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Rodríguez-Ausín, K. Pachkoria" "autores" => array:2 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Rodríguez-Ausín" "email" => array:1 [ 0 => "pazrausin@telefonica.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "K." "apellidos" => "Pachkoria" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Clínica Oftalmológica Suárez Leoz, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Micropunción estromal anterior como tratamiento del síndrome de Brown–McLean" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1484 "Ancho" => 811 "Tamanyo" => 144329 ] ] "descripcion" => array:1 [ "en" => "(A) Stromal micropuncture with cystotome at about 150μm depth and (B) fluorescein image immediately after the puncture." ] ] ] "textoCompleto" => "IntroductionThe Brown–McLean syndrome (BMS) consists in the appearance of peripheral corneal edema sparing the central area. It was first described in 1969<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and is generally associated to previous intracapsular lens surgery.BMS patients are usually asymptomatic although some documented cases exhibited chronic irritation symptoms, pain and septic corneal ulcers. Various treatment options with varying degrees of success have been published for symptomatic patients including hypertonic saline solutions or lubricants,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> extended use soft contact lenses, penetrating keratoplasty, removal of the phakic lens in the anterior chamber and anterior stromal micropuncture.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>This paper presents a symptomatic BMS case successfully treated with anterior stromal micropuncture (ASM).Case reportMale patient, 72, intervened for phacoemulsification with intraocular lens implant in both eyes 12 years before, also requiring vitrectomy for removing nuclear remains in the right eye. The patient had to use soft contact lenses starting 5 years before with substitution every 2 months due to persistent discomfort in the right eye (RE). Non-corrected and best corrected visual acuity was of 20/30 in both eyes (BE). Biomicroscopy revealed pseudophakia in the anterior chamber of BE and a 3mm peripheral annular corneal edema in the RE sparing the central cornea with peripheral endothelial pigment dispersion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). No gutattas were observed in BE. The LE cornea did not exhibit pathological findings. Intraocular pressure (IOP) was normal in BE and central endothelial cell density measured with SP-3000P TOPCON® mirror microscope was of 1300 and 1500cells/mm2 in RE and LE respectively. The peripheral density was not displayed due to edema in RE.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In April 2011, ASM was performed in slit lamp under topical anesthesia with 0.5% tetracaine (Colircusí Anestésico®, Alcon-Cusí, Barcelona, Spain), consisting in 40–50 superficial micropunctures (one fourth thickness, approximately 150μm) in each quadrant utilizing a 25G cystotome (BD Visitec™, Waltham, USA) sparing the central cornea (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B). Antibiotic prophylaxis was applied with moxifloxacin (Vigamox®, Alcon-Cusí, El Masnou, Barcelona, Spain) before and after the procedure.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>2 weeks later, the patient was able to stop using the contact lens undisturbed and in 3 weeks subepithelial fibrosis was observed in the treated area. The patient remains asymptomatic after 12 months of follow-up (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A and B).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>DiscussionBMS consists in peripheral corneal edema with circumferential progression which typically spares the central cornea. In addition, dotted brownish-orange pigmentation may appear in the peripheral endothelium. Central endothelial density is somewhat below normal values and cornea gutatta may coexist. It has been described mainly after intracapsular lens extraction and with less frequency after extracapsular extraction, phacoemulsification, keratoplasty, IOL implant in CA and vitrectomy. In addition, it has been reported in the absence of surgery associated to ocular traumatism, closed angle glaucoma, myotonic dystrophy and lens subluxation.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>Suggested pathogenics include iris peripheral endothelial traumatism, IOL haptics, dislocated vitreous or lens which causes endothelial abrasion and cell loss in the periphery, without discarding associated genetic predisposition.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>The period of time in which BMS appears after surgery has been reported between 1.5 and 34 years. In the instant case it appeared after 10 years and unilaterally. This extended period of time has made us consider progressive RE endothelial damage without knowing the intra- and post surgery details of previous surgeries which could have played a role in the unilateral expression of BMS.In many cases the patient remains asymptomatic although persistent pain may appear due to bullous keratopathy. This pain is related to the rupture of the bullae and the ensuing exposure of corneal nervous endings. If treatment with hypertonic saline solution or lubricants is not enough, extended use soft contact lenses may be required with the ensuing risk of infection. In the case of progressive decompensation which could affect the center of the cornea, as can occur particularly with anterior chamber phakic lenses, penetrating keratoplasty could be indicated. However, this would not be adequate in the typical syndrome because the VA is maintained and larger diameters would be required, thus significantly increasing the risk of surgery due to rejection caused by proximity to the limbus. The possibility of carrying out an “annular” Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) would not be feasible. The patient of this report exhibited a spontaneous and highly satisfactory VA of 20/30, for which reason keratoplasty of any type was discarded.Syndrome cases with association to anterior chamber phakic lenses in which the condition has been halted by withdrawing the lens are altogether different.Stromal puncture has been applied as an alternative to keratoplasty in eyes with bullous keratoplasty without visual expectations and in cases of relapsing erosion. The mechanisms by means of which ASM relieves discomfort in symptomatic patients will therefore be related to the disappearance of epithelial bullae although the stroma exhibits edema and thickening due to endothelial pump failure.The biomicroscopic finding of subepithelial fibrosis after ASM can be explained at the histological level with the appearance of epithelial–stromal projections which would act as anchoring system of the epithelium to the base membrane, preventing the penetration of liquid in the subepithelial space.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>It has been suggested that stromal puncture may activate the basal cells layer and keratocytes, thus stimulating the expression of extracellular matrix proteins (fibronectin, laminin, collagen type IV).In 2004, Martins<a class="elsevierStyleCrossRef" href="#bib0015">3</a> successfully performed ASM in 2 symptomatic BMS cases, both aphakic. Micropuncture was performed with 25G needle with bent tip. It was necessary to repeat the procedure in one case. The instant case is pseudophakic without evidencing pseudophakodonesis. The procedure was performed with a disposable cystotome that was used for phacoemulsification surgery as its curvature facilitated puncturing.ASM reduces peripheral edema and alleviates pain in BMS symptomatic patients, being a simple and low cost procedure.Conflict of interestsNo conflict of interests has been declared by the authors." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres208461" "titulo" => array:3 [ 0 => "Abstract" 1 => "Case report" 2 => "Discussion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec195744" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres208462" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec195745" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-12-18" "fechaAceptado" => "2012-04-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec195744" "palabras" => array:5 [ 0 => "Peripheral corneal edema" 1 => "Anterior stromal puncture" 2 => "Bullous keratopathy" 3 => "Brown–McLean syndrome" 4 => "Keratoplasty" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec195745" "palabras" => array:5 [ 0 => "Edema corneal periférico" 1 => "Punción estromal anterior" 2 => "Queratopatía bullosa" 3 => "Síndrome de Brown–McLean" 4 => "Queratoplastia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Case reportThe Brown–McLean syndrome is defined by peripheral corneal edema sparing the central cornea. We report a patient with bullous annular keratopathy following phacoemulsification and implantation of posterior chamber intraocular lens. The uncorrected and best corrected visual acuity was 20/30. The patient required the use of a bandage contact lens for almost 5 years to relieve the ocular discomfort. DiscussionAnterior stromal puncture was performed using a cystotome. Two weeks after the procedure the ocular discomfort disappeared and the use of bandage contact lens was no longer required. Anterior stromal puncture is a simple procedure that is performed under the slit lamp, and can alleviate the symptoms in patients with Brown–McLean syndrome." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El síndrome Brown–McLean consiste en la presencia de edema corneal periférico respetando la córnea central. Presentamos un paciente con queratopatia bullosa anular años después de facoemulsificación e implante de lente en cámara posterior. Su agudeza visual espontánea y corregida era 20/30 y precisaba lente de contacto blanda para aliviar molestias desde hacía 5 años. Practicamos micropunción estromal anterior con cistitomo, y en 2 semanas las molestias desaparecieron y no precisa porte de lente blanda. La micropunción estromal es un procedimiento simple que se realiza en lámpara de hendidura y que puede eliminar la sintomatología del síndrome de Brown–McLean." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez-Asuín P, Pachkoria K. Micropunción estromal anterior como tratamiento del síndrome de Brown–McLean. Arch Soc Esp Oftalmol. 2013;88:193–6." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Presented as a verbal communication at the 87.° Congreso de la Sociedad Española de Oftalmología, Oviedo, 2011." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2282 "Ancho" => 1375 "Tamanyo" => 286770 ] ] "descripcion" => array:1 [ "en" => "(A) Cornea with blurred ring and presence of soft contact lens and (B) peripheral edema with pigmented deposits." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1484 "Ancho" => 811 "Tamanyo" => 144329 ] ] "descripcion" => array:1 [ "en" => "(A) Stromal micropuncture with cystotome at about 150μm depth and (B) fluorescein image immediately after the puncture." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1815 "Ancho" => 1038 "Tamanyo" => 163002 ] ] "descripcion" => array:1 [ "en" => "(A) Two weeks after the puncture, without contact lens and (B) subepithelial fibrosis in the punctured area after 3 weeks." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Peripheral corneal edema after cataract extraction: a new clinical entity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.I. Brown" 1 => "J.M. McLean" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Trans Am Acad Ophthalmol Otolaryngol" "fecha" => "1969" "volumen" => "73" "paginaInicial" => "465" "paginaFinal" => "470" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5791370" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior stromal punctures for bullous keratopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Cormier" 1 => "I. Brunette" 2 => "H.M. Boisjoly" 3 => "M. LeFrançois" 4 => "Z.H. Shi" 5 => "M.C. Guertin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Ophthalmol" "fecha" => "1996" "volumen" => "114" "paginaInicial" => "654" "paginaFinal" => "658" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8639074" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical findings in Brown–McLean syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T.W. Gothard" 1 => "D.R. Hardten" 2 => "S.S. Lane" 3 => "D.J. Doughman" 4 => "J.H. Krachmer" 5 => "E.J. 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De Freitas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrs.2003.09.068" "Revista" => array:6 [ "tituloSerie" => "J Cataract Refract Surg" "fecha" => "2004" "volumen" => "30" "paginaInicial" => "1575" "paginaFinal" => "1577" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15210241" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anterior stromal puncture. Immunohistochemical studies in human corneas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.K. Hsu" 1 => "R.S. Rubinfeld" 2 => "P. Barry" 3 => "J.V. Jester" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Ophthalmol" "fecha" => "1993" "volumen" => "111" "paginaInicial" => "1057" "paginaFinal" => "1063" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8352688" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000008800000005/v1_201307100543/S2173579413000819/v1_201307100543/en/main.assets" "Apartado" => array:4 [ "identificador" => "5812" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Short communications" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000008800000005/v1_201307100543/S2173579413000819/v1_201307100543/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579413000819?idApp=UINPBA00004N"]

ISSN: 2173-5794
e-ISSN: 1989-7286

Archivos de la Sociedad Española de Oftalmología is the official journal of the Ophthalmology Society of Spain, that has over 4,000 members. It gives priority to the publication of basic, translational and clinic research including reviews, original articles, short communications, editorials, letters to the editor and clinic practice guides related to Ophthalmology and its subspecialties. A small section of the journal is reserved for the most relevant papers presented at the annual Congress of the Society. All manuscripts considered for publication are reviewed by expert examiner peers (double blind). The journal is published monthly and even though its official language is Spanish all articles are translated into English to increase the dissemination of scientific information. At present, Archivos is the only Spanish language Ophthalmology journal indexed in PubMed/MEDLINE in addition to other prestigious international databases such as Scopus.

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