Ectropion of the lacrimal point: the shoelace technique.

PURPOSE: To describe an alternative technique to repair the ectropion of the lacrimal point, either alone or combined with an ectropion related to outer angle laxity. METHODS/RESULTS: After diamond shape resection of the conjunctiva and the retractors, sutures are placed with each bridle interlacing on the posterior portion of the eyelid below the lacrimal point in a shoelace fashion. CONCLUSIONS: The technique combines treatment of hyperlaxity of several anatomic structures in a single operation and has the advantage of reinforcing the Horner muscle, which is essential for the cure of this type of ectropion.

[Use of mitomycin C (MMC) for dacryocystorhinostomy interventions]. / Utilisation de la mitomycine C pour les interventions de la dacryocystorhinostomie.

Mitomycin C (MMC) has been described as having a positive effect in different types of dacryocystorhinostomy (DCR) surgery such as external DCR, endonasal and transcanalicular DCR. MMC, an antineoplastic antibiotic, acts as an alkylating agent by inhibiting DNA, RNA and protein synthesis. Topical use of MMC can modulate the scarring process, which is useful in glaucoma surgery and pterygium excision. In DCR, MMC is also useful because it reduces the scarring process and thus prevents the occlusion of the osteotomy site related to the fibroblast activity. An increase in the success rate for long-term results has been observed by different authors, resulting from a larger osteotomy size as well as a decrease in the density and cellularity of the mucosa. No complications have been seen with topical use of MMC.

[Rationale for a diagnostic approach in non-Graves' orbital inflammation--Report of 61 patients]. / Établissement d'un arbre décisionnel diagnostique dans les orbitopathies inflammatoires non basedowiennes chroniques--à propos de 61 patients.

INTRODUCTION: Orbital inflammatory syndromes include a wide variety of inflammatory intraorbital processes which are very different in terms of clinical presentation and prognosis. We currently prefer to differentiate so-called "specific" inflammations, for which an etiology is able to be identified, from idiopathic orbital inflammatory syndromes (IOIS), for which the etiology remains unknown and the histology is nonspecific. PURPOSE: To propose an efficient diagnostic approach for clinicians managing patients with non-Graves' orbital inflammations. MATERIALS AND METHODS: This is a retrospective and prospective study concerning 61 patients managed by the medical team for non-Graves' orbital inflammations between May, 1999 and May, 2013 in the ophthalmology departments of Nice and Limoges university hospitals in France. Seventeen specific inflammations, 19 orbital lymphomas and 25 idiopathic orbital inflammatory syndromes were included. Patients were divided into two groups. Thirty-six patients (group 1) underwent primary biopsy, while for the other 25 (group 2), therapy was begun empirically without biopsy. We could therefore compare both approaches in terms of diagnostic efficiency and time until identification of a specific etiology. RESULTS: Our statistical results show that an approach without primary biopsy leads to a number of specific diagnoses statistically much lower than that obtained by the approach with primary biopsy. Also, the risk of missing a specific inflammation (with as a consequence an inappropriate treatment and a risk of functional sequelae as well as a fatal risk of missing a lymphoproliferative pathology) is very clearly higher in the case of not performing primary biopsy. Finally, the average time elapsed between the initial consultation with the ophthalmologist and a specific diagnosis was one month in the case of the first approach, while this delay was almost three times higher with the second approach, with a mean of 2.91 months (P<0.01). DISCUSSION: Our study shows that biopsy should be the mainstay of diagnostic management. A trial of empiric treatment is only performed first in myositis or in locations where biopsy could jeopardize functional prognosis. It should only be done after biopsy in all other cases. Of course, in all cases of relapse or recurrence after treatment, biopsy should be performed or repeated. CONCLUSION: The diagnostic work-up of a patient with an orbital inflammatory process must of course include blood testing and orbital imaging, but also a systematic primary biopsy for histological examination in the vast majority of cases. It must be repeated at least in the case of any doubt about the diagnosis or in the case of any recurrence or resistance to treatment.

Comparative review of topical ophthalmic antibacterial preparations.

The choice of an antibacterial is based on considerations of pharmacodynamic, pharmacokinetic and bacteriological characteristics, risk of selecting resistant mutants, and cost. In this article we review 16 commercially available ophthalmic antibacterial preparations. Fusidic acid and bacitracin are selective for gram-positive bacteria whereas polymyxin B targets gram-negative species. Aminoglycosides and quinolones are broad spectrum antibacterials. The widespread use of an antibacterial increases risks of selecting resistance to it. Acquired resistance is well documented for fusidic acid and rifamycin, and newly described for quinolones. The bioavailability of an antibacterial agent depends on the target bacterial species, the site of infection and the integrity of the haemato-aqueous barrier. Some agents (fusidic acid, quinolones) penetrate the cornea, passing into the anterior chamber of normal eyes at therapeutic concentrations, whereas others (polymixin B, bacitracin) have no penetrating powers and remain at the surface of the eye. Toxicity is mostly manifested by allergic reactions to excipients or active ingredients in topical antibacterial preparations. A few cases of haematological toxicity have brought suspicion on topical chloramphenicol, but the link has yet to be proven. Erythromycin and polymyxin B are probably okay to use as topical applications in pregnant women and nursing mothers. Costs of treatment must be evaluated as a whole (regimen, drug associations). Prices for a bottle of eyedrops may vary 3-fold. The cheapest drugs include chloramphenicol, polymyxin B and gentamicin, the most expensive being fusidic acid and the quinolones.

Bipalpebral sliding flap in the repair of inner or outer canthal defects.

Seven patients were successfully treated with a bipalpebral sliding flap for the repair of medial or lateral canthal defects. In our experience this technique minimises the size of the associated surgical repair-a skin graft for the inner canthus or a cheek rotation flap for the outer canthus.

Anterior chamber concentrations of vancomycin in the irrigating solution at the end of cataract surgery.

PURPOSE: To verify that therapeutic levels of vancomycin were present in the irrigating solution at the end of cataract surgery. SETTING: Service d'ophtalmologie, Université de Limoges, France. METHODS: An irrigating solution that contained 20 mg/L of vancomycin was used in 15 patients having phacoemulsification. Antibiotic concentrations in the phacoemulsification handpiece and in the aqueous humor were measured at the end of surgery. RESULTS: Passage through the phacoemulsifier did not affect antibiotic concentration. In the aqueous humor, after wound closure, the concentration constantly exceeded the minimal inhibitory concentration of the principal gram-positive bacteria responsible for human endophthalmitis. CONCLUSION: Vancomycin added to the irrigating solution used during cataract surgery was found in effective concentrations in the anterior chamber at the end of surgery.

Abnormalities of orbital volume.

New information on the physiopathology and treatment of orbital volumes pathologies is described: 1) In post-enucleation or evisceration socket syndrome placing of synthetic material (HA-TCP) directly in the intraconal orbital fat can correct most of the symptoms. However the best approach is to prevent orbital volume deficiencies during first surgery using an implant large enough to allow a future prosthesis of a volume less than 2 mL. New procedures for placing the implant after enucleation or evisceration are described. 2) In proptosis related to Graves' orbitopathy relative indications are given for orbital decompression by removal of fat or bone.

Circulating antibodies to human and bovine cornea in human keratoplasty.

PURPOSE: To compare anti-human cornea and anti-bovine cornea serum reactivity in corneal transplantation and pathology. METHODS: We investigated the presence of IgG and IgM antibodies to bovine corneal extract (BCE) and human corneal extract (HCE) by ELISA in 48 healthy adults and in 30 corneal allograft recipients before and after grafting. Baseline levels of antibodies in healthy controls served to establish a positivity threshold. Anti-HLA antibodies were investigated in all patients. RESULTS: Preoperatively, five and one patient were positive respectively for IgG and IgM anti-BCE; one and ten patients were positive for IgG and IgM anti-HCE. The presence or absence of antibodies was not modified after grafting, and was not associated with rejection. Anti-HCE of the IgM class were more frequent in patients with keratoconus. Two patients had anti-HLA antibodies. CONCLUSIONS: Antibodies to non-HLA corneal antigens are detectable in corneal allograft recipients. Reactions against bovine and human substrates differ in frequency and class. This reactivity is not modified after grafting or rejection, but is increased in corneal disorders, including keratoconus.

Eyelid hyperlaxity and obstructive sleep apnea (O.S.A.) syndrome.

PURPOSE: An association between the floppy eyelid syndrome and the obstructive sleep apnea syndrome (O.S.A.) has been reported. We studied eyelid tissue elasticity and other ophthalmologic findings in a large number of patients with sleep disorders. MATERIAL AND METHODS: Sixty-nine patients with sleep disorders were evaluated. Two thirds were found to have O.S.A., and one third was treated at night by nasal continuous positive airway pressure (nasal C.P.A.P.). Slit lamp examination, eyelid measurements and Schirmer test were performed. RESULTS: Eyelid hyperlaxity was increased in patients with O.S.A. The floppy eyelid syndrome (associated papillary conjunctivitis), however, was rare. Associated corneal lesions were rare, and most patients were asymptomatic. In some cases, ocular irritation was due to air leaks from nasal C.P.A.P. A significant proportion of patients required treatment for primary open angle glaucoma. CONCLUSIONS: Our study of 69 patients found an association between O.S.A. and eyelid hyperlaxity.

Treatment of proptosis with fat removal orbital decompression in Graves' ophthalmopathy.

PURPOSE: Retrospective evaluation of 41 proptosis reduction procedures using fat removal orbital decompression (FROD) according to a modified Olivari's technique. METHODS: Trans-septal excision of extraconal and intraconal fat was done under the microscope through the upper and lower eyelid blepharoplasty approach. Proptosis was measured with a Hertel exophthalmometer. RESULTS: Mean excision of 7.31 + 1.9 ml (range 3.25-12 ml) of orbital fat reduced proptosis on average by 4.7 + 2.4 mm (range 1-11 mm). Side effects were few, limited only to ocular motility disturbances. There was no significant effect on visual fileds. A postoperative drop in IOP was noted in patients with preoperative IOP above 21 mmHg. Efficient palpebral lengthening can be achieved with combined section of the levator aponeurosis horns in the upper eyelid, and/or auricular cartilage graft in the lower eyelid. CONCLUSIONS: FROD reduces proptosis in Grave's ophthalmopathy.

Human vitreous penetration of imipenem.

The purpose of this study was to determine imipenem concentrations in vitreous humor of non-infected human eyes. Ten patients undergoing vitrectomy were infused with a single dose of either 0.5g (5 patients) or 1g (5 patients) of imipenem. Vitreous humor was withdrawn 2 or 4 hours after the end of the infusion. Results differed in relation to the dose. After 0.5g, vitreous levels were stable (approximately 0.20 mg/l), but after 1g they were significantly higher (approximately 2 mg/l). These levels were above the minimum inhibitory concentration of imipenem for 90% (MIC 90) of the main species responsible for endophthalmitis.

Ciprofloxacin ophthalmic solution in the treatment of conjunctivitis and blepharitis: a comparison with fusidic acid.

The efficacy and safety of ciprofloxacin ophthalmic solution (0.3%) and fusidic acid gel (1%) were compared in the treatment of bacterial conjunctivitis and blepharitis in a randomized, open, parallel group study. Thirty-nine patients, 21 treated with ciprofloxacin solution and 18 treated with fusidic acid gel, were culture-positive on admission and were evaluable for efficacy. At the end of a 7-day treatment, the infecting organism was eradicated in 81% of those treated with ciprofloxacin and 72% of those treated with fusidic acid gel. There was clinical cure or improvement in 95% and 89% respectively. The clinical cure rate appeared to be higher with ciprofloxacin than fusidic acid (62% compared with 28%) but this was related to the higher proportion of patients with acute conjunctivitis in the ciprofloxacin group. Two patients using ciprofloxacin had mild discomfort and stinging on instillation and one given fusidic acid had moderate edema and discomfort; the latter patient stopped treatment. Topical ciprofloxacin is effective and well tolerated and is a useful treatment of bacterial conjunctivitis and blepharitis.

Ciprofloxacin ophthalmic solution versus rifamycin ophthalmic solution for the treatment of conjunctivitis and blepharitis.

The efficacy and safety of ciprofloxacin (0.3%) ophthalmic solution and rifamycin (1%) ophthalmic solution for the treatment of bacterial conjunctivitis and blepharitis was compared in this randomized, double-masked, parallel-group study. Forty-one patients, 19 on ciprofloxacin and 22 on rifamycin, were culture-positive on admission and evaluated for efficacy. There was clinical improvement in more than 90% of patients in each group at the end of the seven-day treatment period. However, clinical cure rates on day 7 appeared to be higher with ciprofloxacin (53%) than rifamycin (23%; p = 0.061, Mann-Whitney test). Bacteriological eradication rates were comparable: the infecting organisms were eradicated in 68% of patients on ciprofloxacin and 77% with rifamycin. There were no serious adverse reactions to either treatment. One patient in each group was withdrawn on account of a mild allergy. In conclusion, topical ciprofloxacin was effective and well tolerated and would be a particularly useful agent for the treatment of bacterial conjunctivitis and blepharitis.

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.

[New ceramic materials for use in anophthalmia surgery]. / Neue Keramikmaterialien zur Verwendung in der Anophthalmuschirurgie.

Over the last 20 years eyeball replacement surgery has improved, especially with the widely accepted use of biocolonisable implants. These implants allow long-lasting biointegration, thus improving prosthesis motility and reducing the rate of postoperative exposure. In this article, we review the chemical structure, toxicity data and manufacturing procedures of the three main commercially available materials: aluminium, hydroxyapatite and porous polyethylene.

[Role of Doppler in the diagnosis of ophthalmic complications of Horton's disease]. / La place du Doppler dans le diagnostic des complications ophtalmiques de la maladie de Horton.

A study of the eyeball was carried out using a double frequency Doppler transducer in 31 patients suffering from histologically confirmed temporal arteritis. These patients were divided into 3 groups depending on the results of the ophthalmological examination: group A: 20 patients; normal ophthalmological exam, group B: 5 patients; non specific ocular anomalies, group C: 6 patients; ocular lesions specific to temporal arteritis (ischemic optic neuropathy with amaurosis, dysoric nodules). Doppler examination demonstrated normal curves in the patients in groups A and B. The mean amplitude of systolic peaks was 7.9 mm in group A and 10.3 mm in group B (P = NS). These data did not differ from those of a control population of 22 subjects not suffering from temporal arteritis. On the other hand, group C demonstrated important anomalies on Doppler examination: lack of ophthalmic signal in one case; marked dampening of curves in 4 cases; zones of turbulence in one patient. The mean amplitude of systolic peaks was drastically decreased (1.8 mm). After steroid treatment, a significant increase in blood velocity was seen leading to a normalization of tracings in the majority of cases, including the patients in group C. Doppler examination would appear capable of reliably assessing the risk of ophthalmic complications of temporal arteritis when blood flow anomalies exist. On the other hand, patients with normal Doppler curves may be considered to be at little risk. Subjects at high risk should be urgently treated with high doses of steroids and can be regularly monitored by repeated Doppler examination.

[Doppler examination in temporal arteritis. Preliminary results (author's transl)]. / Doppler et artérite temporale résultats préliminaires.

Nine patients with histologically confirmed Horton's diseases were explored by Doppler ultrasound examination, before and after corticotherapy, of the cervical arteries, temporal arteries (N = 9), and branches of the ophthalmic artery: internal nasal (N = 9), central retinal, and supraorbital (N = 6). Excellent correlations existed between histological findings and results of Doppler examination, concerning the severity of the lesions (80% correlation). Circulatory slowing was evident in the ophthalmic vessels studied, with alterations in the shape of peak velocities in 6 of the 9 cases. Major abnormalities were present in 3 patients; two of them presenting transient or permanent amaurosis. Doppler curves improved after corticotherapy, their shape and amplitude becoming equivalent to those of a control population of the same age. Doppler examinations appear to be of diagnostic value in Horton's disease, as well as being able to predict the risk of ophthalmological complications; more effective surveillance of corticotherapy is possible.

[Ocular bacterial infections : present and prospective methods of diagnosis]. / Infections oculaires bactériennes: méthodes di diagnostic actuelles et prospectives.

Bacteriological samples and tests are essentiel for the diagnosis of superficial ocular infections and endophtalmitis. The direct examination and the traditional culture of the samples can be in the futur associated with new diagnostic approach using antigen detection (immunofluorescence, enzyme immunosorbent assays) and genome research by hybridation or better by amplification for Chlamydia and for the most frequent species responsible of endophtalmitis. An original genomic strategy of bacterial endophtalmitis diagnosis was developped.

[Cicatricial ectropion and ichthyosis. Apropos of 4 cases]. / Ectropions cicatriciels et ichtyoses. A propos de 4 cas.

Ichthyosis are dystrophic inheritance skin disorders with inconstant palpebral complications like cicatricial ectropion and lagophthalmos due to large skin retractions. The authors report two cases of cicatricial ectropion in two adults. For one of the two cases, it is the first description to our knowledge of cicatricial ectropion associated with ichthyosis vulgaris sex-linked. The authors, after a short description of physiopathology and of classification of the different types of ichthyosis describe the surgical treatment with skin grafts, with good results in the first post operative period only in two adults. The two newborns had good results with medical treatment only.