[Keratoplasty combined with cataract surgery]. / L'intervention combinée greffe-cataracte.

Corneal pathologies leading to keratoplasty are often associated with cataract and combined surgery is therefore mandatory. Triple procedure with penetrating keratoplasty and concurrent cataract extraction followed by intra ocular lens (IOL) implantation is usually the preferential choice because visual rehabilitation is theoretically more rapid. Surgeons have to be aware of surgical conditions during open-sky surgery because vitreous pressure is not counterbalanced by anterior chamber pressure. Today, many surgeons prefer non-simultaneous procedures with cataract surgery performed months after grafting because of the improvement in spherical refractive error. More recently, new triple procedures, Descemet's stripping automated keratoplasty and concurrent cataract surgery have gained popularity, especially in patients with Fuchs dystrophy associated with cataract. Surgery starts with phacoemulsification, followed by endothelium exchange through a 3 to 5 mm incision. Advantages against classic triple procedure are quick visual rehabilitation, fewer induced refractive errors, minimal postoperative discomfort and corneal integrity. Surgeons have to consider an eventual postoperative hyperopic shift secondary to corneal lenticule shape when choosing adequate intraocular lens.

Endoscopic revision of external dacryocystorhinostomy failure.

OBJECTIVE: To evaluate the usefulness of endoscopic analysis and surgery of the lacrimal sac in cases of external dacryocystorhinostomy (DCR) failure. MATERIAL & METHOD: In a retrospective study, 17 endoscopic procedures in 17 patients during 11 years with recurrent lacrimal obstruction after external DCR were performed. Endoscopic analysis and procedures were carried out with a routine silicone tube catheterization for 3 to 6 months. RESULTS: In 13 patients, scar tissue was the cause of the obstacle, while in 3 patients an unsuitable location of the ostia and in 1 case an inflammatory polyp were found. After a long-term follow-up (56 months), the epiphora was controlled in 94% of the cases. The mean delay between the first DCR and the recurrence of epiphora was 22 months. CONCLUSION: A persistent or recurrent epiphora can be explored after an external procedure and treated by endoscopic procedure. The endonasal approach for DCR was considered safe, and effective particularly in patients with unsuccessful external DCR.

Silent sinus syndrome with spontaneous orbital floor reconstruction.

PROBLEM: Silent sinus syndrome is rare and its pathophysiology is unclear. We report a case of silent sinus syndrome characterized by progressive enophtalmos with chronic maxillary atelectasis and asymptomatic chronic maxillary sinusitis. METHODOLOGY: The patient had no history of sinusitis, facial trauma, or sinus surgery. Computed tomography revealed opacification of the right maxillary sinus and inferior bowing of the osteopenic orbital floor. Silent sinus syndrome was diagnosed and functional endoscopic maxillary antrostomy without orbital floor reconstruction was performed. RESULTS: At one-year follow-up, computed tomography showed optimal ventilation of the maxillary sinus, restoration of the orbital floor, and withdrawal of the orbital content to its normal position. CONCLUSION: Endoscopic maxillary antrostomy without orbital floor reconstruction is effective and associated with limited risks for complications; however, the results are observed in the long term.

[Infantile esotropia: comparison of surgery results when the intervention takes place before or after 30 months of age]. / Les ésotropies précoces: comparaison des résultats chirurgicaux en fonction de la date opératoire avant et après 30 mois.

OBJECTIVE: Present and compare surgery results of children with congenital or infantile esotropia, who had surgery before or after 30 months of age, in the Rouen Department of Ophthalmology between 1996 and 2000. PATIENTS AND METHODS: A retrospective study included 37 patients, 23 females and 14 males, 19 in the first group who had surgery before 30 months at an average age of 24 months (15-30) and 18 in the second group who had surgery after 30 months at an average age of 56 months (38-81). Hypermetropia was found up to 2 diopters for 14 of 19 patients in the first group and 13 of 18 in the second. We noted the surgical procedure. We compared pre- and postoperative amblyopia as well as pre- and postoperative objective deviations at near and distance ranges. The exclusion criteria were follow-up for less than 3 months, esotropia emergence after 12 months of age, children aged more than 7 years at the first surgery, and children with central nervous system disorders. Finally, esthetic aspect, postoperative distance and near sensory results were evaluated. Success was defined by orthotropic position, esotropia less than 15 prism diopters, or consecutive exotropia less than 10 prism diopters. RESULTS: The mean follow-up after surgery was 30 months (3-56) for the first group and 28 months (3-67) for the second. Motor results were similar between the two groups: we found 10 out of 19 successes (esotropia (E(T)) less than 15 diopters (D) or exotropia (X(T)) less than 10 D) in the first group, and 15 out of 18 successes in the second group. There were 3 out of 19 failures (E(T) more than 20 D or X(T) more than 15 D) in the first group and 3 out of 18 in the second. Hypermetropia and preoperative deviation were not significantly different for good or bad motor results (p<0.05). A second-step surgery was performed for two children in the first group and three in the second group, and one of the three children of the second group had a third step. Sensory results were very similar with 6 of 19 cases achieving binocular union in the first group and 7 of 18 in the second one. Finally, one patient from each group presented amblyopia after surgery. CONCLUSION: In our study, as in the literature, infantile esotropia surgery can result in excellent motor alignment, while sensory results are not as good. It appears in our study that there is no significant advantage in performing surgery before 30 months for infantile esotropia. The follow-up of our patients may have been insufficient, and our definition of the semi-early surgery (before 30 months) was already too late in comparison with other studies (less than 24 months).

[Comparison of two surgical techniques for the treatment of superior oblique palsy]. / Comparaison de deux techniques chirurgicales dans le traitement de la paralysie du muscle oblique supérieur.

AIM: To compare two surgical techniques for the treatment of superior oblique palsy. PATIENTS AND METHODS: Retrospective study involving 32 patients operated on at the Rouen Teaching Hospital for superior oblique palsy. Group 1 patients were treated by surgical reinforcement of the superior oblique muscle and group 2 patients were treated by surgical loosening (or weakening) of the antagonist muscles. One-year follow-up explored head tilt, diplopia, vertical deviation and cyclotorsion. RESULTS: Functional results (presence of diplopia or stiff neck) were positive in both groups but better in group 1. Only 12.5% of patients required a second operation. Cyclotorsion amounted to less than 2% in group 1 and was still greater than 8% in group 2; on the other hand, vertical deviation had improved more in group 2, where it decreased to 2.1 diopters versus 3.1 in group 1. DISCUSSION: and conclusion: Only reinforcing the superior oblique adequately corrects cyclotorsion, which is the main cause of asthenopia and diplopia, despite an often insufficient height correction that is otherwise clinically well tolerated. We suggest reinforcing the superior oblique as a first intent rather than weakening hyperactive muscles, and in case of excessive postoperative height, we would carry out additional treatment of one of the hyperactive muscles later.

Comparison after 10 years of two 100-patient cohorts operated on for eviscerations or enucleations.

PURPOSE: To compare the indications, surgical techniques, and operative outcome between two 100-patient populations operated on for evisceration or enucleation with a 10-year interval. METHODS: This retrospective study involved 100 patients operated on between 1987 and 1990 (Group 1) compared with another 100 patients operated on between 1996 and 2000 (Group 2). Group 1 included 64 males and 36 females, mean age 49 years; Group 2 included 60 males and 40 females, mean age 53. RESULTS: In Group 1, 19 eviscerations were performed, versus 55 in Group 2. In both groups, half of the indications for surgery were a painful blind eye. In Group 1, endophthalmia (23%) came second, whereas it was trauma (15%) in Group 2. Sixty-eight patients were implanted in Group 1 (silicone spheres 69%) versus 86 in Group 2 (hydroxyapatite spheres 69%). Twenty spheres (20%) were rejected in Group 1 versus 7% in Group 2. DISCUSSION AND CONCLUSIONS: The proportion of eviscerations increased in 10 years. The number of endophthalmitis-related operations decreased and trauma-related operations increased. The number of implantations increased with hydroxyapatite as the first choice material instead of silicone. This most likely contributed to reducing the number of rejections.

Orbital sinus histiocytosis (Rosai-Dorfman disease): a lacrimal gland involvement.

We report the clinical and histopathological features of 2 cases of orbital Rosai-Dorfman disease with lacrimal gland involvement but no lymphadenopathy or cutaneous involvement. The first case was a 7-year-old boy, who was referred to the ophthalmology department with a proptosis in the left eye. The second case involved a 57-year-old African man, who developed oedema of the right upper eyelid over a 4-month period. Ocular involvement in Rosai-Dorfman disease is rare (10%). The diagnosis is histological in combination with immunohistology and is often delicate, especially in extranodal localizations. Histopathologically, normal gland morphology was altered by fibrosis and inflammatory cells. To our knowledge, this is the first report on lacrimal involvement in incomplete, thus uncommon sinus histiocytosis with massive lymphadenopathy.

[Limbal autograft transplantation, eight consecutive cases]. / Déficience des cellules germinatives de l'épithélium cornéen et autogreffe limbique. A propos de 8 case consécutifs.

BACKGROUND: Limbal autograft transplantation is the procedure of choice in the management of ocular surface disorders secondary to stem cells deficiency. The aim of our study was to investigate the indications, results and limits of this infrequent surgery. METHODS: Limbal autograft transplantation was performed in 8 patients and the mean follow-up period was 11 months. Limbal stem cell deficiency was due to chemical burns in 4 patients, history of prior surgery extending to the limbus in 2 patients, chronic limbitis with dystichiasis in one patient and persistent corneal epithelial defect after keratoplasty in one case. RESULTS: In 6 out of 8 cases, the stability of the ocular surface normalized and comfort significantly improved. Four of these patients had increased visual acuity after surgery. Two patients who presented with severe alkali burn did not respond well to limbal autotransplantation. CONCLUSION: Limbal autograft transplantation is a reliable and effective procedure in limbal stem cells deficiencies. New associate procedures such as amniotic membrane transplantation will however be necessary to improve the prognosis of very severe corneal surface disorders.

[Phacoemulsification following radial keratotomy. Topographic and refractive analysis concerning an 18-month period (apropos of a case)]. / Phacoémulsification après kératotomie radiaire. Analyse topographique et réfractive sur une période de 18 mois (à propos d'un cas).

We followed a 45-year-old man who underwent clear cornea phacoemulsification cataract extraction 3 years after radial keratotomy during an 18 month period. We report early and late refractive analysis and corneal topography during the followup period. The patient experienced an hyperopic shift which was different from the aim of 5 diopters due to an early corneal flattening of 3 diopters and an underestimation of the IOL power of 2 diopters using SRKII calculation formula. Corneal flattening regressed after 3 weeks. We recommend that these patients should be informed of an eventual early hyperopic shift and late refractive error, that Binkhorst II or Hoffer-Q intraocular lens calculation formulas be used and keratometry measurements be obtained from computerized videokeratography.

[Peribulbar anesthesia for peroperative and postoperative pain control in eye enucleation or evisceration: 31 cases]. / L'anesthésie péribulbaire pour le contrôle de la douleur per et postopératoire au cours des énucléations ou éviscérations. Trente et un cas.

OBJECTIVES: The aim of this prospective study was to assess peroperative and postoperative analgesia in eye enucleation or evisceration performed under peribulbar anesthesia. PATIENTS AND METHODS: We report 31 patients undergoing an eye enucleation (17 cases) or evisceration (14 cases). The surgical procedure was performed under local anesthesia alone in 22 patients. General anesthesia was associated with local anesthesia in 9 patients. Peribulbar block was achieved with the first insertion of the needle parallel to the inferior orbital floor and the second at level of supraorbital notch. A mixed anesthetic solution of equal quantity of lidocaine 2% with epinephrine (0.25 mg/20 ml) and bupivacaine 0.50% with epinephrine (0.10 mg/20 ml) was injected (total quantity 16.8 +/- 4.3 ml). RESULTS: To assess the peroperative pain we considered the patients with local anesthesia only (22 patients). One of these 22 patients needed one injection (0.50 mg/kg) of propofol for cutting the optic nerve. Surgery was ended without any other drug but that case was considered as a failure. Peroperative analgesia was obtained in 21 of 22 patients (95.4%). To assess analgesia in the postoperative period we included 31 patients. Analgesia was complete from the accomplishment of the peribulbar block to the 4th hour in all patients (efficacy 100%). From the 4th to the 24th hour, pain remained absent in 11 (enucleation 10 cases and evisceration 1 case) of the 31 patients and no drug was used. In 20 patients (enucleation 7 cases and evisceration 13 cases), pain appeared between the 4th and the 10th hour and patients were relieved by paracetamol alone in 14 cases (enucleation 6 cases and evisceration 8 cases) or by its association with nalbuphine in 5 cases (enucleation 1 case and evisceration 4 cases). In one patient (evisceration) the association of the drugs was uneffective. CONCLUSION: Peribulbar anesthesia is safe and generates major postoperative analgesia so we suggest to offer that technique to patients undergoing evisceration or enucleation.

Comparative evaluation of efficacy and safety of ciprofloxacin and norfloxacin ophthalmic solutions.

The efficacy and safety of ciprofloxacin ophthalmic solution 0.3% and norfloxacin ophthalmic solution 0.3% in the treatment of bacterial conjunctivitis and blepharitis were compared in a double masked randomised study. A total of 131 patients, 65 treated with ciprofloxacin (42 with conjunctivitis and 23 with blepharitis) and 66 treated with norfloxacin (39 with conjunctivitis and 27 with blepharitis) were enrolled in the study at five centres in France. In the efficacy population, pathogens were eradicated or reduced in 96% (24/25) of patients in the ciprofloxacin group and 89% (24/27) in the norfloxacin group. There was no difference between treatments with regard to eradication of particular pathogens. In the efficacy population, clinical cure or improvement was seen in 96% of the patients (24/25 in the ciprofloxacin group and 26/27 in the norfloxacin group). There were no significant differences between ciprofloxacin and norfloxacin with respect to improvements in four symptoms or ten clinical signs. No serious treatment-related adverse events were reported and both ciprofloxacin and norfloxacin were well tolerated.

[Dyschromatopsia: manifestation or epiphenomenon in the course of diabetic neuropathy]. / La dyschromatopsie: manifestation ou épiphénomène au cours de la neuropathie diabétique?

We performed a study in 92 diabetic patients (76 Type 1 and 16 Type 2) without retinopathy to determine the relation between diabetic dyschromatopsia and neuropathy, which has been evoked in previous studies. Color vision was explored with Lanthony's desaturated D 15 panel. Peripheral nervous function was explored with an electrophysiological score which has been beforehand validated. Moreover evoked visual potentials were performed in 38 diabetic subjects in order to determine whether dyschromatopsia was related to an impairment of central optic pathways. Fifty-one among the 92 diabetic subjects had a blue-yellow dyschromatopsia. Among the recorded parameters, only peripheral nervous impairment was significantly more frequent in the group with dyschromatopsia than in the group without. Ten among 38 diabetics had impairment of the evoked visual potentials. Frequency of alteration of evoked visual potentials was not different between the group with and the group without dyschromatopsia. Our results confirm the relationship between dyschromatopsia and the alteration of the nervous function in diabetic subjects. In return, lack of significant modification of evoked visual potentials among diabetic patients with dyschromatopsia and the blue-yellow axis of dyschromatopsia are in opposition with a direct neurological origin of dyschromatopsia. We therefore evoke a common process in the beginning of the diabetic dyschromatopsia and of peripheral neuropathy.