[Isolated hypertrophy of the superior oblique muscle in Basedow disease]. / Hypertrophie isoleé du muscle oblique supérieur d'origine basedowienne.

INTRODUCTION: Proptosis is the most common feature of Graves' ophthalmopathy. We report an exceptional case of proptosis in relation with an isolated enlargement of the superior oblique muscle in Graves' ophthalmopathy. OBSERVATION: After ocular contusion a 37 years old man presented a progressive right exophthalmos. On examination there was an unilateral proptosis with dilated conjunctival vessels, without any clinical signs of inflammation and no decreased vision. Ocular movements were full. On general examination signs of hyperthyroidism were present. CT-scan showed a superior oblique muscle enlargement with enlarged superior ophthalmic vein. Cerebral angiography excluded the diagnosis of a carotid-cavernous fistula. Dosage of thyroid hormone revealed hyperthyroidism. DISCUSSION: This case has a double interest: --Diagnostic: a CT-scan picture mimicking a carotido-cavernous fistula in this particular clinical context (history of ocular trauma, enlarged conjunctival vessels). --Isolated enlargement of superior oblique muscle in Graves' disease, which is exceptional in the literature.

[Diagnostic difficulties in pigmented tumor of the optic nerve head. A case report]. / Difficultés diagnostiques face à une tumeur papillaire pigmentée. A propos d'un cas.

Melanocytoma of the optic disc is a benign pigmented tumor located on the optic nerve head. Most cases are visually asymptomatic but in rare cases it can cause visual loss, which does not necessarily involve malignant transformation. We present a case of melanocytoma in a 49-year-old woman who presented with decreased vision in her left eye. The pigmented mass was in close continuity with the juxtapapillary adjacent choroid. Fluorescein angiography demonstrated hypofluorescence with adjacent disc edema. Ultrasonography disclosed a high internal reflectivity mass in the optic nerve head without retrobulbar extension. Magnetic resonance imaging (T1 weighted images) disclosed a hyperintense signal on the optic nerve head. The tumor was stationary for 20 months. This report emphasizes problems differentiating a melanocytoma from malignant melanoma of the optic nerve. Unusual features of melanocytoma (superior nasal location in the optic disc with an adjacent choroidal component, a decrease in visual acuity and disc edema surrounding the tumor) are discussed. Visual loss can be induced by optic neuropathy or retinal vascular obstruction. Melanocytomas grow very slowly over several years or remains stable, in contrast to malignant melanoma. In suspicious cases, close follow-up with serial fundus photographs is essential, although malignant transformation is exceptional.

[Macular serous detachment revealing acute lymphoblastic leukemia]. / Décollement séreux maculaire révélateur d'une leucémie aiguë lymphoblastique.

BACKGROUND: Leukemias are a group of malignant diseases caused by immature hematopoietic cells proliferating in the blood marrow. Some manifestations result from ocular-orbital involvement, which usually occurs through the central nervous system. Other manifestations stem from vasculopathy and/or hemorheologic disorders (anemia, thrombocytopenia, hyperviscosity). OBSERVATION: We report a case of a 42-year-old women presenting with loss of vision caused by serous macular detachment. The investigations showed the diagnosis of acute lymphoblastic leukemia. Steroids and chemotherapy led to complete remission with normal visual acuity during a follow-up of 29 months. DISCUSSION: Ocular involvement is seen in 28%-80% of leukemia cases. The most obvious findings are the presence of retinal hemorrhages, which are most commonly located in the posterior pole. The intraretinal hemorrhage may contain a white component that usually is a white dot in the center of the hemorrhage, but other clinical features are described. Serous detachment of the neuroepithelium is seldom reported, and can be the first symptom of the disease. Other ocular findings include infiltrative involvement of the chorioretina, anterior segment involvement, and orbital location. Ocular location is estimated to be an equivalent of central nervous system involvement, and subsequently requires adequate treatment (steroids, chemotherapy and radiotherapy of the central nervous system). CONCLUSION: Ocular manifestations of leukemia are frequent but rarely reveal the disease. Serous detachment is rarer. However, the diagnosis of leukemia should be considered in case of pigmentary epithelium involvement.

Evaluation of retinal nerve fiber layer thickness measured by optical coherence tomography in Moroccan patients with multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system characterized by focal inflammatory infiltrates, demyelinating lesions and axonal injury. The purpose of the study was to evaluate the retinal nerve fiber layer (RNFL) thickness by optical coherence tomography (OCT) in Moroccan patients with MS and to assess the relationship between RNFL thickness and disease duration, Expanded Disability Status Scale (EDSS) score, visual acuity and automated visual field indices. MATERIALS AND METHODS: Thirty-one patients with definite MS and thirty-one disease-free controls were enrolled in the study. After neurologic consultation, ophthalmologic examination including visual acuity, automated visual field testing and OCT were performed. RESULTS: Significant differences between both groups were observed in OCT parameters (total, temporal and macular ganglion cell layer) with lower thickness in the MS group. In patients without a history of optic neuritis, there were statistically significant inverse correlations between total RNFL thickness and disease duration, neurologic disability evaluated by the EDSS, logMAR visual acuity and automated visual field indices. CONCLUSIONS: OCT seems to be a reproducible test to detect axonal loss of ganglion cells in MS. Further and larger longitudinal prospective studies would be valuable to assess the evolution over time of the RNFL measurements in Moroccan MS patients.

[Solitary retinal astrocytic hamartoma simulating retinoblastoma]. / Hamartome astrocytaire isolé simulant un rétinoblastome.

Retinal astrocytic hamartoma and retinoblastoma may be very similar clinically and their differentiation in atypical cases can be difficult, even with the use of ultrasonography and computed tomography. In such cases, a close follow-up is recommended before enucleation. This paper reviews the case of a 18 month old girl who presented with a solitary retinal astrocytoma of the right eye, without any other physical or ocular disorder. The initial presentation simulated a retinoblastoma; nevertheless atypical patterns as yellow calcifications and the lack of tortuous and dilated feeding blood vessels were present. Ophthalmoscopic and ultrasound regular evaluation did not reveal any change after one year follow-up. Additional investigations performed in order to exclude tuberous sclerosis (neurological and dermatological examination, CT-scans) showed no other organ involvement, which ruled out a phakomatosis. The clinical appearance and course of astrocytic hamartomas, its differential diagnosis from other retinal tumors, especially retinoblastoma, and its association with tuberous sclerosis are discussed.

[Spontaneous orbital hematoma in an adult. A case report]. / Hématome orbitaire spontané chez l'adulte. A propos d'un cas.

Spontaneous orbital hematoma is uncommon, especially in adults. It produces proptosis which progress rapidly and is often associated with ocular movement disturbance. The Authors report a case of spontaneous orbital hematoma in a 45-year-old woman, who had had no previous disease and had experienced sudden onset diplopia associated with moderate proptosis and pain in her right orbit. The diagnosis of orbital hematoma was made by computed tomographic scan. Further investigations revealed arterial hypertension. After a needle aspiration of this hematoma, proptosis resolved, ocular movement began to improve as well as visual acuity. Orbital hematoma revealing arterial hypertension is exceptional. It could be associated with ocular and orbital complications that lead the patient to consult an ophthalmologist. The diagnosis is based essentially on radiology. The other causes of orbital process, inflammation, tumor or vascular malformation, should be considered in the differential diagnosis. Therapeutic management could require surgical evacuation when visual function is compromised (compressive optic neuropathy).

[Choroidal nevi associated with serous macular detachment]. / Décompensation exsudative anatomique et fonctionnelle de 12 naevi choroïdiens.

PURPOSE: To describe the aspect and progression of choroidal nevi associated with macular serous detachment and to analyze different treatments. MATERIAL: and methods: Twelve posterior choroidal nevi were associated with subretinal fluid. The fovea was detached in 11 cases. Tumor thickness was 2 mm or less. RESULTS: No treatment was given in 6 cases and spontaneous subretinal fluid regression was observed in 3 of these 6 cases. Success was also observed in 2 of 3 cases treated with corticotherapy, but subretinal fluid recurred. Gas injection was performed in 1 case and transpupillary thermotherapy in 2 others, all 3 with successful definitive drying of the nevus. Visual acuity decreased in 6 cases (in 3 untreated cases and in 3 cases treated with corticotherapy), remained stable in 3 cases, and increased in 3 cases (in 1 untreated case, in 1 gas injection case, and in 1 case after thermotherapy). Tumor growth was observed in 3 cases, on the average 2 years after diagnosis (25%). CONCLUSION: Subretinal fluid is rarely observed with choroidal nevi and its progression is variable. Various treatments in addition to observation such as corticotherapy, gas injection, transpupillary thermotherapy seem effective in stabilizing or improving visual function. Supervision is nevertheless needed to detect tumor growth that can be frequent in these nevi associated with subretinal fluid.

[Diabetic cystoid macular edema and vitrectomy. Preliminary results: about 19 cases]. / Oedème maculaire cystoïde du diabétique et vitrectomie. Résultats préliminaires: à propos de 19 cas.

INTRODUCTION: Vitrectomy can be performed to release the anteroposterior and tangential vitreoretinal tractions that sometimes create diabetic macular edema. The present study evaluates the efficacy of this treatment. MATERIAL AND METHODS: We retrospectively studied 19 operated eyes in 15 patients with diabetes over 17 months. The group's mean age was 61.4 years. There were 11 men and 4 women, with 13 cases of noninsulinodependent and two cases of insulinodependent diabetes. A vitrectomy was done by the same surgeon to detach posterior hyaloidal and inner limiting membranes. Two groups were defined and compared, one including patients whose visual acuity had improved and the other, patients with no improvement. We used Student's t test and Leven's test from SPSS. RESULTS: Improvement in visual acuity was observed in 57.8% of the eyes studied, stabilization was achieved in 26.3%, and regression was noted in 15.7%. Cystoid macular edema resolved in 68.42% of eyes. Furthermore, inner limiting membrane colored by indocyanine green was removed. An angiographic improvement was noted in 68.42% of eyes. There was no significant difference between the two groups allowing a definition of success criteria. CONCLUSION: Vitrectomy for diabetic cystoid macular edema is currently under study and seems effective given its encouraging results.

[Should associated intraoperative and/or postoperative photocoagulation be systematic during or after vitrectomy for proliferative diabetic vitreoretinopathy?]. / L'endophotocoagulation per-opératoire et/ou la photocoagulation post-opératoire doivent-elles être systématiques en association à la vitrectomie dans la vitréorétinopathie diabétique proliférante?

PURPOSE: To analyze the results of vitrectomy in proliferative diabetic vitreoretinopathy and to check whether systematic intra- and/or postoperative photocoagulation is necessary in most cases. PATIENTS AND METHODS: We retrospectively reviewed 108 patient records (137 eyes) of vitrectomy performed for complications of proliferative diabetic vitreoretinopathy between 1982 and 2000. Fifty-eight percent of the patients were women. The average age was 44 years. Sixty percent of the patients presented with diabetes type 1. Only 39% of the eyes had complete preoperative panretinal photocoagulation. Preoperative visual acuity was lower than 2/200 in 81% of eyes, 27% presenting initially with traction retinal detachment involving the macula. The surgical technique used was segmentation-delamination. Endodiathermy was necessary in 45% of the eyes and intraoperative photocoagulation was not performed. Postoperative complementary photocoagulation was carried out in only 9% of the eyes. RESULTS: Results were analyzed with an average follow-up of 66 months. Anatomical success was obtained in 69% of the eyes, with 55% visual improvement. These results were unchanging at long-term follow-up in 95% of the eyes studied. Iatrogenic retinal breaks were observed in 8% of the eyes. Postoperative complications were dominated by single (8%) or recurrent vitreous hemorrhage (8%). The rate of postoperative neovascular glaucoma was approximately 5%. These results are similar to the rates reported by other authors using intraoperative endophotocoagulation. CONCLUSION: Intra- and/or postoperative photocoagulation should not be systematic but reserved for management of iatrogenic retinal breaks and also for extensive panretinal photocoagulation in recurrent vitreous hemorrhage.

[Outcome of Behçet disease in ophthalmologic practice in Morocco]. / Devenir de la maladie de Behçet en milieu ophtalmologique marocain.

We treated 123 patients with Behçet's disease during a period of 10 years (1984-1993). The ocular lesions include uveal lesions especially the posterior lesions and vascular retinal. Uveitis was total in 72% of cases. Periphlebitis occurred in 51% of cases, vein occlusion in 10% of cases, macular oedema in 16% and papillary oedema in 10%. Clinical course and prognosis were studied. The functional prognosis is poor as such lesions may lead to blindness, particularly due to papillary oedema maculopathy. The treatment used is based on immunosuppressive and corticoid steroid drugs.

[Outcome of Behçet disease in ophthalmological milieu in Morocco]. / Devenir de la maladie de Behçet en milieu ophtalmologique marocain.

We treated 123 patients with Behçet's disease during a period of 10 years (1984-1993). The ocular lesions include uveal lesions especially the posterior lesions and vascular retinal. Uveitis was total in 72% of cases. Periphlebitis occurred in 51% of cases, vein occlusion in 10% of cases, macular oedema in 16% and papillary oedema in 10%. Clinical course and prognosis were studied. The functional prognosis is poor as such lesions may lead to blindness, particularly due to papillary oedema maculopathy. The treatment used is based on immunosuppressive and corticoid steroid drugs.

[Wolfram syndrome. Three case reports]. / Syndrome de Wolfram. A propos de 3 cas.

Wolfram syndrome is a rare disorder defined by the occurrence of diabete mellitus, diabete insipidus, optic atrophy and deafness; DIDMOAD is a commonly accepted acronym. We report 3 further cases: two girls and one boy. Their age ranged from 12 to 17 years. The diagnosis was based on the presence of juvenile diabete mellitus, bilateral optic atrophy, urologic signs, with urinary tract dilation; and deafness in two cases. The ophthalmic signs of Wolfram syndrome are progressive decrease in visual acuity, constriction of the peripheral visual field with or without central scotoma, color vision disturbances and bilateral optic disc atrophy. Diabetic retinopathy is a rare complication. The other clinical features are discussed so as to differentiate between Wolfram syndrome and other optic atrophies associated with diabete mellitus. We discuss of the pathogenic hypothesis including the mitochondrial dysfunction.

[Melanoma of the iris and pregnancy]. / Mélanome de l'iris et grossesse.

Iris melanoma is a malignant melanocytic tumor, making up 1.2%-6.6% of uveal malignant melanomas. The growth of choroidal melanoma during pregnancy is described and a hormonal influence is suggested. We present a case of iris melanoma occurring during pregnancy. A 32-year-old woman, in the 28(th) week of her fifth pregnancy, was referred to the ophthalmologist with a 2-month history of blurred vision and pain in her left eye. The visual symptoms became progressively worse with decreasing vision. Her visual acuity was 20/70 in her left eye, with a temporal, pigmented, prominent iris mass extending into the trabecular meshwork and the corneal endothelium. Elsewhere other pigmented localizations were found in the iris and in the trabecular meshwork. There was secondary glaucoma with intraocular pressure of 36mmHg and C/D=0.9. The right eye was normal. A general physical examination found no pigmented lesions. Chest radiography and hepatic ultrasonography revealed no metastasis. The diagnosis of iris malignant melanoma was made from the diffuse involvement extending into the trabecular meshwork and the advanced secondary glaucoma; an enucleation was performed and histopathological examination confirmed the diagnosis of iris melanoma with involvement of the trabecular meshwork. The patient had no further problems (follow-up of 11 months). From this case report, we discuss the differential diagnosis of iris melanoma and the hormonal influence on its growth.

[Retinal vasculitis]. / Les vascularites retiniennes.

PURPOSE: The purpose of this study is to determine aetiologies of vasculitis of retina in Morocco. MATERIAL AND METHODS: This is a retrospective study on 108 cases of vasculitis of retina admitted in the ophthalmology department, for a 5-year period (1987-1993). Our patients had a complete ophthalmological examination : fluorescine angiography, colour vision, general examination and biological study. RESULTS: Many aetiologies have been found, predominantly Behcet's disease. The neovascularization of retina which complicates the vasculitis was detected in 30 % of our patients. A laser photocoagulation was performed on these cases, sometimes a vitrectomy was necessary when a haemorrhage of vitreous body occurred, complicating the neo-vessels of retina. The therapeutics received by our patients was based on the corticotherapy. An immunosuppression treatment was prescribed in most cases of Behcet's disease and in severe vasculitis. Outcome after treatment has been satisfactory, but many patients relapse very frequently, mainly those with Behcet's disease. CONCLUSION: Causes of vascular retinitis are variable, most of them are due to Behcet's disease.

[Ophthalmic manifestations of acute leukemia]. / Manifestations ophtalmologiques des leucémies aiguës.

Orbital and ocular lesions are the third most frequent extramedullar locations of acute leukemia after the meninges and testicles. These lesions are treated as a central nervous system lesion; therefore diagnosis is essential to therapeutic adjustment. We present a retrospective study on charts of children treated for acute leukemia between 1996 and 1998. Ophthalmic examination was carried out when there were ocular symptoms. One hundred ninety-six children were treated for acute leukemia. Twelve children (6.1%) had an ocular and orbital lesion: 7 boys and 5 girls, with an average age of 6 years. Six had acute lymphoblastic leukemia, 6 had acute myeloid leukemia. Visual acuity was 1/10 in 9 children. Four children had an initial orbital lesion with a rapidly progressing exophthalmos. The hemogram and myelogram showed a granulocytic sarcoma. Two children who had been previously treated for acute leukemia presented a bilateral anterior uveitis with hypopyon; anterior chamber paracentesis showed blast cells and confirmed the ocular relapse. A corneal lesion was found in 2 children and in 2 cases, the optic nerve had edema; a decrease in visual acuity was the sign of the optic nerve lesion. Two patients had retinal infiltration with hemorrhages in the posterior pole. Prophylaxis consists of intrathecal injection of methotrexate and reinforcement of chemotherapy. Central nervous system irradiation is seldom used in children. Orbital and ocular lesions carry a poor prognosis according to the majority of authors. Two years after diagnosis of the ocular lesions, only 1 of the children studied remains alive.

[Risk factors for failure of scleral buckling in rhegmatogenous retinal detachment. A Moroccan series]. / Facteurs d'échec de la chirurgie épisclérale dans le décollement de rétine rhegmatogène. À propos d'une série marocaine.

PURPOSE: To evaluate risk factors for failure of scleral buckling in rhegmatogenous retinal detachment (RRD) in an adult Moroccan population. METHODS: A retrospective study of 432 eyes of 422 patients undergoing scleral buckling (SB) for primary RRD between 2001 and 2009 was carried out. Statistical analysis of risk factors for failure was performed using binary logistic regression. RESULTS: Mean patient age was 43 ± 15 years, and 45.4% were myopic. The median recurrence was at 10 months. The final failure rate was 22.5%. Univariate analysis shows that significant risk factors for failure were extent of RRD ≥ 3 quadrants (P<0.001), advanced PVR (P<0.001) and worsening PVR postoperatively (P<0.001). In the multivariate model, the only significant risk factor for failure was the worsening postoperative PVR (P<0.001). CONCLUSIONS: Our findings suggest that worsening of PVR after surgery is the major risk factor for failure of SB in RRD. Thus, it is necessary to recognize the risk factors contributing to PVR and to plan the most appropriate, earliest and least traumatic surgical treatment of RRD.

[Retrobulbar optic neuropathy secondary to an undifferentiated carcinoma of the sphenoid sinus]. / Neuropathie optique rétrobulbaire révélant un carcinome indifférencié du sinus sphénoïdal.

Undifferentiated carcinoma of the paranasal sinuses is a rare malignant tumor, characterized by rapid growth, local/regional invasion, metastatic potential and poor prognosis despite aggressive treatment. Clinically, this tumor may manifest as episodes of epistaxis, headache or ophthalmic signs, particularly oculomotor nerve palsies, optic atrophy or even proptosis in the case of orbital extension. We report the case of a patient admitted with a left retrobulbar optic neuropathy, which led to a diagnosis of undifferentiated carcinoma of the sphenoid sinus.