Hymenoptera insect stings: Ocular manifestations and management.

PURPOSE: To describe the ocular findings and management of Hymenoptera insect stings. METHODS: We treated and followed 8 patients with ocular Hymenoptera stings. All patients were admitted through emergencies and hospitalized at the Hedi Rays eye institute in Tunis. RESULTS: The site of the sting was the cornea in 5 cases, limbus in one case, conjunctiva in one case and upper lid in the last case. Retained stingers were objectified in 4 cases. Immediate surgical extraction carried out in all cases. We also followed one case of post-sting Adie's syndrome and one case of retrobulbar optic neuritis. The sting was conjunctival in one case and palpebral in the other case. Corticosteroids were ineffective in these two cases. CONCLUSION: Ocular Hymenoptera stings are rare environmental accidents. They may cause various severe ocular complications. Early management, adapted to the clinical manifestations, is the key to a good outcome.

Ligneous conjunctivitis due to plasminogen deficit: Diagnostic and therapeutic approach. With literature review.

Ligneous conjunctivitis is a rare and poorly understood pathology. Infections and repeated microtraumas are often involved in acute disease flare-ups. This masquerade may lead to misdiagnosis and delayed treatment. We report two cases of ligneous conjunctivitis, describing various presentations of its natural history and focusing on the treatment of this rare disease.

Radiation Therapy for Primary Eyelid Cancers in Tunisia.

Management of eyelid cancers is based on surgery and/or radiotherapy (RT). The treatment objective is to control tumors with acceptable functional and esthetic outcomes. The aim of this study was to evaluate the results of radiation therapy in management of epithelial eyelid cancers, reviewing retrospectively the clinical records of patients treated in our institution from January 1989 to December 2013. We focused on clinical and histological features, treatment characteristics, tolerance and disease control. One hundred and eight patients (62 men and 46 women) were enrolled, with a mean age of 61 years [ranges 1587]. The most frequent tumor location was the inner canthus (42.6%). Median tumor size was 21 mm [ranges 470]. Histological type was basal cell carcinoma in 88 cases (81.5%), squamous cell carcinoma in 16 (14.8%) and sebaceous carcinoma in 4 (3.7%). Radiation therapy was exclusive in 67 cases (62%) and postoperative for positive or close margins in the remaining cases. Kilovoltage external beam radiotherapy (KVRT) was used in 63 patients (58.3%) and lowdoserate interstitial brachytherapy in 37 (34.3%). Eight (7.4%) were treated with cobalt or with a combination of KVRTcobalt, KVRTelectron beams, KVRTbrachytherapy or cobaltelectron beams. The total delivered radiation doses were 70 Gy (2 Gy/fraction) in 62 patients (57.4%), 66 Gy (2 Gy/fraction) in 37 (34.3%) and 61.2 Gy (3.4Gy/fraction) in 9 (8.3%). After a median followup of 64 months, we noted 10 cases of local recurrences(9.2%): 7 after exclusive and 3 after postoperative RT. No local recurrence occurred in patients treated with brachytherapy. Actuarial 5year local recurrencefree rate, diseasefree survival and overall survival were respectively 90%, 90% and 97%. Tstage was found to be a significant factor for recurrence (p=0.047). All acute radiationrelated reactions were scored grade I or II. Delayed effects were eye watering in 24 cases (22.2%), eye dryness in 19 (17.6%), unilateral cataract in 7 (6.4%) and ectropion in 4 (3.7%). Radiation therapy and especially brachytherapy is an efficient treatment of eyelid cancers, allowing eye conservation and functional preservation with good local control rates and acceptable toxicity.

[Prognosis of primary malignant tumors of the conjunctiva]. / Le pronostic des tumeurs malignes primitives de la conjonctive.

PURPOSE: To discuss possible factors that could influence the prognosis of primary malignant conjunctival tumors. PATIENTS AND METHODS: We retrospectively analyzed medical records of 79 patients followed for primary malignant conjunctival tumors between January 1997 and July 2011. RESULTS: The mean age at the time of diagnosis was 61.1 years; male/female ratio was 2.59. The mean tumor size was 13.9 mm. The histological type was invasive squamous cell carcinoma in 43 cases (54.4%), epithelial dysplasia in 11 cases (13.9%), carcinoma in situ in 7 cases, conjunctival malignant melanoma in 5 cases, conjunctival lymphoma in 4 cases and other rare tumors in 9 cases. We performed an excisional biopsy with a safety margin in 89.8% of cases, associated with cryotherapy in 46.6% of cases. Enucleation was performed in two cases and orbital exenteration in 5 cases. We noted tumor recurrence in 33.3% of patients after an average period of 9.5 months. Radiation therapy was indicated in 44 cases (55.7%). The mean follow-up of our patients was 42 months. Tumor recurrences were statistically associated with a history of xeroderma pigmentosum (P=0.012), a diagnostic delay more than 11 months (P=0.001), caruncular location (P=0.004), tumor size greater than 10mm (P=0.044), scleral extension (P=0.011), initial treatment limited to excisional biopsy (P=0.033) and histopathologic involvement of the margin of the tumor resection (P=0.008). CONCLUSION: A better understanding of the prognostic factors of primary malignant conjunctival tumors is essential for management and may improve the prognosis of these tumors.

[Macula analysis by spectral domain OCT in rhegmatogenous retinal detachment surgery]. / Analyse de la macula par OCT spectral domain dans la chirurgie du décollement de rétine rhegmatogène.

INTRODUCTION: Despite surgical reattachment of retinal layers, postoperative functional outcomes after rhegmatogenous retinal detachment (RRD) may be limited. This can be explained by microstructural changes in the macula inherent to the pathology itself as well as the surgery. PURPOSE: To evaluate the various changes in the macula by OCT pre- and postoperatively, and correlate them with functional and clinical outcomes in patients with RRD. To establish pre- and postoperative prognostic factors. METHODS: This was a prospective study of 50 eyes of 50 patients operated for RDD. Each patient underwent a complete clinical examination and macular OCT using the Heidelberg Spectralis; preoperatively and then successively at 7 days, 1 month, 3 months and 6 months after RRD surgery. RESULTS: Preoperative tomographic results revealed an average height of submacular fluid of 742 ± 345 µm. Ninety-six percent of patients exhibited thickening of photoreceptor outer segments (PROS), 62% an outer layer undulation, 60% cystic cavities in the outer and/or inner nuclear layers (ONL, INL), 36% disruptions of the external limiting membrane (ELM) and 64% disruption of the IS/OS junction. Postoperatively, 24% of patients had persistent submacular fluid. The average thickness of the central fovea, the ONL, the IS/OS junction and the PROS were 172 ± 51.3 µm, 88.4 ± 30.9 µm, 11.36 ± 5.4 µm and 19.54 ± 13.1 µm respectively. Postoperative disruptions of the ELM, the IS/OS junction and Verhoeff's membrane (VM) were present in 24%, 60% and 82% of patients respectively. The preoperative tomographic risk factors for poor visual outcome were: submacular fluid height > 800 µm (P<0.001), disruptions of the MLE and/or IS/OS junction (P<0.001), as well as cystic cavities in the ENL and/or INL (P=0.002). Postoperative risk factors were: thinning of the fovea (≤ 250 µm), central fovea (≤ 160 µm), ONL (≤ 90 µm), IS/OS junction (≤ 10 µm) and PROS (≤ 18 µm) layers (P<0.001), as well as a discontinuous or absent appearance of the ELM (P<0.001), IS/OS junction (P<0.001) and VM (P=0.006). CONCLUSION: Spectral domain OCT allows detection of specific microscopic, quasi-histologic macular changes in rhegmatogenous retinal detachment. These anomalies could be predictive of final postoperative visual outcome.

[Clinical features of retinoblastoma in Tunisia]. / Le profil clinique du rétinoblastome en Tunisie.

PURPOSE: To report the relative frequency of presenting signs in Tunisian children with retinoblastoma and to evaluate their prognostic impact. METHODS: A retrospective study was undertaken of 200 patients with retinoblastoma examined and treated between January 1993 and June 2009. RESULTS: There were 123 boys and 77 girls. For all cases, mean age at diagnosis was 29.8 months (range, 1 month to 9 years). There were 138 (69%) unilateral cases and 62 (31%) bilateral cases. Nineteen children (9.5%) had a family history of retinoblastoma. The most common signs were leukocoria (80%) and strabismus (28%) followed by proptosis. Orbital inflammation, hyphemia and phthisis are rare presenting findings in retinoblastoma. In our series, 26 children (13%) presented with extraocular retinoblastoma. Leukocoria and proptosis are significantly associated with a worse prognosis. CONCLUSION: The ability to recognize the presenting signs and symptoms of retinoblastoma can lead to earlier diagnosis and better prognosis.

[Viral retinitis following intravitreal triamcinolone injection]. / Rétinite virale secondaire à une injection intravitréenne de triamcinolone.

Necrotizing viral retinitis is associated with infection by the Herpes family of viruses, especially herpes simplex virus (HSV), varicella zoster virus (VZV) and occasionally cytomegalovirus (CMV). When the diagnosis is suspected clinically, antiviral therapy must be instituted immediately. We report the case of a patient presenting with necrotizing viral retinitis 3 months following intravitreal injection of triamcinolone acetonide for diabetic macular edema. Fluorescein angiography demonstrated a superior temporal occlusive vasculitis. A diagnostic anterior chamber paracentesis was performed to obtain deoxyribo-nucleic acid (DNA) for a polymerase chain reaction (PCR) test for viral retinitis. PCR was positive for CMV. The patient was placed on intravenous ganciclovir. CMV retinitis is exceedingly rare in immunocompetent patients; however, it remains the most common cause of posterior uveitis in immunocompromised patients. The incidence of this entity remains unknown. Local immunosuppression, the dose and the frequency of injections may explain the occurrence of this severe retinitis.

[Massive bilateral subconjunctival hemorrhage revealing acute lymphoblastic leukemia]. / Hémorragie sous-conjonctivale bilatérale massive révélatrice d'une leucémie aiguë lymphoblastique.

We report the case of 20-year-old patient who presented in emergency with bilateral massive, spontaneous subconjunctival hemorrhage. Clinical findings suggested a blood dyscrasia, which was confirmed by blood cell count. The patient was urgently referred to hematology where the diagnosis of acute lymphoblastic leukemia was made. This case highlights the importance of working up any unusual subconjunctival hemorrhage, as it may reveal, in certain cases, a severe life-threatening disease.

[Conjunctival limbal autograft versus simple excision with intra-operative mitomycin C in pterygium surgery: a comparative study]. / L'autogreffe conjonctivo-limbique versus l'exérèse simple avec mitomycine C dans la chirurgie du ptérygion : étude comparative.

PURPOSE: The purpose of our study is to evaluate the long-term anatomical and functional results of conjunctival-limbal autograft (AGCL) compared to simple excision with intraoperative mitomycin C. PATIENTS AND METHODS: We conducted a prospective comparative study of 60 eyes of 60 patients presenting with primary pterygium. These patients were divided into two groups, matched according to the age and the stage of the pterygium. Thirty eyes of 30 patients were treated with conjunctival limbal autograft (AGCL group), and 30 eyes of the other 30 patients were treated with simple excision with intraoperative mitomycin C (MMC group). Minimum follow-up was 24 months. RESULTS: The mean age of our patients was 50.6 and 51.3 years in the AGCL and MMC groups, respectively. A male predominance with male to female ratio of 1.5 was noted in both groups. We found more pterygium recurrences in the MMC group. Indeed, seven patients (23.3%) in the MMC group experienced a recurrence. In comparison, we found only a single recurrence (3.33%) in the AGCL group with a statistically significant difference (P=0.026). With regard to postoperative complications, we noted three inflammatory granulomas in the AGCL group (10%). In the MMC group, we observed two cases (6.66%) of delayed corneal healing with superficial punctate keratitis and epithelial defect and one case (3.33%) of symblepharon. There was no statistically significant difference in mean visual acuity gain between the two groups (AGCL: 1.76 lines; MMC: 2.82 lines; P=0.133). CONCLUSION: Pterygium surgery by excision with conjunctival limbal autograft is an effective technique offering a low rate of long-term recurrences and few complications.

[Orbital subperiosteal hematoma in child with sickle cell thalassemia. A case report]. / Hématome sous-périosté orbitaire chez un enfant drépano-thalassémique.

Sickle cell anemia is the most common hemoglobinopathy worldwide; its musculoskeletal complications consist more often of medullary infarctions involving long bones. Orbital infarction is uncommon. We report on a case of orbital subperiosteal hematoma in a 9-year-old male with a medical history of sickle cell thalassemia.

[MRI exploration for the evaluation of orbital implant biocolonization in children enucleated for retinoblastoma]. / Apport de l'IRM dans la surveillance de la biocolonisation des implants intra-orbitaires chez des enfants énucléés pour rétinoblastome.

PURPOSE: To evaluate the contribution of MRI exploration for the evaluation of orbital prothesis biocolonization. PATIENTS AND METHODS: We studied ten eyes of ten children who underwent enucleation for retinoblastoma and synthetic hydroxyapatite orbital implantation. Each patient was examined by MRI imaging with gadolinium within 2 months to 1 year. RESULTS: After gadolinium administration, five implants showed an enhancement. Nodular enhancement around the implant was noted in one patient with a recurrence of retinoblastoma, and brain metastases were shown in two cases. None of the orbital implants was rejected. CONCLUSION: Fibrovascular colonization reduces the risk of orbital implant migration. Magnetic resonance imaging is safe and effective in detecting extrusion or tolerance of the orbital implant.