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ARCH SOC ESP OFTALMOL.

2011;86(1):2730
ARCHIVOS
DE LA SOCIEDAD
ESPAOLA
DE OFTALMOLOGA

ARCHIVOS DE LA SOCIEDAD
ESPAOLA DE OFTALMOLOGA

Vol. 85

Mayo 2010

Nm. 5

Contenido
Editorial
La retina como marcador biolgico de dao neuronal
Artculos originales
Comparacin de tres instrumentos de tomografa de
coherencia ptica, un time-domain y dos Fourierdomain, en la estimacin del grosor de la capa de
fibras nerviosas de la retina
Idoneidad de tratamiento en sospechosos de glaucoma. Estudio de concordancia con el grupo de estudio RAND
Atrofia de la capa de fibras nerviosas de la retina en
pacientes con esclerosis mltiple. Estudio prospectivo con dos aos de seguimiento
Comunicaciones cortas
Hipercorreccin secundaria a transposicin muscular
aumentada
Crtica de libros, medios audiovisuales y pginas
web oftalmolgicos
Clinical Neuro-Ophthalmology: The Essentials
Seccin histrica
Del mal de la rosa y la queratoconjuntivitis pelagrosa
Seccin iconogrfica
El estrabismo de Rembrandt
Sociedades y Reuniones Cientficas
Ofertas de trabajo

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Short communication

Neurotrophic corneal ulcer in an HIV patient


J. Paz Moreno-Arrones,a,b,* J. Bentez-Herreros,a,b P. Drake-Rodrguez,a,b
A. Romero-Garca Tenoriob,c
aUniversidad

de Alcal de Henares, Alcal de Henares, Madrid, Spain


Universitario Prncipe de Asturias, Madrid, Spain
cUniversidad Complutense de Madrid, Madrid, Spain
bHospital

A RT I C L E I N F O R M AT I O N

A B S T R A C T

Article history:

Case report: We present the case of a 29 year-old man who came to the Emergency

Received on Aug. 2, 2010

Department due to pain in the right eye. There was demonstrated a complete corneal de-

Accepted on Oct. 26, 2010

epithelialisation. There was no clinical improvement after appropriate treatment, which


was complicated by migraine and vomiting. The computerized tomography (CT) scan

Keywords:

showed images suggestive of cerebral toxoplasmosis. After the complete tarsorrhaphy a

Tarsorrhaphy

restitution ad integrum was observed.

Neurotrophic ulcer

Conclusion: The diagnosis of a neurotrophic corneal ulcer due to an affected trigeminal

Cerebral toxoplasmosis

nerve in the context of a cerebral toxoplasmosis, tarsorrhaphy is an effective procedure to


take in account in corneal epithelial defects resistant to other treatments.
2010 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L.
All rights reserved.

lcera corneal neurotrfica en paciente con VIH


R E S U M E N

Palabras clave:

Caso clnico: Se presenta el caso de un varn 29 aos acude a Urgencias de oftalmologa por

Tarsorrafia

dolor en ojo derecho. Se evidenci una desepitelizacion corneal completa. Tras un trata-

lcera neurotrfica

miento adecuado no se evidenci mejora clnica, complicndose el cuadro con cefalea y

Toxoplasmosis cerebral

vmitos. la tomografa axial computarizada (TAC) evidenci imgenes sugestivas de toxoplasmosis cerebral. Tras la tarsorrafia completa se observ una restitucin ad integrum del
cuadro.
Conclusin: Ante el diagnstico de una lcera corneal neurotrfica por afectacin del trigmino en el contexto de toxoplasmosis cerebral, la tarsorrafia es un procedimiento eficaz a
tener en cuenta ante defectos epiteliales corneales resistentes a otros tratamientos.
2010 Sociedad Espaola de Oftalmologa. Publicado por Elsevier Espaa, S.L.
Todos los derechos reservados.

Presented

at the 85th Congress of the Spanish Ophthalmological Society.


*Corresponding author.
E-mail: javier_paz_moreno@hotmail.com (J. Paz Moreno-Arrones).

0365-6691/$ - see front matter 2010 Sociedad Espaola de Oftalmologa. Published by Elsevier Espaa, S.L. All rights reserved.

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ARCH SOC ESP OFTALMOL. 2011;86(1):2730

Figure 1 De-epithelization with stromal edema and folds in


Descemet membrane.

Figure 2 The CAT images shows a general blurriness of the


cerebellum grooves with hypodense areas compatible with
areas of edema.

Introduction
Neurotrophic ulcers consist of a degenerative corneal
condition caused by any noxa that affects corneal sensitivity.
The absence of corneal sensitive trophic effects entails the
impossibility of corneal healing which associates an epithelial
defect, ulceration and even perforation.
Tarsorrhaphy is a simple, efficient and safe procedure
for managing various ocular surface conditions such as
neurotrophic ulcers due to the involvement of the trigeminal
nerve, facial paralysis, lagophthalmos among others, carried
out in isolation or in combination with other ocular plastic
surgical techniques.

the right cerebellum hemisphere and temporal lobe (fig. 2),


compatible with edema areas. Internal medicine established
antitoxoplasmic oral treatment together with ganciclovir.
The magnetic resonance imaging (RMI) with contrast
evidenced several space-occupying lesions in the right and
left cerebellum hemispheres, in the temporal lobe and the
frontal operculum of the left islet surrounded by edema
(fig. 3) suggesting cerebral toxoplasmosis. The lumbar
puncture yielded normal results. In an additional anamnesis,
the patient referred he was HIV-positive for 2 years due to
a high risk sexual relationship. He did not refer consuming

Clinical case
African male, 29, who visits the ophthalmological emergency
section due to pain and diminished vision in the right eye (RE).
The exploration revealed a visual acuity (VA) of finger counting
at 3 m in RE which did not improve with the stenopeic hole,
and of 1 in the left eye (LE).
In the anterior biomicroscopy a ciliary injection was
observed with complete corneal de-epithelization, stromal
edema and folds in Descemet membrane (fig. 1), with the
rest of the ophthalmological exploration being normal. It was
decided to initiate an occlusive treatment with cycloplegic
eyedrops comprising antibiotics. Two days later, apart from
not evidencing improvement in the ocular condition, the
patient associated holocranial headache and vomiting. It was
decided to maintain the ophthalmological treatment and to
refer the patient to the internal medicine emergencies for
a full assessment. After a systemic exploration, diminished
facial sensitivity was evidenced in the fourth branch of the
trigeminal, with corneal anesthesia. A computerized axial
tomography (CAT) was taken which evidenced triventricular
hydrocephalia, with two hypodense areas being observed in

Figure 3 RMI image showing lesions with different sizes


surrounded by vasogenic edema. The ring-shaped capture
of lesions is marked with arrows.

ARCH SOC ESP OFTALMOL. 2011;86(1):2730

Figure 4 Image showing the partial tarsorrhaphy of the


2 external thirds of the eyelid and the improved appearance
of the ocular surface.

drugs. In the light of this finding, the following serological tests


were carried out: ELISA and Western blot for HIV, IgM and IgG
for toxoplasmosis, with positive results. The diagnostic was
cerebral toxoplasmosis in patient with HIV. The lymphocyte
T CD 4+ was of 69/l, with a number of HIV-RNA copies of
147.460/ml.
Our
ophthalmological
diagnostic
was
neurotrophic ulcer due to involvement of the trigeminal
in the context of cerebral toxoplasmosis. As no
ophthalmological improvement was evidenced with the
previous treatment, autogenous serum and therapeutic
contact lens was prescribed without achieving the resolution
of the ophthalmological clinical condition. Due to the slow
evolution of the corneal ulcer, paralytic ptosis was induced
by injecting 12 international units of botulin toxin at the
level of the RE upper eyelid elevator. However, due to the
poor cooperation of the patient, who continually raised the
eyelid in a reflex action, the ulcer failed to heal. Finally it was
decided to carry out a permanent tarsorrhaphy of the two
external thirds in the RE, suturing the anterior and posterior
lamellae of both eyelids and treating with autogenous serum,
antibiotic eye drops and cycloplegic, upon which the patient
evidenced clinical improvement (fig. 4).

Discussion
The cornea is a highly sensitive structure that is able to
perceive different feelings such as pain, heat, cold or touch.
The absence of corneal sensitivity involves a disruption of the
integrity of the corneal surface.
A neurotrophic keratoplasty is a clinical entity which
comprises all the degrees of corneal and conjunctival
degeneration secondary to the loss of the sensitive function
in the pathway of the nasocilliar branch (V1) of the trigeminal
nerve with or without diminished tear production.

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The most frequent etiology of the clinical condition known


as corneal anesthesia is the infection of the corneal surface by
Herpes Simplex and Herpes Zoster.1 It is known that corneal
sensitive nerves play a crucial role in maintaining the anatomic
and functional integrity of the cornea and its epithelium, even
though the exact mechanism is yet not fully determined. It is
known that the damage of these nerves causes a reduction
in metabolism and mitosis of epithelial cells together with
an increase of their permeability.2,3 The corneal epithelium
proliferation is probably regulated by a two-way control, i.e.,
sensitive neuromediators that promote mitosis in epithelial
cells and sympathetic mediators that reduce them. As a
result of this neurologic disruption, in neurotrophic ulcers the
epithelium defect persists and therefore cannot heal. However,
if the ocular surface is protected from the environment with
therapeutic contact lenses or tarsorrhaphy, the ulcer almost
always heals.
It must be noted that heroine addicts can evidence false
corneal neurotrophic ulcers either to direct inoculation of
heroine in their eyes as a result of manipulating or inhaling it,
which can be difficult to diagnose.
The
neurological
complications
of
the
human
immunodeficiency syndrome (AIDS) are frequently symptoms
of opportunistic infections of the central nervous system
(CNS), as in this case toxoplasmosis. The reactivation of
the latent infection occurs in patients having their immune
system compromised, mainly causing meningoencephalitis,4
but it can also cause a condition of polyradiculoneuritis and
miositis. Similarly, cerebral toxoplasmosis is the most frequent
cause of space-occupying lesions in AIDS patients (typically in
advanced stages or in patients with less than 200 lymphocytes
T CD4+/l) characterized by being lesions with mass effect,
affecting the basal ganglions. The definitive diagnosis requires
brain biopsy which, due to its high morbidity, is reserved only
for cases that do not improve with empirical treatment. This
clinical condition is more frequent with lower lymphocyte T
CD 4+ counts. In clinical practice, the diagnostic and treatment
for cerebral toxoplasmosis are initially presumptive, based on
clinic and radiological findings.5
The determination of IgM and IgG positive antibodies at
the plasma level established the definitive diagnostic of this
disease even when this serology is negative at the level of
the cerebrospinal fluid because up to one third of cerebral
toxoplasmosis patients exhibit repeated negative IgG in the
lumbar puncture. However, it must be noted that with these
patients we must take into account the differential diagnosis
with other diseases affecting the central nervous system such
as progressive multifocal leucoencephalopathy, criptococcic
meningoencephalitis and malign cerebral lymphoma.
The HAART antiretroviral therapy has demonstrated
improvements in the efficacy of anti-toxoplasma drugs
through our recovery of the immune system, in addition to
reducing mortality in HIV-positive patients.
In cases involving neurotrophic corneal ulcers the
treatment of the epithelial defects must be established
as soon as possible in order to prevent its progression to
corneal perforation and the sequels this produces. It must be
remembered that, in these cases of severe corneal anesthesia,
penetrating keratoplasty exhibits poor results, even after a

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ARCH SOC ESP OFTALMOL. 2011;86(1):2730

corneal transplant. Thus, the therapeutic alternatives consist


in occlusion with patches, placement of contact lenses, botulin
toxin injection in the upper eyelid elevator, translocation
of a conjunctival flap to the cornea, amniotic membrane
transplants and, in the failure of these techniques, the last
option to be considered is either temporary or permanent
tarsorrhaphy.
In our case, due to the brief period of action exhibited in this
patient at the corneal level surface, the amniotic membrane
transplant was not utilized. However, as a result of the torpid
evolution of corneal de-epithelization which resisted different
conservative treatments, it was decided to form a permanent
tarsorrhaphy of the 2 external thirds, previously separating
the anterior and posterior lamellae of both eyelids to join
them together, adding cycloplegic and antibiotic eyedrops
and achieving adequate corneal epithelization.
We would like to emphasize the need of establishing this
type of treatment if conservative therapeutic efforts fail in
these conditions.

Conflict of interest
None of the authors have declared any conflict of interest.

R e f e r e n c e s

1. Groos EB. Neurotrophic tis. In: Krachmer JH, Mannis MJ,


Hooland EJ, editors. Cornea: Fundamentals of corneal
and external disease. St. Louis: Mosby; 1997. p. 1339-62.
2. Sigelman S, Friedenwald JS. Mitotic and wound healing
activities of the corneal epithelium: effect of sensory
denervation. Arch Ophthalmol. 1954;52:46-57.
3. Simone S. De ricerche sul contenuto in acqua totale ed in
azoto totale della cornea di coniglio in condizioni di cheratite
neuroparalitica sperimentale. Arch Ottalmol. 1958;62:151.
4. Hill D, Dubey JP. Toxoplasma gondii: transmission, diagnosis
and prevention. Clin Microbiol Infect. 2002;8:634-40.
5. Cohen B. Neurological manifestations of toxoplasmosis in
AIDS. Semin Neurol. 1999;19:201-11.

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