[Advantages of confocal microscopy in the analysis of epiretinal membranes and internal limiting membranes after macular surgery]. / Intérêt de la microscopie confocale in vitro dans l'étude des membranes épirétiniennes et des membranes limitantes internes après chirurgie maculaire.

PURPOSE: To study specimens obtained from epiretinal membrane (ERM) and macular hole surgery with confocal microscopy and to evaluate its advantages in understanding their pathophysiology. MATERIAL AND METHODS: This retrospective study included 50 patients undergoing surgery for epiretinal membrane (40 patients) or idiopathic macular hole (10 patients). Infracyanine green was used in 45 cases. Immunohistological examination of the excised tissues was undertaken using confocal microscopy after labeling with antibodies to glial fibrillary acidic protein (GFAP) and vimentin. RESULTS: Confocal microscopic analysis of epiretinal membranes identified three types of tissues: 13 ERMs, which appeared thick and rich in cells, 20 internal limiting membranes (ILMs), which appeared thin, wrinkled and poor in cells, and seven composite tissues, where ERM and ILM were removed at the same time. The analysis of ten specimens obtained from macular hole surgery revealed nine ILMs and one composite tissue that were quite similar to those removed in epiretinal membrane surgery. In all, 27 specimens (10 ERMs, 12 ILMs and five composite tissues) contained GFAP-positive glial cells. CONCLUSION: The confocal microscope provided a fast, three-dimensional analysis of ERMs and ILMs. An immunohistological study identified cells that take part in the genesis of the membranes. Glial cells were found both in ERM and ILM specimens. Our findings suggest that Müller's cells may contribute to the pathogenesis of ERM and macular hole development.

Sub-Tenon's anaesthesia: an efficient and safe technique.

AIM: To evaluate sub-Tenon's anaesthesia as an alternative to peribulbar anaesthesia. METHODS: 109 consecutive patients listed for various eye operations (including cataract, trabeculectomy, and vitrectomy) under peribulbar anaesthesia were operated on under sub-Tenon's anaesthesia instead. After topical anaesthesia a buttonhole was fashioned through the conjunctiva and Tenon's capsule 10 mm posterior to the limbus. 1.5 ml of lignocaine 2% was then delivered to the posterior sub-Tenon's space using a blunt cannula. The surgical procedure was performed immediately after the completion of the anaesthetic procedure. Chemosis, conjunctival haemorrhage, degree of akinesia, and pain scoring were analysed. RESULTS: There were no anaesthesia related complications. The administration of the block was painless for 99.1% of the patients. In all, 97.3% reported no pain during surgery. There was no akinesia when assessed just after the completion of the block and akinesia was limited when assessed after surgery. Chemosis and conjunctival haemorrhage were frequent but caused no intraoperative problems. CONCLUSION: Sub-Tenon's anaesthesia is an efficient and safe anaesthetic technique. It is a good alternative to peribulbar anaesthesia.

Topical versus peribulbar anesthesia in cataract surgery.

PURPOSE: To compare the use of topical anesthesia with that of peribulbar anesthesia in cataract surgery. SETTING: Quinze-Vingts Hospital, Paris, France. METHODS: This prospective study comprised 45 patients who had phacoemulsification and intraocular lens implantation in both eyes with 1 to 9 months between surgeries. Each patient had peribulbar anesthesia for one surgery and topical anesthesia for the other. The anesthesia method for the first eye was randomly selected. After surgery, patients were asked to rate their pain and whether they preferred one anesthesia technique over the other. RESULTS: When topical anesthesia was given, 82.2% of patients required no intravenous medications. Overall, 62.2% preferred topical over peribulbar anesthesia, with most patients citing the lack of periocular injection as the reason. CONCLUSION: Despite the increased technical difficulty, topical anesthesia proved an effective alternative to peribulbar anesthesia for cataract surgery that avoids the risks of periocular injection and reduces the need for intravenous medications.

Surgically induced astigmatism with superior and temporal incisions in cases of with-the-rule preoperative astigmatism.

PURPOSE: To evaluate surgically induced astigmatism (SIA), postoperative astigmatism, and uncorrected visual acuity (UCVA) after cataract surgery with superior corneal, superior scleral, and temporal corneal 4.0 mm sutureless incisions in cases of preoperative with-the-rule (WTR) astigmatism. SETTING: Hopital des Quinze-Vingts, Paris, France. METHODS: This prospective evaluation included patients having phacoemulsification with foldable lens implantation through a 4.0 mm incision. Patients with preoperative WTR astigmatism were randomly assigned to 1 of 3 incisions: superior corneal (Group 1), superior scleral (Group 2), or temporal corneal (Group 3). All patients had autokeratometry preoperatively and postoperatively (1 day, 1 week, 1 month, 1 year). Surgically induced astigmatism using the vector method, postoperative astigmatism, and UCVA (patients whose spherical equivalent was with +/- 1 diopter) were evaluated. RESULTS: Ninety patients were included in the study; there were 30 in each incision group. One year postoperatively, Group 1 had 1.52 diopters (D) of SIA and 1.36 D of postoperative astigmatism; 53.5% of patients had a UCVA of 20/32 or better, Group 2 had 0.69 D of SIA (P < .05) and 0.67 D of postoperative astigmatism (P < .05); 82.7% of patients had a UCVA of 20/32 or better (P < .05). Group 3 had 0.69 D (P > .05), 0.98 D (P < .05), and 79.3% (P > .05), respectively. CONCLUSIONS: In this study, the superior corneal incision produced significant SIA, leading to high postoperative astigmatism and poor UCVA. The scleral and temporal incisions produced minimal SIA and good UCVA.

[Value of corticoids in the treatment of postoperative endophthalmitis]. / Intérêt des corticoïdes dans le traitement de l'endophtalmie postopératoire.

Postoperative endophthalmitis, which has a dreadful reputation, needs early and aggressive treatment. Apart local and systemic antibiotic therapy, the place of corticosteroid treatment is still discussed. The authors retrospectively compared three groups of patients treated with appropriate antibiotics but with different corticosteroid. Group I received high dose corticosteroids early regimen, group II received delayed corticosteroids treatment and group III did not receive corticosteroids. Visual recovery as well as vitreous transparency better in group I.

[Astigmatism caused by superior and temporal corneal incisions in cataract surgery]. / Astigmatisme induit par les incisions cornéennes supérieures et temporales dans la chirurgie de la cataracte.

PURPOSE: To compare induced astigmatism and postoperative astigmatism of a 4 mm corneal superior incision to a 4 mm temporal incision for cataract phacoemulsification surgery. METHODS: Sixty eyes underwent cataract surgery for this prospective study. Thirty had a superior corneal incision (group 1) and 30 had a temporal incision (group 2). The incision was placed according to the pre operative astigmatism:temporal approach in case of against the rule astigmatism and superior location in case of with the rule astigmatism. The incision was enlarged to 4 mm just before implantation of a foldable lens. The patients had a pre operative and a post operative (day 1, 8, 30, 180) keratometry. Some had a corneal topography too. The surgically induced astigmatism was calculated using Naeser method. RESULTS: The incision having a relaxing effect on the meridian where it is placed, the surgically induced astigmatism is against the rule for a superior location and with the rule for a temporal location. At day 30 the mean surgically induced astigmatism was 0.98 diopter in group 1 and 0.58 in group 2. At ay 30 the postoperative astigmatism was 0.51 diopter against the rule in the first group and 0.13 diopter with the rule in the second group. CONCLUSION: The superior corneal incision rarely allows to reach a minimum postoperative astigmatism as with a temporal location.

[Choice of the site of incision for cataract surgery without suture according to preoperative astigmatism]. / Choix du site d'incision pour la chirurgie de la cataracte sans suture en fonction de l'astigmatisme pré-opératoire.

PURPOSE: To compare surgically induced astigmatism, postoperative astigmatism and uncorrected visual acuity after cataract surgery depending on the site of a 4 mm sutureless incision (superior scleral or corneal temporal) and on the preoperative astigmatism. METHODS: According to preoperative astigmatism and to the site of incision 4 groups have been distinguished. Group I: with-the-rule preoperative astigmatism and superior scleral incision, group II: with-the-rule preoperative astigmatism and corneal temporal incision, group III: against-the-rule preoperative astigmatism and superior scleral incision, group IV: against-the-rule preoperative astigmatism and temporal incision. The patients had a preoperative and postoperative (Day 1, 8, 30, 180, 360) keratometry. Surgically induced astigmatism, preoperative and postoperative astigmatism have been expressed according to Naeser method. The uncorrected visual acuity at Day 30 has been compared in each group. RESULTS: Preoperative astigmatism was similar in the four groups. Surgically induced astigmatism was -0.18 diopter (D) at day 30 and -0.41 D at day 360 for the scleral incisions and +0.60 D at day 30 and +0.33 D at day 360 for the temporal incisions. The postoperative astigmatism was +0.5 D at day 30 and +0.27 at day 360 for the group I and +1.22 D at day 30 and +0.95 D at day 360 for group II. There was no statistical difference in the uncorrected visual acuity. Postoperative astigmatism was -0.8 D at day 30 and -1.03 D at day 360 in group III and -0.04 D at day 30 and -0.31 D at day 360 in group IV. The visual acuity was significantly better in group IV than in group III. CONCLUSION: In cases of preoperative with-the-rule astigmatism < or = 0.75 D the two sites of incisions are possible. In cases of WTR astigmatism over 0.75 D we perform a superior scleral approach. In cases of against-the-rule astigmatism the temporal incision is the only one to consider.

[Pars plana vitrectomy: causal affections, material employed, and approach in 1400 cases (author's transl)]. / A propos de 1400 vitrectomies par la pars-plana. Affections causales, matériel et voie d'abord.

Isolated vitrectomy was employed in half of 1,400 cases operated upon, the other patients receiving an intra-ocular injection of silicone fluid. Emphasis is placed on the simplification undergone by the materials employed, the progress represented by the addition of an autonomous infusion for each instrument complementary to the vitrectomy, and the need for all ophthalmic surgeons, particularly those in training, to become familiar with the use of the vitreotome.

[Surgical treatment of retinal detachment with macular holes by vitrectomy and silicone oil injections (author's transl)]. / Traitement chirurgical des décollements de rétine avec trou maculaire par la technique de la vitrectomie associée à l'injection de silicone liquide.

A total of 18 patients with retinal detachment from macular holes were treated by intra-ocular injections of silicone oil after vitrectomy. Successful reapplication was obtained in all cases operated upon by primary intention (12 out of 12). This procedure has the advantage of not requiring coagulation around the hole, as employed by other methods, thus avoiding enlargement of the central scotoma.

[Myopic anterior chamber intraocular lens implantation: evaluation at 8 years]. / Implants myopiques en P.M.M.A. de chambre antérieure: bilan à 8 ans.

PURPOSE: The aim of this study was to analyse the tolerance of Myopic Anterior Chamber IOL's 8 years after surgery. MATERIAL AND METHODS: We have studied 21 eyes implanted with an anterior chamber phakic IOL between May 1989 and June 1990. The 21 eyes had a very high myopia (mean pre-operative myopia--13.5 Dipters). Surgical technique was easy, without peroperative complications. RESULTS: Post-operative refractive results were excellent with a mean refraction of -0.25 D. Post-operative complications were a pupillary ovalisation in 42% of the eyes and glare in 50% of the eyes. Specular microscopy was normal pre-operatively for all the eyes but at 8 years, 4 (19%) of the eyes have had a strong loss of their endothelial cells and have to be explanted. Decreasing of endothelial cells is the most severe complication occurring after Phakic anterior chamber myopic IOL implantation. CONCLUSION: These 21 Myopic Anterior chamber IOL's have given a very good refractive result for all the eyes. 4 (19%) of the eyes operated on with these IOL's had a decreasing of their endothelial cells and the IOL had to be removed. Rigourous follow-up of the implanted eyes is required.

[Phacoemulsification and topical anesthesia. Apropos of 40 cases]. / Phacoemulsification et anesthesie topique. A propos de 40 cas.

BACKGROUND: To evaluate topical anaesthesia for cataract surgery. METHODS: Thirty-nine patients (40 eyes) underwent cataract surgery by phacoemulsification with topical anaesthesia consisting in instillations of tetracaine eyedrops. Thirty-four eyes were implanted with a foldable lens and 6 eyes received a PMMA lens. Final visual acuity (1 month minimum follow-up), patients reactions (sensibility, pain), anaesthetic and surgery difficulties were specially studied. RESULTS: Mean initial corrected visual acuity was 0.21. Mean final corrected visual acuity was 0.72; 90 % of the subjects experienced no pain. Implantation was the most sensitive moment. Eye mobility was not a problem except during capsulhorexis which had to be done with forceps. CONCLUSION: Simplicity of topical anaesthesia eliminates the complications of the other anaesthetic methods. It is necessary to have a close patient-surgeon relationship. Carefully chosen topical anaesthesia is an interesting alternative.

[Specular microscopy in the diagnosis of the iridocorneal endothelial syndrome]. / Apport de la microscopie spéculaire dans le diagnostic du syndrome endothélial irido-cornéen.

Irido-corneal endothelial syndrome regroups three disorders including: endotheliopathy, peripheral anterior synechiae and iris changes. According to the aspect of these abnormalities, three syndromes are described: essential iris atrophy, Chandler's syndrome and iris naevus (Cogan-Reese) syndrome. Endothelial changes studied by specular microscopy are typical: in early stages, a rounding off cell angles and intracellular blackout areas can be seen; in former stages, black out areas increase and there is a disruption of the regular mosaic. These features are a major point for differential diagnosis. We present six cases reports among which three where effectively diagnosed as iridocorneal endothelial syndrome and three were not.

[Cataract and implantation in the vitrectomized eyes]. / Cataracte et implantation sur oeil vitrectomisé.

Cataract is a frequent complication of vitreous surgery after some months or years. In these cases cataract extraction is somewhat difficult. We performed cataract surgery with implantation in 38 eyes from 37 patients between 1986 and 1991. Twenty patients underwent vitreous or vitreoretinal surgery with or without internal tamponade by gas, 17 underwent silicone oil tamponade and silicone oil removal, prior to cataract surgery. Timing of surgery, number of surgical procedures and complications previous to cataract surgery are detailed in the paper. Cataract extraction was extracapsular in 7 cases, intracapsular in 6 cases; phako was performed in 24 cases and phacophagy in one case. A posterior IOL was inserted in 31 cases, an anterior chamber IOL in 7 cases. Anatomical and visual results were satisfying. Visual acuity improved postoperatively in 29 cases (up to 20/20 in 4 cases), was unchanged in 6 cases, decreased in 3 cases. Among these, loss of vision occurred in 5 cases due to retinal detachment or redetachment. For anatomical reasons, lack of vitreous support and the frequent zonular weakness of these eyes, account for surgical difficulties. Thus, phakoemulsification appears the best way to manage cataract in vitrectomized eyes.

[Phacoemulsification by the anterior approach combined with vitreoretinal surgery]. / Phacoémulsification par voie antérieure combinée à la chirurgie vitréo-rétinienne (22 cas).

Phacoemulsification was combined with vitreoretinal surgery in 22 cases in which lens opacity prevented good visualisation of the fundus. The main indications were proliferative diabetic retinopathy and retinal detachment complicated by proliferative vitreoretinopathy. Phacoemulsification was achieved by a limbal approach. The technique was adapted to the hardness of the lens nucleus. The incision was temporarily or definitely closed. The visualisation system was set up and the endocular surgery performed. In 5 cases an implantation in the bag was realised at the end of surgery. This type of combined procedure offers both the benefits of extra capsular surgery: avoids neovascular glaucoma in diabetic patients, keeps silicone oil in good position, possible implantation in the capsular bag, and those of a small incision: absence of leakage, of myosis, of corneal clouding, rapid rehabilitation.

[Acute retinal necrosis syndrome. Retrospective study apropos of 14 eyes in 11 patients]. / Le syndrome de nécrose rétinienne aiguë. Etude rétrospective à propos de 14 yeux de 11 patients.

PURPOSE: The authors present a retrospective study of fourteen eyes of eleven patients suffering from acute retinal necrosis syndrome (ARN) and compare the results with previously published data. MATERIAL AND METHODS: All patients were referred to us between 1985 and 1993. The results of initial examination, the epidemiological and aetiologic data, as well as the clinical course and treatment are summarized in two tables. RESULTS: First clinical examination found a prominent ocular inflammatory reaction, several sites of peripheral retinal necrosis and one retinal vasculopathy. Bilateralisation occurred in 28% of the patients. An optic neuropathy developed in 57% of the cases, and a retinal detachment in 78%. Initial examination and data on the clinical course are discussed and compared with those described in the literature. CONCLUSION: The results of the current study are representative of the various clinical and biological profiles of acute retinal necrosis and are similar to those described in previous publications. Earlier care in specialized departments of ophthalmology should allow a better anatomical and functional prognosis in the future.

[Corneal pseudo-dystrophic complication caused by contact lenses]. / Complication cornéenne pseudo-dystrophique des lentilles de contact.

The authors report the cases of two patients suffering of a rare long-term complication of contact lens wearing. Both patients wore daily soft contact lens for 5 and 8 years respectively. They presented with bilateral central predescemetic avascular haze associated with mild corneal stromal edema, descemetic folds in one patient and polymegethism on endothelial specular microscopic examination. The vision impairment was severe, unilateral in one patient and bilateral in the other. More than one year after removal of the contact lenses, only one patient fully recovered her initial visual acuity. The mechanisms of the onset of this corneal pseudo-dystrophy are discussed. Hypoxia and acidosis of the cornea induced by the contact lens are most probably responsible for this complication through endothelial metabolic dysfunction.

[Macular imaging with optical coherence tomography]. / Imagerie maculaire en OCT.

PURPOSE: Optical Coherence Tomography (OCT) is a novel noninvasive and noncontact imaging technique providing cross-sectional representations of the eye structures. OCT is analogous to Ultrasound B-scan, except that it analyzes the reflection of a 850 nm light wave. The aim of this study was to assess the potential of ocular coherence tomography for diagnosing and monitoring macular diseases. METHODS: Cross-sectional images were performed with the Zeiss-Humphrey OCT. Over one year period, we examined approximately 300 patients with idiopathic full thickness macular hole, lamellar hole, cystoid macular edema, choroidal new vessels, epiretinal membrane, diabetic maculopathy, and central serous chorioretinopathy. RESULTS: OCT can provide new information concerning the posterior pole diseases mentioned above. OCT can also be useful in thickness measurements. CONCLUSION: OCT allows tomographic analysis of macular diseases. The information obtained is different from that obtained by histologic study which is sometimes hard to interprete. OCT is mostly useful in studying internal layers of the retina. Further applications may be developed.

[Comparative prospective study of effects of Biovisc and Healonid on endothelial cell loss and intraocular pressure in cataract surgery]. / Etude prospective comparative des effets du Biovisc et du Healonid sur la perte endothéliale cellulaire et de la pression intraoculaire dans la chirurgie de la cataracte.

PURPOSE: The goal of this trial was to evaluate the efficacy (protective action on corneal endothelium and ability to facilitate the procedure) as well as safety (effect on intraocular pressure and inflammation) of Biovisc (new viscoelastic agent made of 1% sodium hyaluronate produced by bacterial fermentation) versus Healonid) postcataract surgery (manual or phacoemulsification). METHODS: 106 patients, 45 males and 61 females (31-94 years) were included in this prospective randomized multicentre trial and followed up for three months. Specular microscopy and intraocular pressure (IOP) measurement were the main evaluation criteria. RESULTS: At D 90, no significant difference was observed between the two viscoelastic agents on the mean endothelial cell loss (group Viovis: -8.6%; group Healonid: -6%) as well as on IOP (early peaks were transitory and resolutive). CONCLUSION: Biovisc and Healonid were similar in terms of efficacy and tolerance.

[Fifty-two cases of postoperative endophthalmitis treated with one protocol: anatomical and functional results]. / 52 cas d'endophtalmie post-opératoire traités par un protocole thérapeutique unique: résultats anatomiques et fonctionnels.

PURPOSE: To evaluate our management of postoperative endophthalmitis and compare our protocol to the Endophthalmitis Vitrectomy Study's (EVS) recommended protocol. PATIENTS AND METHODS: This study comprises 52 patients with postoperative endophthalmitis treated with the same protocol in 1996 and 1997. Patients were given an intravitreal injection of antibiotics (vancomycin-amikacin) and steroids (dexamethasone), systemic antibiotics (pefloxacin-piperracillin), and systemic steroids in bolus. Vitrectomy was not systematic. So as not to delay the treatment, cultures were obtained only from an anterior chamber paracentesis. RESULTS: Visual acuity was measurable in 86.5% of the patients, with 20/100 in 63.4% and 20/40 in 44.2%. Our results are similar to those of the EVS even when initial visual acuity was Light Perception. CONCLUSION: Our protocol is simple and easy to perform in all ophthalmology centers. It is based on intravitreal injection, which must be performed as quickly as possible.

[Intrastromal epithelial cysts of the iris: two case studies]. / Kyste congénital du stroma irien.

AIM: Intrastromal epithelial cysts, congenital or acquired, are rare tumors of the anterior chamber. We report two cases, one in a 4-Month-old girl and one in a 14-Year-old teenage girl. MATERIAL AND METHODS: In the infant case, a large cyst with a superior base obstructed the visual axis. The child had already developed amblyopia and intermittent esotropia, with normal ocular pressure. Aspiration of the cyst with complete excision was done without iridectomy. Two Years later, a secondary corectopia required an inferior iridectomy. Finally, 4 Years later, endophthalmitis developed on a corneal stitch, and the eye was enucleated. In the second case, the teenage girl had noticed a modification in her iris due to an inferior temporal iris cyst. The cyst was excised with a peripheral iridectomy. Despite a first complete excision, a recurrence the following Year was treated by Yag laser. One Year later, the clinical aspect was stable. COMMENTS AND CONCLUSION: These benign tumors present the problem of local extension and recurrence. Surgical treatment with iridectomy is often proposed despite eventual aesthetic or functional consequences. Yag laser may be a therapeutic alternative. The two operations reported here did not prevent recurrence. In conclusion, intrastromal epithelial cysts of the iris are rare and benign tumors that may induce local complications and lead to recurrence. Many treatments can be discussed for each case.