Usefulness of colour Doppler flow imaging in the management of lacrimal gland lesions.

OBJECTIVE: To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions. METHODS: Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination. RESULTS: The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %. CONCLUSION: CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management. KEY POINTS: • CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

[How to deal with orbital syndrome: diagnostic approach]. / Conduite à tenir devant un syndrome orbitaire : approche diagnostique.

Evaluation of a patient with orbital disease needs a multidisciplinary approach. Clinical examination should seek to glean information regarding pathophysiologic effect and location and to evaluate consequences of this disease on cosmetic, vision and ocular motility. Procedures of imaging are based on the implied complementary exams that should be done according to the suspected clinical location and characters help to characterize the underlying process. Imaging can define the location, size, limits and relationship of the disease to other tissues and especially to the vascular system. It may be completed by blood test. The final diagnosis is based on several arguments and can appeal for a diagnostic biopsy in the most difficult cases.

[Periocular aging: physiopathogenesis, clinical aspect, and treatment]. / Vieillissement péri-oculaire ; physiopathogénie, aspect clinique et prise en charge.

Aging around the eyes plays a considerable role in facial aging. The demand for periocular rejuvenation is increasingly frequent. Until the past few years, eyelid esthetics was synonymous with blepharoplasty: surgery that consisted in resecting the myocutaneous excesses and reducing fatty deposits. The contribution of new medical and surgical treatments combined with new and more rigorous analysis of the esthetic disorders makes it possible to respond more precisely to patient demand and individualize surgical and/or medical treatment that is not highly aggressive and only uses products that are well tolerated, biocompatible, or resorbable.

[Reconstruction of full-thickness lower eyelid defects]. / Reconstruction de la paupière inférieure de pleine épaisseur.

This review covers the techniques of reconstruction of large full-thickness defects of the lower eyelid. The authors describe tree cases of basal cell carcinoma of the lower eyelid, with large excision of the tumor. We excised the tumor and examined the edges with an extemporaneous histological exam. Reconstruction combined grafts and flaps. The advantages and disadvantages of the various techniques of lower-eyelid reconstruction are discussed.

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.

[Complications of blepharoplasty]. / Complications des blépharoplasties.

Blepharoplasty complications are infrequent, most often minor and transitory, rarely major and permanent with functional or esthetic consequences. Treatment is above all preventive: screening at risk patients with a history of ophthalmic problems, but also general illnesses that would contraindicate blepharoplasty. Patients must be informed of possible risks through informative booklets with the most important points underlined. Complications can be purely ophthalmological, the more serious sequelae being partial or complete visual loss due to ischemic optical neuropathy, with very poor prognosis, or more rarely compression of the ocular globe by intraorbital hemorrhage, which has a better prognosis provided the origins are quickly recognized and treated immediately. Other visual complications include oculomotor problems, keratoconjunctivitis sicca, epiphora, and chemosis of lymphatic origin. Eyelid complications are more frequent: ptosis on the upper eyelid or lagophthalmia caused by incorrect resection of the skin, scarring and eyelid fold anomalies. The most serious esthetic complication is the malposition of the lower eyelid, which can manifest as retraction, lagophthalmia, ectropion, deformation of the external canthus, or lower eyelid tissue relaxation. These malpositions are quite often minor, sometimes reversible, but at times major, with psychological, esthetic and functional consequences that are difficult for the patient. Other local complications also arise: enophthalmia with a sunken lid, as well as under- and overcorrection. General complications can include scarring related to pigmentation problems and residual hematomas, and exceptionally infections going as far as the orbital fat tissue. Finally, other complications are related to new laser surgical techniques that are responsible for ectropion of the lower eyelid and even burns or residual redness, or complications related to periocular injections of filling material. A comprehensive review of prevention, diagnosis, and management of complications after blepharoplasty is presented.

[Dehiscence and disinsertion of the aponeurotic bundle of the upper eyelid levator in acquired ptosis]. / Déhiscence et désinsertion du faisceau aponévrotique du releveur de la paupière supérieure au cours des ptosis acquis.

Aponeurotic defects and disinsertion of the levator aponeurosis are responsible for many cases of acquired ptosis. The typical clinical findings in aponeurotic defects are: history of prior orbital swelling, injury, ocular surgery, blepharochalasis; good to excellent levator function, thinning of the eyelid above the tarsus, high to absent lid crease, and normal Müller's muscle function. The purpose of the treatment is to repair a defect or advance the aponeurosis onto the tarsus. Levator aponeurosis surgery was used to treat 18 upper eyelids with acquired ptosis. Local anesthesia and surgery from an anterior approach were used in all cases. The advantages of this technique are: The lid height is determined by asking the patient to look in various fields of gaze. A blepharoplasty can be performed when necessary. The lid crease is formed. The exposition of the levator aponeurosis disinsertion is easier to recognize.

[Surgical treatment of ptosis by resection of the superior tarsal muscle employing a cutaneous approach (author's transl)]. / Résection du releveur par voie cutanée dans la cure chirurgicale du ptosis.

A simple technique for resection of the superior tarsal muscle through a cutaneous approach, for the surgical treatment of ptosis, was employed in severe or moderate, congenital and acquired forms of the affection. Muller's muscle and the aponeurotic fascia are removed in a single piece, while conserving the tarsus.

[Emergency surgical treatment of injuries to the internal angle of the eyelids (author's transl)]. / La chirurgie d'urgence de l'angle interne des paupières en traumatologie.

Reconstruction of the normal internal angle after injury raises the problem of conservation of the lacrimal pathways and the fixation of this angle when the ligament has been sectioned. Emergency treatment for the main types of lesion encountered are discussed. Superficial and deep lacerations require careful suturing in three planes and reconstruction of the lacrimal pathways; evulsions and tears should be treated by blepharopexy after determining the conjugated points; evulsion of the internal angle is often associated with an orbitonasal dislocation and has to be treated by transnasal internal canthopexy.

[Medical treatment of dysthyroid orbitopathy]. / Traitement médical de l'orbitopathie dysthyroïdienne.

The majority of Graves' patients have mild and nonprogressive ocular involvement that does not require aggressive treatment. Local supportive measures such as wearing tinted lenses, proper eyelid hygiene, and the use of wetting agents or gels are usually sufficient to obtain symptomatic relief until eye disease becomes inactive. Smoking must be stopped and euthyroidism controlled. Management of severe forms (10% of patients) is often difficult and does not provide consistently favorable results. The use of glucocorticoids is a well-established method of treatment, indicated in severe inflammatory forms as well as in complicated forms of optic neuropathy, ocular hypertension, and corneal exposure, and are used orally or intravenously, at high doses and for prolonged periods of time. Prisms are useful in cases of diplopia. Favorable effects are reported in slightly more than 60% of cases. Glucocorticoids can be combined with orbital radiotherapy in patients with severe orbitopathy.

[Repair of the orbital cavity by a dermoadipose graft after enucleation]. / Réfection de cavité orbitaire par greffe dermo-graisseuse après énucléation.

Dermis fat graft as a movable implant within the muscle cone is considered. The graft's survival depends mainly on its early vascularization which is bound to dermis, quality of the socket and suture of the recti muscles. The results of the twenty three first grafts emphasize two types of indications: Essential indications for the treatment of enophthalmos and for the treatment of migrated or extruded orbital implants. Relative indications: primary grafts and dermis-fat implantation for the treatment of contracted sockets.

[Conjunctiva--Müller's muscle monobloc resection in the surgical treatment of minor ptosis]. / La résection monobloc conjonctive-muscle de Müller dans la cure chirurgicale des ptosis mineurs.

The Müller's muscle-conjunctival resection procedure is a relatively simple technique for mild ptosis, with good levator function and phenylephrine test positive. The advantages are: preservation of tarsus, very good and predictable results.

[Suspension of the eyelid to the frontal muscle in the surgery of ptosis. Technic and indications]. / La suspension de la paupière au muscle frontal dans la chirurgie du ptosis. Technique et indications.

Twenty seven frontalis sling procedures were performed with use of autogenous fascia-lata. The choice of this procedure was performed sometimes at the first stage for severe ptosis with poor levator function: isolated congenital ptosis, blepharophimosis syndrome, Marcus Gunn Jaw-Winking ptosis, ptosis with severe myopathy, some traumatic ptosis. This procedure was also performed in a second stage after failure of the useful procedures (levator resection) and after verification that the levator was not exploitable. Sometimes the choice of the procedure is done during the exploration of the eyelid and the levator because there is not always "parallelism" between the levator function and his anatomy. So operative technique must always be performed by a complete anterior palpebral approach, the surgeon can passed the suspensory material from the tarsus to the roof of the orbit, just anterior to the levator aponeurosis, and then out above the eyebrow. The pulley this created by the periosteum of the superior orbital margin prevents vertical traction lines. The skin crease is created with sutures which pick up the tarsus and the lid retractors. If, during the explorations the levator is "exploitable", a super maximum levator resection will be performed at the first stage, the frontalis suspension will be maintained in case of failure of the levator resection.

[Primary congenital ectropion. Apropos of 2 cases]. / L'ectropion congénital primitif. A propos de 2 cas.

PURPOSE: Congenital lid ectropion is a rare anomaly. In the usual classification, primary ectropion caused by tightening of the anterior lamella may sometimes be confused with secondary ectropion, especially with blepharophimosis syndrome or euryblepharon. METHODS: Through analysis of two representative cases of congenital ectropion and review of literature we discuss similarities and differences between primary and secondary ectropion including blepharophimosis and euryblepharon. RESULTS: Horizontal narrowing of palpebral fissure and inversus epicanthal folds are the main clinical feature to be considered when differential diagnosis is difficult between primary forms and blepharophimosis, as ptosis is often an underlying abnormaly in both cases. CONCLUSION: To be effective, the surgical management of congenital lid ectropion requires precise clinical examination, clear understanding of causative factors and several procedures.

[Surgical treatment of diplopia caused by fractures of the orbital floor]. / Traitement chirurgical des diplopies secondaires aux fractures du plancher orbitaire.

Oculomotor disturbance resulting from orbital floor fractures have different etiologic factors, sometimes damage of one of the ocular motor nerves, caused by direct injury to the orbit; this damage occurs also to one or more of the extrinsic ocular muscles, especially the obliques; frequently, the diplopia is caused by prolapsed orbital tissues with or without muscle entrapment or by a muscle fibrosis; when the diplopia appears after orbital floor reconstruction there is often a palsy of the inferior rectus muscle in front of silicone implant or bone graft on the orbital floor. In oculomotor disturbance after orbital floor fracture, the first stage will be to recognize the mechanism of the diplopia by a clinical examination, motility in the nine positions, Hess Charts, binocular vision and field, forced duction, radiography and sometimes coronal computed tomography which also allow visualization of soft tissues densities, including all extraocular muscles. If there is an indication of orbital surgery, it will be done always in first; oculomotor surgery will be done if necessary at the second stage, if there is a permanent diplopia without evolution during six months. The purpose of the treatment is to obtain orthophoria in primary position and in down gaze. A series of cases of fracture of the orbital floor with resulting diplopia are described. The method, the time, and the indications of orbital or oculomotor surgery are discussed according the variety of cases.

[Treatment of cicatricial ectropions of the eyelids (author's transl)]. / Traitement des ectropions cicatriciels des paupières.

Cicatricial ectropions arise following burns, certain dermatoses, trauma with subsequent development of vicions scar tissue, and after evulsion of the eyelids. Operations on the ocular globe or eyelids may also lead to a cicatricial ectropion, while skin retraction during the advanced stages of ectropion due to hypotonia and congenital ectropions have to be considered as a separate group. Surgical treatment consists of correcting the skin deficiency by means of flaps or grafts, and reconstituting the internal angle when necessary. The principal surgical techniques and the types of flaps employed are described, as well as the indications for therapy as a function of the clinical form.

[Surgical treatment of the sequelae of Basedow's ophthalmopathy]. / Traitement chirurgical des séquelles de l'ophtalmopathie basedowienne.

Functional and cosmetic ophthalmic complications of Graves' disease are exophthalmos, eyelid retraction and oculomotor disturbances. This paper describes and takes over the surgical procedures used when these complications are associated. In severe exophthalmos, we used an orbital decompression of the orbital floor sometimes combined with the medial wall by an anterior approach. In eyelid retraction, we perform a recession of the levator muscle with scleral graft implantation. In incomitant strabismus, surgery is usually limited to recessions of the involved muscles, most of the surgery is directed to the inferior rectus 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 at the first stage by treatment of the retraction and if it is not sufficient, we perform an orbital decompression at the second stage. For severe exophthalmos with oculomotor disturbances, we perform at the first stage the orbital decompression and at the second stage the strabismus surgery. For oculomotor disturbances with eyelid retraction, we perform the strabismus surgery at the first stage and the eyelid retraction at the second stage. When there is the association of exophthalmos, eyelid retraction and oculomotor disturbances, the indication and the choice of treatment are difficult and depend on numerous factors. If an 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 chronology of the treatment depends on the modification we observed on the other components of the ophthalmopathy when one stage treatment is performed on one component: for example orbital decompression can modify the oculomotor disturbance and oculomotor surgery can modify eyelid retraction.

[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.

[Steinert myotonic dystrophy and blepharoptosis surgery: 9 case reports]. / Chirurgie du ptosis dans la dystrophie myotonique de Steinert. A propos de 9 cas.

UNLABELLED: Steinert myopathic dystrophy is a generalized, hereditary disease with bone, muscular, heart and ocular involvement. PATIENTS AND METHODS: This is a retrospective study of nine patients with significant blepharoptosis due to Steinert disease, who were treated at the Adolphe de Rothschild Ophthalmology Foundation over a period of 5 years. Ptosis was symmetric and major in all cases with poor levator excursion. Severity criteria were an absence of the Bell phenomenon and diminished orbicularis tone. A frontalis suspension was performed in eight cases with intentional undercorrection. The outcome was favorable in all cases, 2 with a slight overcorrection underwent a second operation DISCUSSION: conclusion: Surgical treatment of ptosis in Steinert disease is difficult because of a risk of lagophthalmic, keratopathy due to the severity of the disease, an absence of the Bell phenomenon and ophthalmoplegia. This surgery must be undertaken with caution, most often using a frontalis suspension. Undercorrection must be systematic, with the single goal of freeing the pupil in the primary position.

[Orbital decompression for dysthyroid orbitopathy: a review of techniques and indications]. / Techniques et indications chirurgicales des décompressions osseuses de l'orbitopathie dysthyroïdienne.

Orbital bony decompression has a definite place in the management of severe manifestations of dysthyroid orbitopathy such as optic neuropathy, exposure keratitis, and exophthalmos. This surgical procedure can be undertaken when medication and radiation therapy fail. Esthetic and functional results are globally satisfying and explain the interest taken in this technique. This article will describe the development of this procedure and will outline the surgical techniques and their complications. It emphasizes the multifactor indications for this procedure.