FORMS OF OCULAR LARVAL TOXOCARIASIS IN CHILDHOOD. A REVIEW.

The aim of this paper is to present an outline of forms of ocular manifestations of visceral larva migrans in children, as illustrated by the extensive photographic documentation. Ocular larval toxocariasis (OLT) has various clinical manifestations even in childhood age, in which age representation has an influence. The most common is presence of peripheral granuloma of the eye, frequently with a tractional vitreal streak leading from the retinal periphery to the optic nerve papilla. This is followed by granuloma of the posterior pole of the eye, usually reaching from the macular landscape to the central retinal periphery, always with vitritis. In children OLT may be manifested also in affliction of the optic nerve (cystic granuloma of the head of the optic nerve or neuropathy with vitreal reaction), fulminant endophthalmitis and in rare cases also diffuse chorioretinitis. The diagnosis rests upon a clinical ophthalmological finding, as well as laboratory examination of the levels of antibodies with potential eosinophilia. Histological examination may demonstrate spherical polypoid ossification in the choroid at the posterior pole of the eye as a consequence of fibrotisation and calcification, proceeding from the surrounding area of the absorbed larva. General combined treatment with antihelminthics and corticosteroids is arduous and does not always produce the desired effect in the sense of a satisfactory improvement of visual acuity. In differential diagnostics, manifestations of OLT in small children are still associated with retinoblastoma and a clinical picture of other intraocular diseases.

ATYPICAL FORMS OF EYE TOXOPLASMOSIS IN CHILDHOOD. CASE REPORTS.

AIM: To present an outline of acquired atypical forms of ocular toxoplasmosis (OT) in childhood, with reference to the 100th anniversary of the discovery of this etiology by Professor Janků from Czechoslovakia, who was first to describe the clinical congenital picture of OT characterised by macular scar. MATERIAL AND METHODS: Symptoms of intraocular bilateral neuritis appeared in a 6-year-old girl, with visual acuity (VA) bilaterally 0.1. Toxoplasmic etiology was demonstrated in laboratory tests, and the patient was immunocompetent. Following treatment with macrolide antibiotic and parabulbar application of corticosteroid, the condition was normalised stably at VA 1.0 in both eyes. Bilateral retinal vasculitis was determined in an 8-year-old boy, with VA of 0.25 in the right eye and 0.25 in the left, with a medical history of strabismus detected after suffering from varicella. The examination for toxoplasmosis was negative, but pronounced general hypogammaglobulinaemia classes IgG, IgM and IgA was detected. Immunosuppressive and immunomodulatory therapy did not produce the desired effect, and the condition progressed to retinochoroiditis. Due to blindness and dolorous glaucoma, enucleation of the right eye was performed at the age of 15 years. Histologically toxoplasmic cysts with bradyzoites were detected, a subsequent laboratory test demonstrated toxoplasmic etiology upon a background of persistent regressing hypogammaglobulinaemia. General anti-toxoplasma and subsequent immunosuppressive treatment did not produce the desired effect, and at the age of 22 years the patient lost his sight also in the left eye. CONCLUSION: Atypical form of OT intraocular neuritis in an immunocompetent patient had a favourable course, whereas retinal vasculitis with retinochoroiditis in a temporarily immunocompromised patient ended in bilateral blindness.

BILATERAL AMYLOIDOSIS OF THREE EYELIDS. A CASE REPORT.

AIM: To present rare form of lids amyloidosis, in the context with literature and remind a Czech professor Vrabec, F., MD, an important pan-European ocular histologist. CASE REPORT: 37 years aged man was examined for eyelids mass on the department of ophthalmology of the Teaching Hospital Kralovske Vinohrady, Prague, Czech Republic in June 2018. The finding looked like chronic chalazion on the right side and chronic hordeolum on the left side. No acute phase was noted within last several months by the patient. Yellowish to lightly brown friable, partially transparent mass was obtained by excision. Amyloidosis of the AL type was revealed histologically, and diagnosis was followed by extended excision and plastic surgical reconstruction of the lower eyelids on both sides. No systemic disease underlying the amyloidosis was disclosed by following through diagnostic work-up of the patient. RESULTS: Amyloidosis was illustrated initially by Congo red staining with characteristic dichroism in the polarized light, then it was analysed immunohistochemically, with positivity for kappa light chains. Systemic amyloidosis was excluded, as well as monoclonal gamapathy. Only slightly increased number of plasmacytes (up to 10 %) was revealed in the bone marrow biopsy. The surgical solution was optimal for the patient, and he was without any recurrence and problems of lower eyelids three years. CONCLUSION: Described case of bilateral eyelids amyloidosis without underlying systemic disease belongs to rare cases and also illustrates necessity of complex interdisciplinary cooperation in the diagnostic process.

Merkel Cell Carcinoma of the Eyelids (Clinical-Histological Study).

AIM: To get acquainted with the issues of Merkel cell carcinoma (MCC) when the eyelid is affected and with its surgical solution. MATERIALS: MCC of the right upper eyelid was at the Department of Ophthalmology in the Faculty Hospital Královské Vinohrady in Prague (Czech Republic, EU) in 1998 woman 78 year. Another cases of the MCC on the left upper eyelid were observed in two women aged 48 and 67 years and they were pick up in a retrospective study covered 1033 operated tumors eyelids years 2007 - 2015. 47,5% of operated tumors were benign and 52,5% malignant. Most common malignant processes were basal cell carcinoma in 77,3% and squamous cell carcinoma at 15,7%. RESULTS: The oldest patient died after three years of cardiopulmonary failure. 48 year old patient (age of diagnosis MCC) has been monitoring for five years without proven recurrence or metastasis dissemination. Oncological initial staging was negative regarding. An ultrasound examination of the lymphatic system of the neck was followed every six months. Another 67 year old patient (age of diagnosis MCC) was followed for 2,5 years. There was a suspicion of a metastatic process in the same side salivary gland and lungs, therefore chemotherapy was performed. Definitely, this process has not been proven. Now there is continuing follow up without sings of local recurrence or metastatic dissemination. CONCLUSION: The authors confirmed a rare occurrence of MCC, and only 0,37% among malignant eyelids tumors. Essential importance for successful treatment is a sufficiently radical excision supported by histological verification and a subsequent plastic surgery of the eyelid is also necessary. Key words: Merkel cell carcinoma, tumor of eyelid, ultrasound examination of nodes.

Vertical Strabismus - Indication of Surgical Techniques on the Inferior Rectus Muscle.

Aid: Familiarize themselves with the operating techniques in their own modulation to solve hypotropic states with elevation or hypotropic states with depression. METHODS: Surgery technique “cul-de-sac” is a procedure with fixed adjustable sutures (non-absorbable suture), which are guided in parallel on both peaks original insertion of inferior rectus muscle. The node itself of suture is done in cutting the muscle and through the original insertion only leads arc suture. During „counterclockwise transposition“ procedure sec. Knapp, the horizontal rectus muscles are fixed at the straight inferior rectus muscle level. The author included their graphical diagrams. MATERIAL: At the Department of Ophthalmology in the Faculty Hospital Královské Vinohrady in Prague (Czech Republic, EU) in the years 1996 - 2014 a release relaxing operation of the inferior rectus musle by the technique “cul-de-sac” on 49 eyes. Indication was double elevator palsy in 31 patients, congenital fibrosis of the extraocular muscles in 15 patients and in 3 cases, it was thyroid eye disease. “Counterclockwise transposition” procedure sec. Knapp was indicated twice for paresis of the inferior rectus muscle in 2015 and 2016. For the first time, it was a congenital form. It was detected histologically atrophy of stripped muscle with hypertrophy collagen. The second traumatic form was formed after an orbital injury. RESULTS: We provided adequate relaxation of the inferior rectus muscle and practical restoration of eye elevation by the technique “cul-de-sac“ in 18 preschool children with the double elevator palsy and three adult patients with thyreiod eye disease. We had to restore motility to complete the procedure by classical transposition procedure sec. Knapp of both horizontal rectus muscles to the direct superior rectus muscle in elderly children and adults with the double elevator palsy, as well as in all patients with the congenital fibrosis of the extraocular muscles. Indicate the inclusion of this transposition influenced the degree of fibrotic rectus inferior muscle given by age. “Counterclockwise transposition“ procedure sec. Knapp ensured the practical disappearance hypertropie in both cases of paresis of the inferior rectus muscle. The alignment of the position of the eyes without diplopia in the direct view was ensured by prismatic correction. CONCLUSIONS:   To release the fibrotically altered inferior rectus muscle in the double elevator palsy, the congenital fibrosis of the extraocular muscles and the thyroid eye disease, the operation of adjustable sutures was necessary in accordance with our experience with the technigue “cul-de-sac“ in its own modification. The transposition procedure sec. Knapp, either classical or “”counterclockwise” “ in its own modification, was of paramount importance for the solution of the vertical deviation of a paretic ethiology. Key words: adjustable sutures, congenital fibrosis of the extraocular muscles, double elevator palsy, thyroid eye disease, transposition procedure sec. Knapp, vertical strabismus.

Sarkoidosis and its Eye Ocular Manifestation (an Analysis of Six Case Report).

AIM: To introduce the range of eye changes in sarcoidosis in the individual casuistics. MATERIALS: At the Ophthalmic Clinic of Teaching Hospital Královské Vinohrady in Prague were examined and treated six patients with ocular forms of sarcoidosis in the years from 1998 to 2015. Three patients were unilateral lesions of the lacrimal gland without systemic symptoms. One patient experienced orbital inflammatory syndrome that accompanied the hilar form of pulmonar sarcoidosis. Two other patients underwent intraocular inflammation, panuveitis / iridocyclitis and bilateral intermedial uveitis. Both of these patients also had systemic affections of mediastinal lymph nodes and lung, in the first of these, signs of neurosarcoidosis first appeared. RESULTS: In the treatment of lacrimal glands, the diagnosis was determined by histological examination of the removed lacrimal gland in external orbitotomies, also, the orbital process has been verified by biopsy and the subsequent comprehensive examination revealed the systemic process. Definitive diagnosis of sarcoidosis was established bioptically in both uveitides and has also been demonstrated in imaging methodologies including galli scintigraphy. All patients were successfully treated with corticosteroid therapy. CONCLUSION: Biopsy results have always been a surprise in orbital processes. Both cases of uveitis were associated with systemic involvement and initiated comprehensive investigation which showed the need for interdisciplinary collaboration in the diagnosis and treatment of sarcoidosis. Key words: sarkoidosis, biopsy, corticosteroids, gallii scintigraphy, MRI, uveitis.

Results of the first 12 months treatment of macular edema complicating BRVO in patients treated with ranibizumab.

THE AIM OF THE STUDY: Retrospective evaluation of the first 12 months treatment of macular edema in BRVO with ranibizumab based on anatomical and functional parameters. METHODS: 54 eyes with macular edema complicating BRVO were included in the study, with an average initial best corrected visual acuity 4/16 ETDRS charts, an average central retinal thickness 512.3 µm, and in average 4 months till the beginning of treatment with ranibizumab. After 3 initial injections of 0.5 mg ranibizumab treatment was performed in pro re nata regimen, with adjuvant laser (grid laser photocoagulation) as an additional treatment option.  The number of injections administered, the number of eyes where grid laser photocoagulation was provided, functional parameters as a letter gain and BCVA (eyes with final BCVA ≥ 4/8 ETDRS, final BCVA in according to initial BCVA) and anatomical parameters as a mean CRT and  CRT ≤ 250 µm, respectively ≤ 300 µm were evaluated. RESULTS: In the whole group, an average of 4.8 injections of ranibizumab were administered in the first 12 months. Grid laser photocoagulation was performed in 42 eyes: in 8 eyes prior to the beginning of treatment with ranibizumab, 7 eyes before and during the treatment, 29 eyes only during the treatment. The main gain of letters after 12 months of treatment was +16.5 letters, with 63¨% (n = 34) eyes earning ≥ 15 letters. In the whole group 72 % (n = 39) eyes achieved the resulting BCVA ≥ 4/8 ETDRS after 12 months of treatment. The eyes with initial BCVA ≥ 4/10 ETDRS resulted in BCVA ≥ 4/8 ETDRS in 96 % (n = 23 eyes) and 11 eyes even  achieved BCVA ≥ 4/4. The mean CRT after 12 months of treatment was 290.3 µm, 33.3 %  of eyes had final CRT ≤ 250 µm, and 64.8 % had final CRT ≤ 300 µm. CONCLUSION: When applying a relatively low number of injections in the first year of treatment with ranibizumab, the final best corrected visual acuity was very good at the end of the observation period, and its dependence on the initial best corrected visual acuity was confirmed. Satisfactory results of central retinal thickness were found as well. Key words: branch retinal vein occlusion, macular edema, ranibizuma.

[Anophthalmic conjunctival sac plastic surgery using the modified cul-de-sac method]. / Plastika anoftalmického spojivkového vaku upravenou metodikou cul-de-sac.

AIM: The author refers about the plastic surgery technique of deepening the conjunctival sac in acquired anophthalmos without the orbital implant. The condition without the implant was caused primarily or secondarily after the enucleation or evisceration. The principal of the cul-de-sac technique is the fixation of the lower fornix conjunctiva to the orbital periosteum. MATERIAL AND METHODS: The modification of the original surgery technique applied by the author is from the nineties of the last century. It consists of the use of long-term resorbable suturing material for vascular sutures made from polydiaxonone (PDS 6-0) and the suture primarily fixated to the orbital periosteum. Only in the second phase, the tarsal and bulbar part of the conjunctiva of the lower fornix is fixated to the orbital rim. The result is the deepening of the conjunctival sac making possible better positioning of the eye prosthesis in the interpalpebral fissure from the cosmetic and functional point of view. RESULTS: The author presents the successfulness of this surgical technique in six patients operated on during the period from 2009 to 2014, presenting photographs of four of them in the child and adult age. Shallow of the lower fornix was caused by spontaneous elimination of the implant at the school age after the enucleation due to the inborn malformation of the eye globe in three years old boy. Extrusion of the implants occurred also in two young men after previous enucleation due to the malignant intraocular tumors in infant age. In these cases, the influence of the growth to the physiognomy of the conjunctival - palpebral area was evident. Among included adults were: Eighty-three years old female patient, twelve years after the enucleation without the implant due to the endophthalmitis of unknown etiology; 62 years old man after the evisceration of the eyeball at the age of seven years due to the endophthalmitis after the perforating injury; and 55 years old male patient five years after the enucleation of the eye globe with adjacent fat tissue removal without implant due to the malignant intraocular tumor with the suspicion of its extrascleral growth. Always, the co-incidence of the involution process in the conjunctival sac itself took its part. CONCLUSION: The surgical technique of deepening the conjunctival sac using the cul-de-sac method and using the suturing material made from polydiaxonone (PDS 6-0) may be applied in shallow anophthalmic conjunctival sac in the lower fornix. At the same time, with this method, the possible ectropion of the lower eyelid is treated as well. To prevent the occurrence of the conjunctival sac not suitable for the orbital prosthesis application, it should be used the orbital implant during enucleation or evisceration surgery.Key words: anophthalmos, plastic surgery of the conjunctiva, polydiaxonone.

[Strabismus Sursoabductorius (put into the Context of eighteen Years of Strabismus Surgery Analysis)]. / Strabismus sursoabductorius (v kontextu osmnáctiletého rozboru operativy strabismu).

AIM: To familiarize with the form of combined horizontal and vertical deviations and its development and put it into the context of eighteen years of strabismus surgery analysis. MATERIAL AND METHODS: During the period from 1996 to 2014, there were at the Department of Ophthalmology, 2nd Medical Faculty, Charles University and Faculty Hospital Královské Vinohrady, Prague, Czech Republic, E.U., operated on 2 248 patients due to the eye position misalignment. The surgery of dynamic (comitant) strabismus (esotropia, exotropia, vertical deviations and their combinations) was altogether performed in 81.7 % of patients. Out of them, horizontal-vertical deviations comprised 12.9 % - it was the strabismus sursoadductorius in 211 patients. Strabismus sursoabductorius (SAB) comprised 3.5 %; the initial type without excess of divergence (I-SAB) was established in 39 patients, and in other 43 patients it was the type already with the excess of divergence (E-SAB). The remaining surgeries were dealing with paralytic strabismus (14.7 %), and torticollis due to horizontal and torsional nystagmus (3.6 %). RESULTS: In the clinical picture of SAB dominated the elevation of the eyeball in abduction as well as in adduction, which was at the same time insufficient, negatively influencing the second phase of convergence. The divergent part of the deviation for far vision was on average in I-SAB 12 prisms (prism diopters)(), and in E-SAB 30 . The age of the patients at the time of the surgery was on average 12 years in I-SAB and 19.5 years in E-SAB. The difference between both evaluations was significant (p < 0.005), confirming the developmental relation. The I-SAB with the increasing age changes into the E-SAB. Between the two forms of this vertical-horizontal deviation was not significant difference in the minimal deviation at near (I-SAB 2.5 and E-SAB 4.0 ). In the vertical part of the deviation was the difference even smaller (I-SAB 5.0 and E-SAB 6.0 ). The simple binocular vision was maintained in less than half of the patients with I-SAB and roughly in one-fifth of the patients with E-SAB. In I-SAB, the stereopsis was confirmed in one half of the patients, and it was rare (1/10) in E-SAB. The examination on the Hess screen confirmed extorsion, but excluded incomitant relationship as well. This sursoabduction includes in itself some separate signs of dissociated vertical deviation (DVD), and adduction activity of overactioning inferior rectus muscle (IOOA), but does not represent either of these clinical entities. Recession of the inferior oblique muscle with its eventual simultaneous resection (anteposition) of the insertion at the level of inferior rectus muscle, in E-SAB supplemented by recession of the lateral rectus muscle was found as the ultimate surgical solution. The stereoscopic functions after the surgeries restored in part only, they were present altogether in two-thirds of patients with I-SAB and in two-fifths of patients with E-SAB. Substantially improved the convergence. The vertical deviation improved and eventual residual divergence was corrected by means of prisms. CONCLUSIONS: The author expresses his own theory of this deviations appearance. Presumed decompensated exophoria was transformed into intermittent form of exotropia, which was probably accompanied by appendant abduction of the inferior oblique muscle, because it was overacting at the same time. Insufficient adduction and convergence corresponded with that. In further development, the horizontal deviation developed into the excess of divergence with the maintenance of the inferior oblique muscle overacting (hyperfunction) and above-mentioned motility disorders. Post-operative position of the inferior oblique muscle insertion weakened its function in elevation and, simultaneously, the function of abductor transformed to function of adductor, and thereby decreased the divergence part of pathological misalignment of the eye position. KEY WORDS: strabismus sursoabductorius, vertical deviation, horizontal deviation, exotrophia, hypertrophia, comitant strabismus, inferior oblique muscle recession.

[About Cryptophthalmos (2nd Czech Study)]. / O KRYPTOFTALMU (2. ceská studie).

AIM: To get acquainted with the 2nd Czech study about cryptophthamos and with self-surgical methods. MATERIAL: The boy with unilateral complete cryptophthalmos of left eye was treated from 2 to 20 years. The girls was treated from 4 month to 5 year yet for right abortive cryptophthalmos with microblepharon and left complete type still waiting for solutions.Surgical methods and results: Authors present a surgical procedures for correction of the upper and lower eyelids and ocular anomalies both patients studied. Successful reconstruction of palpebral fissure took place in several stages at the boy. The surgical procedure gradually contained: the insertion of gradually increased convex concave circular-shaped implant (silicone ruber) due a modeling of palpebral fissure, an enucleation of rudimentary eye, a reconstruction of bottom palpebral fissure by retro-auricular skin graf and a releasing of the lower transitory fold by the cul-de-sac method. An adequate depth of palpebral fissure to allow perfect position of an aesthetic protesis. Enucleated eye was atypically shaped, remiding partly sand-glass clock. The cornea was replaced by thick fibrous membrane, the iris and the lens were not revealed. Gliomatic retina was detached nearly totaly and the optic nerv was rudimental. The repairing the upper lid coloboma of girl by a lid rotation flap reconstruction using the inferior eyelid was performed at the age 17 month. Corneal dermoid simultaneously removed (histologically verified). Upper conjunctival fornix was formed using the spherical covering foil (silicone rubber) before and after the reconstruction of the lid. CONCLUSIONS: Plastic reconstructions required the need for patient access without trying immediate effect. An important role played silicone rubber implants (elastomer medical grade) which used temporarily. KEY WORDS: cryptophthalmos, microblepharon, relief surgery, silicon ruber implants.

[Lymphangioma of the orbitopalpebral area]. / Lymfangiom orbitopalpebrální oblasti.

AIM: The authors refer about five patients with different types of lymphangioma, who were followed-up at the Department of Ophthalmology, Faculty Hospital Královské Vinohrady (Kings Vinegards), Charles University, Prague, Czech Republic, E.U., during the period 1995 - 2013; the follow-up period lasted from 5 to 17 years. The lymphangioma of the orbitopalpebral area is discussed according to the evaluation of the tumor development, histological verification, treatment, and its results. METHODS: In four boys, the first signs of tumor were eyeball protrusion (exophthalmos) and bleeding into the conjunctiva or palpebral skin before the age of 5 years. In all four patients, the histological confirmation of the orbital lymphangioma was performed in the beginning of the disease. In three cases, it was the orbital type, and the fourth one was frontal type with bilateral orbital lymphangiomatosis. In one girl, there were present conjunctival changes only, appearing as one-sided hyperplastic changes. For these changes, she was followed-up since her 13 years of age under the false diagnosis of chronic conjunctivitis. The definite histological confirmation of only conjunctival lymphangioma was done from the diagnostic probatory biopsy not until ten years of symptoms and unsatisfactory treatment. RESULTS: In the girl with superficial conjunctival lymphangioma and in the patient with lymphangiomatosis, the follow-up was recommended only. In two patients with extraconal type of orbital tumor, the total or sub-total resection was performed. In the years of the follow-up, the remission of the disease was observed. In the patient with mostly intraconal type of the tumor, causing decrease of the visual acuity according to the optic nerve neuropathy and macular cystoid edema, the focused actinotherapy by means of linear accelerator treatment with the dose of 30 Gy after previous evacuation of chocolate cysts under ultrasound control. The regression of the tumor and normalized visual functions lasted for 17 years. CONCLUSION: As method of treatment of extraconal lymphangiomas, it seems, it is its resection, and in the intraconal localization of the tumor it is the focused actinotherapy by means of linear accelerator.Key words: orbital lymphangioma, conjunctival lymphangioma, lymphangiomatosis, tumor resection, linear accelerator actinotherapy.

[Orbital tumors in adults--a 10-year study]. / Orbitální tumory u dospelých--desetiletá studie.

UNLABELLED: The authors refer about diagnostic procedures, treatment and follow-up of 87 adult patients with orbital tumors during the period 1998 - 2007 in the Department of Ophthalmology, Faculty Hospital Královské Vinohrady, Charles University, Prague, Czech Republic, E.U. The group consists of 42 men and 45 women, age range 18-89 years. In 49 patients, the tumors were of benign origin (age 18-80 years, median, 48 years), and 38 patients suffered from malign tumors (age 38-89 years, median, 61 years). Among basic examinations methods ranked the magnetic resonance imaging and the histological verification of the tumor. Sixty-four tumors were treated by means of 70 surgical procedures. The anterior diagnostic or therapeutic orbitotomy was used in 72.5% of the cases, lateral osteoplastic orbitotomy (Kronlein) in 14.5%, and exenteration of the orbit in 13% of the cases. Altogether 23 patients were treated without surgery by means of corticosteroids, or are followed-up due to a benign tumor only. As the most common, the inflammatory pseudotumors of the orbit were diagnosed in 40%. Clinically they were of the anterior nodular, or posterior diffuse form, dacryoadenitis or orbital myositis. All patients were treated by means of prednisolon for at least three months; due to the relapse of the immunopathologic process, in 16 % of the cases the therapy was supplemented with azathioprime. The surgical procedure was the choice of treatment in 66% of inflammatory processes in the lacrimal gland region. In four cases the sarcoidosis was established.The second tumor in the final ranking was lymphoma in 19.5%; the MALT-lymphoma was diagnosed in 59% of these cases. The chemotherapy was chosen for the treatment in 2/3 of the cases, and in all cases the remission was reached.The actinotherapy was chosen especially in other types of lymphoma; the follicular form and "molding" lymphoma were the causes of the death in two patients. Among malignant tumors, the most serious clinical courses were histological different primary carcinomas of the orbitopalpebral region in 14% of the cases, and secondary melanoma spreading from the conjunctiva in 5.5%. Both these tumors, counting the same number as lymphomas, were the only indications to the exenteration of the orbit, and causes of the death in four patients. CONCLUSION: Among orbital tumors in adults, the most common were inflammatory pseudotumor and lymphoma. The decisive procedure was always the histological verification, which directed the following therapy.

[Spherical covering foil--silicone implant forming conjunctival fornices]. / Kulová krycí fólie--silikonový implantát formující prechodné rasy spojivky.

METHOD: The authors refer about primary development of elastic and sufficiently strong device, which due to its spherical shape bandages the conjunctival space of the palpebral fissure and is used to form the inferior and superior cul-de-sac. It is made from a silicone mixture for medical use - Silastic Medical Grade Elastomer. Its layer in the shape of spherical cap of outer diameter 24.4 mm, height 8.5 mm; the layer thickness is 0.5 mm. Its advantage is the oxygen permeability. RESULTS: The spherical covering foil was applied as an arrangement before keratoplasty in four adult men to form fornices after relieving of symblephara reaching the cornea caused by alkali (lime) burn (in three of them) and after liquid aluminium burn (thermal injury). In five years old boy, the spherical covering foil helped to form the palpebral fissure and to improve the eye motility; the symblepharon was related to the inborn coloboma of the upper eyelid. To prevent the symblepharon appearance, the spherical covering foil was used in an adult man after molten polypropylene burn and in an eight years old boy with Stevens - Johnson syndrome. CONCLUSION: The spherical covering foil is used for cul-de-sac forming after relieving of the symblepharon or to prevent its appearance after the eye burn.

[Analysis of movement disorders surgeries at the Department of Ophthalmology, the FNKV Hospital, Prague, Czech Republic, during the ten-years period]. / Desetiletý rozbor operací poruch motility na Ocní klinice FNKV v Praze.

The authors analyzed medical records of 1644 surgeries of strabismus and ptosis performed during the ten-years period (1997-2006). The surgeries were divided into three groups according to the age of the patients: 531 surgeries were performed in patients until the age of 6 years, 508 surgeries were in children aged 7-18 years, and the study included also 605 operative procedures in adult patients aged 19 years and older. The strabismus operations formed 1401 single or multi-phases surgeries and the ptosis correction was performed in 243 patients. The most common surgical procedures in strabismus were weakening or strengthening procedures on the horizontal muscles (65 %). Out of the weakening procedures, the authors positively preferred the adjustable partial myotomy acc. Gonin-Hollwich, which formed 51 % of surgeries on horizontal muscles. The very favorable results underlined the importance of this type of surgery in congenital esotropia, Duane syndrome I., and in excess of divergence. This surgical technique was also used as a weakening procedure as a part of the Kestenbaum procedure in the treatment of torticollis in horizontal nystagmus. The solely surgery on oblique or vertical muscles was performed in 16 %, and the most common operative procedure was the retro-position of the lower oblique muscle acc. to Parkes, and on the second place, there was its partial myotomy with electro-cautery acc. to Romer-Martinez. The weakening procedures were used together on the horizontal and oblique muscles in 10 %. Different surgical procedures, including the transposition's ones, were indicated in external ocular muscles palsies and torticollis. Altogether they formed 12 % of all strabismus surgeries. The most common procedure to treat the ptosis in children and teenagers was the fronto-tarsal suspension acc. to Fox (51 %), and in adults, it was the tarso-resection of the upper eyelid acc. to Fasanella (74 %).

[Multidisciplinary use of contrast sensitivity]. / Multidisciplinární vyuzití citlivosti na kontrast.

BACKGROUND: Contrast sensitivity (CS) gives information about quality of different spatial frequency sent from sensory cells to the brain cortex through different pathways. METHODS AND RESULTS: From the age of 6 to 10 years average CS threshold was defined for each frequency. 3c/deg=1,82 (SD 0,13), 6 c/deg=2,04 (SD 0,14), 12 c/deg=1,74 (SD 0,15), 18 c/deg=l,29 (SD 0,11). In the age between 11 and 19 years following values were determined: 3c/deg=1,92 (SD 0,09), 6 c/deg=2,19 (SD 0,12), 12 c/deg=1,89 (SD 0,10), 18 c/deg=1,42 (SD 0,12). There was no significant difference between each frequency on CS curve. Average threshold for all frequencies was the 6th contrast level of circle in younger children and the 7th contrast level of circle in older. According to the standard deviations the threshold for all the frequencies was the 5th contrast level of circle in children from 6 to 10 and the 6th contrast level of circle in children older then 11. As the CS can be distorted by hidden form of anisometric amblyopia, proper correction of refractive error is essential. CS helps to detect hidden neuropathy in Graves disease or in Septo-optic dysplasia. Initial stages of demyelinisation of optic nerve in Multiple Sclerosis are manifested always by decrease of CS. This helps to evaluate the affection of the optic pathway and CNS in Alzheimer disease, in Parkinson's disease and schizophrenia. Decrease of CS goes along with retinopathy and with some forms of preretinopathy in Diabetes mellitus. Dynamic changes of CS can be related to treatment of several diseases including Cystic fibrosis, Chronic renal insufficiency, Neonatal hypothyreosis, Menopause or Osteoporosis. CONCLUSIONS: Author proves that CS can be reliably examined using the device CSV-1000 in children from the age of 6 years within the framework of multidisciplinary use.

[The orbital implant after exenteration of the orbit with the preservation of the eyelids and the conjunctival sac]. / Orbitální protéza po exenteraci ocnice se zachováním vícek a spojivkového vaku.

In ophthalmology, the orbital exenteration presents the most mutilating surgical procedure. The surgical technique presented by authors, preserves the eyelids and conjunctival sac. This surgical procedure was suggested and repeatedly performed in adult patients with extensive benign tumors (mostly meningeomas) by J. Otradovec and J. Safár. The enucleation of the eyeball preceded this type of surgery. The final state made it possible to put the prosthesis into the conjunctival sac. Today we inform about further development of this surgical technique and according to our own experiences we widen its indications to some malignant tumors (rhabdomyosarcoma and metastases of the retinoblastoma, etc.) in children. The initial cutaneous incision starts in the eyebrow area and is directed toward the bone of the orbital rim. The preparation of the tissue underneath the intact conjunctival sac to the lower aspect of the bone orbital rim follows. After folding the conjuctival-cutaneous sac back, the real content of the orbit is exenterated in the classical manner. After the hemostasis in the orbital apex, the flap is returned to its primary position and suturing of the primary incision in anatomical layers terminates the surgery. The authors refer about a boy, now 17 years old, who underwent at the age of three years the exenteration of the orbit in this manner due to a rhabdomyosarcoma. The authors also refer about the development and application of a special type of prosthesis made from silicone rubber--implant grade--filling out the orbital space and forming the anterior segment of the eye. The prosthesis was created from a classical orbital implant, regularly used in enucleation surgery and a conjunctival implant, a convex-concave plate with diameter of 20 mm. Both parts are made from the same type of silicon rubber and were connected together by vulcanization. The orbital implant was eliptically extended according to the measurements of the orbital casting made from dental impression matter. The cosmetic part, simulating the colored iris and the pupil, was prepared from a polyester sheet, painted with acrylic paint. It was fixated on the conjunctival prosthesis and covered with a transparent silicone foil. For the first time, the prosthesis was applied at the age of seven years, and during the next ten-years period, it was three times exchanged mostly for a bigger model. This procedure guaranteed proper growing of the orbital area and symmetrical development of the face. The prosthesis also carries out the prosthetic role and cosmetically it looks similarly like after the enucleation without the implant.

[Ligneous conjunctivitis: complication of inborn plasminogen deficiency (a case report)]. / Conjunctivitis lignea: komplikace vrozeného deficitu plazminogenu (kazuistika).

Authors refer about detailed analysis of ten years follow up of a child patient with ligneous conjunctivitis. They document presence of all typical eye findings (especially recurrent formation of granulomatous pseudotumors in affected mucous membrane) related to this rare pseudomembranous conjunctivitis. The clinical picture of the disease includes plasminogen deficiency, a factor newly considered as primary cause of the disease. The diagnosis was confirmed histologicaly by repeated probatory excisions. Pseudomembranous inflammation with mixed inflammatory infiltrate containing large amount of elements of chronical as well as acute inflammatory reaction is typical. Granuloma with the accumulation of the PAS-positive amorphous matrix with high content of the fibrin and with the network of newly formed vessels is the component of the inflammatory picture. The treatment was based on successively discovered knowledge of the possible etiopathogenesis of the disease. Only the ninth, last surgical procedure induced longer-term remission, which lasts sixteen months until now. The granuloma excision was combined with the mitomicin application on the wound surface and a conjunctivoplasty. During the postoperative period, the ointment with heparin, corticosteroid and antibiotic was applied. The purpose of the mitomicin use is to slow down the fibroproliferative reparative reaction. Covering of the wound surface decreases the number of microtraumas on the uneven postoperative scleral surface. Heparin in the interstitial tissue of the wound surface blocks the conversion of fibrinogen to fibrin.

[Angiolymphoid hyperplasia with eosinophilia or Kimura disease?]. / Angiolymfoidní hyperplazie s eozinofilií nebo Kimurova choroba?

Angiolymphoid hyperplasia with eosinophilia (ALHE) and Kimur's disease are two rarely occurring and mutually very similar, yet independent nosological units. For the frequency of similar features these diseases were long considered to be modifications of one disease. In the last years most authors considered these diseases to be independent entities with certain specific clinical and morphological features. The case of a 76-year white man, suffering from occurrence of subcutaneous tumor formations in various part of the body for the period of six years, is described. Six years after the first signs of the disease, swelling of eyelids on the right eye with palpable resistance under the upper temporal margin of eye socket developed. A similar finding also developed on the left side eight months later. The tumors were removed by surgery and subjected to histological examination. One year later a unilateral relapse developed to be again subjected to surgical treatment and histological examination. In the first two orbital excisions the tumor infiltrate was in topical connection with structure of the tear gland, the third excision did not contain such structures. The histological diagnosis was established as ALHE in spite of some common features with the Kimur's disease. The diagnosis of ALHE was especially supported by absence of the formation of lymphatic follicles, absent fibrotization in the infiltrate and epithelium-like or even histiocyte-like appearance of proliferating endothelia, which formed minute vascular lumina. A substantial exceptionality in the occurrence of the Kimur's disease in white Europeans further supported the diagnosis of ALHE. Our own experience indicates that both units mutually overlap even in features considered to be of distinctly different character. A question arises, whether the strict division of these two nosological units is really possible in practice with unequivocal certainty.

[Indications for refractive procedures in adult patients with strabismus and results of the subsequent therapeutic procedures]. / Indikace refrakcního výkonu u dospelých pacientu se strabismem a výsledky následného lécebného postupu.

The authors estimated the contribution of the refraction intervention and a possible evolution in the position of eyes in 102 adult individuals considering a refraction intervention. The indications for this intervention were a disorder in eye position or amblyopia in those who were interested in this operation and were examined in the years 1996 to 2002. The basic refraction examination was always supplemented by a detailed orthoptic analysis. Based on this examination the intervention was not recommended in 14 examined subjects (14%). ARK represented the contraindication of the refraction intervention in 9 patients, since subsequent changes in the size of the deviation or operation adjustment of strabismus could result in diplopia. An excessive convergence with a high AC/A in hyperopia was also considered as an unsuitable indication, since a lasting cosmetic and functional significant convergent deviation into near distances could not be excluded. Five patients declined from the refraction intervention on the basis of this explanation. The paper is mainly dealing with an analysis of the development of position of the eyes and binocular functions in 46 adult patients, who decided to undergo a refraction intervention and further orthoptic care after a complex stroboscopic and refraction examination. The adjustment of refractive error was made by the LASIK methods (Laser in Situ Keratomileusis) on 69 eyes (80%) and CLE (Cleans Lens Extraction) on 17 eyes (20%). The orthoptic analyses before and the refraction intervention revealed that in all 29 even only partially accommodating esotropia, the deviation was diminished after the refraction intervention on the average by +11.2 degrees (in the rage of +2 degrees to +30 degrees) to 5.4 degrees (in the range of parallel position to +20 degrees) in the predominantly represented hyperopia, but also in 6 myopias. The improved position of the bulbs was not directly associated with the degree of hyperopia with the original deviation. The deviation after the refraction intervention in 23 patients (79%) with esotropia was not higher than degrees. The cosmetic position of the eyes was completely satisfactory and did not therefore represent even indication for the operation. The 9 patients (35%) with esotropia and hyperopia there were an improvement of binocular functions. It could be theoretically due to the newly developed emetropia making permanent optimal sensory information possible. In all 17 exotropias there were not any significant changes in the size of deviation and the binocular functions were not reestablished, if they were not retained before. The position of eyes was solved surgically in 12 patients, while exotropia predominated in two thirds of them. The weakening or strengthening interventions on horizontal straight muscles were selected according to character of strabismus in 11 patients. Recession of the lower oblique muscle was indicated one case only for the simultaneously present torticollis with exotropia. The residual deviation was not greater than 5 degrees immediately after the operation or during the following months. Binocular functions were not reestablished in any patients. A alternate suppression or suppression of perception on one eye were proved.

[Detection of tumor circulating cells in patients with ocular melanoma]. / Prukaz cirkulujících nádorových bunek u pacientu s ocním melanomem.

The authors investigated a group of 51 patients (29 men and 22 women) with intraocular melanoma: 41 patients with melanoma of the chorioid, 10 patients with melanoma of the ciliary body. They evaluated the clinical and pathological finding according to the TNM classification recommended by UICC (International Union Against Cancer). In all investigated patients they assessed circulating tumour cells (melanocytes) in the peripheral blood stream based on the detection of mRNA tyrosinase and marker MART 1. When evaluating the presence of markers according to the diagnosis irrespective of time, they found in patients in the clinical stage of T2 choroidal melanoma a 19% positivity of different markers and very rare a concurrent positivity of both markers. Patients in the clinical stage T3 had a 51% positivity of one marker and 34% concurrent positivity of both markers. In melanoma of the ciliary body evidence of individual markers was positive in 17% and only in 11% both markers were positive concurrently. On comparison of therapeutic procedures from the aspect of development in time in patients treated by brachytherapy only rare positivity was found at the time of administration the radioactive plaque, following an eight-month interval after brachytherapy the positivity of markers increased to 28%. On evaluation of markers of choroidal melanoma and ciliary body melanoma resolved by enucleation had their positivity at the time of operation was 36%, and during check-ups up to one year or longer it persisted at similar levels. Concurrent presence of both markers before this operation was rare, during postoperative check-up examinations it was within a range of 23 and 33%. The presence of both markers was repeatedly proved in five patients with chooidal melanoma after enucleation of the eye, in four of them in direct correlation with a metastatic process.