Radiation therapy for thyroid eye diseases.

Sixty-two patients (28 men and 34 women, 26 to 84 years old) with thyroid ophthalmopathy were treated with approximately 20 Gy of fractionated photon irradiation. Eight of 14 patients with motility problems improved after treatment. Ten of 14 with thyroid optic neuropathy improved or stabilized, but four had recurrences within five months after completion of irradiation. Generally, patients who had disease durations of less than six months responded better than those with more long-term ocular changes.

Choice of surgical treatment for Graves' disease.

Functional and cosmetic ophthalmic complications of Graves' (1835) disease are dysthyroid optic neuropathy, exophthalmos, eyelid retraction and oculomotor disturbances. This paper describes and elaborates on the surgical procedures used when these complications are present. In severe exophthalmos and optic neuropathy we use an orbital decompression of the orbital floor sometimes combined with the medial wall, via an anterior approach. In eyelid retraction, we perform a recession of the levator muscle with scleral graft implantation. In concomitant strabismus, surgery is usually limited to recessions of the involved muscles, most of the surgery is directed to the inferior and medial rectus, as these are the most commonly affected muscles. The indications depend on the status of the patient at the time of referral. For severe exophthalmos with true retraction of the upper eyelid, we begin by treatment of the retraction and if this is not sufficient, we perform orbital decompression. For severe exophthalmos with oculomotor disturbances, we perform orbital decompression and later, the strabismus surgery. For oculomotor disturbances with eyelid retraction, we perform the strabismus surgery at the first and the eyelid retraction at the second stage. When there is a combination of exophthalmos, eyelid retraction and oculomotor disturbance, the indications and the choice of treatment are difficult and depend on numerous factors. If orbital decompression is indicated, it will be done first, followed by the strabismus surgery and at a later stage, the eyelid retraction. If only the eyelid retraction is treated, it will be done after the strabismus surgery. The chronological order of treatment depends on the modification we observe on the other components of the ophthalmopathy.

[Immature palpebral capillary angioma. A case commented on]. / Angiome capillaire immature palpébral. Observation commentée.

A three-year-old girl presented a voluminous capillary haemangioma associated with amblyopia. This case failed to respond to steroid treatment. Surgical treatment was necessary. The authors describe evolution, complications and therapeutic management of eyelid angiodysplasia.

[Colobomatous cyst of the orbit in congenital microphthalmos]. / Kyste colobomateux de l'orbite au cours d'une microphtalmie congénitale.

Colobomatous orbital cyst with microphthalmos is an anomaly of the orbital contents occurring during embryogenesis. In this study, we report the case of a 3 year-old child referred with the initial diagnosis of voluminous orbital angioma. Radiological investigations and histological study of the ablated mass established the correct diagnosis of colobomatous cyst. Pathogeny, diagnostic and therapeutic problems are discussed.

[Canalicular stenoses complicating the insertion of lacrimal plugs. Incidence and mechanisms]. / Sténoses canaliculaires compliquant la pose de bouchons lacrymaux. Incidence et mécanismes.

Changes in canalicular permeability following the insertion of punctum plugs was studied. This occlusive method was used to treat dry eye syndrome in 43 patients over a period of 32 months. All had normal canalicular patency, confirmed on the day of implantation. One hundred and five large plugs were used (2.4 plugs per patient). Twenty seven (25.7%) impassable acquired canalicular stenoses were seen in 15 patients. The canalicular site of the 27 stenoses was the same: junction between the vertical and horizontal portions. Among the 27 stenoses: 4 plugs had disappeared at an unknown time, with follow-up probing taking place after a mean interval of 7.5 (months range: 1 to 15 months); 17 plugs had been expelled after being in place for an average of 5 months (range: 1 to 12 months; standard deviation 3.47), with follow-up examination taking place on average 12 months after insertion (range: 6 to 17 months; standard deviation 3.4); and 6 plugs were still in place after a mean of 7 months (range: 2 to 15 months; standard deviation 4.73) and the stenosis was discovered when they were removed. They were intact. These 6 Cases eliminate any possibility of intra-canalicular migration of the prosthesis--of all or part--of the prosthesis. Stenoses appeared to develop rapidly: 45% of cases were discovered during the first 3 months. 16/27 (59%) of stenoses were investigated a second time, 6 months later on average (range: 2 to 12 months): these 16 canaliculi all remained impassable.

[Complications of punctum plug in the symptomatic treatment of dry eye]. / Complications des bouchons lacrymaux employés dans le traitement symptomatique des sécheresses oculaires.

76 patients with dry eyes were treated by mechanical obstruction of lacrymal puncta. The sex ratio is: 62 females and 14 males. The age average was 55, ranging from 12 to 88. The etiologies were: Sjögren's syndrome: 16 cases (21%); filamentous kerato-conjonctivitis sicca: 12 cases (15%); anxiolytical and anti-depressant treatments: 10 cases (13%); complicated viral kerato-conjonctivitis: 4 cases (5%); post radiotherapy dry syndrome: 3 cases (4%); idiopathic and various etiologies: 31 cases (40%). The 149 plugs are completely made of hydrophobic silicone; 20 had a barb inclined on the neck axis. Insertion was achieved after tropical anesthesia in 90% of the cases. 121 plugs (81%) did not lead to any anatomical complication (the average duration remaining on time interval of implantation per plug was of 5 months). Functional tolerance depends on the quality of plug-punctum adjustment. Plug protrusion is the main cause of intolerance and disappearance. The complications were: rupture of punctum during dilation: 1%; suppurative canaliculitis: 1.3%; disappearance: 16%; epiphora: 22%. No intra-canalicular migration was observed. We check canalicular permeability in 26 cases, after loss or removal: che was normal 23 times (average time-interval: 5 months). We had 3 cases of canalicular stenosis after 4 months, 5 months and 18 months of intubation.

[Unusual preseptal location of an orbital cavernous hemangioma in African patient]. / Localisation inhabituelle préseptale d'un hémangiome caverneux orbitaire chez une patiente d'origine africaine.

Cavernous hemangioma is the most common primary vascular orbital tumor in adults. Generally the benign tumor arises within the muscle cone, revealed by proptosis with choroidal folds, and more rarely develops in other orbital localizations. We report the case of a 42-year-old female African patient who had a cavernous hemangioma in an unusual anterior localization. Clinically, a small superficial tumor was palpated in the right superior nasal orbital angle. After complete surgical excision, the histopathological study established the diagnosis of cavernous hemangioma

[Residual left orbital phlebolith. An anatomic-clinical observation]. / Phlébolithe résiduelle orbitaire gauche. A propos d'une observation anatomo-clinique.

A 29-year-old female patient displayed a dense and hard left orbital mass, inferiorly, 3 years after she was treated through a neurosurgical approach for a left orbital varix. The lesion was hyperdense on CT-scan and was removed through a trans-conjunctival approach, with an excellent result. The histological diagnosis was a phlebolith.

[Eyelid neurofibroma affecting a young woman]. / Neurofibrome palpébral chez une femme jeune.

A 43-year-old female patient had an amelanotic single tumor thickening the upper right eyelid and observed since early childhood. Clinically, it appeared as a firm mass, without sharp margins, giving a thickened appearance to the superior eyelid. The ophthalmic clinical examination was normal but some subcutaneous nodules attested to the diffusion of the disease recognized as a limited form of neurofibromatosis 1. Although well tolerated, it gave rise to a cosmetic disturbance and the patient was willing to undergo an excision. A complete surgical excision was performed on the lesions and the pathological study disclosed a typical neurofibroma. Regular observation of the different cutaneous nodules was recommended.

The management of congenital malpositions of eyelids, eyes and orbits.

Congenital malformations of the eye and its adnexa which are multiple and varied can affect the whole eyeball or any part of it, as well as the orbit, eyelids, lacrimal ducts, extra-ocular muscles and conjunctiva. A classification of these malformations is presented together with the general principles of treatment, age of operating and surgical tactics. The authors give some examples of the anatomo-clinical forms, eyelid malformations such as entropion, ectropion, ptosis, levator eyelid retraction, medial canthus malposition, congenital eyelid colobomas, and congenital orbital abnormalities (Craniofacial stenosis, orbital plagiocephalies, hypertelorism, anophthalmos, microphthalmos and cryptophthalmos).

Orbito-palpebral reconstruction in anophthalmos and severe congenital microphthalmos.

In patients with congenital anophthalmos and severe microphthalmos, a tiny orbit and socket exist with little eyelids, frequently preventing retention of a standard conformer or prosthesis. Socket expansion is sometimes impossible with microorbitism; the retention of a prosthesis is also difficult when malformations of the eyelids exist. The treatment of these difficult cases includes three stages. The first stage is orbital expansion that depends on the cephalometric studies of the patient: transverse osteotomy on the maxilla and the zygomatic bone with lateral bar by extracranial route, vertical osteotomy on the roof of the orbit by intracranial route. In some cases, the osteotomy includes expansion in the transverse and vertical diameter with bone grafts in the defects and on the lateral and superior rims. Simultaneously, socket expansion is performed by incision of the conjunctival sac circumferentially, with mucosal or split skin grafts on a conformer. The second stage includes eyelid reconstruction by different flaps. A third stage is frequently needed for correction of eyelid malposition on the prosthesis: ptosis, entropion surgery. Two cases of congenital anophthalmos are reported. Methods and indications of treatment are discussed.

[Surgical treatment of myopathic ptosis. Apropos of 20 surgically treated cases]. / Traitement chirurgical des ptosis myopathiques. A propos de vingt cas opérés.

Twenty cases of severe progressive ophthalmoplegia (Myopathic ptosis) with significant ptosis were treated by various procedures, including levator resection with blepharoplasty or frontalis suspension using temporalis fascia. Surgical indications were generally limited to cases with poor or absent levator function. The results are analysed after an average follow-up of 6 months. The particular problems concerning surgery of myopathic ptosis are discussed.

[Bovine heterologous bone graft in orbital surgery]. / Greffe osseuse hétérologue d'origine bovine dans la chirurgie orbitaire.

Lubboc (T650) is a bovine heterologous bone implant obtained by specific preparation of trabecular of bone. In vitro and in vivo biocompatibility studies have revealed the absence of any cytotoxicity or systemic toxicity. Lubboc has many fields of application, including all bone graft surgical indications. We report our first results concerning the use of this product in orbital surgery either as a filling or contention material or as an apposition material. On all 20 operated patients we did not encounter any intolerance, inflammation or infection. The follow-up is still too short to appreciate the long term integration of this material which has the advantage of being a substitute for autologous bone, avoiding bone graft harvesting.

[Surgery of post-traumatic ptosis]. / Chirurgie des ptosis post-traumatiques.

Post-traumatic ptosis may be classified as follows: ptosis occurring during lid avulsion, ptosis associated with fractures of the orbital roof and with foreign bodies, post-contusional ptosis, cicatricial ptosis, neurogenic ptosis and post-surgical ptosis. The patient must be thoroughly examined, including examination of the eye-ball, extra-ocular muscles, eyelid and evaluation of upper eyelid levator function and orbital and facial examination. The various surgical methods proposed include levator muscle surgery, aponeurotic surgery, Müller's muscle surgery and frontalis suspension surgery. Surgical indications and choice of surgical method essentially depend on the anatomo-clinical forms. The general rule is to operate under local anesthesia to obtain better control of the muscular function. Some cases are simple to treat such as post-contusional ptosis with good levator function which allows functional surgery with excellent static and dynamic results. Other relatively simple cases with non functional levators may only be treated on a static basis. Last but not least are more difficult cases in which levator function is difficult to evaluate pre-operatively because of severe fibrosis. The aim in such cases is to explore the eyelid by an anterior approach under local anesthesia and to propose either muscular surgery or a frontalis suspension according to the anatomical and functional status of the levator muscle.

The surgical management of orbitopalpebral neurofibromatosis.

Orbitopalpebral neurofibromatosis may cause severe soft tissue deformity. Exophthalmos is either due to an intraorbital mass or to the absence of the greater wing of the sphenoid (mesodermal dysplasia). Five patients are presented. Surgical procedures and craniofacial techniques are detailed and discussed.

Orbito-palpebral reconstruction in two cases of incomplete cryptophthalmos.

Two cases of congenital symblepharon (variant of cryptophthalmos) are reported. Cryptophthalmos is a very rare congenital defect, with incomplete or complete failure in the development of one or both eyelids with skin recovering the anterior segment. Surgical treatment is described including expansion of the conjunctival fornix with eyeball conservation if possible. At the same time or later, the upper eyelid is reconstructed by inferior eyelid flap. The ophthalmic features of cryptophthalmos and its systemic associations are reviewed.

[Orbital decompression in exophthalmos due to thyroid disease. Report of 69 cases]. / Décompression orbitaire au cours de l'exophtalmie dysthyroïdienne. A propos de 69 cas.

Dysthyroid exophthalmos is due to mismatching of the orbit and its contents, essentially due to muscle enlargement, and, to a lesser degree, fat volumetric changes. Surgical treatment is designed to expand the orbital volume by bone removal or to reduce orbital contents by fat removal, or a combination of the two techniques. Our series consisted of 69 patients who underwent orbital decompression for proptosis, with osteotomy (12 cases) or associated with fat removal (57 cases). We obtained good results for all cases, and did not encounter any complications. Several factors now appear to play a role in the choice of surgical technique, particularly the preoperative radiologic (CT) examination which determines the muscular and fat involvement, wall orbital changes and appearance of the sinuses. Orbital fat removal seems to be useful in proptosis reduction in those cases in which fat is more involved and easy to remove. Anthral ethmoidal decompression is the best technique in the case of dysthyroid optic neuropathy.