity is the pattern of rapid, subacute vision loss observed in nearly all affected individuals. Several clinical genetic studies, cybrid experiments, and histochemical studies have been conducted to address the three enigmas of gender bias, variable penetrance, and tissue specificity. Despite elucidation of these three aspects of the pathophysiology, the mechanism behind the rapid, significant vision loss remains a mystery.