André Gustavo Bombana Nicoletti

Mediastinitis after cardiac transplantation

OBJECTIVE Assessment of incidence and behavior of mediastinitis after cardiac transplantation. METHODS From 1985 to 1999, 214 cardiac transplantations were performed, 12 (5.6%) of the transplanted patients developed confirmed mediastinitis. Patients ages ranged from 42 to 66 years (mean of 52.3 +/- 10.0 years) and 10 (83.3%) patients were males. Seven (58.3%) patients showed sternal stability on palpation, 4 (33.3%) patients had pleural empyema, and 2 (16.7%) patients did not show purulent secretion draining through the wound. RESULTS Staphylococcus aureus was the infectious agent identified in the wound secretion or in the mediastinum, or both, in 8 (66.7%) patients. Staphylococcus epidermidis was identified in 2 (16.7%) patients, Enterococcus faecalis in 1 (8.3%) patient, and the cause of mediastinitis could not be determined in 1 (8.3%) patient. Surgical treatment was performed on an emergency basis, and the extension of the débridement varied with local conditions. In 2 (16.7%) patients, we chose to leave the surgical wound open and performed daily dressings with granulated sugar. Total sternal resection was performed in only 1 (8.3%) patient. Out of this series, 5 (41.7%) patients died, and the causes of death were related to the infection. Autopsy revealed persistence of mediastinitis in 1 (8.3%) patient. CONCLUSION Promptness in diagnosing mediastinitis and precocious surgical drainage have changed the natural evolution of this disease. Nevertheless, observance of the basic precepts of prophylaxis of infection is still the best way to treat mediastinitis.

Retinal thickness assessed by optical coherence tomography (OCT) in pseudophakic macular edema

PURPOSE To evaluate the usefulness of the optical coherence tomography (OCT) retinal map in angiographic pseudophakic macular edema (ACME). METHODS This is a prospective analysis of a group of 36 pseudophakic eyes at the fifth postoperative week, submitted to optical coherence tomography 2 macular map and fluorescein angiography on the same day and, a control group of twenty-two 20/20 vision eyes with a minimum 6-month postoperative period, submitted to optical coherence tomography 2 macular map only. Exclusion criteria were diabetes, any macular pathology and unreadable optical coherence tomography or angiogram. The angiograms were divided into three groups according to the edema intensity: Group I: level 0 (absence of angiographic pseudophakic macular edema); group II: levels 1 and 2 (incomplete and complete perifoveal angiographic pseudophakic macular edema respectively) and group III: levels 3 and 4 (up to one disc diameter and greater than one disc diameter angiographic pseudophakic macular edema area respectively). The nine zones of the optical coherence tomography macular map were compared between the control and the three subgroups of the study group and, between group I and groups II and III. RESULTS Among the 36 eyes, 23 (64%) were classified as group I, 10 (28%) as group II and three (8%) as group III. The mean thickness of the fovea zone was 185+/-15 microm for the control group, 189+/-24 microm for group I, 213+/-33 microm for group II and 455+/-38 microm for group III. Significant differences: between group III and the control or group I for all zones (p<0.01) and, between group II and control or group I for the fovea and temporal inner zones (p<0.05). CONCLUSION The optical coherence tomography retinal map is useful in angiographic pseudophakic macular edema diagnosis.

Treatment of eyelid xanthelasma with 70% trichloroacetic acid.

Purpose: To analyze the results of treatment of eyelid xanthelasma (EX) with 70% trichloroacetic acid (TCA) with regard to efficacy, cosmetic appearance, patient satisfaction, and recurrence rate. Methods: Twenty-four patients with EX of up to one third of the affected palpebral area were treated with 70% TCA. All patients were photographed at the start of treatment and 3 months after the last application. The recurrence rate was analyzed at the end of 6 months of treatment. Results: The average number of applications of 70% TCA until the xanthelasma resolved was 1.5. Eleven patients (45.8%) had an excellent result, 8 (33.3%) a good result, and 5 (20.8%) had a satisfactory result. The most common complication was hypopigmentation (33.3%). All patients reported an improved final cosmetic result. Six patients (25%) treated with 70% TCA had a recurrence 6 months after treatment. Conclusions: The results of prospective treatment of 24 patients with EX with 70% TCA indicated that this is a simple and effective method, achieves a satisfactory cosmetic result, has an acceptable recurrence rate, and high patient satisfaction.

Blefaroespasmo essencial: revisão da literatura

Essential blepharospasm is a focal distonia characterized by involuntary, spasmodic, bilateral contractions of eyelid protractors. This is a rare disease, which diagnosis is frequently late and symptoms may progress until functional blindness. In this article, we perform a review and describe the most important features of the disease, including historical aspects, epidemiology, etiology, clinical findings, differential diagnosis and treatment.

Browlifting as an alternative procedure for apraxia of eyelid opening.

Essential blepharospasm is an idiopathic disorder that consists of spontaneous, spasmodic, and involuntary eyelid closure in the absence of ocular disease. Some patients develop an inability to open their eyelids in the absence of orbicularis spasms. These patients have essential blepharospasm combined with apraxia of eyelid opening. Botulinum toxin injections are the treatment of choice for blepharospasm but results may be insufficient, especially in cases associated with apraxia. Apraxia can be treated surgically by levator aponeurosis advancement, frontalis suspension, and upper myectomy. The authors report the first browlift using polypropylene suture to manage eyelid apraxia associated with blepharospasm as an alternative and minimally invasive procedure.

Patients with essential blepharospasm and glaucoma: case reports

Essential blepharospasm is a facial dystonia characterized by spontaneous, spasmodic and involuntary contractions of the eyelid muscles. In advanced cases, blepharospasm patients develop severe eyelid spasms that render them functionally blind, socially reclusive, and unable to work or care for themselves. Oculoplastic surgeons frequently have to deal with patients with blepharospasm. The decrease in quality of life caused by this pathology drives all the attention to the resolution of the spasms. However, other conditions may be associated with them and must be kept in mind during the ophthalmological examination. Four patients with essential blepharospasm were diagnosed as glaucomatous during their follow-up at the Oculoplastic Service. All of them showed glaucomatous optic neuropathy and corresponding visual field defect and no clinically apparent secondary cause for their glaucoma. Forced eyelid closure may lead to intraocular pressure peaks. These patients with blepharospasm present repetitive and spasmodic eyelid contractions and the intraocular pressure rise observed during eyelid squeezing could be an additional risk factor for glaucomatous damage. Our case series suggest that patients with blepharospasm should be seriously evaluated for glaucoma.

Anomalias congênitas do disco óptico associadas à doença de Moyamoya: relato de caso

Congenital anomalies of the optic disc can be associated with intracranial vascular abnormalities. We report a 9-year old boy with morning glory disc anomaly in one eye and optic disc and infrapapilar choroidal coloboma in the other. His past medical history was remarkable for a transient ischemic attack. A magnetic resonance angiogram of the brain was consistent with moyamoya disease. This case illustrates the important association between optic disc abnormalities and moyamoya disease. Funduscopic examination of suspicious cases can be helpful in establishing the clinical diagnosis. Early identification of the intracranial vascular anomalies may be of help in preventing severe neurological complications.

Ivermectina no tratamento de miíase orbitária: relato de caso

OBJECTIVE: We report a case of myiasis in a patient with basocellular carcinoma of the orbit, treated with ivermectine prior to surgery. METHODS: We report a case and emphasize the efficacy of ivermectine in the treatment of myiasis, as alternative therapy. RESULTS: After oral administration of a single dose of ivermectine we saw a complete resolution of the myiasis in a 48-hour period. CONCLUSION: Ivermectine can be used successfully in the treatment of orbital myiasis, turning the mechanical removal of larvae an unnecessary procedure.

ATYPICAL CHOROIDAL MELANOMA: REPORT OF 3 CASES

hemorrhage were considered. The option was echography every 2 weeks, upon which the presence of low internal reflectivity, forming an angle kappa highly suggestive of melanoma of the choroid 3 was evidenced. The presence of arterial vascularization in the interior of the lesion on Doppler ultrasound reinforced this hypothesis. Clinical staging tests did not show systemic dissemination of the tumor. The proposed treatment was enucleation of the of the right eyeball, which was initially rejected by the patient; however, within 30 days, she progressed with signs of pain, total retinal detachment, light perception visual acuity, 58 mm Hg IOP, rubeosis iridis on biomicroscopy, and angle neovascularization on gonioscopy, characterizing neovascular glaucoma. Enucleation of the right eyeball was performed, and histopathologic examination revealed a neoplasm of choroidal origin predominantly occupying the inferior quadrants with an approximate thickness of 15 mm at the greater axis associated with total retinal detachment. The tumor was extensively necrotic (over 90%) with hemorrhagic areas and lymphocyte infiltration. The search for melanin in the whole tumor, including necrotic cells, was positive. The immunohistochemical tests were positive for S-100, vimentin, and HMB-45, confirming the diagnosis of choroidal melanoma. The patient is without evidence of local or systemic relapse after 18 months of follow-up.